Association between hospital process performance and outcomes among patients with acute coronary syndromes
Eric D Peterson1, Matthew T Roe, Jyotsna Mulgund
1Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA. peter016@mc.duke.edu
Insights
Higher adherence to American College of Cardiology/American Heart Association guidelines for acute coronary syndrome (ACS) care was linked to lower in-hospital mortality rates. This study supports using guideline adherence metrics to improve hospital quality.
Area of Science:
- Cardiology
- Healthcare Quality Improvement
- Clinical Practice Guidelines
Background:
- Hospital quality is increasingly measured by care processes, but evidence linking process performance to patient outcomes is scarce.
- Assessing adherence to clinical guidelines is crucial for evaluating and enhancing healthcare quality.
Purpose of the Study:
- Evaluate adherence to American College of Cardiology/American Heart Association (ACC/AHA) guidelines for acute coronary syndrome (ACS).
- Examine variations in hospital performance and identify predictors of guideline adherence.
- Determine the association between composite guideline adherence and in-hospital mortality rates.
Main Methods:
- Observational analysis of 64,775 patients with non-ST-segment elevation ACS across 350 US centers (CRUSADE initiative, 2001-2003).
- Assessed adherence to 9 ACC/AHA class I guideline-recommended treatments.
- Correlated hospital performance on individual processes and overall composite adherence.
Main Results:
- Overall adherence to guideline treatments was 74%, with significant variation in composite adherence across hospitals (median scores from 63% to 82%).
- Higher composite adherence was significantly associated with lower in-hospital mortality (observed rates decreased from 6.31% to 4.15%).
- A 10% increase in hospital composite adherence correlated with a 10% decrease in mortality risk (adjusted OR, 0.90; P<.001).
Conclusions:
- A strong association exists between adherence to ACS care processes and patient outcomes.
- Broad, guideline-based performance metrics are valuable tools for assessing and improving hospital quality.
- Implementing comprehensive guideline adherence can reduce in-hospital mortality for ACS patients.
Context:
Selected care processes are increasingly being used to measure hospital quality; however, data regarding the association between hospital process performance and outcomes are limited.
Objectives:
To evaluate contemporary care practices consistent with the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations, to examine how hospital performance varied among centers, to identify characteristics predictive of higher guideline adherence, and to assess whether hospitals' overall composite guideline adherence was associated with observed and risk-adjusted in-hospital mortality rates.
Design, Setting, And Participants:
An observational analysis of hospital care in 350 academic and nonacademic US centers of 64,775 patients enrolled in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) National Quality Improvement Initiative between January 1, 2001, and September 30, 2003, presenting with chest pain and positive electrocardiographic changes or cardiac biomarkers consistent with non-ST-segment elevation acute coronary syndrome (ACS).
Main Outcome Measures:
Use of 9 ACC/AHA class I guideline-recommended treatments and the correlation among hospitals' use of individual care processes as well as overall composite adherence rates.
Results:
Overall, the 9 ACC/AHA guideline-recommended treatments were adhered to in 74% of eligible instances. There was modest correlation in hospital performance among the individual ACS process metrics. However, composite adherence performance varied widely (median [interquartile range] composite adherence scores from lowest to highest hospital quartiles, 63% [59%-66%] vs 82% [80%-84%]). Composite guideline adherence rate was significantly associated with in-hospital mortality, with observed mortality rates decreasing from 6.31% for the lowest adherence quartile to 4.15% for the highest adherence quartile (P<.001). After risk adjustment, every 10% increase in composite adherence at a hospital was associated with an analogous 10% decrease in its patients' likelihood of in-hospital mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.84-0.97; P<.001).
Conclusion:
A significant association between care process and outcomes was found, supporting the use of broad, guideline-based performance metrics as a means of assessing and helping improve hospital quality.
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