Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) initiative. (Original Contribution)

Hospitals can create educational materials to help doctors comply with practice guidelines for the treatment of heart attack. Practice guidelines are documents that recommend the best treatments for specific conditions based on scientific evidence.
Context: Quality of care of patients with acute myocardial infarction (AMI) has received intense attention. However, it is unknown if a structured initiative for improving care of patients with AMI can be effectively implemented at a wide variety of hospitals. Objective: To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI. Design and Setting: The Guidelines Applied in Practice (GAP) quality improvement project, which consisted of baseline measurement, implementation of improvement strategies, and re-measurement, in 10 acute-care hospitals in southeast Michigan. Patients: A random sample of Medicare and non-Medicare patients at baseline (July 1998-June 1999; n = 735) and following intervention (September 1-December 15,2000; n=914) admitted at the 10 study centers for treatment of confirmed AMI. A random sample of Medicare patients at baseline (January-December 1998; n=513) and at re-measurement (March-August 2001; n=388) admitted to 11 hospitals that volunteered, but were not selected, served as a control group. Intervention: The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators; identification and assignment of local physician and nurse opinion leaders; grand rounds site visits; and premeasurement and postmeasurement of quality indicators. Main Outcome Measures: Differences in adherence to quality indicators (use of aspirin, [beta]-blockers, and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion; smoking cessation and diet counseling; and cholesterol assessment and treatment in ideal patients, compared between baseline and postintervention samples and among Medicare patients in GAP hospitals and the control group. Results: Increases in adherence to key treatments were seen in the administration of aspirin (81% vs 87%; p=.02) and [beta]-blockers (65% vs 74%; p=.04) on admission and use of aspirin (84% vs 92%; P=.002) and smoking cessation counseling (53% vs 65%; P = .02) at discharge. For most of the other indicators, nonsignificant but favorable trends toward improvement in adherence to treatment goals were observed. Compared with the control group, Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge (5% vs 10%; P Conclusions: Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers. This initial project provides a foundation for future initiatives aimed at quality improvement.