Patricia L Baker

University of California, San Francisco, San Francisco, CA, United States

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Publications (17)118.35 Total impact

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    ABSTRACT: The American College of Cardiology's Guidelines Applied in Practice (GAP) initiative for acute myocardial infarction (AMI) has been shown to increase the use of guideline-based therapies and improve outcomes in patients with AMI. It is unknown whether hospitals that are more successful in using the standard discharge contract--a key component of GAP that emphasizes guideline-based medications, lifestyle modification, and follow-up planning--experience a proportionally greater improvement in patient outcomes. Medicare patients treated for AMI in all 33 participating GAP hospitals in Michigan were enrolled. We aggregated the hospitals into 3 tertiles based on the rates of discharge contract use: 0% to 8.4% (tertile 1), >8.4% to 38.0% (tertile 2), and >38.0% to 61.1% (tertile 3). We analyzed 1-year follow-up mortality both pre- and post-GAP and compared the mortality decline post-GAP with discharge contract use according to tertile. There were 1368 patients in the baseline (pre-GAP) cohort and 1489 patients in the post-GAP cohort. After GAP implementation, mortality at 1 year decreased by 1.2% (P = .71), 1.2% (P = .68), and 6.0% (P = .03) for tertiles 1, 2, and 3, respectively. After multivariate adjustment, discharge contract use was significantly associated with decreased 1-year mortality in tertile 2 (odds ratio 0.43, 95% CI 0.22-0.84) and tertile 3 (odds ratio 0.45, 95% CI 0.27-0.75). Increased hospital utilization of the standard discharge contract as part of the GAP program is associated with decreased 1-year mortality in Medicare patient populations with AMI. Hospital efforts to promote adherence to guideline-based care tools such as the discharge contract used in GAP may result in mortality reductions for their patient populations at 1 year.
    American heart journal 09/2007; 154(3):461-9. · 4.65 Impact Factor
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    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.
    Archives of Internal Medicine 06/2006; 166(11):1164-70. · 11.46 Impact Factor
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    ABSTRACT: We sought to assess the impact of the American College of Cardiology's Guidelines Applied in Practice (GAP) project for acute myocardial infarction (AMI) care, encompassing 33 acute-care hospitals in southeastern Michigan, on rates of mortality in Medicare patients treated in Michigan. The GAP project increases the use of evidence-based therapies in patients with AMI. It is unknown whether GAP also can reduce the rate of mortality in patients with AMI. Using a before (n = 1,368) and after GAP implementation (n = 1,489) cohort study, 2,857 Medicare patients with AMI were studied to assess the influence of the GAP program on mortality. Multivariate models tested the independent impact of GAP after controlling for other conditions on in-hospital, 30-day, and one-year mortality. Average patient age was 76 years, 48% were women, and 16% represented non-white minorities. The rate of mortality decreased after GAP for each interval studied: hospital, 10.4% versus 13.6%; 30-day, 16.7% versus 21.6%; and one-year, 33.2% versus 38.3%; all p < 0.02. After multivariate adjustment, GAP correlated with a 21% to 26% reduction in mortality, particularly at 30 days (odds ratio of GAP to baseline 0.74; 95% confidence interval [CI] 0.59 to 0.94; p = 0.012) and one year (odds ratio 0.78; 95% CI 0.64 to 0.95; p = 0.013), particularly in the patients for whom a standard discharge tool was used (1-year mortality, odds ratio 0.53; 95% CI 0.36 to 0.76; p = 0.0006). Embedding AMI guidelines into practice was associated with improved 30-day and one-year mortality. This benefit is most marked when patients are cared for using standardized, evidence-based clinical care tools.
    Journal of the American College of Cardiology 10/2005; 46(7):1242-8. · 14.09 Impact Factor
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    ABSTRACT: We reported previously that acute ischemic stroke patients encountered delays in obtaining neuroimaging and receiving thrombolysis, and that deep venous thrombosis prophylaxis was used only in a minority of eligible patients. We investigated whether these and other measures improved after a quality improvement initiative. Medicare fee-for-service ischemic stroke and transient ischemic attack discharges in 136 acute care hospitals in Michigan were identified by International Classification of Diseases, 9th Revision, Clinical Modification codes. Only patients with stroke symptoms persisting for >1 hour and present on arrival were included in the analysis. Seven quality indicators were abstracted from chart review at baseline (discharges between July 1, 1998, and June 30, 1999) and at remeasurement (discharges between January 1, 2001, and June 30, 2001) after an intensive quality improvement initiative throughout Michigan hospitals. Quality indicators were compared at baseline and remeasurement. Indicators of care were determined in 5146 patients at baseline and 4980 patients on remeasurement. Four quality-of-care indicators showed significant improvement on remeasurement: antithrombotic prescribed at discharge (81.9 baseline versus 83.7% remeasurement; P=0.026), avoidance of sublingual nifedipine in patients with acute ischemic stroke (97.1 versus 99.7%; P<0.0001), documentation of a computed tomography (CT)/MRI during hospitalization (98.0 versus 99.1%; P=0.024), and appropriate deep venous thrombosis prophylaxis (13.8 versus 26.9%; P<0.0001). Time to CT/MRI did not significantly change, but time to thrombolysis improved (113 versus 88.5 minutes; P=0.045). Improvement occurred in several indicators of quality of care in Michigan Medicare beneficiaries presenting with acute stroke symptoms.
