Sex differences in the application of evidence-based therapies for the treatment of acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice projects in Michigan.

Abstract

Studies have shown that women with acute myocardial infarction (AMI) are less likely to receive evidence-based care compared with men. The American College of Cardiology's AMI Guidelines Applied in Practice (GAP) program has been shown to increase the rates of evidence-based medicine use and reduce mortality in patients with AMI. The objective of this study was to investigate the relative benefits of the GAP program in men and women.
By using a predesign-postdesign, standard orders, and a discharge tool to improve evidence-based indicator rates and long-term mortality in patients with AMI in Michigan, this study compared the success of GAP in men vs women. Logistic regression was used to develop predictive models for death at 30 days and 1 year in men and women.
Use of evidence-based care, including use of beta-blockers and aspirin in men and women at hospital discharge and lipid-lowering agent use in men, was higher in the post-GAP sample (P<.01 for all). Use of the discharge tool promoted by the GAP program was independently protective against death at 1 year in women (adjusted odds ratio, 0.46; 95% confidence interval, 0.27-0.79), and a trend existed for similar results in men (adjusted odds ratio, 0.62; 95% confidence interval, 0.36-1.06). However, the tool was used slightly less often with women (27.9% vs 33.96%; P=.003).
The GAP program increased the use of evidence-based therapies in male and female patients. In addition, the GAP discharge tool may decrease mortality rates at 1 year in patients with AMI; however, the tool was used less often with women. Greater use of the GAP discharge tool in women might narrow the post-MI sex mortality gap.

Full text

Page 1

ORIGINAL INVESTIGATION
Sex Differences in the Application
of Evidence-Based Therapies for the Treatment
of Acute Myocardial Infarction
The American College of Cardiology’s Guidelines Applied
in Practice Projects in Michigan
Sandeep M. Jani, MPH; Cecelia Montoye, RN, MSN; Rajendra Mehta, MD; Arthur L. Riba, MD;
Anthony C. DeFranco, MD; Robert Parrish, MM; Stephen Skorcz, MPH; Patricia L. Baker, MS; Jessica Faul, MPH;
Benrong Chen, PhD; Canopy Roychoudhury, PhD; Mary Anne C. Elma, BA; Kristi R. Mitchell, MPH; Kim A. Eagle, MD;
for the American College of Cardiology Foundation Guidelines Applied in Practice Steering Committee
Background:Studieshaveshownthatwomenwithacute
myocardialinfarction(AMI)arelesslikelytoreceiveevi-
dence-basedcarecomparedwithmen.TheAmericanCol-
lege of Cardiology’s AMI Guidelines Applied in Practice
(GAP) program has been shown to increase the rates of
evidence-basedmedicineuseandreducemortalityinpa-
tients with AMI. The objective of this study was to in-
vestigatetherelativebenefitsoftheGAPprograminmen
and women.
Methods:Byusingapredesign-postdesign,standardor-
ders,andadischargetooltoimproveevidence-basedin-
dicatorratesandlong-termmortalityinpatientswithAMI
in Michigan, this study compared the success of GAP in
men vs women. Logistic regression was used to develop
predictivemodelsfordeathat30daysand1yearinmen
and women.
Results: Use of evidence-based care, including use of
?-blockersandaspirininmenandwomenathospitaldis-
charge and lipid-lowering agent use in men, was higher
in the post-GAP sample (P?.01 for all). Use of the
discharge tool promoted by the GAP program was inde-
pendently protective against death at 1 year in women
(adjustedoddsratio,0.46;95%confidenceinterval,0.27-
0.79), and a trend existed for similar results in men (ad-
justed odds ratio, 0.62; 95% confidence interval, 0.36-
1.06).However,thetoolwasusedslightlylessoftenwith
women (27.9% vs 33.96%; P=.003).
Conclusions:TheGAPprogramincreasedtheuseofevi-
dence-basedtherapiesinmaleandfemalepatients.Inad-
dition, the GAP discharge tool may decrease mortality
rates at 1 year in patients with AMI; however, the tool
wasusedlessoftenwithwomen.GreateruseoftheGAP
discharge tool in women might narrow the post-MI sex
mortality gap.
Arch Intern Med. 2006;166:1164-1170
T
ous hospitals throughout Michigan.1-3
The GAP program incorporates ACC/
AmericanHeartAssociationnationalAMI
standardsintoeverydaycarebychanging
the processes used to treat patients.4
Throughtheuseofclinicalcaretools,such
as standardized orders and a discharge
document,andsystemsthatreinforcethe
useofevidence-basedAMIcarethatisof-
ten omitted, the GAP program has been
shown to increase the use of evidence-
basedmedicinesathospitalarrivalanddis-
charge,smokingcessationcounseling,and
dietary counseling.2-8Furthermore, re-
HE AMERICAN COLLEGE OF
Cardiology (ACC) Acute
Myocardial Infarction
(AMI) Guidelines Applied
in Practice (GAP) pro-
gram has been implemented in numer-
centdata9haverevealedthattheGAPpro-
gram reduced mortality at 30 days and
1 year post-AMI.
Much literature has examined differ-
ences in symptom presentation and care
providedtomenandwomen.Womenwith
AMI have presented to the hospital differ-
entlythanmen.Womenaremorelikelyto
have nausea and vomiting, neck, back, or
jaw pain, and dyspnea and correspond-
inglylesslikelytocomplainofanteriorchest
pain.10-12Research13-15has also shown that
women with AMI are less likely to un-
dergo primary angioplasty within 2 hours
and that women presenting with AMI are
For editorial comment
see page 1162
Author Affiliations are listed at
the end of this article.
Group Information: A list of
the members of the American
College of Cardiology
Foundation Guidelines Applied
in Practice Steering Committee
appears on page 1169.
(REPRINTED) ARCH INTERN MED/VOL 166, JUNE 12, 2006WWW.ARCHINTERNMED.COM
1164
©2006 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013

