An Electronic Order Set for Acute Myocardial Infarction Is Associated With Improved Patient Outcomes Through Better Adherence to Clinical Practice Guidelines

Study Questions:

What is the impact of an evidence-based, electronic order set (OS) for acute myocardial infarction (AMI-OS) and AMI processes and patient outcomes?

Methods:

This was a retrospective cohort study of 5,879 AMI patients hospitalized between 2008 and 2010, at 21 community hospitals associated with the large integrated health care delivery system, Kaiser Permanente Northern California. The authors ascertained whether patients were treated using the AMI-OS or individual orders (a la carte). Dependent process variables of interest were use of aspirin within 24 hours of admission, beta-blockers, anticoagulation, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and statins. In-hospital mortality, 30-day mortality, and readmission were key outcome variables.

Results:

The 3,531 patients treated using the AMI-OS were more likely to receive evidence-based therapies (50% received five different therapies vs. 36% of patients who received a la carte orders, p < 0.0001) and had lower 30-day mortality rates (5.7% vs. 8.5%). The benefit of the AMI-OS was eliminated in analyses adjusted for recommended therapies. The impact of incrementally more evidence-based therapies was not associated with length of stay or readmission. In a chart audit of 105 randomly selected records, the following were reasons for not using an AMI-OS: emergent catheterization or transfer to a facility with percutaneous coronary intervention capability occurred (36%), presence of other significant medical conditions, patient or family refusal of treatments, issues around end-of-life care, and specific contraindications (1%).

Conclusions:

Use of an electronic OS in AMI patients is associated with increased adherence to evidence-based therapies, and such adherence is adjusted with lower mortality rates.

Perspective:

The limitations of this retrospective analysis aside, the authors provide evidence for the benefits of an evidence-based electronic AMI-OS integrated into a comprehensive electronic medical record. It is not surprising that such an order entry system would have improved adherence to provision of evidence-based therapies. Future studies should identify barriers to more widespread use of electronic evidence-based OS in the inpatient medical setting and how to overcome such obstacles.

Clinical Topics: Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Nonstatins, Novel Agents, Statins

Keywords: Electronic Health Records, Angiotensin Receptor Antagonists, Myocardial Infarction, Hospital Mortality, California, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hospitals, Community, Percutaneous Coronary Intervention


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