Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Quality Improvement in Acute Coronary Care: Combining the Use of an Interactive Quality Registry with a Quality Improvement Collaborative to Improve Clinical Outcome in Patients with Acute Myocardial Infarction
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The quality of care for Swedish patients with acute myocardial infarction (AMI) is continuously increasing. Nevertheless, a great potential for improvement still exists.

The aim of the present study was to design and implement a systematic quality improvement (QI) collaborative in the area of AMI care, and to validate its usefulness primarily by analyzing its effect on hospital adherence to national guidelines. Also, the impact on patient morbidity and mortality was to be evaluated. The intervention was based on proven QI methodologies, as well as interactive use of a web-based quality registry with enhanced, powerful feedback functions.

19 hospitals in the intervention group were matched to 19 similar control hospitals. In comparison with the control group, the intervention group showed significantly higher post-interventional improvements in 4 out of 5 analyzed quality indicators (significance shown for ACE-inhibitors, Clopidogrel, Heparin/LMWH, Coronary angiography, no significance for Lipid-lowering therapy).

From baseline to the post-intervention measurement, the intervention hospitals showed significantly lower all-cause mortality and cardiovascular re-admission rates (events per 100 patient-years; -2,82, 95% CI -5,26 to -0,39; -9,31, 95% CI -15,48 to -3,14, respectively). No significant improvements were seen in the control group.

The improved guideline adherence rates in the intervention hospitals were sustained for all indicators but one (ACE-inhibitors), this during a follow-up measurement three months after study support withdrawal. No effects were seen on any indicators other than those primarily targeted.

