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Cardiac Care Improves with Education, Pathway

Kate Traynor

A program that emphasizes patient education and an explicit plan for managing therapy can achieve high-quality care for patients who have had an acute myocardial infarction, say University of Michigan researchers.

During a two-year study of the quality improvement program at one of the University of Michigan hospitals, the prescribing of four key discharge medications—aspirin, beta-blockers, angiotensin-converting-enzyme (ACE) inhibitors, and lipid-lowering agents—was highest for "ideal" patients whose physician reviewed treatment goals during the hospital stay. These ideal patients, said lead author Rajendra H. Mehta, M.D., had no "absolute contraindications" to the drug therapy.

The treatment review, which the authors described as a "patient education tool," was provided to about half of all patients selected for study.

At least 90 percent of the ideal patients recovering from an acute myocardial infarction received beta-blockers, aspirin, and ACE inhibitors at discharge, the researchers reported in the Nov. 13 Archives of Internal Medicine (PDF). Results were less dramatic when all study participants, not just ideal patients, were considered. Physicians' prescribing of the key discharge medications, termed "quality indicators," was lowest for ACE inhibitors—49 percent of patients—and highest for aspirin—95 percent.

Ninety-three percent of the ideal patients and 85 percent of all study patients did not receive calcium-channel blockers. Use of this group of drugs is generally contraindicated for patients who have had an acute myocardial infarction.

Physicians' use of the patient education tool also resulted in their greater compliance with nonpharmacological indicators of quality care: provision of smoking-cessation counseling and referral for outpatient cardiac rehabilitation.

The care of all patients admitted between April 1, 1995, and Feb. 28, 1997, to the hospital's cardiology service with a diagnosis of acute myocardial infarction was managed with a critical pathway—a standardized daily plan. The pathway was based on preliminary recommendations that were finalized in 1996 by the Task Force on Practice Guidelines of the American College of Cardiology and the American Heart Association. These guidelines were updated in 1999.

The study participants ranged in age from 20 to 99 years, with an average age of 62. They were almost exclusively white, and 33 percent were women. During the 23-month study, 11.6 percent of the 555 patients with a diagnosis of acute myocardial infarction died while in the hospital.