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

Effectiveness of Quality Improvement Initiatives in Acute Coronary Syndromes

For many years, emergency physicians have focused on rapid evaluation and targeted intervention for the most severe clinical manifestation of ACS, ST-segment-elevation myocardial infarction (STEMI). This is because STEMI can be readily identified with an electrocardiogram (ECG), and the time-dependent benefit of reperfusion therapy is clearly understood and well established.[19] Consequently, quality improvement initiatives have evolved with a focus on care of patients with STEMI.

The first initiative to improve clinical outcomes in patients with acute myocardial infarction was the Cardiac Hospitalization Atherosclerosis Management Program (CHAMP).[20] This initiative was undertaken at a single teaching hospital and was targeted toward patients hospitalized for CAD, including patients with unstable angina, acute myocardial infarction, and ischemic heart failure and those who underwent cardiac procedures (catheterization, angioplasty and/or stent placement, and coronary bypass). The CHAMP initiative focused on implementation of secondary prevention treatments and risk-reduction counseling. Efforts to improve utilization of secondary-prevention drug therapies involved the use of a focused treatment algorithm, standardized admission orders, and educational lectures by local opinion leaders. In addition, the proportions of patients receiving secondary-prevention drugs were tracked and reported. Implementation of CHAMP achieved a significant increase in the use of life-saving drugs. Before and after CHAMP, aspirin use in patients at discharge improved from 68% to 92% of patients (p<0.01), β-blocker use improved from 12% to 62% (p<0.01), ACE inhibitor use increased from 6% to 58% (p<0.01), and statin use increased from 6% to 86% (p<0.01). The improvement in drug use was associated with improved clinical outcomes, as reflected in significant reductions in recurrent myocardial infarction and 1-year mortality rates in the post-CHAMP versus pre-CHAMP era (7.8% vs 3.1%, and 7.0% vs 3.3%, respectively, p<0.05 for both comparisons).[20] The CHAMP was the first initiative to demonstrate that a systems approach to quality improvement could not only increase utilization of guideline-recommended therapies, but also reduce the risk of recurrent events.

The success of the CHAMP initiative subsequently led to the initiation of an AHA-associated pilot program called Get with the Guidelines (GWTG).[21,22] This initiative used an internet-based data-management system that facilitated analysis of the care of patients with CAD while they were in hospital, as well as hospital performance with regard to guideline adherence. Teams from participating hospitals attended quarterly meetings, which included reviews of the guidelines and workshops. In addition to prospectively collecting data and measuring performance, the Web-based patient management tool incorporated reminder screens to provide immediate reference to the relevant guideline and alerts if measurements or interventions had been omitted. The participating hospitals, including both large academic centers and small rural community hospitals, implemented data collection in patients with acute myocardial infarction; some centers also collected data on patients with unstable angina, coronary revascularization, and heart failure. During a 1-year pilot period, the rates of utilization of aspirin, β-blockers, and ACE-inhibitors at discharge remained at 82−90% of eligible patients; the use of lipid-lowering therapy at discharge rose from 54% to 78% of patients and smoking-cessation counseling rose from 48% to 81% of patients.[22]

The GWTG program has since been expanded nationally and has proved to be a sustainable and effective continuous quality improvement program that takes advantage of the "teachable moment" immediately after an acute event when the patient is most likely to heed the advice of the health care provider.[23] This concept of the teachable moment has, for example, been discussed in the context of initiating appropriate secondary prevention therapy before hospitable discharge after a percutaneous coronary intervention (PCI) and the associated improvements in treatment rates and in patients' long-term compliance and clinical outcomes.[24] The teachable moment represents an ideal time at which pharmacists can directly affect quality of care through appropriate education of patients. The AHA has predicted that more than 80,000 lives could be saved annually if all acute care hospitals in the United States would adopt the GWTG program.[22]

Further demonstration that continuous quality improvement can be implemented across a variety of institutions, patients, and caregivers is provided by the Guidelines Applied in Practice (GAP) quality improvement project.[25] This project was designed to improve guideline adherence in hospitals treating patients with acute myocardial infarction. The project involved 10 hospitals and targeted patients with a principal discharge diagnosis code for acute myocardial infarction. Participating hospitals made use of a customized "tool kit" that included standard orders for acute myocardial infarction, clinical pathway pocket guides or pocket cards, patient information forms, patient discharge forms, chart stickers, and hospital performance charts. The GAP project had a rapid timeline (1 yr) and, during this period, achieved significant increases in the use of aspirin (from 81% to 87% of patients, p=0.02) and β-blockers (from 65% to 74%, p=0.04) on admission, and aspirin (from 84% to 92%, p = 0.002) and smoking-cessation counseling (from 53% to 65%, p = 0.02) at discharge.[25]

A cohort study conducted among Medicare patients with acute myocardial infarction before (1368 patients) and after (1489 patients) implementation of the GAP project showed that the use of guideline-recommended therapies significantly reduced the risk of death at both 30 days and 1 year.[26] Adjusted odds ratios (OR) for mortality were 0.74 (95% confidence interval [CI] 0.59−0.94, p = 0.012) at 30 days and 0.78 (95% CI 0.64−0.95, p = 0.013) at 1 year.

The success of these quality improvement initiatives has provided the rationale for applying quality improvement initiatives to treatment strategies for unstable angina and NSTEMI. To assist in the assessment of guideline adherence and identify opportunities for improvement, an ACC-AHA task force recently issued performance measures for acute myocardial infarction, as shown in Table 1 .[27] These performance measures are similar to those issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).[28]


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