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Despite
the proliferation of clinical practice guidelines
in recent years, there's plenty of evidence that
there's still a big gap between what guidelines
recommend and what health care providers actually
do. Last year, the American College of Cardiology
(ACC) developed a plan for improving adherence
to guidelines. This year, the College can demonstrate
the effectiveness of that plan.
"We've
shown that we can make guidelines come alive in
practice," said Kim Eagle, MD, of the University
of Michigan, and principal investigator of the
Guidelines Applied in Practice (GAP) Project.
Dr. Eagle also chairs the ACC/American Heart Association
(AHA) Task Force on Performance Measures. Yesterday,
at a special presentation here in Orlando, Dr.
Eagle announced the initial results of the first
GAP Project.
With
the ACC/AHA
guideline on acute myocardial infarction as
its first target, the College came together in
a unique collaboration with the Southeast Michigan
Quality Forum Cardiovascular Subgroup of the Greater
Detroit Area Health Council and the Michigan
Peer Review Organization. Together they developed
materials designed to make it easier for hospitals
to put the guideline's recommendations into practice.
Dr. Eagle then assessed the materials' impact
on the care received by more than 800 acute myocardial
infarction patients in 10 hospitals in the Detroit
area.
The
results were striking, Dr. Eagle told the audience.
“For virtually all of the key quality indicators
we were interested in, we saw either a positive
trend or a significant improvement in adherence,”
he said. Take smoking-cessation counseling, for
example. Before the GAP initiative, only 42 percent
of patients’ charts revealed evidence that smokers
had been advised to stop smoking. After the project,
that figure jumped to 65 percent.
The
results were especially impressive for Medicare
patients, Dr. Eagle noted. Before GAP, for instance,
only 63 percent of Medicare patients received
beta blockers within 24 hours of arriving at the
hospital; afterward, that figure rose to 73 percent.
Similarly, the percentage of patients receiving
aspirin within 24 hours rose from 76 percent to
87 percent. The percent of patients who were prescribed
aspirin on discharge from the hospital rose from
82 percent to 92 percent.
The
key to all of these improvements, explained Dr.
Eagle, lies in the “toolkit” developed by the
GAP collaborators. The materials included a pocket
guideline for physicians, a clinical pathway for
nurses, standard orders, chart stickers, and hospital-specific
performance charts. Patients received educational
materials and signed customized discharge “contracts”
outlining their plans for medication use, dietary
and lifestyle changes, and medical follow up.
“This
may be one of the first quality-improvement initiatives
where patients played a big role,” said Dr. Eagle.
“The doctor, nurse, and patient are the triangle
of care.”
Now
the ACC’s GAP Steering Committee hopes to expand
the project, Dr. Eagle reported. Possibilities
include taking the acute myocardial infarction
project statewide in Michigan and developing new
projects based on other guidelines. The College
also hopes to put the “toolkit” on its Web site
for use in other hospitals. “The whole idea is
to share as much as we can so that others can
take advantage of part or all of this program
in their own hospitals,” said Dr. Eagle.
GAP
Program 
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