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Improving Quality of Cardiovascular Care in the Real World: How Can We Remove the Barriers?

The American Journal of Managed CareJuly 2004 - Part 2
Volume 10
Issue 7 Pt 2

Cardiovascular disease remains the leading causeof morbidity and mortality in the United States.1The last decade has seen a phenomenal increasein pharmacologic therapies with proven efficacy inreducing morbidity and mortality in patients with vasculardiseases. These agents, which include antiplateletagents, statins, beta-blockers, and angiotensin-convertingenzyme (ACE) inhibitors, are effective individuallyin reducing secondary cardiovascular events. However,when prescribed together they are even more effectiveand may have incremental benefits.2,3 Despite strongand unequivocal benefits of these agents, secondarypreventive therapies continue to be underutilized.4,5

For patients with coronary artery disease, observationalstudies and several clinical trials have demonstratedthe unequivocal benefit of aspirin therapy,which also has tremendous long-term benefits in secondaryprevention.6-8 However, despite its clinicallyproven advantages and cost effectiveness, aspirinremains underutilized in secondary prevention. Despiteincreased aspirin use over time, utilization remains low,perhaps as low as one quarter of eligible outpatients inone study9 and just 38% in 2001 in another study.10

The AmericanJournal of Managed Care

Substantial gaps also exist in the treatment of riskfactors for coronary artery disease, as pointed out byAndrade et al elsewhere in this issue of .11 They demonstrated thatblood pressure control rates remain suboptimal in thecontemporary era and considerable opportunities existto improve care of patients with hypertension.11 In theirstudy, only 11% of patients were at target blood pressurefor all outpatient visits.11 In the future, more extensiveuse of automated electronic data systems could streamlineassessment of hypertension care.12


Goff et al5 recently described the results of a randomized,practice-based effectiveness trial designed totest a quality improvement project that was intended toenhance the use of lipid-lowering therapy, beta-blockertherapy, and ACE inhibitor therapy in a managed caresetting. The investigators demonstrated that coordinatedmailings of guideline summaries, performance feedbackreports, and chart reminders had no observableeffect on quality of care in their setting. The resultswere disappointing since prior studies had shown thatsuch initiatives led to significant improvements in qualityof care in other settings.13-17 As reported in this issueof the , Zuckerman et al demonstrated that atargeted intervention toward physicians with educationalmaterials translated into a small (~6%) but significantincrease in beta-blocker prescriptions for patientsafter acute myocardial infarction (MI).18 The educationalintervention also resulted in cost savings as a result ofreduced hospitalization and decreased mortality.18 Intheir study, Goff et al5 attributed the lack of effectivenessof sending guideline summaries to physicians to afailure of implementation. The responsibility forreviewing the guideline summaries and feedback wasentirely that of the practicing clinician. No implementationsystem was in effect to translate this knowledgeinto changes in actual clinical care. These results havesignificant clinical implications. They confirm theexistence of an opportunity to improve the quality ofcare provided to patients with cardiovascular diseases.They also confirm the notion that passive disseminationof knowledge may have little or no effect on practicepatterns.19

Contrariwise, quality improvement exercises whichpromote use of systems that embed guideline-basedknowledge into the care process itself are more successful.In one such initiative, the Guidelines Applied inPractice (GAP) project in the state of Michigan, 1 physicianand 1 nurse leader from a different health systemwere assigned to assist hospital teams as they workedwith their internal champions to improve post-MIcare.16 The project demonstrated successful qualityimprovement among a variety of institutions, patients,and caregivers.16 The success of the GAP initiative couldbe attributed to emphasis on standard orders and dischargetools that reminded caregivers to consider evidence-based therapies in every patient from admissionto discharge. Creation of a quality improvement systemand inclusion of the patient, nurse, and physician in areview of care priorities are methods that promotedquality.


Some purchasers and insurers are attempting to optimizequality of care by developing a system of "pay-for-performance"financial incentives. As an example, somepartners are looking at specified services and outcomes,including clinical and preventive measures drawn fromthe Health Plan Employer Data and Information Set(HEDIS) as well as performance scores from patient satisfactionsurveys. Perhaps the most significant factor inthe success of pay-for-performance arrangements iswhether payment will be large enough to influencephysician behavior. Currently, several insurers are providingup to 10% more reimbursement for successfuldemonstration of quality in episode-based care (eg,acute MI) or disease management care (eg, diabetes).The long-term effect of this type of quality-based reimbursementis not known. In this issue of the ,Berthiaume et al20 demonstrated that financial incentivesby a commercial insurer for implementation of"Get With The Guidelines" sponsored by the AmericanHeart Association resulted in rapid deployment of hospitalsecondary prevention programs for coronaryartery disease.

As healthcare costs continue to climb, purchasersare looking for new ways to ensure that their increasedhealthcare expenditures will result in healthier patientsand greater patient satisfaction. It appears likely thatone of the most effective ways that purchasers and payersmay accomplish this goal is by arranging for a portionof a provider's reimbursement to be tied toachieving high-quality outcomes. Ideally, purchasers,plans, providers, and patients should reach consensuson which outcomes are to be rewarded and which measuresare appropriate to use. Purchasers and payersshould link financial incentives to quality improvementefforts that will benefit the largest number of patientspossible, have easily identifiable and measurable performancemeasures, and are feasible for providers toimplement.

