Comprehensive Coronary Artery Disease Care in a Safety-Net Hospital: Results of Get With The Guidelines Quality Improvement Initiative

    AUTHORS: Mori J. Krantz, William A. Baker, Raymond O. Estacio, Deborah K. Haynes, Philip S. Mehler, Gregg C. Fonarow, Carlin S. Long


    SUMMARY: Background: Adherence to published coronary artery disease (CAD)
    guidelines is suboptimal, particularly among minorities and the poor. While
    hospital-based quality-improvement programs may increase the use of
    evidence-based therapies, little data exist regarding the impact of such
    programs in sociodemographically disadvantaged (vulnerable) populations.
    Vulnerable patients in the United States are cared for primarily within the
    safety-net health system, which comprises urban public hospitals and
    outpatient community health centers. Denver Health is an example of an
    integrated system that encompasses both types of facilities.
    Objective: To assess evidence-based medication use in CAD patients after
    initiation of an inpatient quality-improvement program at Denver Health.
    Methods: We reviewed the medical records of 499 patients with
    angiographically proven CAD who were hospitalized between July 1998
    and December 2002. Patients were prospectively identified through a
    multidisciplinary intervention led by a nurse manager, and their records
    were input retrospectively into the American Heart Association’s Get With
    The Guidelines patient management tool. The association’s program, which
    recommends initiating 4 cardioprotective drug classes while patients are
    hospitalized, was started 2 years into the observation period (August 2000).
    Treatment rates were compared over the ensuing years.
    We evaluated temporal trends in discharge use of 4 drugs: (1) betablockers,
    (2) angiotensin-converting enzyme inhibitors (ACEIs), (3) hydroxymethylglutaryl
    coenzyme A reductase inhibitors (statins), and (4) aspirin. We
    calculated the proportion of eligible patients (no documented contraindication)
    who were prescribed each drug category as well as the proportion who
    received all 4 drug categories, our principal composite outcome. If any one
    drug was absent, the composite criterion was considered unmet.
    Results: We observed progressive improvement in discharge use of the 4-
    drug composite: 18% in 1998-1999 (95% confidence interval [CI], 12%-25%),
    50% in 2000 (95% CI, 37%-63%), 62% (95% CI, 54%-70%) in 2001, and 72%
    (65%-79%) in 2002 (P <0.001 for between-year differences). Among eligible
    patients discharged in 2002, 90% received beta-blockers, 91% received
    ACEIs, 86% received statins, and 93% received aspirin.
    Conclusions: Implementation of a multidisciplinary program led by a nurse
    manager was associated with increased CAD guideline compliance among
    sociodemographically disadvantaged patients. This compliance exceeded
    national averages. Achievement of the composite measure of use of all 4
    recommended drug categories at discharge improved from 18% in 1998-1999
    to 72% in 2002.
    Keywords: Coronary artery disease, Get With The Guidelines, Safety-net

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