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Updated 10:00 AM February 20, 2006




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Room for improvement in angioplasty, ways to cut risks

Each year, more than 600,000 Americans have angioplasty procedures to open clogged arteries near their hearts and treat or prevent a heart attack. New research shows that the quality of and risks from treatment can vary widely depending on where patients go for the procedure. The study also demonstrates how outcomes could be improved.

In a paper published in the journal Circulation, U-M researchers report data from a multi-hospital project that studied angioplasty care and outcomes at five hospitals where doctors and nurses received guidance and data to help them improve care, and seven hospitals where they did not.

The results yielded a dramatic before-and-after contrast. Before the start of the project, the 3,731 patients treated at the five hospitals in one year received widely varying levels of care. Many never received drugs that could help prevent complications during or after their angioplasty, while others received far more than necessary of the blood-thinning drug heparin, or the dye that lets doctors see blockages while they perform the minimally invasive procedure.

There also was wide variation in how patients fared afterward, including their risk of kidney damage related to the dye, and their need for emergency heart surgery and blood transfusions.

Five years later, however, after the intensive quality-improvement project was under way, the 5,901 patients treated at the same five hospitals in one year received much better and more uniform care, including much higher rates of preventive medication use, less use of heparin, and more appropriate amounts of dye. They also did better overall, with lower rates of complications related to their hearts and kidneys.

At the seven comparison hospitals, researchers looked at data from 10,287 patients who had angioplasties during 2002, the same year as the "after" measurements at the five hospitals. They found wide variation in the use of preventive medications, heparin and dye, and higher rates of some complications than at the five other hospitals.

"The technology used in these procedures has reached such a point that patients' outcomes today depend more on practice variations than on limitations of technology," says Dr. Mauro Moscucci, the U-M cardiologist who leads the project with Blue Cross Blue Shield of Michigan researcher Dr. David Share. "It is crucial that we understand how individual physicians and hospitals vary and work to reduce that variation so that each patient's care is delivered in a way that reduces risks and complications, and gives patients the best chance at a good outcome."

The BCBSM Foundation initially funded the project, which is led by researchers from the Cardiovascular Center (CVC). Ongoing funding is from BCBSM and Blue Care Network for the project called the BCBSM Cardiovascular Consortium, or BMC2. All seven hospitals in the comparison group are part of the quality-improvement project.

Moscucci, who is director of interventional cardiology for the CVC and associate professor of cardiovascular medicine, notes that many factors are at the heart of the variation in angioplasty and other procedures known as percutaneous coronary interventions, and that it takes a focused effort to overcome them.

For example, a lack of time or up-to-the-minute knowledge on the part of an individual doctor may mean that he or she doesn't always make sure that patients scheduled for an angioplasty receive aspirin before their procedure, even though the medication has been shown to reduce complications during and after angioplasty. Individual doctors may not realize how much their care differs from their colleagues at the same hospital, much less another hospital.

Project participants developed quick-reference tools that could be used to calculate how much dye was appropriate for each patient, or what their risk of suffering complications might be, thereby allowing doctors and nurses to customize the treatment before, during and after that patient's angioplasty.

Each doctor and hospital in the study also received quarterly reports about how they measured up against others in the project. Regular meetings of participating clinicians, and visits by Moscucci and his team, helped all participants share results and plan new improvements.

While the data reported cannot show cause and effect because the hospitals were not randomized to the intervention or control groups, Moscucci and Share note that the association between the project and the improvement in patient outcomes is strong.

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