Page 2

treated, on average, less aggressively than men. The older
ageofwomenandthedelayinpresentationwhenseeking
care for AMI have been suggested as potential causes for
these findings.16-18
Building from these studies, we sought to under-
stand the benefits of the GAP program and its associ-
ated discharge document on men and women. We stud-
ieduseofevidence-basedcare,includingmedicationsat
discharge, use of the discharge tool, and mortality, be-
tween men and women in the GAP program.
METHODS
THE GAP PROJECTS
Following initial development at the University of Michigan
Health System,19the ACC AMI GAP projects included a 10-
hospital pilot study in southeast Michigan3in 1999; a 5-hos-
pital project in Flint and Saginaw, Mich,2in 2001; and an 18-
hospitalexpansionprojectinsoutheastMichigan1in2002.The
AMIGAPprojectswereconductedinpartnershipwithMPRO,
the Medicare Quality Improvement Organization for Michi-
gan;localhealthcoalitions;theACC;andlocalhospitals.Each
new project built on lessons learned from the previous GAP
projects. A rapid-cycle quality improvement model was cre-
ated, emphasizing a collaborative culture of learning, sharing,
and problem solving among hospitals and designing care pro-
cessestoensureclinicaltooluse.1TheGAPprojectfosterssys-
tems-basedcarefromadmissiontodischargebyincorporating
evidence-based tools into practice and targeting patients, phy-
sicians, and nurses. Patients included Medicare and non-
Medicare recipients diagnosed as having AMI (principal diag-
nosiscode410.xx,excluding410.x2).Themethodsusedinthe
ACC GAP projects have previously been described.1-3,20,21The
clinicalcaretooltemplatesarereadilyavailableattheACCWeb
site (http://www.acc.org/gap/gap.htm).
THE MEDICARE SAMPLE
We examined the impact of GAP on Medicare beneficiaries by
studying patients treated in each hospital before and immedi-
ately after implementation of GAP. Because follow-up informa-
tioncouldonlybeobtainedinMedicarepatients,onlythispopu-
lation was included in the study. Baseline samples were created
usinga50%randomsamplewithatleast20casesperhospitalof
MedicarepatientswithAMI(principaldiagnosiscode410.xx,ex-
cluding410.x2)treatedintheyearprecedingGAPimplementa-
tion.Thepost-GAPsampleincludeda95%to100%samplingof
all Medicare patients with AMI in the 4 months immediately af-
terGAPimplementationateachhospital.Hospitalrecordsforeach
patient were copied and forwarded to DynKePRO’s Centers for
Medicare & Medicaid Services’ Clinical Data Abstraction Cen-
ter,Rockville,Md.EachrecordwasscreenedtoensurethatAMI
was the principal diagnosis. Then, data regarding patient his-
tory, presenting symptoms and signs, comorbidities, diagnostic
studies, therapies, outcomes, and use of standard orders and/or
thedischargetoolwereextracted.Forquality-of-careindicators,
onlyidealcaseswereincludedinthedenominatorand,thus,pa-
tientswithcontraindicationstoevidence-basedtherapieswereex-
cluded from analyses. Ideal cases refer to indicator-specific in-
clusion and exclusion criteria developed by the Centers for
Medicare & Medicaid Services, where patients without absolute
or relative contraindications to that indicator remain in the de-
nominator.22,23Toensurequality,datawerereabstractedforaran-
domsampleofbaselineandpost-GAPrecordsbytheClinicalData
Abstraction Center. Reliability (94%) and accuracy (97%) were
