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The Guidelines Applied in Practice (GAP) Initiative

Rajendra H. Mehta, MD, MS; Cecelia K. Montoye, MSN; Meg Gallogly, BA; Patricia Baker, MS; Angela Blount, MPH; Jessica Faul, MPH; Canopy Roychoudhury, PhD; Steven Borzak, MD; Susan Fox, MSN; Mary Franklin, CNS; Marge Freundl, MSN; Eva Kline-Rogers, MSN; Thomas LaLonde, MD; Michele Orza, ScD; Robert Parrish, MM; Martha Satwicz, MSN; Mary Jo Smith, MSN, MPH; Paul Sobotka, MD; Stuart Winston, DO; Arthur A. Riba, MD; Kim A. Eagle, MD; for the GAP Steering Committee of the American College of Cardiology

JAMA. 2002;287:1269-1276.

Context  Quality of care of patients with acute myocardial infarction (AMI) has received intense attention. However, it is unknown if a structured initiative for improving care of patients with AMI can be effectively implemented at a wide variety of hospitals.

Objective  To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI.

Design and Setting  The Guidelines Applied in Practice (GAP) quality improvement project, which consisted of baseline measurement, implementation of improvement strategies, and remeasurement, in 10 acute-care hospitals in southeast Michigan.

Patients  A random sample of Medicare and non-Medicare patients at baseline (July 1998–June 1999; n = 735) and following intervention (September 1–December 15, 2000; n = 914) admitted at the 10 study centers for treatment of confirmed AMI. A random sample of Medicare patients at baseline (January–December 1998; n = 513) and at remeasurement (March–August 2001; n = 388) admitted to 11 hospitals that volunteered, but were not selected, served as a control group.

Intervention  The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators; identification and assignment of local physician and nurse opinion leaders; grand rounds site visits; and premeasurement and postmeasurement of quality indicators.

Main Outcome Measures  Differences in adherence to quality indicators (use of aspirin, -blockers, and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion; smoking cessation and diet counseling; and cholesterol assessment and treatment) in ideal patients, compared between baseline and postintervention samples and among Medicare patients in GAP hospitals and the control group.

Results  Increases in adherence to key treatments were seen in the administration of aspirin (81% vs 87%; P = .02) and -blockers (65% vs 74%; P = .04) on admission and use of aspirin (84% vs 92%; P = .002) and smoking cessation counseling (53% vs 65%; P = .02) at discharge. For most of the other indicators, nonsignificant but favorable trends toward improvement in adherence to treatment goals were observed. Compared with the control group, Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge (5% vs 10%; P<.001). Use of aspirin on admission, ACE inhibitors at discharge, and documentation of smoking cessation also showed a trend for greater improvement among GAP hospitals compared with control hospitals, although none of these were statistically significant. Evidence of tool use noted during chart review was associated with a very high level of adherence to most quality indicators.

Conclusions  Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers. This initial project provides a foundation for future initiatives aimed at quality improvement.

Author Affiliations: Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor (Drs Mehta and Eagle, and Ms Kline-Rogers); American College of Cardiology, Bethesda, Md (Mss Montoye and Gallogly, and Dr Orza); Michigan Peer Review Organization, Plymouth (Mss Baker, Blount, and Faul, Dr Roychoudhury, and Ms Satwicz); Division of Cardiology, Department of Internal Medicine, Henry Ford Health System, Detroit, Mich (Dr Borzak, Ms Fox); Division of Cardiology, Department of Internal Medicine, St John Hospital and Medical Center, Detroit, Mich (Dr LaLonde); Disease Management, St John Health System, Warren, Mich (Ms Freundl); Greater Detroit Area Health Council, Detroit, Mich (Mr Parrish); Division of Cardiology, Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Mich (Ms Smith, Dr Winston); Department of Internal Medicine, Division of Cardiology, Detroit Medical Center, Detroit, Mich (Dr Sabotka); and Department of Internal Medicine, Division of Cardiology, Dearborn, Mich (Ms Franklin, Dr Riba).

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