In conclusion, by combining a systematic QI collaborative with the utilization of a national quality registry, significant improvements in quality of care for patients with AMI can be achieved.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. , 66 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 813
Keyword [en]
Quality Improvement, Quality Registry, Acute Coronary Care, Guideline Adherence
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
URN: urn:nbn:se:uu:diva-180327ISBN: 978-91-554-8470-5 (print)OAI: oai:DiVA.org:uu-180327DiVA: diva2:550472
Public defence
2012-10-26, Enghoff salen, Uppsala University Hospital, Entrance 50, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2012-10-04 Created: 2012-09-03 Last updated: 2013-01-23Bibliographically approved
List of papers
1. Improving guideline adherence through intensive quality improvement and the use of a National Quality Register in Sweden for acute myocardial infarction
Open this publication in new window or tab >>Improving guideline adherence through intensive quality improvement and the use of a National Quality Register in Sweden for acute myocardial infarction
Show others...
2007 (English)In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 16, no 1, 25-37 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Data from the Swedish National Register in Cardiac Care have shown over the last 10 years an enduring gap between optimal treatment of acute myocardial infarction (AMI) according to current guidelines and the treatment actually given. We performed a controlled, prospective study in order to evaluate the effects of applying a multidisciplinary team-based improvement methodology to the use of evidence-based treatments in AMI, together with the use of a modified National Quality Register. The project engaged 25% of the Swedish hospitals. METHOD: Multidisciplinary teams from 20 hospitals participating in the National Register in Cardiac Care, ranging from small to large hospitals, were trained in continuous quality improvement methodology. Twenty matched hospitals served as controls. Our efforts were focused on finding and applying tools and methods to increase adherence to the national guidelines for 5 different treatments for AMI. For measurement, specially designed quality control charts were made available in the National Register for Cardiac Care. RESULTS: To close the gap, an important issue for the teams was to get all 5 treatments in place. Ten of the hospitals in the study group reduced the gap in 5 of 5 treatments by 50%, while none of the control hospitals did so. CONCLUSIONS: This first, controlled prospective study of a registry supported by multidisciplinary team-based improvement methodology showed that this approach led to rapidly improved adherence to AMI guidelines in a broad spectrum of hospitals and that National Quality Registers can be helpful tools.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-124560 (URN)17235249 (PubMedID)
Available from: 2010-05-04 Created: 2010-05-04 Last updated: 2017-12-12Bibliographically approved
2. Improved adherence to Swedish national guidelines for acute myocardial infarction: the Quality Improvement in Coronary Care (QUICC) study
Open this publication in new window or tab >>Improved adherence to Swedish national guidelines for acute myocardial infarction: the Quality Improvement in Coronary Care (QUICC) study
Show others...
2006 (English)In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 152, no 6, 1175-1181 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The adherence to evidence-based treatment guidelines for acute myocardial infarction (AMI) is still suboptimal. Therefore, we designed a study to evaluate the effects of a collaborative quality improvement (QI) intervention on the adherence to AMI guidelines. The intervention used a national web-based quality registry to generate local and regular real-time performance feedback. METHODS: A 12-month baseline measurement of the adherence rates was retrospectively collected, comprising the period July 1, 2001, through June 30, 2002. During the intervention period of November 1, 2002, through April 30, 2003, multidisciplinary teams from 19 nonrandomized intervention hospitals were subjected to a multifaceted QI-oriented intervention. Another 19 hospitals, unaware of their status as controls, were matched to the intervention hospitals. During the postintervention measurement period of May 1, 2003, through April 30, 2004, a total of 6726 consecutive patients were included at the intervention (n = 3786) and control (n = 2940) hospitals. The outcome measures comprised 5 Swedish national guideline-derived quality indicators, compared between baseline and postintervention levels in the control and QUICC intervention hospitals. RESULTS: In the control and QI intervention hospitals, the mean absolute increase of patients receiving angiotensin-converting enzyme inhibitors was 1.4% vs 12.6% (P = .002), lipid-lowering therapy 2.3% vs 7.2% (P = .065), clopidogrel 26.3% vs 41.2% (P = .010), heparin/low-molecular weight heparin 5.3% vs 16.3% (P = .010), and coronary angiography 6.2% vs 16.8% (P = .027), respectively. The number of QI intervention hospitals reaching a treatment level of at least 70% in 4 or 5 of the 5 indicators was 15 and 5, respectively. In the control group, no hospital reached 70% or more in just 4 of the 5 indicators. CONCLUSIONS: By combining a systematic and multidisciplinary QI collaborative with a web-based national quality registry with functionality allowing real-time performance feedback, major improvements in the adherence to national AMI guidelines can be achieved.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-23877 (URN)10.1016/j.ahj.2006.07.028 (DOI)000243110400031 ()17161072 (PubMedID)
Available from: 2007-02-15 Created: 2007-02-15 Last updated: 2017-12-07Bibliographically approved
3. Improved clinical outcome after acute myocardial infarction in hospitals participating in a Swedish quality improvement initiative
Open this publication in new window or tab >>Improved clinical outcome after acute myocardial infarction in hospitals participating in a Swedish quality improvement initiative
Show others...
2009 (English)In: Circulation. Cardiovascular quality and outcomes, ISSN 1941-7713, Vol. 2, no 5, 458-464 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The Swedish quality improvement initiative Quality Improvement in Coronary Care previously demonstrated significant improvements in caregiver adherence to national guidelines for acute myocardial infarction. The associated impact on 1-year clinical outcome is presented here. METHODS AND RESULTS: During the baseline period July 2001 to June 2002, 6878 consecutive acute myocardial infarction patients <80 years were included at the 19 intervention and 19 control hospitals and followed for a mean of 12 months. During the postintervention period of May 2003 to April 2004, 6484 patients were included and followed in the same way. From baseline to postintervention, improvements in mortality and cardiovascular readmission rates (events per 100 patient-years) were significant in the intervention group (-2.82, 95% CI -5.26 to -0.39; -9.31, 95% CI -15.48 to -3.14, respectively). However, in the control hospitals, there were no significant improvements (0.04, 95% CI -2.40 to 2.47; -4.93, 95% CI -11.10 to 1.24, respectively). Bleedings in the control group increased in incidence (0.92, 95% CI 0.41 to 1.43), whereas the incidence remained unchanged in the intervention group (0.07, 95% CI -0.44 to 0.58). When the difference of changes between the study groups were evaluated, the results still were in favor of the intervention group, albeit significant only for bleeding complications (mortality: -2.70, 95% CI -6.37 to 0.97; cardiovascular readmissions: -6.85, 95% CI -16.62 to 2.93; bleeding complications: -0.82, 95% CI -1.66 to 0.01). CONCLUSIONS: With a systematic quality improvement initiative aiming to increase the adherence to acute myocardial infarction guidelines, it is possible to achieve long-term positive effects on clinical outcome.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-124525 (URN)10.1161/CIRCOUTCOMES.108.842146 (DOI)000276078200011 ()20031877 (PubMedID)
Available from: 2010-05-04 Created: 2010-05-04 Last updated: 2013-01-23Bibliographically approved
4. Quality improvement in coronary care: Analysis of sustainability and impact on adjacent clinical measures after a Swedish controlled, multicenter quality improvement collaborative
Open this publication in new window or tab >>Quality improvement in coronary care: Analysis of sustainability and impact on adjacent clinical measures after a Swedish controlled, multicenter quality improvement collaborative
Show others...
2012 (English)In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, ISSN 2047-9980, E-ISSN 2047-9980, Vol. 1, no 4, e000737Article in journal (Refereed) Published
Abstract [en]

