Use of critical pathways to improve the care of patients with acute myocardial infarction

doi:10.1016/S0002-9343(99)00239-9

The American Journal of Medicine

Volume 107, Issue 4, October 1999, Pages 324-331

https://doi.org/10.1016/S0002-9343(99)00239-9 Get rights and content

Abstract

Purpose: While critical pathways have become a popular strategy to improve the quality of care, their effectiveness is not well defined. The objective of this study was to investigate the effect of a critical pathway on processes of care and outcomes for Medicare patients admitted with acute myocardial infarction.

Subjects and Methods: A retrospective cross-sectional and longitudinal cohort study was made of Medicare patients aged 65 years and older hospitalized at 32 nonfederal Connecticut hospitals with a principal diagnosis of myocardial infarction during two periods: June 1, 1992, to February 28, 1993, and August 1, 1995, to November 30, 1995. The main endpoints of the cross-sectional analyses for the 1995 cohort were the proportion of patients without contraindications who received evidence-based medical therapies, length of stay, and 30-day mortality. Hospitals with specific critical pathways for patients with myocardial infarction were compared with hospitals without critical pathways. The main endpoints of the longitudinal analyses were change between 1992–93 and 1995 in the proportion of patients receiving evidence-based medical therapies, length of stay, and 30-day mortality.

Results: Ten hospitals developed critical pathways between 1992–93 and 1995. Eighteen of 22 nonpathway hospitals employed some combination of standard orders, multidisciplinary teams, or physician champions. Patients admitted to hospitals with critical pathways did not have greater use of aspirin within the first day, during hospitalization, or at discharge; beta-blockers within the first day or at discharge; reperfusion therapy; or use of angiotensin-converting enzyme inhibitors at discharge in 1995. The mean (± SD) length of stay in 1995 was not significantly different between pathway (7.8 ± 4.6 days) versus nonpathway hospitals (8.0 ± 4.2 days), and the change in length of stay between 1992–93 and 1995 was 2.2 days for pathway hospitals and 2.3 days for nonpathway hospitals. Patients admitted to critical pathway hospitals had lower 30-day mortality in 1995 (8.6% versus 11.6% for nonpathway hospitals, P = 0.10) and in 1992–93 (12.6% versus 13.8%, P = 0.39), but the differences were not statistically significant.

Conclusions: Hospitals that instituted critical pathways did not have increased use of proven medical therapies, shorter lengths of stay, or reductions in mortality compared with other hospitals that commonly used alternative approaches to quality improvement among Medicare patients with myocardial infarction.

Section snippets

Methods

The Cooperative Cardiovascular Project was designed to evaluate and improve the quality of care received by Medicare beneficiaries with acute myocardial infarction (8). The project was pilot-tested in four states (Alabama, Connecticut, Iowa, and Wisconsin) during 1992–93. Patients with myocardial infarction were identified from the Medicare Provider Analysis Record file (ICD-9-CM principal diagnosis code 410). Patients were excluded if the fifth digit of ICD-9-CM code was 2, because this

Results

During the period between 1992–93 and 1995, 10 of the 32 hospitals approved a critical pathway for the treatment of patients with myocardial infarction. These critical pathways provided reminders for the appropriate use of thrombolytic therapy, aspirin on admission and discharge, beta-blockers on admission and discharge, and ACE inhibitors at discharge. Instructions for nursing care, patient teaching, diagnostic testing, patient activity, and discharge planning were also standard. The length of

Discussion

Patients with myocardial infarction who were admitted to hospitals with critical pathways were not more likely to receive guideline-based therapies or to have shorter lengths of stay. Nonpathway hospitals had similar reductions in length of stay between 1992–93 and 1995 as did pathway hospitals, and they were equally proficient in using processes of care that have been shown to improve outcomes in myocardial infarction. Pathway hospitals did show improvement in some processes of care, but

