Evidence of disparity in the application of quality improvement efforts for the treatment of acute myocardial infarction: The American College of Cardiology's Guidelines Applied in Practice Initiative in Michigan
Received 23 December 2008; accepted 18 December 2009.
Background
Racial disparities exist in the management of patients with cardiovascular disease in the United States. The aim of the study was to evaluate if a structured initiative for improving care of patients with acute myocardial infarction (Guidelines Applied in Practice [GAP]) led to comparable care of white and nonwhite patients admitted to GAP hospitals in Michigan.
Methods
Medicare patients comprised 2 cohorts: (1) those admitted before GAP implementation (n = 1,368) and (2) those admitted after GAP implementation (n = 1,489). The main outcome measure was adherence to guideline-based medications/recommendations and use of the GAP discharge tool. χ2 and Fisher exact tests were used to determine differences between white patients (n = 2,367) and nonwhite patients (n = 490).
Results
In-hospital GAP tool and aspirin use significantly improved for white and nonwhite patients. β-Blocker use in hospital improved significantly for nonwhite patients only (66% vs 83.3%; P = .04). At discharge, nonwhite patients were 28% and 64% less likely than white patients to have had the GAP discharge tool used (P = .004) and receive smoking cessation counseling (P < .001), respectively. Among white patients, GAP improved discharge prescription rates for aspirin by 10.8% (P < .001) and β-blockers by 7.0% (P = .047). Nonwhite patients' aspirin prescriptions increased by 1.0% and β-blocker prescriptions decreased by 6.0% (both P values nonsignificant).
Conclusions
The GAP program led to significant increases in rates of evidence-based care in both white and nonwhite Medicare patients. However, nonwhite patients received less quality improvement discharge tool and smoking cessation counseling. Policies designed to reduce racial disparities in health care must address disparity in the delivery of quality improvement programs.
aDepartment of Medicine, Michigan State University, East Lansing, MI
bDepartment of Emergency Medicine, Wayne State University, Detroit, MI
cMichigan Peer Review Organization, Farmington Hills, MI
dSection of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
eDepartment of Cardiology, University of Michigan Health System, Ann Arbor, MI
ABSTRACT