Background Quality Improvement in Coronary Care, a Swedish multicenter, controlled quality-improvement (QI) collaborative, has shown significant improvements in adherence to national guidelines for acute myocardial infarction, as well as improved clinical outcome. The objectives of this report were to describe the sustainability of the improvements after withdrawal of study support and a consolidation period of 3 months and to report whether improvements were disseminated to treatments and diagnostic procedures other than those primarily targeted.

Methods and Results Multidisciplinary teams from 19 Swedish hospitals were educated in basic QI methodologies. Another 19 matched hospitals were included as blinded controls. All evaluations were made on the hospital level, and data were obtained from a national quality registry, Swedish Register of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS-HIA). Sustainability indicators consisted of use of angiotensin-converting enzyme inhibitors, lipid-lowering therapy, clopidogrel, low-molecular weight heparin, and coronary angiography. Dissemination indicators were use of echocardiography, stress tests, and reperfusion therapy; time delays; and length of stay. At the reevaluation period of 6 months, the improvements at the QI intervention hospitals were sustained in all indicators but 1 (angiotensin-converting enzyme inhibitor). Between the 2 measurements, the control group improved significantly in all but 1 indicator (angiotensin-converting enzyme inhibitor). However, at the second measurement, the absolute adherence rates of the intervention hospitals were still numerically higher in all 5 indicators, and significantly so in 1 (clopidogrel). No significant changes were observed for the dissemination indicators.

Conclusions The combination of a systematic QI collaborative with a national, interactive quality registry might lead to substantial and sustained improvements in the quality of acute myocardial infarction care. However, to achieve disseminated improvements in adjacent clinical measures, those adjacent measures probably should be made explicit before any QI intervention.

Keyword
Acute myocardial infarction, guideline adherence, quality registry
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-180325 (URN)10.1161/JAHA.112.000737 (DOI)000326334800004 ()23130153 (PubMedID)
Available from: 2012-09-03 Created: 2012-09-03 Last updated: 2017-12-07Bibliographically approved

Open Access in DiVA

fulltext(2429 kB)313 downloads
File information
File name FULLTEXT01.pdfFile size 2429 kBChecksum SHA-512
76ae4c8a9c90e3b33c15c5a093184a147cab8490d9e7edae49c02b772f77532973cc82d5951c3f24e26ef57f3f5bf1dce51800d7adfd98c032d7976bb31c5d33
Type fulltextMimetype application/pdf
Buy this publication >>

Search in DiVA

By author/editor
Carlhed, Rickard
By organisation
Cardiology
Cardiac and Cardiovascular Systems

Search outside of DiVA

GoogleGoogle Scholar
Total: 313 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 733 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf