Quality: Hospital Guideline Adherence and Dosing Safety Among ACS Patients | Journal Scan

Study Questions:

Are quality and safety performance metrics (as assessed by the appropriate dosing of intravenous heparin or low molecular weight heparin or glycoprotein IIb/IIIa inhibitors), individually and in combination, associated with in-hospital patient outcomes among non–ST-elevation acute coronary (NSTE-ACS) patients?


This was an analysis of data from the large national quality improvement initiative, CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association [ACC/AHA] Guidelines). Patients included in CRUSADE had ischemic symptoms at rest within 24 hours prior to presentation and high-risk features that included ST-segment depression, transient ST-segment elevation, and/or positive cardiac biomarkers. The authors evaluated the use of ACC/AHA 2002 Class I guideline-recommended therapies. Hospital safety performance was assessed with appropriate dosing of intravenous heparin or low molecular weight heparin or glycoprotein IIb/IIIa inhibitors. Hospitals were grouped into four performance quadrants based on guideline adherence rates and antithrombotic dosing safety profile.


Among participating patients, the overall composite median adherence rate for recommended therapies was 85%; the median hospital safe drug-dosing rate was 53%. Correlation between hospital composite adherence and safety metrics was low (r = 0.16, p = 0.008). For every 10% increase in appropriate dosing at a given center, in-hospital mortality odds ratio fell by a corresponding 18% (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.73-0.93). In adjusted analyses, this relationship was attenuated, but persisted. The lowest unadjusted in-hospital mortality was observed in the high adherence and high safety group.


The authors concluded that antithrombotic dosing safety provided information on mortality that was complementary to that provided by guideline adherence.


This is an interesting study that draws attention to the need to focus on guideline adherence and dosing safety when considering performance and quality improvement initiatives. The best outcomes were seen in hospitals that excelled at both safety and guideline adherence. While limited by a less than contemporary analysis, the authors provided a case for broader metrics of quality that include both compliance with guideline-based care and hospital safety.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Anticoagulation Management and ACS

Keywords: Acute Coronary Syndrome, Angina, Unstable, Guideline Adherence, Heparin, Heparin, Low-Molecular-Weight, Platelet Glycoprotein GPIIb-IIIa Complex, Quality Improvement, Risk, Hospital Mortality, Safety, Outcome Assessment (Health Care)

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