    Stroke 06/2005; 36(6):1227-31. · 6.16 Impact Factor
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    ABSTRACT: Several factors have been linked to the variation in the quality of care for patients with atrial fibrillation (AF). Whether hospitalization primarily for AF (primary diagnosis of AF) as opposed to another primary diagnosis but having concomitant AF (secondary diagnosis of AF) impacts quality of care for AF is not known. Accordingly, we sought to evaluate the differences in quality of care of Medicare patients admitted with primary diagnosis versus secondary diagnosis of AF. We studied a random sample of Medicare fee-for-service discharges from Michigan's acute care hospitals over a 1-year period with a primary or secondary diagnosis of AF (ICD-9-CM 427.31). Main outcome measure. Warfarin use at the time of discharge. Of 5993 patients in the study, 772 had a primary diagnosis of AF and 5221 had a secondary diagnosis of AF. Patients with a secondary diagnosis of AF were older, more likely to be male, and less likely to be hypertensive. Patients with a secondary diagnosis of AF 'ideal' for anticoagulation (n = 1648) were less likely to receive warfarin compared with 'ideal' patients with primary diagnosis of AF (n = 363) (52.6% versus. 59.8%, P < 0.001). Adherence to test indicators was lower in patients with secondary diagnosis of AF. Secondary diagnosis of AF rather than AF as a primary diagnosis appears to account for most Medicare patients with AF admitted to hospitals. Whereas quality of care is lower in patients with secondary diagnosis of AF, opportunity for quality improvement exists for both groups of patients with AF.
    International Journal for Quality in Health Care 06/2005; 17(3):255-8. · 1.79 Impact Factor
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    ABSTRACT: This project evaluated if by focusing on process changes and tool use rather than key indicator rates, the use of evidence-based therapies in patients with acute myocardial infarction (AMI) would increase. The use of tools designed to improve quality of care in the American College of Cardiology AMI Guidelines Applied in Practice Pilot Project resulted in improved adherence to evidence-based therapies for patients, but overall, tool use was modest. The current project, implemented in five hospitals, was modeled after the previous project, but with greater emphasis on tool use. This allowed early identification of barriers to tool use and strategies to overcome barriers. Main outcome measures were AMI quality indicators in pre-measurement (January 1, 2001 to June 30, 2001) and post-measurement (December 15, 2001 to March 31, 2002) samples. One or more tools were used in 93% of patients (standard orders = 82%, and discharge document = 47%). Tool use was associated with significantly higher adherence to most discharge quality indicator rates with increases in aspirin, angiotensin-converting enzyme inhibitors, and smoking cessation and dietary counseling. Patients undergoing coronary artery bypass grafting (CABG) had low rates of discharge indicators. Patients undergoing percutaneous coronary revascularization were more likely to receive evidence-based therapies. These data validate the results of the pilot project that quality of AMI care can be improved through the use of guideline-based tools. Identifying and overcoming barriers to tool use led to substantially higher rates of tool use. The low rates of adherence to quality indicators in patients undergoing CABG suggest that these patients should be particularly targeted for quality improvement efforts.
    Journal of the American College of Cardiology 07/2004; 43(12):2166-73. · 14.09 Impact Factor
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    ABSTRACT: This study describes several quality indicators of care in hospitalized stroke patients in Michigan from 1998 to 1999. Median times from admission to head CT/MRI (89.5 minutes) and thrombolysis (113 minutes) exceeded recommended guidelines. Deep venous thrombosis prophylaxis was used in only 13.8% of eligible patients. Timing for brain imaging and acute ischemic stroke symptom onset need to be better documented, along with more provider education for routine deep venous thrombosis prophylaxis.
    Stroke 02/2004; 35(1):e22-3. · 6.16 Impact Factor
  • Journal of The American College of Cardiology - J AMER COLL CARDIOL. 01/2004; 43(5).
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    ABSTRACT: Modern management of acute stroke, including the use of tissue plasminogen activator (t-PA), requires hospitals to be better prepared for rapid diagnosis and treatment. Surveillance of practice of acute stroke treatment by Michigan hospitals was performed in 1998. We determined variation in hospital preparedness for treatment by number of emergency department visits. Factors associated with hospital use of t-PA were analyzed using logistic regression. Surveys were returned by 97 (55%) hospitals. Hospitals with a greater number of emergency department visits were significantly more likely to have a clinical pathway, to have given t-PA, and to be better prepared for stroke treatment. After multivariate analysis, greater number of stroke patients per year (P < .001) and availability of skilled intensive care department staff (P = .056) were associated with hospital t-PA use. Specific hospital characteristics are associated with t-PA use. Consideration of these may be used to devise new strategies for improved delivery of acute stroke treatment.
    Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 01/2004; 13(6):262-6.
  • Journal of The American College of Cardiology - J AMER COLL CARDIOL. 01/2004; 43(5).
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    ABSTRACT: BACKGROUND: This American College of Cardiology (ACC) Acute Myocardial Infarction (AMI) Guidelines Applied in Practice (GAP) collaborative in Michigan represented ACC's third initiative, in partnership with local health care coalitions and the Michigan Peer Review Organization. The GAP Pilot Project formed the basis for this project, which supported caregivers' efforts to improve their processes and consistently apply the evidence-based guidelines for AMI care. THE SOUTHEAST MICHIGAN EXPANSION PROJECT: The Institute for Healthcare Improvement (IHI) Breakthrough Series model of improvement was modified to merge the GAP Pilot Project's design with a rapid-cycle quality improvement model. The collaborative included learning sessions that focused on five phases--planning, tool implementation, monitoring tool use, remeasurement, and results--and on increasing tool use rates in each phase. CONCLUSIONS: Building on the work of two previous efforts, the ACC AMI GAP projects yielded substantial collective knowledge. Developing and fostering a collaborative culture allowed hospital teams to avoid barriers or overcome them successfully based on others' experiences and collectively solve problems, and it shortened the learning curve and accelerated QI.
    Joint Commission journal on quality and safety 10/2003; 29(9):468-78.
  • Journal of The American College of Cardiology - J AMER COLL CARDIOL. 01/2003; 41(6):376-376.
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    ABSTRACT: Quality of care of patients with acute myocardial infarction (AMI) has received intense attention. However, it is unknown if a structured initiative for improving care of patients with AMI can be effectively implemented at a wide variety of hospitals. To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI. The Guidelines Applied in Practice (GAP) quality improvement project, which consisted of baseline measurement, implementation of improvement strategies, and remeasurement, in 10 acute-care hospitals in southeast Michigan. A random sample of Medicare and non-Medicare patients at baseline (July 1998--June 1999; n = 735) and following intervention (September 1--December 15, 2000; n = 914) admitted at the 10 study centers for treatment of confirmed AMI. A random sample of Medicare patients at baseline (January--December 1998; n = 513) and at remeasurement (March--August 2001; n = 388) admitted to 11 hospitals that volunteered, but were not selected, served as a control group. The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators; identification and assignment of local physician and nurse opinion leaders; grand rounds site visits; and premeasurement and postmeasurement of quality indicators. Differences in adherence to quality indicators (use of aspirin, beta-blockers, and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion; smoking cessation and diet counseling; and cholesterol assessment and treatment) in ideal patients, compared between baseline and postintervention samples and among Medicare patients in GAP hospitals and the control group. Increases in adherence to key treatments were seen in the administration of aspirin (81% vs 87%; P =.02) and beta-blockers (65% vs 74%; P =.04) on admission and use of aspirin (84% vs 92%; P =.002) and smoking cessation counseling (53% vs 65%; P =.02) at discharge. For most of the other indicators, nonsignificant but favorable trends toward improvement in adherence to treatment goals were observed. Compared with the control group, Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge (5% vs 10%; P<.001). Use of aspirin on admission, ACE inhibitors at discharge, and documentation of smoking cessation also showed a trend for greater improvement among GAP hospitals compared with control hospitals, although none of these were statistically significant. Evidence of tool use noted during chart review was associated with a very high level of adherence to most quality indicators. Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers. This initial project provides a foundation for future initiatives aimed at quality improvement.
    JAMA The Journal of the American Medical Association 04/2002; 287(10):1269-76. · 29.98 Impact Factor
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    ABSTRACT: BACKGROUND: The Guideline Applied in Practice (GAP) program was developed in 2000 to improve the quality of care by improving adherence to clinical practice guidelines. For the first GAP project, the American College of Cardiology (ACC) partnered with the Southeast Michigan Quality Forum Cardiovascular Subgroup and the Michigan Peer Review Organization (MPRO) to develop interventions that might facilitate the use of the ACC/AHA Acute Myocardial Infarction (AMI) guideline in the practice setting. Ten Michigan hospitals participated in implementing the project, which began in March 2000. DESIGNING THE PROJECT: The project developed a multifaceted intervention aimed at key players in the care delivery triangle: the physician, nurse, and patient. Intervention components included a project kick-off presentation and dinner, creation and implementation of a customized tool kit, identification and assignment of local nurse and physician opinion leaders, grand rounds site visits, and measurement before and after the intervention. IMPLEMENTING THE PROJECT: The GAP project experience suggests that hospitals are enthusiastic about partnering with ACC to improve quality of care; partners can work together to develop a program for guideline implementation; rapid-cycle implementation is possible with the GAP model; guidelines and quality indicators for AMI are well accepted; and hospitals can adapt the national guideline for care into usable tools focused on physicians, nurses, and patients. DISCUSSION: Important structure and process changes--both of which are required for successful QI efforts--have been demonstrated in this project. Ultimately, the failure or success of this initiative will depend on an indication that the demonstrated improvement in the quality indicators is sustained over time.