high.Toassessfor30-dayand1-yearmortality,Medicareclaims
were screened using each patient’s unique identifier.
DATA ANALYSIS
Wecomparedmenandwomentreatedbefore(baseline)andim-
mediately after (post) GAP implementation. By using standard
statistics,demographics,presentationvariables,comorbidities,di-
agnostictestresults,treatments(includingevidence-basedthera-
pies and use of AMI discharge tools), and outcomes were ana-
lyzedinthe2cohorts.Weexamined30-dayand1-yearmortality
inthebaselinesamplecomparedwithmenandwomeninthepost-
GAPsample.ToassessthepotentialindependentbenefitofGAP
on mortality rates of men and women, separate multivariate lo-
gisticregressionmodelsfor30-dayand1-yearmortalitywerede-
veloped for each sex, including use of the discharge document
asanexplanatoryvariable.Patientswhodiedinthehospitalwere
excluded from the patient population used to develop the post-
discharge multivariate mortality models. Each hospital was also
includedasanindependentvariableintoeachmodeltoaccount
forpracticevariationbetweenthefacilities.Age,heartrateatad-
mission,andtroponinincreaseswereanalyzedascontinuousvari-
ables,whileallothervariablesweredichotomous.Candidatevari-
ablesineachmodelincludedparticipationintheGAPprogram;
useofthedischargetool;age;historyofMI,congestiveheartfail-
ure,cerebrovasculardiseaseorstroke,hypertension,diabetesmelli-
tus,andchronicobstructivepulmonarydisorder;currentsmok-
ing; percutaneous coronary intervention; and coronary artery
bypass grafting. We also assessed in-hospital variables, includ-
ingheartrateatadmission,congestiveheartfailure,MIlocation,
atrial fibrillation, hematocrit of less than 30%, reduced left ven-
tricularejectionfraction,percutaneouscoronaryintervention,coro-
nary artery bypass grafting, elevated creatine kinase level, hypo-
tension,shock,stroke,renalfailure,transfusion,andhemorrhage.
RESULTS
Womenrepresented48.1%ofthestudypopulation,48.0%
of the baseline population, and 48.2% of the post-GAP
population. The mean age of men was 69 years; and of
women, 75 years.
Baselineandpost-GAPdemographics,medicationuse,
and unadjusted mortality information are shown in
Table 1. Focusing on women, the post-GAP popula-
tion had a higher rate of history of MI and prior coro-
naryarterybypassgrafting.Meninthepost-GAPsample
were more likely to have hypertension and less likely to
have a left ventricular ejection fraction of less than 25%
compared with men in the baseline sample.
When men post-GAP were compared with women
post-GAP, several interesting results emerge (Table 1).
Women were significantly older than men and were less
likelytohavehadapriorMIorpriorcoronaryarteryby-
pass grafting. Women were more likely to have hyper-
tension and a history of congestive heart failure com-
pared with men.
Women in the post-GAP period were more likely to
be given aspirin within 24 hours of admission. Men and
women in the post-GAP population were more likely to
be given aspirin and ?-blockers at discharge compared
with their counterparts in the baseline group. Rates of
lipid-lowering drug use and angiotensin-converting en-
zyme inhibitor use at discharge were also significantly
higher for men in the post-GAP group.
(REPRINTED) ARCH INTERN MED/VOL 166, JUNE 12, 2006WWW.ARCHINTERNMED.COM
1165
©2006 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013

