If it's not the heart attack, it might be the care given by doctors afterward that kills a heart attack victim-a problem that Duke doctors are hoping to confront with a new push for greater education of their peers.
According to a Medical Center study last fall, some cardiologists are unnecessarily putting the lives of recovering heart attack victims at risk by not adhering to established guidelines by the American Heart Association and the American College of Cardiology. In response, Duke and the University of North Carolina at Chapel Hill are paving the way with a nationwide initiative to publicize this issue of quality improvement.
"What is novel about these findings is that we were able to link adherence to guidelines to patient outcome," said Dr. Eric Peterson, author of the recent study and associate professor of cardiology at the Medical Center. "Physicians hadn't previously received such feedback."
Peterson's results emphasized adhering to guidelines to care for heart attack patients. The study, presented at the AHA Conference last November, found that heart attack victim mortality rates were nearly twice as high in hospitals that followed the guidelines the least, when compared to leading hospitals.
"We [physicians] all thought we were delivering the best care, until we realized what was actually delivered," Peterson said.
Duke is heavily involved with increasing awareness of the gap in heart attack patient treatment. One such program is CRUSADE, a collaboration with UNC, designed to provide feedback to hospitals nationwide on their adherence to the established heart attack patient care guidelines.
"Doctors need to be involved in the quality improvement process, evaluate their practices and improve them," said Dr. Kristin Newby, who worked with Peterson on the Duke study.
Other programs, such as AHA's "Get with the Guidelines," have also promoted guideline use. Duke will likely remain at the forefront of this effort through 2003 since Duke cardiology professor Dr. Augustus Grant is president of the AHA.
Besides identifying "leading" hospitals as having lower mortality rates, 8.3 percent, than "lagging" hospitals, 15.3 percent, the study found that an overall large gap exists between the guideline suggestions and the actual use of the recommended care to heart attack patients, and that the magnitude of this alleged gap varies widely across the nation and among hospitals.
Records from over 250,000 heart attack victims in the past two years were reviewed in order to determine a correlation between the number of patients who died while in the hospital and how strictly the hospital followed the established guidelines for patient care. A total of 1,247 hospitals were ranked according to the level of adherence to patient guidelines, and the top 312 "leading" hospitals were compared to the bottom 312 "lagging" hospitals. Fifteen guideline-indicated treatment measures tracked immediate and discharge care.
"What Eric Peterson has done is extremely important," said Dr. Pascal Goldschmidt, chief of the Division of Cardiology at the Medical Center. "To show that successful patient outcome is a function of the degree of the compliance to the guidelines is a breakthrough."
Dr. Imad Alhaddad, director of vascular services and cardiology division at the Johns Hopkins University School of Medicine, agreed. "Adherence to the guidelines are good because patient welfare is important. Guidelines recommend procedures that are known to offer better patient care and ultimately can save lives."
Despite what may seem as overwhelming support for adhering to the guidelines, resistance to having "algorithms of care" or "cookbook medicine" still exists.
"Everybody practices medicine differently. If a doctor finds that something not suggested by the guidelines [works] better, that has some validity," said Priya Singh, a nurse at Cardiovascular Care of North Carolina.
Nonetheless, such arguments are waning when confronted with patterns correlating better overall patient outcome with guideline use. "Physicians aren't perfect," Newby said. "[And] although there are lots of subtleties that make judgment often difficult, we must find a way to enhance adherence to the guidelines."
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