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Hospitals That Don't Follow Heart Attack Care Guidelines Have Significantly Higher Death Rates

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Duke Health News 919-660-1306

CHICAGO, IL -- Heart attack patients treated at hospitals
that are less likely to follow established treatment guidelines
have almost twice the mortality rate as those treated at
hospitals whose practices have been proven effective by
clinical trials, Duke Medical Center cardiologists have
found.

"The study underscores the importance of following clinical
practice guidelines to improve patient outcomes," said Eric
Peterson, M.D., who with his colleagues conducted the study.
"Some physicians may balk at being held accountable to
guidelines-based medicine, but this study demonstrates that
adhering to guidelines saves lives."

In their review of more than 250,000 patients who suffered a
heart attack in the U.S. in the past two years, Peterson and
his colleagues found that the death rate at hospitals that
adhere the most to established guidelines have mortality rates
of 8.3 percent, compared to 15.3 percent for those hospitals
least likely to adhere to the guidelines. The researchers
measured how many of the patients died while in the
hospital.

Peterson, who presented the results of the analysis today
(Nov. 17, 2002) at the 75th annual scientific session of the
American Heart Association (AHA), said that theirs is one of
the first studies actually demonstrating that following
guidelines established by such organizations as the AHA and
American College of Cardiology can improve the outcomes for
heart attack patients.

For his analysis, Peterson and his colleagues sought to
determine how often hospitals followed 15 different guidelines
for the immediate and discharge care of heart attack patients.
The immediate care guidelines included the use of specific
drugs and procedures within the first 24 hours of a heart
attack, while the discharge guidelines covered use of
medications, smoking cessation and rehabilitation.

In order to determine what effects these actions had on
actual patient outcomes, the researchers consulted the National
Registry of Myocardial Infarction 4 (NRMI-4), which has
collected data on 257,482 heart attack patients seen at 1,247
U.S. hospitals between June 2000 and June 2002. They
specifically examined how often each hospital followed each of
the 13 guidelines and the effect those actions had on
outcomes.

To compare how the best, or "leading" hospitals, compared to
the worst, or "lagging" hospitals, the researchers ranked the
1,247 hospitals based on their adherence to the guidelines.
They then divided this ranking into the 312 hospitals at the
top of the list, and compared them to the 312 hospitals at the
bottom of the ranking, and found that as a group, the leading
hospitals reported significantly better mortality rates.

The researchers also found marked variation nationally in
the treatments given to patients with heart attack. As one
would expect, the larger hospitals and academic medical centers
tended to more consistently follow the guidelines, Peterson
said, adding however, that the results of the analysis still
show room for improvement at even the top hospitals.

"Even for well-accepted treatments, such as giving
beta-blockers within the first 24 hours of a heart attack,
patients treated at lagging hospitals have only a 50-50 chance
of getting the drugs," Peterson said. "In contrast, at leading
US centers, nearly 82 percent of patients were given beta
blockers. This degree of variation in care seems
unacceptable."

In addition to giving acute heart attack patients
beta-blockers within the first 24 hours, other immediate
quality measures included:

* clot-busting treatment within 30 minutes of arrival at the
hospital and angioplasty within 90 minutes

* aspirin within 24 hours

* heparin within 24 hours

* ACE inhibitors within 24 hours

* echocardiogram (ECG) within 10 minutes., and

* glycoprotein IIbIIIa inhibitors within 24 hours of
admission.

The discharge quality measures used were the continued use
of aspirin, beta-blockers, ACE inhibitors and
cholesterol-lowering therapy; smoking cessation counseling; and
physical activity, such as cardiac rehabilitation.

As another example of the disparity in care, the use of
aspirin within 24 hours is commonly accepted standard of care,
yet only 72 percent of patients at lagging hospitals, compared
to 91 percent at leading hospitals, received aspirin.

Variation among hospitals in giving smoking cessation advice
was especially discouraging, said Peterson. In the hospitals
that lagged behind, only 24 percent of patients were given this
advice, while 68 percent of patients in leading hospitals were
advised to stop smoking.

The researchers also found variation in the numbers of
patients prescribed lipid-lowering drugs, such as statins. At
lagging hospitals, 58 percent of patients were discharged with
these prescriptions, compared to 78 percent at the leading
hospitals.

For Peterson, this analysis provides one of the clearest
snapshots at the state of acute heart attack care in the
U.S.

"This registry includes all patients with heart attack,
unlike most clinical trials that only enroll specific types of
heart attack patients," Peterson said. "This represents what is
seen in the real world every day."

Additionally, Peterson said this study demonstrates the
importance of programs such as the NRMI-4, which routinely
feeds care practice information back to health care providers.
The gap between guidelines recommendations and actual care is
also a strong argument for programs such as the American Heart
Association's "Get With The GuidelinesTM program" and the
CRUSADE National Quality Improvement Program, whose aims are to
disseminate clinical practice guidelines and encourage
adherence to them.

The NRMI-4 databank is supported by grants from Genentech,
South San Francisco, Calif.

Other members of the team included Lori Parsons, Ovation
Research Group; Charles Pollack, M.D., University of
Pennsylvania Hospital; Kristin Newby, M.D., Duke; and Katherine
Littrell, Ph.D., Genentech.

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