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Citation Excerpt :
Our study also provides support for the potential importance of protocols and standardized order sets as tools to promote system changes within hospitals. The impact of standardized orders, clinical pathways, and protocols on improvements in AMI care in other studies has been inconsistent.9,11,19,22 Nevertheless, a variety of experts have recommended that some type of standardized protocol or order set should be an integral part of efforts to assure high-quality AMI care.14
Although organizational change has been advocated as a critical component of quality improvement, there is little data available on the variation and effectiveness of organizational elements in the care of acute myocardial infarction (AMI).
This study was designed to examine the impact of organizational infrastructure on the use of aspirin and β-blockers during and after AMI.
We assessed organizational infrastructure for AMI care in 44 hospitals in Kansas and linked these data to patient-specific process of care data collected in Kansas as part of the Cooperative Cardiovascular Project. While controlling for clustering within hospitals, we examined the relationships between hospital infrastructure and use of aspirin and β-blocker both at admission and discharge.
Hospitals varied widely in their inclusion of aspirin and β-blockers in AMI pathways, protocols, and standardized order sets. Hospitals also varied in the involvement of their physicians in AMI quality improvement and in their ability to identify a physician champion for AMI care. Patients were more likely to receive aspirin on admission in hospitals that included aspirin in their emergency department order sets (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.01-2.48) and were more likely to receive β-blockers on admission and at discharge if β-blockers were included in an emergency department protocol or pathway (OR 2.14, 95% CI 1.25-3.77 and OR 3.5, 95% CI 1.14-14.38, respectively). Use of β-blockers at discharge was also associated with commitment of administration to AMI care and the presence of a physician champion.
Quality improvement efforts should include a close examination of the organization of AMI care to assure that critical elements in the care of AMI patients are not inadvertently omitted.
Evaluation of clinical practice in patients admitted with community-acquired pneumonia over a 4-year period
2006, Archivos de Bronconeumologia
En nuestro hospital utilizamos desde marzo de 2000 una guía clínica para el tratamiento de los pacientes diagnosticados de neumonía adquirida en la comunidad (NAC). El objetivo de este estudio ha sido analizar la evolución de la calidad del tratamiento facilitado a los pacientes ingresados por NAC.
Se ha realizado un estudio observacional prospectivo. Se compararon, en 4 períodos consecutivos de 1 año (1 de marzo de 2000 a 29 de febrero de 2004), el tratamiento y los resultados de los pacientes ingresados por NAC.
A lo largo de los 4 años se demostraron tendencies estadísticamente significativas en los siguientes indicadores: reducción de los ingresos hospitalarios (p < 0,001), de la duración de la estancia hospitalaria (p < 0,05) y de la duración total del tratamiento antibiótico (p < 0,05); aumento de la cobertura de gérmenes atípicos (p < 0,001) y de la administración del antibiótico en las primeras 8 h (p < 0,001). No se observaron diferencias significativas en la mortalidad intrahospitalaria, en la mortalidad en 30 días y en los reingresos en 30 días. También se identificaron 2 áreas de mejora: el bajo porcentaje de ingresos en la unidad de cuidados intensivos (4,4%) y los ingresos injustificados entre los pacientes de riesgo bajo (36,8%).
El control sistemático de los indicadores de nuestra guía clínica nos permitió conocer y evaluar nuestra práctica clínica. Se comprobó una evolución favorable de muchos de estos indicadores y se identificaron áreas de mejora.
Since March 2000 we have been using a clinical practice guideline in the management of patients diagnosed with community-acquired pneumonia (CAP). The objective of this study was to analyze the evolution of quality of care received by these patients.
This was a prospective observational study comparing the process of care and outcomes of 4 consecutive 1-year periods (March 1, 2000 through February 29, 2004) in patients admitted for CAP.
Over the 4 years studied, the following statistically significant trends were observed: reductions in hospital admissions (P<.001), length of hospital stay (P<.05), and total duration of antibiotic treatment (P<.05); and increases in the coverage of atypical pathogens (P<.001) and administration of antibiotics within 8 hours of hospital arrival (P<.001). No significant differences were found in readmissions within 30 days, or in-hospital and 30-day mortality. Two other areas for improvement were also identified: a low percentage of admissions to the intensive care unit (4.4%) and the rate of unnecessary hospitalization of lowrisk patients (36.8%).
Systematic monitoring of the indicators of our clinical guidelines provided us with information about our clinical practice and facilitated an evaluation of the same. Many of these indicators were found to have evolved favorably and areas of improvement were identified.
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2005, Respiratory Medicine
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A related and highly relevant factor when studying variability in CAP is the management evolution over time. Thus, some studies have documented that in a competitive environment such as that found in the USA, secular trends have led to changes in the administration of care13 or reduction in the average length of stay.14,15 Better understanding of the secular changes associated with the clinical practice of CAP management in European hospitals would reinforce the need for implementing improvement strategies if needed.
Study objetives: The goal of this study was to assess variability in the management of patients admitted to hospitals with community-acquired pneumonia (CAP), and changes in secular trends of this condition.
Methods: Observational study carried out, in 5 teaching hospitals, in northern Spain of patients admitted with CAP between March 1,1998 and March 1,1999 (baseline period), and between March 1, 2000 and September 30, 2001 (follow-up period). Clinical histories were analyzed retrospectively for relevant parameters for process-of-care and outcome performance. Those parameters among hospitals during the baseline period were compared. For each hospital, changes in these parameters between baseline and follow-up were also measured. All parameters were adjusted for disease severity.
Results: A total of 844 patients were included in the baseline period, and 654 in the follow-up period. During the baseline period, adjusted analyses revealed statistically significant differences in all process-of-care parameters except the coverage of atypical pathogens. With regard to clinical outcomes, however, only the 30-day readmission rate was significantly different ( $P = 0.03$ ). Adjusted mean length of stay ranged from 6.3 to 9.2 days ( $P < 0.0001$ ). In adjusted analyses of temporal changes within hospitals for process-of-care and outcome performance, revealed few statistically significant differences.
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Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure
2004, American Journal of Medicine
Citation Excerpt :
For patients with myocardial infarction, this was one of the few intervention studies that addressed improving the quality of outpatient care. Past studies have generally involved hospital-based interventions that have yielded mixed results (11-17). Interventions to improve the care of patients with heart failure have focused on outpatient care but have generally been resource intensive (e.g., implementing a case management program) (18-23).
To assess the effects of an intervention involving dissemination of treatment recommendations to primary care physicians treating outpatients with acute myocardial infarction or heart failure.
The study comprised 509 patients with myocardial infarction and 323 patients with heart failure who were discharged from hospital. The primary care physicians caring for these patients were assigned randomly to either the intervention or control group; the intervention group was mailed practice guidelines immediately after patient discharge, and patients were cited by name. During a 6-month assessment period, the records of primary care physicians (and cardiologists, if any) were reviewed to assess mean conformance with the guidelines, using seven measures of care for myocardial infarction and eight measures of care for heart failure.
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Mailing treatment recommendations did not improve the quality of care of recently discharged patients with myocardial infarction or heart failure. However, efforts to include cardiologists in the care of these patients might be worthwhile.
Antithrombotic and thrombolytic therapy: From evidence to application: The seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
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If the reference included one of the strategies or the title did not mention the specific strategy, we reviewed the abstract of the study. We identified 23 relevant studies.1718192021222324252627282930313233343536373839 The studies varied widely in methodology and clinical problems.
This chapter about implementation strategies for practice guidelines is part of the 7th ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that feasibility, acceptability and cost related to implementation strategies may lead to different choices depending on the practice setting (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S). To encourage uptake of guidelines to reduce thrombosis, we recommend that appreciable resources be devoted to distribution of educational material (Grade 2B). We suggest that few resources be devoted to educational meetings (Grade 2B), to audit and feedback (Grade 2B), or to educational outreach visits (Grade 2B) to encourage uptake of the guidelines. We suggest that appreciable resources be devoted to computer reminders (Grade 2A) and to patient-mediated interventions (Grade 2B) to encourage uptake of the guidelines. This review suggests that there are few implementation strategies that are of unequivocal, consistent benefit, and that are clearly and consistently worth resource investment. Fully informed decisions will require additional research to identify effective guideline implementation strategies to optimize antithrombotic and thrombolytic therapy.
Comparison of presenting features, diagnostic tools, hospital outcomes, and quality of care indicators in older (>65 years) to younger, men to women, and diabetics to nondiabetics with acute chest pain triaged in the emergency department
2004, American Journal of Cardiology
In a total of 4,843 consecutive patients admitted to an emergency department (ED) with acute chest pain over a 1-year period, presenting features, diagnostic tools, hospital outcomes, and quality-of-care indicators were compared between older (n = 1,781) and younger (n = 3,062) patients, men (n = 3,095) and women (n = 1,748), and diabetics (n = 856) and nondiabetics (n = 3,987). The results showed that after critical pathway implementation, there was an increase in the use of evidence-based treatment strategies in the ED and improved outcomes in older patients, women, and diabetics, with no more differences in the length of ED stay, diagnostic accuracy for myocardial infarction in the ED, door-to-thrombolysis time, and door-to-balloon time compared with younger patients, men, and nondiabetics.

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^☆: Supported in part by Contract Number 500–96-P549, entitled “Utilization and Quality Control Peer Review Organization for the State of Connecticut,” sponsored by the Health Care Financing Administration, Department of Health and Human Services.

¹: Dr. Krumholz is a Paul Beeson Faculty Scholar. This article was written by CDR Eric S. Holmboe while a fellow in the Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.

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Clinical StudiesUse of critical pathways to improve the care of patients with acute myocardial infarction1☆,

Abstract

Section snippets

Methods

Results

Discussion

J Vasc Surg

J Vasc Surg

Am J Card

Lancet

Jt Comm J Qual Improv

Critical pathways as a strategy for improving careproblems and potential

Ann Intern Med

A model for management of patients with stroke during the acute phase:outcome and economic implications

Stroke

Clinical Studies
Use of critical pathways to improve the care of patients with acute myocardial infarction1☆,