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Best practices effective for in-patient heart attack care


Grace seems an unlikely acronym for a study of acute coronary events, but given the findings of the Global Registry of Acute Coronary Events published in the Journal of the American Medical Association, the name may be apropos.

A seven-and-a-half year study of more than 44,000 patients from 113 hospitals in Europe, South America, Canada and the United States, GRACE found increased use of angioplasty and effective new drugs reduced the incidence of deaths, cardiogenic shock and severe heart failure in patients hospitalized for heart attack or life-threatening chest pain by nearly half.

Experts say the study is solid confirmation that consistent application of best practices works. "Without question there are those who have looked askance at the idea of guidelines," says Clyde Yancy, MD, medical director of the heart and vascular institute at Baylor University Medical Center in Dallas. "These data are confirmatory that disease management does work and the application of best practices and guidelines are appropriate."


Once disparaged as cookbook medicine, best-practice guidelines have demonstrated their effectiveness. Part of the beauty of the guidelines is that they are "embarrassingly simple" to apply, says Kenneth Berkovitz, MD, chair of the department of cardiology for Akron, Ohio-based Summa Health System.

"Nobody complains when a pilot, who has flown from Chicago to New York 400 times before, goes over the same checklist before a flight," he says. "Everyone recognizes that as an important safety procedure and that's the direction we're headed in medicine."

Raymond Gibbons, MD, president of the American Heart Assn. (AHA), says the GRACE data prove what, until now, has been an attractive hypothesis.

"Throughout the 1990s many hundreds of individuals volunteered thousands of hours developing best-practice guidelines because they believed that it was important to try to summarize the evidence for physicians to improve care," he says. "This report really affirms that they were right and that the guidelines have improved outcomes and saved lives."

In 2001, the AHA launched an initiative encouraging physicians to apply evidence-based best-practice guidelines. Insurers quickly got on board. In 2005, as part of an overall quality improvement initiative, the Centers for Medicare and Medicaid Services (CMS) began docking reimbursement rates-now as much as 2%-for hospitals that did not report what percentage of their patients were receiving certain guideline-related therapies. Last month, CMS went a step further by posting broad comparisons of hospital death rates for heart attack and heart failure on its Hospital Compare Web site.

Private insurers have likewise been working behind the scenes to encourage hospitals to apply best-practice guidelines. Blue Cross and Blue Shield of Minnesota, for example, participates in three programs that encourage physicians to apply guidelines and report on how they use them. Like many other payers, the insurer pays a bonus to healthcare organizations that meet benchmarks for prescribing statins, beta blockers and other medications; a practice physicians complain rewards institutions, rather than providers.

Similarly, plans are using quality data to identify preferred providers. In 2008, WellPoint will publish a list of preferred provider groups based on data from the Society of Thorasic Surgeons. "We want to identify physicians who are truly going the extra mile," says Lisa Latts, MD, vice president of programs in clinical excellence for WellPoint.

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