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Treatment of TRICARE Beneficiaries Diagnosed with Acute Myocardial Infarction

TriWest Healthcare Alliance oversees the quality and delivery of clinical health care for TRICARE West Region beneficiaries. TriWest’s Clinical Quality Management (CQM) department completed a study of network providers in 2007 that measured the hospital care of beneficiaries who presented to the emergency department (ED) with acute myocardial infarction (AMI) during 2006. The study included 11 indicators developed by the American Heart Association (AHA) and the American College of Cardiology (ACC).

Outcomes for several of the indicators favorably surpassed national averages. Beneficiaries received aspirin on ED arrival in 99 percent of the cases abstracted, and were given a prescription for aspirin on discharge 98 percent of the time. A beta-blocker was administered within 24 hours of arrival and prescribed on discharge 96 percent of the time. Reperfusion therapy was administered in 100 percent of instances where guidelines require it.

Providers received education on ways to improve outcomes where opportunities were identified. A re-measurement was conducted in April, 2008, of beneficiaries who presented to the ED with AMI during 2007.

Results of that re-measurement are summarized below:

Methodology of the re-measurement included ordering medical records for the entire population (N=747) of TRICARE West Region beneficiaries who presented to the ED with AMI between January 1, 2007 and December 31, 2007. After eliminating records not received during the audit period (n=13) and those excluded from the whole study (n=39), the team abstracted 687 medical records, or a little over 92 percent of the total population. The final population consisted of 518 men and 169 women. The number of men diagnosed with ST segment elevation myocardial infarction (STEMI) was 231. The number of men with non-STEMI (NSTEMI) was 287. The number of women diagnosed with STEMI was 45; the number of women with NSTEMI was 124.

Outcomes for all indicators re-measured met or surpassed national averages. Two of the increases were statistically significant. Compliance with time to percutaneous coronary intervention (PCI) increased from 45 percent to 82 percent (z=6.620; p=.000) and compliance with low-density lipoprotein cholesterol (LDL-c) assessment increased from 74 percent to 82 percent (z=3.767; p=.000). Compliance with another indicator, lipid-lowering medication prescribed at discharge, met our long-term goal of 96 percent.

Favorable outcomes such as these may be attributed in large part to providers who are utilizing policies and procedures that address both the complexity of treating AMI and the need for prompt treatment.

The TriWest CQM department has dentified the following opportunities that TriWest network providers can pursue to further improve the care of TRICARE West Region beneficiaries who present to the ED with AMI:

  • Prescribe angiotensin-converting enzyme inhibitor (ACEI) or Angiotensin II receptor blocker (ARB) at discharge when the ejection fraction is < 40 percent and there are no other known contraindications.
  • Provide adult smoking cessation advice or counseling when there is a positive history of smoking within the past year.
  • Decrease time from “door to balloon” for PCI to 90 minutes or less.
  • Assess LDL-c status during hospitalization, record known pre-hospital LDL-c level, or order the assessment to be done status post hospitalization.
The TriWest CQM department will re-measure the following indicators in 2009 for beneficiaries who presented to the ED with AMI in 2008: ACEI or ARB prescribed at discharge, adult smoking cessation advice/counseling provided, PCI performed within 90 minutes, and LDL-c assessed.

TriWest CQM has developed a short term goal of increasing compliance rates for these indicators by five percentage points. TriWest recommends you review your policies and procedures and update them as needed to ensure alliance with best practice standards for the treatment of AMI.

Further information about national compliance rates for these measures may be found by going to http://www.jointcommissionreport.org/ and clicking on Quality and 1Safety Performance Detail and then Heart Attack Care Performance Detail, or at Hospital Compare, http://www.hospitalcompare.hhs.gov/. To study them as originally developed by the AHA and the ACC go to http://content.onlinejacc.org/cgi/reprint/47/1/236.

We are looking forward to sharing the results of our second re-measurement in 2009.

Published Date: 08/27/2008