Management of Acute Coronary Syndromes at Hospital Discharge: Do Targeted Educational Interventions Improve Practice Quality?

Abstract

Evidence-based guidelines exist for the management of patients with acute coronary syndromes (ACS), yet adherence is suboptimal. The Discharge Management of Acute Coronary Syndrome project used a quality improvement approach, with targeted intervention strategies to optimize: prescription of guideline-recommended medications; education regarding lifestyle modifications, including cardiac rehabilitation (CR); and communication between hospital staff, patients, and general practitioners. Hospitals across Australia participated in a quality improvement cycle of audit, feedback, intervention, and reaudit. Interventions involved educational meetings, academic detailing and point-of-care reminders, and feedback of baseline audit results. Outcome measures included prescription of guideline-recommended medications, referral to CR, and documentation and communication of management plan. At baseline, 49 hospitals recruited 1,545 patients, and postintervention, 45 hospitals remained active in the project and recruited 1,589 patients. Three thousand and thirty-four hospital staff attended group education or academic detailing sessions. Postintervention, there was a significant increase in the prescription of all four guideline-recommended medications (69% vs. 57%; p<.0001); short-acting nitrates (68% vs. 56%; p<.0001); and documented referral to CR (68% vs. 57%; p<.0001). There were significant increases in documented discharge medication counselling, smoking cessation counselling, and communication of management plans. Targeted educational interventions used as part of a quality improvement cycle can enhance adherence to evidence-based guidelines for the management of patients with ACS.

Evidence-based interventions in primary care following acute coronary syndrome in Australia and New Zealand: a systematic scoping review

“…Wachtel (2008) [40]Retrospective cohort: analyses of hospital records & follow-up in GP clinicsRiverland, Australia34 MI patients with GP records, of 55 with hospital records, of 77 eligible participantsLifestyle managementPsychological managementa. Peterson (2012) [32]b. Wai (2012) [20]Before-after evaluation of a quality improvement program discharge care (ACS)AustraliaPre: 49 hospitals; 1545 ACS patients recruitedPost: 45 hospitals remained in program; 1589 ACS patients recruitedBehaviour changePharmacological management

ACS acute coronary syndrome, CABG coronary artery bypass grafting, CCU coronary care unit, CR cardiac rehabilitation, HF heart failure, MI myocardial infarction, NZ New Zealand, PCI percutaneous coronary intervention, RCT randomised clinical trial

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“…Wai (2012) [20]b. Peterson (2012) [32]To improve the management of ACS at the point of hospital discharge, across the continuum of careIn 2009, at a median of 96-day- follow-up (range 49–204):• 48 % reported using 4 evidence-based medications (EBMs), with a significant decrease in anti-platelet agents, statins, β blockers and all 4 EBMs• 67 % recalled referral to CR of whom 33 % completed CR and 21 % were still attending CR• 731 GPs (47 % of patient-nominated GPs) participated in survey• 77 % received a discharge summary for patients with ACS at a median time of 3 days (0–41 days) after discharge• Of these 88 % contained a list of prescribed medications; 81 % included dose titration and duration of therapy and 55 % contained details of ongoing risk management• 65 % of GPs rated the quality of information as ‘very good’ to ‘excellent’• 6 % increase in communication of ACS management plan to GP• 18 % increase in patients with documentated chest pain action planTargeted educational intervention can improve management of patients post-ACSImprovements evident in:• Evidence based prescribing• Communication between patient/carer 7 GP• Referrals to CR• Accuracy of sample representation not documented• Based on medical record documentation and GP survey• Potential for Hawthorne effect• Low response rate of eligible GPsMMAT: 75 % ACEi/ARB angiotensin-converting enzyme inhibitor/angiotensin-II receptor blocker, ACS acute coronary syndrome, β B beta-blockers, BMI body mass index, CABG coronary artery bypass grafting, CR cardiac rehabilitation, DAPT dual antiplatelet therapy, EBM evidence-based medication, GP general practitioner, GTN glycerol trinitrate, HDL high-density lipoprotein, LDL low-density lipoprotein, LLD lipid-lowering drugs, MMAT Mixed Methods Appraisal Tool, MI myocardial infarction, NSTEMI Non-ST elevation myocardial infarction, NZ New Zealand, PCI percutaneous coronary intervention, QI quality improvement, TC total cholesterol, UA unstable angina …”

“…When medication was stopped post-discharge, “the GP stopped it” was a major reason cited for discontinuation. The subsequent study to these baseline findings [32] did not report any medication usage rates in follow-up.…”

“…Toms et al [34] compared CR participants with non-participants in a observational study, and found that non-participants cited non-referral most commonly as the reason for their non-attendance, and that younger patients were more likely to be participate in CR. In results from a 2012 Australia-wide quality improvement study [32], both GPs and patients reported a 6 % increase in CR referral by GPs post-educational intervention ( n  = 636, p-values = 0.05 and 0.001 for GPs and patients, respectively).…”

Monitoring guideline adherence in the management of acute coronary syndrome in hospitals: design of a multicentre study

“…These efforts increased the likelihood that patients were treated on time with PCI [29], risk scores were documented [30] and the recommended discharge medication was prescribed [31]. Therefore the monitoring of guideline adherence as the foundation for targeted quality improvement efforts seems promising.…”