Is quality improvement sustainable? Findings of the American College of Cardiology's Guidelines Applied in Practice

Abstract

Objective: (i) To examine the sustainability of an in-hospital quality improvement (QI) intervention, the American College of Cardiology's Guideline Applied to Practice (GAP) in acute myocardial infarction (AMI). (ii) To determine the predictors of physician adherence to AMI guidelines-recommended medication prescribing.

Design: Prospective observational study.

Setting: Five mid-Michigan community hospitals.

Participants: 516 AMI patients admitted consecutively 1 year after the GAP intervention. These patients were compared with 499 post-GAP patients.

Main outcome measures: The main outcome was adherence to medication use guidelines. Predictors of medication use were determined using multivariable logistic regression analysis.

Results: 1 year after GAP implementation, adherence to most medications remained high. We found a significant increase in beta-blocker (BB) use in-hospital (87.9 vs. 72.1%, P < 0.001) whereas cholesterol assessment within 24 h (79.5 vs. 83.6%, P > 0.225) did not change significantly. However, discharge aspirin (83 vs. 90%, P < 0.018) and BB prescriptions (84 vs. 92%, P < 0.016) dropped to preintervention rates. Discharge angiotensin-converting enzyme inhibitor and treatment of patients with low-density lipoprotein of ≥ 100 were unchanged. Predictors of receiving appropriate medications were male gender (for aspirin and BBs) and treatment with percutaneous coronary intervention compared with coronary artery bypass graft. Notably, prescription rates for discharge medications differed significantly by hospital.

Conclusions: Early benefits of the Mid-Michigan GAP intervention on guideline use were only partially sustained at 1 year. Differences in guideline adherence by treatment modality and hospital demonstrate challenges for follow-up phases of GAP. Additional strategies to improve sustainability of QI efforts are urgently needed.

Keywords: adherence to medications; cardiovascular disease, disease categories; guidelines, appropriate healthcare; predictors of medication use; quality improvement, quality management; quality indicators, measurement of quality; sustainability.