Page 3

Unadjusted mortality was lower for men post-GAP
in the hospital, at 30 days after discharge, and at
1 year after discharge. Women treated after GAP
implementation also had significantly lower mortality
at 1 year.
Useofthedischargedocumentwassubstantiallyhigher
in men (34.0% vs 1.5%; P?.01) and women (27.9% vs
1.3%; P?.01) after the implementation of GAP.
Women in the post-GAP population were less likely
thanmentohavehadthedischargedocumentused.Mor-
tality in the post-GAP population at 30 days and 1 year
was also significantly higher in women.
Table 2 focuses on medication use rates at dis-
chargewhenthedischargedocumentisused.Inwomen,
the use of lipid-lowering agents was significantly higher
when the discharge document was used and there was a
trendtowardhigheruseofaspirinatdischargewhenthe
toolwasused.Similarresultswereseeninmenwhenthe
dischargedocumentwasused.Ratesofaspirinandlipid-
loweringagentuseatdischargeweresignificantlyhigher
when the discharge tool was used.
Multivariatemodelsformortalityat30daysand1year
showed a trend for the GAP program to lower mortality
rates for women (Table 3) and men (Table 4). How-
Table 2. Quality Indicator Rates at Discharge According to the Discharge Tool
Agent Given at Discharge
Aspirin
?-Blockers
Lipid-lowering agent
ACE inhibitor
Women
Men
No Discharge
Tool
(n = 691)*
85.9
90.1
67.1
76.9
Discharge
Tool
(n = 267)*
91.8
91.1
86.3
79.6
P
Value
.08
.86
?.001
.72
No Discharge
Tool
(n = 731)*
88.6
91.8
77.3
79.6
Discharge
Tool
(n = 376)*
95.4
93.1
88.1
88.0
P
Value
.005
.71
.01
.12
Abbreviation: See Table 1.
*Data are given as percentage of each group.
Table 1. Demographic, Medication Use, and Mortality Variables for Men and Women Before and After GAP
Variable
Demographics
Age, mean (SD), y
Prior AMI
Prior congestive heart failure
Prior CABG
Diabetes mellitus
Hypertension
LVEF ?25%
Anterior AMI
Inferior AMI
Hematocrit ?30%
Congestive heart failure on
hospital admission
PCI this admission
CABG this admission
Medication use
Aspirin within 24 h
?-Blockers within 24 h
Aspirin at discharge
?-Blockers at discharge
Lipid-lowering agent at discharge
ACE inhibitor at discharge
Mortality
In hospital
30 d
1 y
Discharge tool use
Women
Men
P Value for
Men vs
Women
After GAP
Before GAP
(n = 656)*
After GAP
(n = 717)*
P
Value
Before GAP
(n = 712)*
After GAP
(n = 772)*
P
Value
75.0 (12.8)
35.2
37.5
11.4
36.6
80.3
8.7
31.7
29.6
11.9
20.9
74.7 (12.5)
40.2
38.8
14.4
36.7
82.3
8.1
37.1
30.8
14.4
18.5
.90
.006
.47
.02
.96
.17
.56
.002
.49
.05
.11
68.9 (13.5)
48.2
33.4
27.2
37.4
69.7
15.4
27.7
34.4
10.5
17.7
69.2 (13.3)
50.1
33.0
24.7
37.1
75.8
12.7
30.8
36.4
10.6
17.1
.90
.31
.82
.13
.87
?.001
.04
.07
.26
.93
.67
.02
?.001
.02
?.001
.87
.002
.004
.01
.02
.03
.48
16.0
7.3
19.9
6.8
.006
.60
22.1
8.8
26.0
11.5
.01
.02
.005
.002
81.8
68.1
79.4
80.3
71.2
78.9
86.9
70.8
87.9
90.5
73.6
77.8
?.001
.12
?.001
?.001
.15
.15
87.3
72.5
83.2
86.5
74.6
75.6
87.6
74.9
91.5
92.4
81.6
83.2
.81
.15
.63
.04
.008
.12
?.001
.002
?.001
?.001
?.001
?.001
12.5
20.7
38.7
1.3
10.7
20.1
35.1
27.9
.13
.69
.05
14.7
22.3
37.9
1.5
10.1
15.2
31.3
34.0
?.001
?.001
?.001
?.001
.70
.01
.12
.003
?.001
Abbreviations: ACE, angiotensin-converting enzyme; AMI, acute myocardial infarction; CABG, coronary artery bypass grafting; GAP, Guidelines Applied in
Practice; LVEF, left ventricular ejection fraction; NS, not significant; PCI, percutaneous coronary intervention.
*Data are given as percentage of each group unless otherwise indicated. For medication use and discharge tool use, the denominator for women before GAP
was n = 889; for women after GAP, n = 958; for men before GAP, n = 1003; and for men after GAP, n = 1107.
(REPRINTED) ARCH INTERN MED/VOL 166, JUNE 12, 2006WWW.ARCHINTERNMED.COM
1166
©2006 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013

