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BMJ. Mar 20, 2004; 328(7441): 664.
PMCID: PMC381257

Hospitals that follow heart attack guidelines save lives

More patients who have had a heart attack walk out the door alive when hospitals stick to guidelines of the American Heart Association and the American College of Cardiology, says a study from Duke University presented at the college's meeting in New Orleans, Louisiana.

It is one of the first studies to show the effect of guidelines on inhospital mortality in "real world patients," said Dr Eric Peterson, a cardiologist at Duke Clinical Research Institute in Durham, North Carolina. "Typically, patients in randomised controlled trials are healthier and younger, good for testing efficacy of a drug. This population was older, sicker, at higher risk. They had two to three times the mortality of patients in clinical trials," he told the BMJ .

Dr Peterson and his colleagues recruited 400 hospitals across the United States to participate in the CRUSADE study ("Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC and AHA guidelines" study). It is a national quality improvement initiative funded by Millennium Pharmaceuticals, Schering Corporation, and Bristol-Meyers Squibb/Sanofi Pharmaceuticals Partnership. At the meeting he reported outcomes on 64 775 patients; the study now includes 89 000 patients.

The guidelines say that in the first 24 hours patients with a suspected myocardial infarction should receive aspirin, antiplatelet medications, heparin, glycoprotein IIb/IIIa inhibitors (clot inhibitors), and Β blockers. At discharge, they should be prescribed drugs such as aspirin, Β blockers, angiotensin converting enzyme inhibitors, statins, and clopidogrel and be taught lifestyle modifications.

Hospitals systematically monitor information on their patients. Duke University coordinates the data and reports back to the hospitals every three months.

The analysis describes the best practices and tells each hospital how its care compares with others in the study. "There's a gulf between what ought to be done and what is done. The first step is knowing you have a problem," Dr Peterson told the BMJ , adding: "Next is getting the tools to do better. For every 10% increase in adherence, mortality fell by 11%."

An unusual feature of the CRUSADE study is what Dr Peterson calls "academic detailing," borrowed from the pharmaceutical industry. Experts travel to talk to doctors at institutions to alert them to best practices. The Duke centre also provides order forms, a discharge checklist, and educational materials.

Hospitals were divided into four groups based on their adherence to the guidelines. Those in the top quarter had a mortality of 4.17% compared with 6.33% in those in the bottom quarter.

Compared with the bottom quarter, leading hospitals tended to be larger (a mean of 388 beds compared with 321), to be an academic centre (34% v 21%), and to have the ability to perform cardiac catheterisation and coronary artery bypass surgery (81% v 59%) (all P<0.001).

A similar study, called GAP (Guidelines applied in practice), from the University of Michigan Cardiovascular Center followed 2800 Medicare patients at 33 Michigan hospitals and found they had a 25% lower risk of dying within a year after discharge if hospitals followed national guidelines and taught their patients how to follow those standards at home.

The guidelines are available at www.acc.org/clinical/guidelines/nov96/1999


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