Doing the Right Things and Doing Them the Right Way: The Association Between Hospital Guideline Adherence, Dosing Safety, and Outcomes Among Patients with Acute Coronary Syndrome
Background—Performance metrics currently focus on measurement of application of guidelines-indicated medications without considering appropriate dosing of these drugs.
Methods and Results—We studied 39,291 patients from CRUSADE with non-ST-segment elevation acute coronary syndromes. We evaluated hospital variability in composite use of ACC/AHA guidelines-recommended therapies (adherence) and the proportion of treated patients with recommended dose of heparins or a Gp IIb/IIIa antagonists (safety), and its association with risk adjusted in-hospital mortality and bleeding. Rates of composite guideline adherence (median 85% [25th, 75th percentile 82, 88]) and antithrombotic dosing safety (53% [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-hospitals mortality was inversely related to both guidelines adherence (OR-10% increment 0.80, 95% CI 0.67-0.94) and safety metrics (OR-10% increment 0.90, 95% CI 0.83-0.98). Safety was inversely related to major bleeding (adjusted OR-10% increment 0.93, 95% CI 0.87-0.98). Compared with hospitals with low adherence and safety (≤median performance) metrics, those with mixed performance metrics (high adherence and low safety, low adherence-high safety) had intermediate risk adjusted mortality rates while hospitals with above average performance on both metrics (>median performance) had a trend for lowest risk adjusted mortality rates (OR 0.83, 95% CI 0.68-1.01). Hospitals with high safety had lower bleeding compared 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.
- Received September 25, 2014.
- Revision received December 16, 2014.
- Accepted January 12, 2015.