The findings are the first to show that participating in a quality improvement program, such as Get With The Guidelines-CAD, can eliminate disparity gaps in quality cardiovascular care while increasing the overall use of evidence-based care for heart attack patients.
Researchers looked at records for 142,593 patients (121,528 Caucasian, 10,882 African American, 10,183 Hispanic) treated for heart attacks at 443 hospitals participating in Get With The Guidelines-CAD between January 2002-June 2007. They examined trends over time in hospitals' use of performance measures that evaluate treatments and interventions that improve patient outcomes.
Use of individual performance measures in the overall population was high and steadily improved for all three patient groups throughout the five years, said Mauricio G. Cohen, M.D., lead author of the study.
"These are considered the 'must-dos' and are supported by strong clinical trial data and ample consensus," said Cohen, associate professor of medicine in the cardiovascular division of the University of Miami Miller School of Medicine in Miami, Fla.
Performance measures for treating heart attack patients include interventions such as administrating aspirin, beta-blockers and other appropriate medications, starting cholesterol-lowering therapies and smoking cessation counseling.
The combination of these measures, known as defect-free care, is the proportion of patients receiving all the appropriate treatments for which they were eligible. A significant gap in defect-free care for African Americans observed in the first half of the study was gone by the end of the study, Cohen said.
- In 2002, 68 percent of Caucasian patients were receiving defect-free care, compared to 93 percent by 2007.
- In 2002, 58 percent of African-American patients were receiving defect-free care, compared to 93 percent by 2007.
- In 2002, 65 percent of Hispanic patients were receiving defect-free care, compared to 95 percent by 2007.
- Looking at the five years of the study all together, defect-free care overall was 81 percent for Caucasians, 79.5 percent for Hispanics and 77.7 percent for African Americans. Cohen said those differences were driven by the unequal care provided during the early years of the study.
"Our most notable finding was that the initial racial-ethnic differences in care slowly decreased as sites continued to participate in the Get With The Guidelines quality improvement initiative," Cohen said. "By the second half of the study (after the first quarter of 2004), the differences were no longer significant and by the end of the study the differences were completely eliminated.
"Additionally, care improved across all hospitals over the study period - even at those that disproportionately cared for African Americans and Hispanics. Prior research has suggested that one of the reasons for disparate care is that minority patients are more likely to be treated at hospitals that provide inferior care. But our findings demonstrated that this is not the case in hospitals participating in this quality improvement program."
Eliminating healthcare disparities is a top objective for the American Heart Association, said Clyde Yancy, M.D., president of the American Heart Association and medical director at the Baylor Heart and Vascular Institute in Dallas, Texas.
"We now demonstrate that a hospital-based performance improvement program that subscribes to a structured, quality focused initiative works to not only improve care but to also reduce and possibly even eliminate in-patient evidence of healthcare disparities," Yancy said. "This work highlights a strong solution that may initiate the kind of changes that will ultimately lead to less evidence of disparate care."
"Ideally, all patients would be receiving 100 percent defect-free care," Cohen said. "This study reinforces the importance of quality improvement initiatives and public reporting because it does make a difference in improving care. The next step is to make sure that patients continue to receive appropriate care and have access to preventive care after they leave the hospital. It's equally important that patients be compliant to the treatments initiated during their hospital stay and modify their lifestyle to become more physically active, maintain a healthy diet and avoid cigarette smoking."
In an accompanying editorial, Nakela L. Cook, M.D., M.P.H., of the National Heart, Lung, and Blood Institute, Bethesda, Md., said the study takes an important first step in the evaluation of particular strategies to eliminate healthcare disparities, but may raise more questions than answers. "Will achieving 100 percent defect-free care in all patients also eliminate disparities in clinical outcomes, or do we need specific initiatives targeted at contributors or sub-populations to move toward the true elimination of health disparities? The question will not be easy to answer and may require complementary contributions from both approaches," Cook wrote. "Perhaps we need future studies that employ rigorous designs, such as trials that compare compelling targeted (multi-level and multifactorial), generalized, or combined approaches."
Co-authors are Gregg C. Fonarow, M.D.; Eric D. Peterson, M.D., M.P.H.; Mauro Moscucci, M.D., M.B.A.; David Dai, M.H.S.; Adrian F. Hernandez, M.D., M.H.S.; Robert O. Bonow, M.D.; and Sidney C. Smith, Jr., M.D. Author disclosures are on the manuscript.
Get With The Guidelines-CAD is provided by the American Heart Association/American Stroke Association. The data analyzed in this manuscript were collected while the program was supported in part through an unrestricted educational grant from Merck.
The American Heart Association's Get With The Guidelines® quality improvement program is designed to help hospitals and healthcare providers treat patients with evidenced-based medicine known to improve health outcomes. For more information, visit
Source
American Heart Association