Page 4

ever,useoftheGAPprogram’sdischargetoolwashighly
protective against death at 1 year in women and possi-
bly at 30 days. In men, there was a nonsignificant trend
towardthedischargetoolbeingprotectiveagainstdeath
at 1 year and at 30 days.
COMMENT
This study suggests that use of the GAP discharge tool
isimportantinincreasingtheuseofevidence-basedmedi-
cations and preventing death after AMI at 1 year. Men
andwomenolderthan65yearshadpositivebenefitsfrom
theGAPprogram.Thedischargetoolwascorrelatedwith
substantial increases in the rates of lipid-lowering drug
use at discharge in men and women and increased dis-
charge aspirin use in men. These increases in medica-
tion use could explain the promising late outcome re-
sultsfoundinourstudy.Inwomen,useofthedischarge
document may reduce the odds of death at 1 year after
AMI by nearly 50%. Despite these protective benefits,
women were significantly less likely to have the dis-
chargedocumentusedaspartoftheirprocessofcarecom-
pared with men.
Why the discharge document is less likely to be used
in women may be explained by the older age of women
presenting with an AMI. Several studies16-18have found
thatasageincreases,useofevidence-basedtreatmentde-
creases,anditisthisage?sexinteractionthatisrespon-
sible for the lower use of evidence-based care observed
in women. This age?sex interaction may also have re-
sulted in the lower use of the discharge document in
women. The women in the post-GAP population were
nearly 6 years older than the men, on average. It is pos-
siblethataspatientageincreases,sodoesuncertaintyof
physicians as to the potential benefits of evidence-based
therapies and, thus, use of the discharge document may
decline. The mean age of women in the post-GAP pe-
riod,however,wasnearly75years,indicatingthatmuch
ofthefemalepatientpopulationthatderivedbenefitsfrom
the GAP intervention was older than 75 years. Further-
more, our mortality results are age adjusted. Thus, we
believe the benefits available by using the GAP program
andthedischargedocumentshouldnotbereservedonly
for younger patients, because older patients can experi-
ence the positive effects of the program as well. We be-
lieve that the GAP program can provide benefits to all
patients regardless of age or sex.
Whyisthedischargedocumentsosuccessfulinreduc-
ingdeathat1yearafterAMI?Thedischargedocumenten-
suresthatpatientsareeducatedabouttheirconditionand
understandhowtocareforthemselvesaftertheyleavethe
hospital.Itiscompletedandexplainedtothepatientinthe
presence of a physician or a nurse and includes instruc-
