Achieving better in‐hospital and after‐hospital care of patients with acute cardiac disease

Abstract

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in‐hospital and after‐hospital care, patient self‐care, and hospital–community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6‐month baseline period and included: ➢clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); ➢educational interventions (seminars, academic detailing); ➢regular performance feedback; ➢patient self‐management strategies; and ➢hospital–community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before–after study design to assess program impact, significantly more program patients compared with historical controls received: ➢ACS: Angiotensin‐converting enzyme (ACE) inhibitors and lipid‐lowering agents at discharge, aspirin and β‐blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. ➢CHF: Assessment for reversible precipitants, use of prophylaxis for deep‐venous thrombosis, β‐blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk‐adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P = 0.06) and from 13.4% to 10.1% (P = 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P = 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

Evidence-based interventions in primary care following acute coronary syndrome in Australia and New Zealand: a systematic scoping review

“…Two interventional studies used medication prescription rates at GP follow-up as a clinical indicator to evaluate programs designed to improve post-ACS care [30, 31]. Hickey et al [30] examined a quality improvement initiative known as the Brisbane Cardiac Consortium (BCC).…”

“…Though the study showed significant improvements in some clinical indicators, it did not report a significant change in prescription rates of medications in primary care follow-up post-intervention ( n  = 89 and n  = 104 for 3- and 6- month follow-up, respectively). Scott et al [31] examined the efficacy of a multi-faceted intervention that included clinical decision support, educational interventions, regular performance feedback, patient self-management strategies, and hospital-community integration. The study found greater prescription rates of aspirin at 3 months post-discharge in intervention patients compared to patients that received usual care ( p  = 0.05), and high rates of aspirin ( p  = 0.03) and β-blocker ( p  = 0.05) continuation among those prescribed these medications at discharge ( n  = 344).…”

“…The study found greater prescription rates of aspirin at 3 months post-discharge in intervention patients compared to patients that received usual care ( p  = 0.05), and high rates of aspirin ( p  = 0.03) and β-blocker ( p  = 0.05) continuation among those prescribed these medications at discharge ( n  = 344). The intervention described in Scott et al [31] also received generally positive feedback from patients.…”

“…Studies of medication prescription rates post-ACS report mostly high rates of antiplatelet therapy prescription [20, 26, 27, 31], with one study reporting an encouraging positive trend in medication prescription over time [26]. However, the prescription rates of other evidence-based medications demonstrate room for improvement, especially angiotensin-converting enzyme inhibitor/angiotensin-II receptor blockers (ACEi/ARBs) and glycerol trinitrate (GTN) spray [27, 28].…”

Prompting Asthma Intervention in Rochester–Uniting Parents and Providers (PAIR-UP)

“…32,33 Similarly, performance feedback on specific practices has been extensively used in health maintenance organizations for quality improvement, 34–38 however, this is not standard practice in health care settings, and information rarely is relayed at the time of a patient visit. Multifaceted interventions, such as PAIR-UP, appear to yield the greatest success in improving asthma care.…”