Guidelines Applied in Practice in Medicare Patients With Acute Myocardial Infarction - GAP: Medicare Patients With Acute MI


The goal of the study was to evaluate the effect on mortality in Medicare patients of implementation of the American College of Cardiology (ACC) Guidelines Applied in Practice (GAP) program, which is designed to improve adherence to key evidence-based therapies in acute myocardial infarction (AMI).


Mortality at one year will be lower in Medicare patients with AMI treated after GAP implementation compared with mortality in patients treated prior to GAP implementation.

Study Design

Patients Enrolled: 2,857
Mean Follow Up: One year
Mean Patient Age: Mean age 76 years
Female: 48

Primary Endpoints:

Mortality at 30 days and one year

Drug/Procedures Used:

In-hospital treatment and outcomes were assessed in Medicare patients with AMI cared for at 33 Michigan hospitals prior to GAP implementation (n=1,368) and post-GAP implementation (n=1,489). The GAP program tools included standing orders, pocket guidelines, discharge contracts, patient information forms, and critical pathways to facilitate adherence to quality indicators.

Principal Findings:

Use of in-hospital catheterization trended higher post-GAP compared with pre-GAP (45.2% vs. 47.9%, p=0.15). Coronary revascularization was used more frequently post-GAP, including both percutaneous coronary intervention (19.1% vs. 23.1%, p=0.008) and coronary artery bypass grafting (8.0% vs. 9.3%).

In-hospital aspirin use was higher post-GAP (84.8% vs. 87.3%, p=0.05), as were discharge medications, including beta-blockers (84.2% vs. 91.6%, p<0.001), aspirin (81.6% vs. 90.0%, p=0.001), and lipid-lowering medication (73.1% vs. 78.2%, p=0.001). Standard orders were used more often post-GAP (19.8% vs. 45.5%, p<0.001). Discharge tools were also used more frequently after GAP implementation (1.8% vs. 30.8%, p<0.001).

Development of in-hospital heart failure trended lower post-GAP (47.4% vs. 44.3%, p=0.07). In-hospital mortality occurred in 13.6% of patients pre-GAP and 10.7% of patients post-GAP (p=0.017). The lower mortality post-GAP was maintained at 30 days (21.6% vs. 16.7%, p=0.001) and one year (38.3% vs. 33.2%, p=0.004).

In a multivariate model adjusting for correlates of mortality, use of GAP was associated with a lower odds ratio (OR) for in-hospital death (OR 0.79, p=0.09), 30-day death (OR 0.74, p=0.012), and one-year death (OR 0.78, p=0.013). When use of discharge tools was added to the one-year multivariate model, GAP was no longer significant (OR 0.95, p=NS), but use of the discharge tools was associated with lower mortality (OR 0.53, p=0.0006).


Implementation of the ACC AMI GAP was associated with lower mortality at one year among Medicare patients with AMI compared with mortality in Medicare patients with AMI prior to GAP implementation. Use of the GAP tools remained a correlate of mortality after adjustment in a multivariate model.

Guideline adherence is varied, with disparities between what the guidelines recommend and actual practice patterns. Use of monitoring and guideline tools is important for improving both quality of care and, as the present study demonstrates, clinical outcomes.


Presented by Dr. Kim Eagle at the American College of Cardiology Annual Scientific Session, March 2004.

Eagle KA, Montoye CK, Riba AL, et al. Guideline-based standardized care is associated with substantially lower mortality in medicare patients with acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan. J Am Coll Cardiol. 2005 Oct 4;46(7):1242-8.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Myocardial Infarction, Michigan, Hospital Mortality, Quality Indicators, Health Care, Catheterization, Heart Failure, Guideline Adherence, Medicare, Coronary Artery Bypass, Percutaneous Coronary Intervention

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