Cardiology/original research
An Analysis of the Association of Society of Chest Pain Centers Accreditation to American College of Cardiology/American Heart Association Non–ST-Segment Elevation Myocardial Infarction Guideline Adherence

https://doi.org/10.1016/j.annemergmed.2009.01.025Get rights and content

Study objective

Since 2003, the Society of Chest Pain Centers (SCPC) has provided hospital accreditation for acute coronary syndrome care processes. Our objective is to evaluate the association between SCPC accreditation and adherence to the American College of Cardiology/American Heart Association (ACC/AHA) evidence-based guidelines for non–ST-segment elevation myocardial infarction (NSTEMI). The secondary objective is to describe the clinical outcomes and the association with accreditation.

Methods

We conducted a secondary analysis of data from patients with NSTEMI enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative in 2005. The analysis explored differences between SCPC-accredited and nonaccredited hospitals in evidence-based therapy given within the first 24 hours (including aspirin, β-blocker, glycoprotein IIb/IIIa inhibitors, heparin, and ECG within 10 minutes).

Results

Of 33,238 patients treated at 21 accredited hospitals and 323 nonaccredited hospitals, those at SCPC-accredited centers (n=3,059) were more likely to receive aspirin (98.1% versus 95.8%; odds ratio [OR] 1.73; 95% confidence interval [CI] 1.06 to 2.83) and β-blockers (93.4% versus 90.6%; OR 1.68; 95% CI 1.04 to 2.70) within 24 hours than patients at non-SCPC-accredited centers (n=30,179). No difference was observed in obtaining a timely ECG (40.4% versus 35.2%; OR 1.28; 95% CI 0.98 to 1.67), administering a glycoprotein IIb/IIIa inhibitor (OR 1.30; 95% CI 0.93 to 1.80), or administering heparin (OR 1.12; 95% CI 0.74 to 1.70). Also, there was no significant difference in risk-adjusted mortality for patients treated at SCPC hospitals versus nonaccredited hospitals (3.4% versus 3.5%; adjusted OR 1.17; 95% CI 0.88 to 1.55).

Conclusion

SCPC-accredited hospitals had higher NSTEMI ACC/AHA evidence-based guideline adherence in the first 24 hours of care on 2 of the 5 measures. No difference in outcomes was observed. Further studies are needed to better understand the association between SCPC accreditation and improved care for patients with acute coronary syndrome.

Introduction

Emergency departments (EDs) in the United States treated more than 115 million patients in 2005, including more than 5 million with undifferentiated acute chest pain.1 Emergency physicians are responsible for rapidly identifying and initiating evidence-based treatment in patients with acute coronary syndromes. The American College of Cardiology/American Heart Association (ACC/AHA) publishes evidence-based guidelines for the management of non–ST-segment elevation myocardial infarction (NSTEMI).2 The ACC/AHA guidelines recommend that patient risk stratification be performed by consideration of history, physical examination, and an ECG. If early diagnostics are inconclusive, serial ECGs and serial cardiac marker tests may be indicated. According to this information, patients are stratified into ST-segment elevation myocardial infarction (STEMI), NSTEMI, unstable angina, or noncardiac chest pain cohorts, and appropriate therapy is initiated.

Despite widespread dissemination of the ACC/AHA guidelines, adherence has been inconsistent.3, 4 The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative and the Society of Chest Pain Centers (SCPC) were formed to help in the care of this population and improve adherence. The CRUSADE initiative was established to improve adherence with ACC/AHA recommendations by providing feedback to each member site on adherence rates and comparison rates. The SCPC was formed in 1998 to educate physicians and assist hospitals in the development of protocolized, evidence-based risk stratification and treatment pathways and protocols for patients with suspected acute coronary syndrome. These pathways incorporate many of the ACC/AHA recommendations, thus helping with evidence-based care. In 2003, the SCPC initiated an accreditation process based on 8 key principles to evaluate the triage and diagnostic processes. To date, approximately 440 centers have been accredited or are in the process of being accredited by the SCPC.5 The association of accreditation with adherence to the ACC/AHA recommendations for patients with NSTEMI has not been evaluated.

Our primary objective was to evaluate the association between SCPC accreditation and adherence to the ACC/AHA evidence-based guidelines for NSTEMI. A secondary analysis was performed to describe the association between accreditation and patient outcomes.

