Administrative Memos

199916

FROM: Theodore O. Will, Chief Executive Officer
DATE: Oct 17, 1999
SUBJECT: Improving the Emergency Treatment of Patients with Acute Myocardial Infarction
IPRO CONTACTS:

Marguerite Shaffer, R.N., Director Downstate, Improvement Strategies QI - Ext. 356 and Barbara Shields, R.N., C.P.H.Q., Director Upstate, Improvement Strategies, (1-800-233-0360)

Enclosed please find the final report on the "Aspirin, Beta Blockers and Clot Busters" (ABC) project and your hospital-specific data sheet. If your hospital had no patients for either baseline or impact indicators, no hospital-specific sheet is included. This quality improvement project focused on improving the emergency treatment of patients presenting with acute myocardial infarction (AMI). The project was based on the impact data from the Cooperative Cardiovascular Project (CCP), which showed that, although substantial improvements in AMI care had been achieved between 1994 and 1996, considerable room for improvement remained, especially in terms of initial therapy. As with the CCP project, the ABC project included all hospitals in New York State with Medicare AMI discharges. IPRO provided regional seminars, hospital-specific baseline data reports and individual follow-up of hospital quality improvement plans to support this project. A total of 171 hospitals implemented improvement plans.

This final impact report documents a substantial and statistically significant increase in all three project indicators between the 1996 baseline and the impact period in the second half of 1998. Provision of aspirin within 24 hours of admission increased from 83% to 88%, initial beta blocker therapy within 12 hours increased from 43% to 51%, and provision of timely reperfusion to ideal candidates for this therapy increased from 40% to 49%. Please see the full report for details of methods and results.

If applicable, the enclosed hospital-specific data sheet describes your hospital's patients at baseline and impact with comparisons to peer groups and the statewide averages. Smaller hospitals, with fewer AMI discharges, may have very few or no patients for some project indicators. It is not possible to determine individual performance from very small numbers of cases, so these need to be interpreted with caution.

While the success of the ABC project is encouraging, it is clear that, at least for some indicators, further improvement is needed. HCFA has identified Acute Myocardial Infarction as a national priority area for quality improvement for Medicare patients in the 1999-2002 period. The new national project will include both the indicators from the ABC project (with modifications) as well as other indicators regarding use of beta blockers, aspirin, ACE inhibitors and smoking counseling. Within the next two months IPRO will issue a baseline report on the national AMI project, including hospital-specific data.

Should you have any questions about IPRO's "Aspirin, Beta Blocker and Clot Busters" project or report, please feel free to call one of the above listed contacts.

EXECUTIVE SUMMARY

The goal of IPRO's "Aspirin, Beta Blockers and Clot Busters" (ABC) Project was to further improve treatment of Medicare patients hospitalized with acute myocardial infarction (AMI) by focusing on treatments received in hospital emergency departments that improve patient survival odds. Patients discharged in the second half of 1996 were compared to patients discharged in September and October of 1998, after hospitals had implemented specific strategies to improve emergency room care. One hundred seventy one hospitals statewide submitted quality improvement projects to IPRO for the ABC project. On remeasurement, all three project indicators showed significant improvements.

Project indicators were based on the updated 1996 clinical guidelines from the American College of Cardiology/American Heart Association (ACC/AHA). The ABC Project quality indicators and summary project results are:

Aspirin Within Twenty-Four (24) Hours: Statewide, this improved from 82.8% of ideal patients in 1996 to 88.1% in 1998. Results for the broader group of "eligible" patients also improved from 75.0% to 81.2%. Aspirin should be given as soon after onset as possible. Median time to first aspirin dose, among ideal patients who received aspirin within 24 hours, improved from 105 minutes at baseline to only 55 minutes on impact.
Beta Blockers Within Twelve (12) Hours. Patients with evolving acute MI should receive early intravenous b adrenergic blocker therapy. Because the time from onset of infarction cannot be reliably assessed for all patients, twelve hours from arrival at the Emergency Department was used. Statewide, only 39.2% of the eligible, and 43.2% of the ideal patients received beta blockers within 12 hours in 1996. By 1998 this had improved to 48.3% and 51.0% respectively. In addition, the median time to beta blockers among those receiving them within 12 hours decreased from 4.2 to 3.6 hours for ideal patients.
Timely Reperfusion. A powerful time dependent effect on mortality has been observed in the administration of thrombolytic agents. Percutaneous Transluminal Coronary Angiography (PTCA), where available, may be performed as an alternative provided it is timely and performed by skilled experienced personnel. Timely reperfusion was defined as both receiving reperfusion and having it "on time" (within sixty minutes of arrival for thrombolytics or within ninety (90) minutes "door to wire time" for PTCA) among all patients who had ideal indications for reperfusion. Statewide only 39.6% of patients met this indicator at baseline versus 48.9% at impact in 1998. This was due both to an improvement in the proportion of ideal patients who received any form of reperfusion (from 66.5% to 74.9%) and an improvement in timeliness among those reperfused (from 59.6% to 65.2%). Many hospitals have a target of thirty minutes to initial reperfusion.

A table of statewide results for all indicators is attached to this report. Although substantial improvements were made between 1996 and 1998, further improvement in AMI care can still be achieved. IPRO will continue to work with New York hospitals to optimize care as part of the National AMI project, which will run from 1999 through 2002.