Antiplatelet Therapy in Patients with Unstable Angina and Non-ST-Segment-Elevation Myocardial Infarction: Findings from the CRUSADE National Quality Improvement Initiative

Michael B. Bottorff, Pharm.D.; Edith A. Nutescu, Pharm.D.; Sarah Spinler, Pharm.D.


Pharmacotherapy. 2007;27(8):1145-1152. 

In This Article

Leading and Lagging Hospitals: Association Between Quality of Care and Mortality

To demonstrate the association between guideline adherence and better clinical outcomes, one group of authors ranked 350 hospitals participating in the CRUSADE initiative in September 2003 according to their overall adherence to nine ACC-AHA guideline-recommended class I care indicators for unstable angina and NSTEMI ( Table 1 ).[69] Hospital rankings were determined by composite scores for adherence to the nine care indicators for individual patients, after the assessment of patients' eligibility for each treatment (according to indications and contraindications specified in the ACC-AHA guidelines) and the number of eligible treatment opportunities. Hospitals were divided into quartiles, although the composite scores were analyzed as a continuous variable. Significant performance gaps for each of the nine class I care indicators were identified between the leading (upper quartile, > 75%) and lagging (lower quartile, < 25%) centers.

Consistent with the comparison of guideline adherence between academic and nonacademic centers in a previously discussed study,[62] leading hospitals in this analysis were more likely to be larger academic institutions with surgical facilities.[69] With respect to antiplatelet therapy, early aspirin administration was achieved in 96% of patients (18,827) in the leading hospital quartile, and in 85% of patients (12,329) in the lagging quartile. Greater differences were noted for early use of GP IIb-IIIa inhibitors and clopidogrel: GP IIb-IIIa inhibitors were administered to 50% and 17% of patients in leading and lagging quartiles, respectively, and clopidogrel was administered to 48% and 28% of patients, respectively. A similar pattern was observed for discharge antiplatelet use: aspirin use was 94% in the leading quartile compared with 80% in the lagging quartile, whereas clopidogrel was used in 62% of patients in the leading quartile and in 37% of those in the lagging quartile.

For all care processes examined, a significant (p<0.001) trend was noted for drug use across hospital quartiles. The composite quality quartiles for hospital guideline adherence were used to demonstrate the relationship between overall guideline adherence and in-hospital mortality (Figure 3). For every 10% increase in guideline adherence, a 10% decrease in mortality rate was achieved (adjusted OR 0.90, 95% CI 0.84−0.97, p<0.001). This observation underscores the simple principle at the heart of the CRUSADE initiative, namely, that adherence to the ACC-AHA guidelines saves lives.[69]

Figure 3.

Furthermore, a study of outcomes in 21,588 patients from 315 hospitals participating in the CRUSADE initiative between 2002 and 2003 has determined that changes in the care processes are definitively linked to changes in in-hospital mortality rates.[70] Hospitals were classified according to quartiles of change in the overall composite ACC-AHA guideline adherence score. Those hospitals that were the worst at following the guidelines (composite adherence score change of -5%) had an increased mortality risk of 3.1%. Those hospitals that achieved the best improvement in guideline adherence (composite adherence score change of +16%) had a decrease in mortality risk of 37%. These data provide an achievable top-performing benchmark for use in physician and hospital feedback, which provides the most compelling motivation for changing practices.[12]


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