BACKGROUND: Performance metrics currently focus on the measurement of the application of guideline-indicated medications without considering the appropriate dosing of these drugs. METHODS AND RESULTS: We studied 39 291 patients from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) registry with non-ST-segment elevation acute coronary syndromes. We evaluated hospital variability in the composite use of American College of Cardiology/American Heart Association guideline-recommended therapies (adherence) and the proportion of treated patients with the recommended dose of heparins or a glycoprotein IIb/IIIa antagonist (safety), and its association with risk-adjusted in-hospital mortality and bleeding. The rates of composite guideline adherence (median, 85%; 25th, 75th percentile, 82, 88) and antithrombotic dosing safety (median, 53%; 25th, 75th percentile, 45%, 60%) varied among hospitals. Correlation between hospital composite adherence and safety metrics was significant but low (r=0.16, P=0.008). Risk-adjusted in-hospital mortality was inversely related to both guideline adherence (odds ratio-10% increment, 0.80; 95% confidence interval, 0.67-0.94) and safety metrics (odds ratio-10% increment, 0.90; 95% confidence interval, 0.83-0.98). Safety was inversely related to major bleeding (adjusted odds ratio-10% increment, 0.93; 95% confidence interval, 0.87-0.98). In comparison with hospitals with low adherence and safety (≤median performance) metrics, those with mixed performance metrics (high adherence and low safety, low adherence and high safety) had intermediate risk-adjusted mortality rates, whereas hospitals with above-average performance on both metrics (>median performance) had a trend for lowest risk adjusted mortality rates (odds ratio 0.83; 95% confidence interval, 0.68-1.01). Hospitals with high safety had lower bleeding rates in comparison to those with low safety. CONCLUSIONS: Guideline adherence and dosing safety appeared to provide independent and complementary information on hospital bleeding and mortality, supporting the need for broader metrics of quality that should include measures of both guideline-based care and safety.
BACKGROUND: Performance metrics currently focus on the measurement of the application of guideline-indicated medications without considering the appropriate dosing of these drugs. METHODS AND RESULTS: We studied 39 291 patients from the Can Rapid Risk Stratification of Unstable AnginaPatients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) registry with non-ST-segment elevation acute coronary syndromes. We evaluated hospital variability in the composite use of American College of Cardiology/American Heart Association guideline-recommended therapies (adherence) and the proportion of treated patients with the recommended dose of heparins or a glycoprotein IIb/IIIa antagonist (safety), and its association with risk-adjusted in-hospital mortality and bleeding. The rates of composite guideline adherence (median, 85%; 25th, 75th percentile, 82, 88) and antithrombotic dosing safety (median, 53%; 25th, 75th percentile, 45%, 60%) varied among hospitals. Correlation between hospital composite adherence and safety metrics was significant but low (r=0.16, P=0.008). Risk-adjusted in-hospital mortality was inversely related to both guideline adherence (odds ratio-10% increment, 0.80; 95% confidence interval, 0.67-0.94) and safety metrics (odds ratio-10% increment, 0.90; 95% confidence interval, 0.83-0.98). Safety was inversely related to major bleeding (adjusted odds ratio-10% increment, 0.93; 95% confidence interval, 0.87-0.98). In comparison with hospitals with low adherence and safety (≤median performance) metrics, those with mixed performance metrics (high adherence and low safety, low adherence and high safety) had intermediate risk-adjusted mortality rates, whereas hospitals with above-average performance on both metrics (>median performance) had a trend for lowest risk adjusted mortality rates (odds ratio 0.83; 95% confidence interval, 0.68-1.01). Hospitals with high safety had lower bleeding rates in comparison to those with low safety. CONCLUSIONS: Guideline adherence and dosing safety appeared to provide independent and complementary information on hospital bleeding and mortality, supporting the need for broader metrics of quality that should include measures of both guideline-based care and safety.
Authors: Ramon Corbalan; Jean-Pierre Bassand; Laura Illingworth; Giuseppe Ambrosio; A John Camm; David A Fitzmaurice; Keith A A Fox; Samuel Z Goldhaber; Shinya Goto; Sylvia Haas; Gloria Kayani; Lorenzo G Mantovani; Frank Misselwitz; Karen S Pieper; Alexander G G Turpie; Freek W A Verheugt; Ajay K Kakkar Journal: JAMA Cardiol Date: 2019-06-01 Impact factor: 14.676
Authors: Robin Mathews; William Wang; Lisa A Kaltenbach; Laine Thomas; Rashmee U Shah; Murtuza Ali; Eric D Peterson; Tracy Y Wang Journal: Circulation Date: 2018-01-31 Impact factor: 29.690
Authors: Francesco Franchi; Fabiana Rollini; Jose Rivas; Andrea Rivas; Malhar Agarwal; Maryuri Briceno; Mustafa Wali; Ahmed Nawaz; Gabriel Silva; Zubair Shaikh; Naji Maailiki; Latonya Been; Andres M Pineda; Siva Suryadevara; Daniel Soffer; Martin M Zenni; Theodore A Bass; Dominick J Angiolillo Journal: JACC Basic Transl Sci Date: 2020-03-25
Authors: Jean-Pierre Bassand; Gabriele Accetta; Wael Al Mahmeed; Ramon Corbalan; John Eikelboom; David A Fitzmaurice; Keith A A Fox; Haiyan Gao; Samuel Z Goldhaber; Shinya Goto; Sylvia Haas; Gloria Kayani; Karen Pieper; Alexander G G Turpie; Martin van Eickels; Freek W A Verheugt; Ajay K Kakkar Journal: PLoS One Date: 2018-01-25 Impact factor: 3.240
Authors: Kumar Dharmarajan; Robert L McNamara; Yongfei Wang; Frederick A Masoudi; Joseph S Ross; Erica E Spatz; Nihar R Desai; James A de Lemos; Gregg C Fonarow; Paul A Heidenreich; Deepak L Bhatt; Susannah M Bernheim; Lara E Slattery; Yosef M Khan; Jeptha P Curtis Journal: Ann Intern Med Date: 2017-09-26 Impact factor: 51.598