The University Record, March 19, 2001

‘Tool kit’ closes gap between cardiac care standards, practice

By Kara Gavin
Health System Public Relations

Ten Detroit-area hospitals are taking better care than ever of their heart attack patients, a new study finds, thanks to a simple tool kit that helps physicians, nurses and patients remember to take advantage of all the proven therapies that national guidelines recommend.

Now, a higher percentage of the hospitals’ patients receive certain key treatments in the hours, days and months after their heart attack. In some cases, the rate has topped 90 percent.

Those findings were presented at the annual Scientific Session of the American College of Cardiology by Kim Eagle, chief of cardiology and co-director of the Cardiovascular Center at the University of Michigan Health System. The Health System made similar gains in an earlier study, using a related strategy. The new 10-hospital study, coordinated by the Health System for the American College, is the first to test a way of meeting its guidelines and those of the American Heart Association.

Eagle and his colleagues hope the results will lead hospitals around the country to adopt the approach, which combines reminders, standards and education to help close the disturbing gap between what medical experts say is best and what heart patients actually get.

“Physicians, nurses and patients are not all-knowing,” says Eagle. “We have a lot of information that’s always changing, we’re often in a rush, and it’s very easy to forget simple things in the heat of the moment. As a result, many patients don’t get all the guideline-recommended treatments, even for something as common as heart attack. This program provides tools that can be used by all of us, and we’ve seen amazing improvements in the quality of care.”

The study was called the Guidelines Applied in Practice (GAP) Initiative in Michigan. It was coordinated by the Health System with help from the Southeast Michigan Health Care Quality Forum of the Greater Detroit Area Health Council and the Michigan Peer Review Organization.

The study tracked how many patients at each hospital received guideline-recommended drugs and treatments, from the emergency room through follow-up. Among the items on the checklist are aspirin and clot busters soon after the heart attack, drugs such as ACE inhibitors and beta blockers, procedures such as angiography and blood cholesterol tests, and advice on diet and smoking. The tool kit includes training for medical staff, clinical pathways for nurses, care standards, patient education materials, pocket cards, discharge checklists and counseling for patients, and more.

The project began in the mid-1990s after a national survey found that heart attack patients across the country weren’t getting all the care that guidelines—based on studies involving thousands of patients—said they should. Eagle and colleagues decided to evaluate heart attack care at the Health System, with a surprising result: Despite being a major academic medical center, the Health System didn’t provide certain therapies to as many as half of its heart attack patients.

“There were gaps in the care, situations where we thought that we were doing certain things in a routine way, but we weren’t,” says Eagle. The situation was the same around the country. “Based upon that reflection in the mirror, we decided to create a program to try to improve.”

That program, designed cooperatively by doctors, nurses and other staff, went into use at the Health System in 1997. Last fall, Eagle and his colleagues published the first results from that initial test in the Archives of Internal Medicine. Use of beta blockers went from 65 percent to more than 94 percent. Smoking advice reached 94 percent, and use of clot busters in the emergency room neared 98 percent.

The gains made at the Health System caught the attention of guideline-setting officials at the American College, who selected southeast Michigan to be the pilot site for what eventually will be a national test of measures to improve guideline adherence. Eagle was selected to lead the oversight of the effort, which focuses not only on heart attack, but on other common cardiovascular conditions too.

The American College of Cardiology needed to find out whether the program could work at different kinds of hospitals, including academic medical centers, community teaching hospitals and non-teaching hospitals. It also wanted to test use in hospitals with diverse patient populations and heart attack volumes.

So, the College, Peer Review Organization and Detroit Health Council approached hospitals in greater Detroit and selected 10 that agreed to implement the tool kit on a pilot basis in 2000: Bi-County, Harper, Henry Ford Wyandotte, Mount Clemens General, Oakwood Dearborn, Oakwood Heritage, Providence, Sinai-Grace, St. Joseph Mercy and St. John.

The Health Council and the Review Organization provided key support and guidance. To fund the initiative, grants were provided by the College, Peer Review Organization and Pfizer Inc.