The appropriate use of evidence-based therapy hassubstantial health outcome and policy implications. Inthe future, substantial national funding and support forquality measurement and improvement initiatives willbe needed to implement the accumulating evidence ofeffective medical therapies into routine clinical practiceand thus translate efficacy into effectiveness.21 Webelieve that the science of knowledge application inmedicine is just beginning. Our medical care is evolvingfrom a culture of missed opportunity to a system ofaccountability. Physicians must partner with nurses,patients, hospitals, practice managers, insurers,employers, and information technologists in a constructivedialogue to successfully enter this new era.

From the Division of Cardiology, University of Michigan, Ann Arbor, Mich.

Address correspondence to: Debabrata Mukherjee, MD, Assistant Professor, Divisionof Cardiology, University of Michigan Health System, University Hospital, TC B1-226, 1500E. Medical Center Drive, Ann Arbor, MI 48103-0311. E-mail: dmukherj@umich.edu.

Heart Disease and Stroke Statistics–2004 Update

1. American Heart Association. . Dallas, Tex: American Heart Association; 2003.


2. Mukherjee D, Lingam P, Chetcuti S, et al. Missed opportunities to treat atherosclerosisin patients undergoing peripheral vascular interventions: insights from theUniversity of Michigan Peripheral Vascular Disease Quality Improvement Initiative(PVD-QI2). . 2002;106:1909-1912.


3. Mukherjee D, Fang J, Chetcuti S, Moscucci M, Kline-Rogers E, Eagle KA.Impact of combination evidence-based medical therapy on mortality in patients withacute coronary syndromes. . 2004;109:745-749.

J Gen Intern Med.

4. Ellis J, Erickson S, Stevenson J, Bernstein S, Stiles R, Fendrick A. Sub-optimalstatin adherence and discontinuation in primary and secondary prevention populations. 2004;19:638-645.

Am Heart J

5. Goff DC Jr, Gu L, Cantley LK, Sheedy DJ, Cohen SJ. Quality of care for secondaryprevention for patients with coronary heart disease: results of the Hastening theEffective Application of Research through Technology (HEART) trial. . 2003;146:1045-1051.

Annu Rev Public Health

6. Hennekens CH. Aspirin in the treatment and prevention of cardiovascular disease.. 1997;18:37-49.

N Engl J Med

7. Lau J, Antman EM, Jimenez-Silva J, Kupelnick B, Mosteller F, Chalmers TC.Cumulative meta-analysis of therapeutic trials for myocardial infarction. . 1992;327:248-254.


8. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomisedtrials of antiplatelet therapy for prevention of death, myocardial infarction,and stroke in high risk patients. . 2002;324:71-86.


9. Stafford RS. Aspirin use is low among United States outpatients with coronaryartery disease. . 2000;101:1097-1101.

J Am Coll Cardiol

10. Stafford RS, Radley DC. The underutilization of cardiac medications of provenbenefit, 1990 to 2002. . 2003;41:56-61.

Am J Manag Care

11. Andrade SE, Gurwitz JH, Field TS, et al. Hypertension management: the caregap between clinical guidelines and clinical practice. . 2004;10:481-486.

Am J Manag Care

12. Borzecki AM, Wong AT, Hickey EC, Ash AS, Berlowitz DR. Can we use automateddata to assess quality of hypertension care? . 2004;10:473-479.

J Crit Care

13. Landry MD, Sibbald WJ. Changing physician behavior: a review of patientsafety in critical care medicine. . 2002;17:138-145.

JFam Pract

14. Baskerville NB, Hogg W, Lemelin J. Process evaluation of a tailored multifacetedapproach to changing family physician practice patterns improving preventive care. . 2001;50:W242-W249.


15. Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematicreview of theoretic concepts, practical experience and research evidence in theadoption of clinical practice guidelines. . 1997;157:408-416.


16. Mehta RH, Montoye CK, Gallogly M, et al. Improving quality of care for acutemyocardial infarction: the guidelines applied in practice (GAP) initiative. . 2002;287:1269-1276.

Arch Intern Med.

17. Mehta RH, Das S, Tsai TT, Nolan E, Kearly G, Eagle KA. Quality improvementinitiative and its impact on the management of patients with acute myocardialinfarction. 2000;160:3057-3062.

Am J Manag Care

18. Zuckerman IH, Weiss SR, McNally D, Layne B, Mullins CD, Wang J. Impactof an educational intervention for secondary prevention of myocardial infarction onMedicaid drug use and cost. . 2004;10:493-500.


19. Gage BF, Boechler M, Doggette AL, et al. Adverse outcomes and predictorsof underuse of antithrombotic therapy in Medicare beneficiaries with chronic atrial fibrillation.. 2000;31:822-827.

Am J Manag Care

20. Berthiaume JT, Tyler PA, Ng-Osorio J, LaBresh KA. Aligning financial incentiveswith "Get With The Guidelines" to improve cardiovascular care. . 2004;10:501-504.

J Am Coll Cardiol

21. Spertus JA, Radford MJ, Every NR, et al. Challenges and opportunities inquantifying the quality of care for acute myocardial infarction: summary from theAcute Myocardial Infarction Working Group of the American HeartAssociation/American College of Cardiology First Scientific Forum on Quality ofCare and Outcomes Research in Cardiovascular Disease and Stroke. . 2003;41:1653-1663.

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