Indicators of Quality of Care for Patients with Acute Myocardial Infarction

The Institute for Clinical Evaluative Sciences, Toronto, Ont.
Canadian Medical Association Journal (Impact Factor: 5.96). 11/2008; 179(9):909-15. DOI: 10.1503/cmaj.080749
Source: PubMed


There is a wide practice gap between optimal and actual care for patients with acute myocardial infarction in hospitals around the world. We undertook this initiative to develop an updated set of evidence-based indicators to measure and improve the quality of care for this patient population.
A 12-member expert panel was convened in 2007 to develop an updated set of quality indicators for acute myocardial infarction. The panel identified a list of potential indicators after reviewing the scientific literature, clinical practice guidelines and other published quality indicators. To develop the new list of indicators, the panel rated each potential indicator on 4 dimensions (reliability, validity, feasibility and usefulness in improving patient outcomes) and discussed the top-ranked quality indicators at a consensus meeting.
Consensus was reached on 38 quality indicators: 17 that would be measurable using chart-abstracted data and 21 that would be measurable using administrative data. Of the 17 chart-review indicators, 13 address pharmacologic and nonpharmacologic care delivered to patients in hospital. In-hospital mortality was recommended as a key outcome indicator. Three system indicators were recommended to measure the collaborative responsiveness of the health care system from the call for help to intervention. It was recommended that hospitals strive for a minimum target benchmark of 90% or greater on process-of-care indicators.
Implementation of strategies by clinicians and hospitals to meet target benchmarks on these quality indicators could save the lives of many individuals with acute myocardial infarction.

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    • "The importance of implementation strategies is often referred to in the course of critical appraisal of guidelines [42]. As for guideline development, implementation strategies are indispensable for the real-life application of QIs [58]. Our results show that even though a wide variety of implementation strategies are reported, they are not always part of the QI development process. "
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    ABSTRACT: Quality indicators (QIs) are used in many healthcare settings to measure, compare, and improve quality of care. For the efficient development of high-quality QIs, rigorous, approved, and evidence-based development methods are needed. Clinical practice guidelines are a suitable source to derive QIs from, but no gold standard for guideline-based QI development exists. This review aims to identify, describe, and compare methodological approaches to guideline-based QI development. We systematically searched medical literature databases (Medline, EMBASE, and CINAHL) and grey literature. Two researchers selected publications reporting methodological approaches to guideline-based QI development. In order to describe and compare methodological approaches used in these publications, we extracted detailed information on common steps of guideline-based QI development (topic selection, guideline selection, extraction of recommendations, QI selection, practice test, and implementation) to predesigned extraction tables. From 8,697 hits in the database search and several grey literature documents, we selected 48 relevant references. The studies were of heterogeneous type and quality. We found no randomized controlled trial or other studies comparing the ability of different methodological approaches to guideline-based development to generate high-quality QIs. The relevant publications featured a wide variety of methodological approaches to guideline-based QI development, especially regarding guideline selection and extraction of recommendations. Only a few studies reported patient involvement. Further research is needed to determine which elements of the methodological approaches identified, described, and compared in this review are best suited to constitute a gold standard for guideline-based QI development. For this research, we provide a comprehensive groundwork.
    Implementation Science 03/2012; 7(1):21. DOI:10.1186/1748-5908-7-21 · 4.12 Impact Factor
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    • "Finally, there may be limitations in the technical quality of care measures used in the present study. Although there is consensus around many of these indicators, the 14 measures used in this study do not entirely overlap with other proposed sets of quality of care indicators (Tu et al. 2008). Thus, a different result may have been obtained regarding the impact of technical quality if additional measures had been included, such as those related to postdischarge out-of-hospital care. "
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    ABSTRACT: Recent studies have suggested that there is a positive impact of patient-centered care (PCC) on both the patient-physician relationship and subsequent patient health-related behaviors. One recent prospective study reported a significant relationship between the degree of PCC experienced by patients during their hospitalization for acute myocardial infarction (AMI) and their postdischarge cardiac symptoms. A limitation of this study, however, was a lack of information regarding the technical quality of the AMI care, which might have explained at least part of the differences in outcomes. The present study was undertaken to test the influence of both PCC and technical care quality on outcomes among AMI patients. We analyzed data from a national sample of 1,858 veterans hospitalized for an initial AMI in a Department of Veterans Affairs medical center during fiscal years 2003 and 2004 for whom data had been compiled on evidence-based treatment and who had also completed a Picker questionnaire assessing perceptions of PCC. Cox proportional hazards models were used to estimate the relationship between PCC and survival 1-year postdischarge, controlling for technical quality of care, patient clinical condition and history, admission process characteristics, and patient sociodemographic characteristics. We hypothesized that better PCC would be associated with a lower probability of death 1-year postdischarge, even after controlling for patient characteristics and the technical quality of care. Better PCC was associated with a significantly but modestly lower hazard of death over the 1-year study period (hazard ratio 0.992, 95 percent confidence interval 0.986-0.999). Providing PCC may result in important clinical benefits, in addition to meeting patient needs and expectations.
    Health Services Research 10/2010; 45(5 Pt 1):1188-204. DOI:10.1111/j.1475-6773.2010.01138.x · 2.78 Impact Factor
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    • "This 60-minute time constraint has been used in previous studies of access to PCI.21,29 In Canada, a recent quality-of-care indicator for acute myocardial infarction (AMI) is reperfusion within 120 minutes from first medical contact.30 Recognizing this longer window, we considered additional pre-hospital transportation times of 90 and 120 minutes. "
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    ABSTRACT: Primary percutaneous coronary intervention (PCI) is preferred over fibrinolysis for the treatment of ST-segment elevation myocardial infarction (STEMI). In the United States, nearly 80% of people aged 18 years and older have access to a PCI facility within 60 minutes. We conducted this study to evaluate the areas in Canada and the proportion of the population aged 40 years and older with access to a PCI facility within 60, 90 and 120 minutes. We used geographic information systems to estimate travel times by ground transport to PCI facilities across Canada. Time to dispatch, time to patient and time at the scene were considered in the overall access times. Using 2006 Canadian census data, we extracted the number of adults aged 40 years and older who lived in areas with access to a PCI facility within 60, 90 and 120 minutes. We also examined the effect on these estimates of the hypothetical addition of new PCI facilities in underserved areas. Only a small proportion of the country's geographic area was within 60 minutes of a PCI facility. Despite this, 63.9% of Canadians aged 40 and older had such access. This proportion varied widely across provinces, from a low of 15.8% in New Brunswick to a high of 72.6% in Ontario. The hypothetical addition of a single facility to each of 4 selected provinces could increase the proportion by 3.2% to 4.3%, depending on the province. About 470 000 adults would gain access in such a scenario of new facilities. We found that nearly two-thirds of Canada's population aged 40 years and older had timely access to PCI facilities. The proportion varied widely across the country. Such information can inform the development of regionalized STEMI care models.
    Open Medicine 02/2010; 4(1):e13-21.
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