Quality improvement initiative and its impact on the management of patients with acute myocardial infarction

Background: Wide variation exists in acute myocardial infarction (AMI) mana gement, leading to differences in outcomes. Objective: To assess the impact of the quality improvement initiative on ap propriate management of AMI. Design: Prospective patient identification, retrospective medical record re view. Patients: All patients with AMI discharged alive (N = 497) from our institu tion between April 1, 1995, and February 28, 1997. Main Outcome Measure: The effect of quality improvements directed at the pa tient, nurse, and physician on the adherence to key quality indicators. Results: The quality improvement initiative correlated with more frequent u se of reperfusion therapy (98%), and with aspirin use in the emergency depa rtment (95%), in ideal eligible patients. Similarly, adherence to discharge quality indicators, including use of aspirin (97%), beta -blockers (94%), angiotensin-converting enzyme inhibitors (90%), and lipid-lowering agents ( 67%); avoidance of calcium channel blockers (93%); a low-fat diet (96%); sm oking cessation counseling (94%); and outpatient rehabilitation referral (7 0%) was higher, including in the very old (those aged greater than or equal to 80 years) and in women. The use of a patient education tool was associa ted with a higher adherence to most quality indicators compared with patien ts in whom this was not used: discharge aspirin (99% vs 96%; P = .02), beta -blocker (98% vs 91%, P = .002), angiotensin-converting enzyme inhibitor ( 95% vs 86%; P = .01), and lipid-lowering agent (71% vs 62%; P = .04) use; o utpatient rehabilitation (82% vs 63%; P = .001); and documentation of smoki ng cessation counseling (98% vs 87%; P = .001). Conclusions: Implementation of a quality improvement program was associated with a high adherence to quality-of-care indicators for AMI. Patient-direc ted feedback before discharge improved adherence to key indicators for AMI beyond that achieved with tools only directed at caregivers.