Cardiac care initiative links 600 hospitals
Cardiac care initiative links 600 hospitals
Evidence-based guidelines set the standard
Using evidence-based guidelines from the American College of Cardiology (ACC) in Bethesda, MD, and the American Heart Association (AHA) in Dallas as their lodestar, cardiologists from the University of North Carolina at Chapel Hill, the Duke Clinical Research Institute in Durham, NC, and the University of Cincinnati are spearheading an initiative called CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines?).
Encouraging use of guidelines
The goal is to encourage physicians to follow these published practice guidelines, thereby improving delivery of cardiovascular health care. "During the next decade, we are likely to see an overwhelming epidemic of coronary artery disease within the aging population," notes E. Magnus Oman, MD, chief of cardiology at the University of North Carolina School of Medicine and co-chair of the CRUSADE executive committee. At present, he says, more than 600 hospitals nationwide are participating in CRUSADE.
"There is considerable literature and research to suggest certain recommendations for the care of patients with acute coronary syndrome," says Oman, explaining that the ACC/AHA guidelines are evidence-based. "What the literature also shows is that physicians do a reasonable job of following the guidelines, but they do not do as well as they should. What everyone wants cardiologists to do is to take all the most appropriate recommendations and convert them into practice for all of our patients. If they do, we will be doing a fantastic job," he adds.
Continuum of care crucial
The other impetus behind the project, says Oman, was the recognition of the need to create a strong continuum of care between the hospital emergency department (ED) and the cardiology department. At the outset, he joined forces with Brian Gibler, MD, an emergency medicine physician at the University of Cincinnati who is particularly well-versed in cardiac care issues. "We came together and said, Wouldn’t it be wonderful to address the continuum of care?’ If the patient gets appropriate care in the ED, this would then translate into better care when they come to cardiology," Oman asserts.
Because of shrinking hospital capacity, more patients are spending a greater length of time in the ED, Oman observes. "We thought the continuum-of-care concept lends itself very nicely to high-risk acute coronary patients," he says, noting that in the ACC/AHA guidelines there are separate sections for ED and cardiology. "We want to see that the guidelines are applied in the ED as well as in cardiology."
The CRUSADE initiative will analyze treatment patterns for up to 60,000 patients being treated for unstable angina, or non-ST-segment elevation acute coronary syndromes (NSTE ACS). The data will be collected on line in a central database. "It will then be fed back to the individual hospitals through processes like CQI [continuous quality improvement]," Ohman explains. Feedback will be received quarterly, allowing participating facilities to assess the appropriateness of care being given. "They will be able to see where they stand compared to the national average," says Ohman.
The complete guidelines cover more than 400 pages, Ohman notes. "We’ll focus on the things that really make a difference — the diagnostic and treatment phases. These are the keys to good care management." (The guidelines can be found at the AHA web site: www.americanheart.org. Use the site’s search engine and type in "ACC/AHA Guidelines for the Management of Patients with Unstable Angina.")
Toward optimal care
Ohman recognizes that 100% compliance with the guidelines may be unrealistic but insists that "if you apply all the guidelines to all patients, they will have optimal outcomes. We know that doesn’t happen now." He says much of the lack of compliance relates to the hospitals themselves, and the failure to institute systems that ensure physicians are compliant with the guidelines. "We think it’s very important to start with the physicians," he says. "We believe CRUSADE will work as an educational tool and bring knowledge as to what to do in practice."
At present, he claims, the average cardiologist does not really know how often he gives specific medications or therapies. "The average doctor thinks he gives aspirin 100% of the time, but the literature shows its closer to 85%," Ohman notes. "We’re trying to close that gap. There are other areas, such as ACE inhibitors and beta-blockers, where we could do a lot better. In the use of anticoagulants and antithrombolytic therapies, we could probably do better as well. Right now, we don’t have real good data on some of these pieces," Ohman explains.
(Facilities that have not yet signed up for the CRUSADE initiative still have time to participate. For contact information, see below.)
Need more information?
• E. Magnus Ohman, MD, University of North Carolina at Chapel Hill, 338 Burnett Womack Building, CB 7075, Chapel Hill, NC 27599. Telephone: (919) 843-5201. E-mail: [email protected].
• Brian Gibler, MD, University of Cincinnati. Telephone: (513) 558-8086. E-mail: Brian. [email protected].
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