tions on taking medications, goals for controlling choles-
terol levels, goals for smoking cessation, instructions on
diet and exercise, heart disease education, and instruc-
tions for follow-up with the patient’s primary care physi-
cians.Thepatientandthephysicianornursemustsignthe
document, attesting to the patient’s understanding of the
material included in the document.
Thedischargedocumentforcesprocessestotakeplace
that may easily be forgotten in the busy environment of
Table 3. Use of the Standardized Discharge Tool as a Predictor of Mortality in Women*
Variable
GAP program
Discharge tool use
Age (continuous)
History of myocardial infarction
History of congestive heart failure
History of cerebrovascular disease or stroke
History of hypertension
History of diabetes mellitus
Current smoker
History of COPD
Chest pain
Heart rate at admission (continuous)
History of PCI
History of CABG
Congestive heart failure on admission
Anterior AMI
Inferior AMI
Atrial fibrillation
Hematocrit ?30%
Left ventricular ejection fraction ?40%
PCI this admission
CABG this admission
30-d Mortality
1-y Mortality
Adjusted OR
(95% CI)
1.03 (0.63-1.68)
0.55 (0.23-1.31)
1.04 (1.01-1.07)
1.50 (0.90-2.52)
1.17 (0.71-1.91)
2.00 (1.22-3.29)
1.08 (0.59-1.98)
0.90 (0.54-1.50)
2.04 (1.06-3.90)
1.30 (0.77-2.19)
0.61 (0.38-0.99)
1.00 (0.995-1.01)
0.86 (0.38-1.99)
0.36 (0.14-0.94)
0.78 (0.43-1.39)
1.38 (0.84-2.26)
0.48 (0.26-0.89)
1.55 (0.93-2.57)
1.00 (0.52-1.94)
1.25 (0.76-2.07)
0.37 (0.12-1.15)
0.24 (0.03-1.92)
P
Value
.90
.18
.006
.12
.54
.006
.80
.68
.03
.32
.05
.37
.73
.04
.39
.20
.02
.09
?.99
.38
.09
.18
Adjusted OR
(95% CI)
1.10 (0.79-1.54)
0.46 (0.27-0.79)
1.05 (1.03-1.07)
1.32 (0.93-1.86)
1.41 (1.01-1.97)
1.19 (0.78-1.60)
1.05 (0.70-1.59)
0.88 (0.63-1.23)
1.57 (1.00-2.47)
1.39 (0.98-1.98)
0.54 (0.39-0.76)
1.00 (0.99-1.01)
0.62 (0.37-1.05)
1.33 (0.82-2.15)
1.35 (0.92-2.00)
0.99 (0.70-1.38)
1.11 (0.78-1.60)
1.35 (0.93-1.95)
1.80 (1.16-2.79)
1.50 (1.06-2.11)
0.36 (0.20-0.64)
0.18 (0.06-0.56)
P
Value
.58
.005
?.001
.12
.05
.54
.82
.46
.05
.06
?.001
.93
.08
.24
.13
.93
.56
.11
.008
.02
?.001
.003
Abbreviations: AMI, acute myocardial infarction; CABG, coronary artery bypass grafting; CI, confidence interval; COPD, chronic obstructive pulmonary disease;
GAP, Guidelines Applied in Practice; OR, odds ratio; PCI, percutaneous coronary intervention.
*The C statistic was 0.80 for 30-day mortality and 0.78 for 1-year mortality.
(REPRINTED) ARCH INTERN MED/VOL 166, JUNE 12, 2006WWW.ARCHINTERNMED.COM
1167
©2006 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013