    The Joint Commission journal on quality improvement 02/2002; 28(1):5-19.
  • Journal of The American College of Cardiology - J AMER COLL CARDIOL. 01/2002; 39:453-453.
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    ABSTRACT: Context Quality of care of patients with acute myocardial infarction (AMI) has received intense attention. However, it is unknown if a structured initiative for improving care of patients with AMI can be effectively implemented at a wide variety of hospitals.Objective To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI.Design and Setting The Guidelines Applied in Practice (GAP) quality improvement project, which consisted of baseline measurement, implementation of improvement strategies, and remeasurement, in 10 acute-care hospitals in southeast Michigan.Patients A random sample of Medicare and non-Medicare patients at baseline (July 1998–June 1999; n = 735) and following intervention (September 1–December 15, 2000; n = 914) admitted at the 10 study centers for treatment of confirmed AMI. A random sample of Medicare patients at baseline (January–December 1998; n = 513) and at remeasurement (March–August 2001; n = 388) admitted to 11 hospitals that volunteered, but were not selected, served as a control group.Intervention The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators; identification and assignment of local physician and nurse opinion leaders; grand rounds site visits; and premeasurement and postmeasurement of quality indicators.Main Outcome Measures Differences in adherence to quality indicators (use of aspirin, β-blockers, and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion; smoking cessation and diet counseling; and cholesterol assessment and treatment) in ideal patients, compared between baseline and postintervention samples and among Medicare patients in GAP hospitals and the control group.Results Increases in adherence to key treatments were seen in the administration of aspirin (81% vs 87%; P = .02) and β-blockers (65% vs 74%; P = .04) on admission and use of aspirin (84% vs 92%; P = .002) and smoking cessation counseling (53% vs 65%; P = .02) at discharge. For most of the other indicators, nonsignificant but favorable trends toward improvement in adherence to treatment goals were observed. Compared with the control group, Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge (5% vs 10%; P<.001). Use of aspirin on admission, ACE inhibitors at discharge, and documentation of smoking cessation also showed a trend for greater improvement among GAP hospitals compared with control hospitals, although none of these were statistically significant. Evidence of tool use noted during chart review was associated with a very high level of adherence to most quality indicators.Conclusions Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers. This initial project provides a foundation for future initiatives aimed at quality improvement. Despite considerable investment in the development and dissemination of national guidelines for the management of acute myocardial infarction (AMI),1 the Center for Medicare and Medicaid Services' (CMS) Cooperative Cardiovascular Project recently reported that quality of care for Medicare beneficiaries with AMI was far from optimal.2 Many subsequent studies have shown similar disappointing adherence to the therapies recommended in published guidelines.3- 6 Furthermore, quality of care of patients with AMI varies with age, sex, race, geographic location, physician specialty, and hospital teaching status.2- 3,7- 16 This variation in care is likely linked to outcomes.11,13,17 Although recent analyses of care patterns over time have suggested steady improvement in the use of key therapies in patients with AMI,18- 19 there remain important opportunities to improve adherence to evidence-based therapies.18- 20 In this report, we describe the initial impact of the Guidelines Applied in Practice (GAP) initiative of the American College of Cardiology (ACC) in southeast Michigan. Conceptually, the program sought to incorporate national guidelines into care processes, focused on both caregivers (physicians and nurses) and patients, in part by creating tools and systems that reinforce adherence to key evidence-based therapies.
    JAMA The Journal of the American Medical Association 287(10):1269-1276. · 29.98 Impact Factor

Publication Stats

446 Citations
118.35 Total Impact Points

Institutions

  • 2007
    • University of California, San Francisco
      • Division of Hospital Medicine
      San Francisco, CA, United States
  • 2005–2006
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 2004–2005
    • Wayne State University
      • Department of Neurology
      Detroit, MI, United States
    • American College of Cardiology
      Washington, Washington, D.C., United States
  • 2002–2004
    • University of Michigan
      • Division of Pediatric Cardiology
      Ann Arbor, Michigan, United States