A new study published in tomorrow's Journal of the American Medical Association suggests that, for heart patients to get the accepted standard of care, the doctors treating them need a system of gentle hints, such as checklists, stickers and reference cards.
"The records showed there was a significant increase in the number of patients who received recommended therapies when these reminder aids were used," says Dr. Rajendra H. Mehta, study author and assistant clinical professor of cardiology at the University of Michigan Public Health system.Not all doctors are taking the findings to heart.
"I think this research raises a suspicion that it may be more of a matter of a lack of documentation of treatment, rather than an issue of quality of care," says cardiologist Dr. Stephen Siegel, assistant professor of medicine at New York University School of Medicine.
The study, which involved 21 hospitals in the Michigan Public Health system, was prompted by earlier research showing there was an alarming disparity in the quality of care administered to heart attack patients at hospitals across the nation.
Even simple therapies, such as the use of aspirin to reduce damage from heart attack, were being overlooked, Mehta says.
Also neglected was the use of beta blocker medications, plus counseling about smoking cessation and the use of aspirin therapy after hospital release. All of those improved when the reminder system was put in place, Mehta says.
However, since the study results were garnered primarily from looking at medical charts, Siegel believes it only reflects what doctors reported, not what they did.
For example, Siegel says, most doctors won't write down that they counseled a patient about quitting smoking, although most routinely do.
"We might need to take a closer look at the documentation issue here before we draw any long-term conclusions about quality of care," Siegel says.
The study parameters were modeled on "The Guidelines Applied in Practice," or GAP, principles -- a standard of care endorsed by the American College of Cardiology.
The GAP strategies included in this study were the use of pre-written, or "standing," orders for medications; a clinical "pathway" indicating routine care; pocket/guide reminder cards for doctors and nurses; patient information forms; stickers for medical charts; a chart showing the overall hospital performance rate; a discharge checklist for doctors and nurses to review with patients; and patient education materials on therapy and lifestyle.
The research included 10 hospitals that agreed to implement the GAP guidelines, and 11 selected as a control group -- aware that an improvement in care was needed, but not using any specific program to implement changes.
At the start of the study, researchers looked at medical charts of 735 cardiac patients admitted to the 10 study sites from July 1998 to June 1999. They simultaneously viewed the charts of 513 patients in the 11 control hospitals.
Following use of the reminder strategies for a number of months, they again analyzed care standards for 914 patients admitted to the 10 study sites between Sept. 1, 2000, through Dec. 15, 2000. They also examined charts of 388 patients admitted to the 11 control hospitals from March 2001 through August 2001.
Mehta's group then analyzed baseline patient care through post-intervention care in the 10 study centers, and compared those findings to the standard of care given in the 11 control hospitals.
The result: The 10 hospitals that utilized the system of reminders saw an increase in aspirin use on admission, from 81 percent to 87 percent; an increase in use of beta blockers, from 65 percent to 74 percent; an increase in counseling on use of aspirin at hospital discharge, from 84 percent to 92 percent, and an increase in counseling on smoking cessation, from 53 percent to 65 percent. The greatest benefits were seen in patients over the age of 75.
Siegel says the reminder system isn't a bad idea, if used like airline pilots and astronauts use checklists to increase safety standards.
"If we can really show a correlation between reminder aids and better quality care, then it can be a worthwhile effort to have some kind of checklists available for doctors and nurses -- because the bottom line is you can never take enough precautions when it comes to saving a life," Siegel says.
What To Do
To learn the warning signs of heart attack, and how to reduce risks, visit this AHA site.