Section snippets

Study Design

A secondary analysis of the CRUSADE initiative study design was performed to assess the association between SCPC accreditation and adherence to treatment guidelines and patient outcomes.

The CRUSADE initiative is a voluntary, observational, quality improvement initiative begun on January 1, 2001, that was designed to improve the quality of evidence-based care for patients with NSTEMI and acute coronary syndrome.6, 7 In confirmed NSTEMI patients, participating hospitals were asked to collect and

Results

The registry contained a total of 189,065 entries at analysis. The number was narrowed to 35,141 patients after limiting of the analysis to 2005. Patients were excluded from this analysis for several reasons. First, 1,646 were excluded because of negative cardiac biomarker results. An additional 174 were excluded because of death within 24 hours because the hospital did not have a full 24 hours to comply with the ACC/AHA guidelines, leaving 33,321 patients. Finally, 83 patients from hospitals

Limitations

There are several issues that should be considered in the interpretation of the results of this study. First, this study is a retrospective observational one and does not establish a causal relationship between SCPC accreditation and guideline adherence. Further studies are required, including prospective longitudinal assessments of care at these hospitals. Second, although the CRUSADE registry is among the largest acute coronary syndrome registries in the world, it enrolled only a subset of

Discussion

Accreditation by the SCPC is associated with improved ACC/AHA guideline adherence to aspirin and β-blocker administration and no difference in door-to-ECG times or heparin and glycoprotein IIb/IIIa administration, as evaluated by the CRUSADE registry of NSTEMI patients. Although our analysis did not demonstrate a difference in death, myocardial infarction, cardiogenic shock, postadmission infarction, congestive heart failure, or major bleeding, larger studies have demonstrated that better

References (16)

There are more references available in the full text version of this article.

Cited by (32)

  • Individual health and the visibility of village economic inequality: Longitudinal evidence from native Amazonians in Bolivia

    2016, Economics and Human Biology
    Citation Excerpt :

    From their answers he developed a cultural visibility index, which explained ∼30% of the variation in total household expenditures. Since then, studies in Germany, South Africa, Indonesia, and the USA have supported his findings (Chandra et al., 2009; Friehe and Mechtel, 2014; Kaus, 2013; Roth, 2015): people spend resources to acquire goods that others notice because getting noticed enhances social status. In industrial societies, status signaling through positional goods happens because anonymous strangers cannot verify one’s wealth unless one makes it noticeable (Bagwell and Bernheim, 1996; Glazer and Konrad, 1996).

  • Hospital disease-specific care certification programs and quality of care: A narrative review

    2016, Joint Commission Journal on Quality and Patient Safety
    Citation Excerpt :

    Results showed that the 3,059 patients treated at the accredited hospitals were more likely to receive aspirin (98.1% versus 95.8%; OR = 1.73; 95% CI, 1.06—2.83, p < 0.05) and beta-blockers (93.4% versus 90.6%; OR, 1.68; 95% CI, 1.04—2.70, p < 0.05) within 24 hours than the 30,179 patients at the nonaccredited hospitals). No difference was observed in obtaining a timely electrocardiogram (ECG) (40.4% versus 35.2%; OR = 1.28; 95% CI, 0.98—1.67), administering a glycoprotein IIb/IIIa inhibitor (OR = 1.30; 95% CI, 0.93—1.80), or administering heparin (OR = 1.12; 95% CI, 0.74—1.70).10 The study’s strengths were similar to those of Ross et al., but its retrospective cross-sectional design might have limited its ability to capture the effect of the certification program over time.

View all citing articles on Scopus

Provide feedback on this article at the journal's Web site, www.annemergmed.com.

Supervising editor: Keith A. Marill, MD

Author contributions: AC was responsible for study conception and design and drafting of the article. F-SO was responsible for analysis and interpretation of data. AC, SWG, F-SO, WFP, JKM, CBC, EDP, EMO, WBG, and MTR revised article critically for important intellectual content. AC, SWG, F-SO, WFP, JKM, CBC, EDP, EMO, WBG, and MTR were responsible for final approval of the submitted article. AC takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. CRUSADE is funded by the Schering-Plough Corporation. Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals Partnership provides additional funding support. Millennium Pharmaceuticals, Inc., also funded this work. WFP and JKM are directly involved with the Society of Chest Pain Centers. No other conflict of interest exists as related to the topic of this manuscript.

Publication date: Available online March 12, 2009.

Reprints not available from the authors.

View full text