Administrative Memos

199919

FROM: Theodore O. Will, Chief Executive Officer
DATE: Dec 30, 1999
SUBJECT: Evaluation and Control of Lipids in Medicare Patients Hospitalized for 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., Upstate Director, Improvement Strategies/QI (1-800-233-0360)

Enclosed please find the final report on IPRO's Lipid Control in Acute Myocardial Infarction Project. This quality improvement project was undertaken in collaboration with twenty hospitals in New York State in 1998-99. Its objective was to improve the rate at which LDL cholesterol is measured in Medicare patients admitted with acute myocardial infarction and the rate at which appropriate therapy is initiated for elevated cholesterol.

This final impact report documents a substantial and statistically significant improvement in the routine measurement of LDL cholesterol from 14% of patients discharged in 1996 to 48% in early 1999. It is notable that routine LDL cholesterol measurement rates varied widely between collaborating hospitals and directly correlated with the degree to which active education, policies and care processes (e.g. pre-printed orders) were implemented.

The project also observed that nearly half of patients identified with an LDL cholesterol of over 130 mg/dl and who were not on medical therapy on admission were started on cholesterol lowering medication by the time of discharge. This compares to fewer such patients found and none treated at the time of baseline. We conclude that routine measurement of LDL cholesterol leads to identification of the highest risk patients and prompt initiation of therapy.

Please see the full report for details of methods and results. Collaborating hospitals will be provided under separate cover a separate report on their baseline and impact performance. As part of the National Acute Myocardial Infarction Project baseline report, to be distributed in early 2000, rates of LDL cholesterol measurement and therapy from 1998 will be calculated for all New York acute care hospitals with AMI discharges in the data set. IPRO encourages all hospitals that have not yet done so to adopt policies ensuring the routine measurement of LDL cholesterol for all admitted coronary heart disease patients.

Should you have any questions about IPRO's Lipid Control in Acute Myocardial Infarction Project, please feel free to call one of the above listed contacts.

EXECUTIVE SUMMARY

Control of serum lipids has been increasingly identified as a major contributor to reducing the rate of disease progression, recurrent events, and mortality among patients with documented coronary artery disease. Screening and intervention for the purpose of secondary prevention of recurrent coronary events, including dietary education and therapy for hyperlipidemia can significantly improve long-term prognosis, and can be carried out during hospitalization.

IPRO worked with twenty collaborating hospitals in New York to improve the in-hospital evaluation and management of serum lipids among patients discharged for acute myocardial infarction (AMI). Baseline data were obtained from Medicare AMI patients discharged in the second half of 1996 and were disseminated to collaborators who implemented hospital specific plans to improve performance. Impact data were gathered from patients discharged in the first quarter of 1999.

Significant improvements were found in three major project indicators.

-Orders for LDL cholesterol during hospitalization increased from 14% to 48% (with orders at time of admission increasing from 10% to 32%). Four hospitals were able to achieve LDL cholesterol measurement rates of over 70%. Best practices identified by collaborators and IPRO include:
-Inclusion of lipid panels on routine CCU admitting orders.
• Inclusion of lipid panels on chest pain/AMI care maps.
• A system of "patient pledges" with current and target cholesterol levels for all cardiac patients (which also drives collection of LDL cholesterol information).
• Among 48 patients with an LDL of 130 mg/dl or higher who were not admitted on lipid lowering agents, 46% were started on these drugs by time of discharge. At baseline fewer patients had LDL measured and none with high levels were started on medical therapy.
• The proportion of patients discharged on lipid lowering agents increased from 11% to 25%, reflecting both a higher rate of use of these medications prior to hospitalization, and a higher rate of starting medication in the hospital. Medications were started in the hospital almost exclusively among those with an elevated LDL cholesterol.