Page 5

a hospital. For the physician or nurse to explain every-
thing on the document to the patient, the physician or
nurse must go through the process to ensure that all the
aspects of the document have taken place. For example,
useoftheGAPdischargedocumentforcesphysiciansto
either prescribe aspirin, ?-blockers, angiotensin-
convertingenzymeinhibitors,andcholesterol-lowering
agents or document the reason these drugs were not in-
dicated. Similarly, the discharge document ensures that
diet counseling and smoking cessation counseling have
occurred, that educational information about heart dis-
easeandheartattackshasbeenprovidedtopatients,and
that exercise and cardiac rehabilitation instructions and
referrals have been given. The success of the discharge
documentliesinitsabilitytomakecertainthatevidence-
based processes occur at discharge and patients are in-
formedaboutplansfortheirmedicalcareaftertheyleave
the hospital.
While the discharge document is an integral com-
ponent in preventing mortality, we do not believe that
the results seen in this study would occur without
implementation of the entire GAP program. The GAP
program emphasizes far more than simply the quality
indicators reported herein. The GAP intervention
focuses on the patient-physician-nurse triangle of care,
trying to ensure that a short list of key care priorities
were emphasized in a consistent way, and with sys-
tems that supported these priorities during the care
itself.
TheGAPsystemalsostronglyendorseslong-termad-
herencetoevidence-basedmedicinesamongeligiblepa-
tients and firmly encourages lifestyle goals in the hospi-
talandatdischarge.Wesuspectthatsuccessinachieving
multiple pharmacological and lifestyle targets is not an
additive effect, but may be multiplicative, just like the
risk that is associated with multiple risk factors.24Fur-
thermore, Fonarow et al25have shown a substantial re-
duction in 1-year mortality at an academic institution
when a program to improve the rates of evidence-based
treatmentofAMIwasinitiated.Astudy26ofaqualityim-
provementprogramatIntermountainHealthSystemsin
Utahalsodemonstratedthatincreasingtheratesofguide-
line-basedtherapiesforpatientswithcardiovasculardis-
easealsosignificantlyreduced1-yearmortalityrates.The
dischargedocumentensuresthatalltheprocessesofthe
GAP program are addressed as the patient transitions to
the outpatient setting.
Unfortunately,mostpatientsinvolvedinthisstudydid
notreceivethebenefitsofthedischargedocument.Sub-
stantial gains can be made in ensuring that all patients
with AMI receive the process of care that the GAP pro-
gramprovides.Furthermore,similarprogramsarebeing
developed for other cardiac and noncardiac conditions
toensurethatevidence-basedcareisprovidedtoabroader
array of patients.
The GAP intervention was not a randomized con-
trolled trial and, as such, we cannot prove that the treat-
mentgainsseeninthisstudyaresolelyduetoGAP.How-
ever,thepost-GAPperiodfollowedimmediatelyafterthe
pre-GAPperiod,suggestingthattheeffectofpassivedif-
fusion of care would not be strong. Also, the post-GAP
period was only 3½ to 4 months long; we believe that
passive diffusion of knowledge would likely take much
longer to have a major impact.
Table 4. Use of the Standardized Discharge Tool as an Independent Predictor of Mortality in Men*
Variable
GAP program
Discharge tool use
Age (continuous)
History of myocardial infarction
History of congestive heart failure
History of cerebrovascular disease or stroke
History of hypertension
History of diabetes mellitus
Current smoker
History of COPD
Chest pain
Heart rate at admission (continuous)
History of PCI
History of CABG
Congestive heart failure on admission
Anterior AMI
Inferior AMI
Atrial fibrillation
Hematocrit ?30%
Left ventricular ejection fraction ?40%
PCI this admission
CABG this admission
30-d Mortality
1-y Mortality
Adjusted OR
(95% CI)
0.65 (0.36-1.20)
0.47 (0.17-1.31)
1.04 (1.00-1.08)
0.99 (0.55-1.77)
1.48 (0.81-2.72)
1.42 (0.81-2.49)
0.55 (0.31-0.98)
1.31 (0.75-2.27)
1.19 (0.60-2.39)
1.44 (0.81-2.55)
0.34 (0.20-0.60)
1.00 (0.99-1.01)
0.32 (0.13-0.80)
1.11 (0.58-2.11)
0.52 (0.26-1.04)
1.55 (0.83-2.88)
1.20 (0.65-2.22)
0.82 (0.41-1.65)
1.85 (0.93-3.66)
1.68 (0.93-3.03)
0.11 (0.02-0.52)
0.08 (0.01-0.68)
P
Value
.17
.15
.03
.97
.21
.22
.04
.34
.62
.22
?.001
.95
.01
.76
.06
.17
.56
.58
.08
.08
.005
.02
Adjusted OR
(95% CI)
0.87 (0.61-1.26)
0.62 (0.36-1.06)
1.05 (1.03-1.07)
1.05 (0.74-1.50)
2.00 (1.37-2.92)
1.27 (0.88-1.83)
0.68 (0.47-0.98)
1.24 (0.88-1.75)
0.75 (0.48-1.17)
1.80 (1.26-2.59)
0.43 (0.30-0.62)
1.00 (0.99-1.01)
1.08 (0.71-1.63)
0.86 (0.51-1.12)
1.07 (0.70-1.63)
1.01 (0.69-1.49)
1.16 (0.77-1.61)
0.92 (0.61-1.39)
1.72 (1.06-2.77)
1.43 (1.00-2.03)
0.27 (0.16-0.48)
0.23 (0.10-0.51)
P
Value
.46
.08
?.001
.77
?.001
.20
.04
.21
.20
.001
?.001
.94
.73
.17
.75
.94
.56
.70
.03
.05
?.001
?.001
Abbreviations: See Table 3.
*The C statistic was 0.85 for 30-day mortality and 0.80 for 1-year mortality.
(REPRINTED) ARCH INTERN MED/VOL 166, JUNE 12, 2006WWW.ARCHINTERNMED.COM
1168
©2006 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013