The management of acute myocardial infarction in the cardiological intensive care units in Italy: the ‘BLITZ 4 Qualità’ campaign for performance measurement and quality improvement

Abstract

Aim:

To assess and promote compliance of Italian cardiological intensive care units (CCUs) with evidence-based guidelines for the management of acute myocardial infarction (MI).

Methods and results:

The process of diagnosis and treatment of MI was prospectively evaluated in 163 CCUs by use of 30 indicators during two enrolment phases, each followed by a feedback of both local and general performance. Overall, 5854 patients with ST-segment elevation MI (STEMI) and 5852 with non-ST-segment elevation MI (NSTEMI) were consecutively enrolled. The target for each indicator was defined as compliance with the relevant recommendations in ≥90% of suitable patients and it was met for nine (30%) and 10 (33.3%) indicators in the first and second phases, respectively. Regardless of target, a significant improvement in compliance was observed in the second phase in 10 out of 30 indicators (33.3%). Use of pre-hospital ECG, expedite delivery of reperfusion therapy, dosage of antithrombotic drugs, and non-pharmacological implementation of secondary prevention were often off target. Similar in-hospital mortality was observed in phases I and II, both in patients with STEMI (4.0 vs. 4.2%, p=0.79) and NSTEMI (1.8 vs. 2.4%, p=0.11). Overall, 30-day mortality were 5.7% for patients with STEMI and 3.4% with NSTEMI.

Conclusions:

Performance indicators can accurately weigh the whole process of diagnosis and treatment of patients with MI and monitor the improvements in the quality of care. In our large population of consecutive patients, satisfactory 30-day outcomes were observed despite suboptimal adherence to guidelines for some indicators of recognised prognostic relevance.

Keywords

Acute myocardial infarction performance measures

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References

Van

Werf

Bax

Betriu

.; ESC Committee for Practice Guidelines (CPG). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2008; 29: 2909–2945.

Bassand

Hamm

Ardissino

. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary sindromes. Eur Heart J 2007; 28: 1598–1660.

Kushner

Hand

Smith

Jr . 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update). Circulation 2009; 120: 2271–2306.

Wright

Anderson

Adams

. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 57: e215–e367.

Shaneyfelt

Centor

. Reassessment of clinical practice guidelines. Go gently into that good night. JAMA 2009; 301: 868–869.

Tricoci

Peterson

Roe

. Patterns of guideline adherence and care delivery for patients with unstable angina and non-ST-segment elevation myocardial infarction (from the CRUSADE quality improvement iniziative). Am J Cardiol 2006; 98: 30Q–35Q.

Peterson

Roe

Mulgund

. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA 2006; 295: 1912–1920.

Mukherjee

Fang

Chetcuti

. Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes. Circulation 2004; 109: 745–749.

Granger

Steg

Peterson

; GRACE Investigators. Medication performance measures and mortality following acute coronary syndromes. Am J Med 2005; 118: 858–865.

10.

Fox

Goodman

Klein

. Management of acute coronary syndromes. Variations in practice and outcome: findings from the Global Registry of Acute Coronary Events (GRACE). Eur Heart J 2002; 23: 1177–1189.

11.

Blomkalns

Roe

Peterson

. Guideline implementation research: exploring the gap between evidence and practice in the CRUSADE Quality Improvement Initiative. Acad Emerg Med 2007; 14: 949–954.

12.

Di Chiara

Chiarella

Savonitto

; BLITZ Investigators. Epidemiology off acute myocardial infarction in the Italian CCU network: the BLITZ study. Eur Heart J 2003; 24: 1616–1629.

13.

Di Chiara

Fresco

Savonitto

.; BLITZ-2 Investigators. Epidemiology of non-ST elevation acute coronary syndromes in the Italian cardiology network: the BLITZ-2 study. Eur Heart J 2006; 4: 393–405.

14.

Jha

Orav

. Care in U.S. hospitals – the Hospital Quality Alliance Program. N Engl J Med 2005; 353: 265–274.

15.

Bonow

Masoudi

Rumsfeld

. ACC/AHA classification of care metrics: performance measures and quality metrics: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol 2008; 52: 2113–2117.

16.

Krumholz

Anderson

Bachelder

. ACC/AHA 2008 performance measures for adults with ST-elevation and non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non–ST-Elevation Myocardial Infarction), developed in collaboration with the American Academy of Family Physicians and American College of Emergency Physicians. J Am Coll Cardiol 2008; 52: 2046–2099.

17.

Khalid

Donovan

; Canadian Cardiovascular Outcomes Research Team/Canadian Cardiovascular Society Acute Myocardial Infarction Quality Indicator Panel. Indicators of quality of care for patients with acute myocardial infarction. CMAJ 2008; 179: 909–915.

18.

Spertus

Bonow

Chan

. ACCF/AHA new insights into the methodology of performance measurement: a report of the American College of Cardiology Foundation/American Heart Association Task Force on performance measures. Circulation 2010; 122: 2091–2106.

19.

Casella

Cassin

Chiarella

; BLITZ-3 Investigators. Epidemiology and patterns of care of patients admitted to Italian intensive cardiac care units: the BLITZ-3 registry. J Cardiovasc Med 2010; 11:450–461.

20.

Schiele

Hochadel

Tubaro

. Reperfusion strategy in Europe: temporal trends in performance measures for reperfusion therapy in ST-elevation myocardial infarction. Eur Heart J 2010; 31: 2614–2624.

21.

Wang

Fonarow

Hernandez

. The dissociation between door-to-balloon time improvement and improvements in other acute myocardial infarction care processes and patient outcomes. Arch Intern Med 2009; 169: 1411–1419.

22.

Kalla

Christ

Karnik

.; Vienna STEMI Registry Group. Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry). Circulation 2006; 113: 2398–2405.

23.

Saia

Marrozzini

Ortolani

. Optimisation of therapeutic strategies for ST-segment elevation acute myocardial infarction: the impact of a territorial network on reperfusion therapy and mortality. Heart 2009; 95: 370–376.

24.

Keeley

Boura

Grines

. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003; 361: 13–20.

25.

Jedrzkiewicz

Goodman

Yan

. Temporal trends in the use of invasive cardiac procedures for non-ST segment elevation acute coronary sindrome according to initial risk stratification. Can J Cardiol 2009; 25: e370–e376.

26.

Mehta

Cannon

Fox

. Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA 2005; 293: 2908–2917.

27.

Bavry

Kumbhani

Rassi

. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006; 48: 1319–1325.

28.

Hirsch

Windhausen

Tijssen

JGP

., for the Invasive versus Conservative Treatment in Unstable coronary Syndromes (ICTUS) Investigators. Diverging associations of an intended early invasive strategy compared with actual revascularization, and outcome in patients with non-ST-segment elevation acute coronary syndrome: the problem of treatment selection bias. Eur Heart J 2009; 30: 645–654.

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