Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 4  |  Page : 202-209

Quality of Care for Patients with Acute Coronary Syndrome


1 Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
2 Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599, USA

Date of Submission22-Nov-2021
Date of Acceptance09-Dec-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Dong Zhao
Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2470-7511.334403

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  Abstract 


Acute coronary syndrome (ACS) is a severe clinical manifestation of ischemic heart disease with a high risk of death. The quality of care provided by the health system and medical providers to patients with ACS in daily clinical practice determines the likelihood of desired health outcomes or prognosis. This review provides an overview of several key issues in the quality of care for ACS, including how to measure the quality of care for ACS and the main strategies to improve the quality of care for ACS patients in both the acute and chronic phases. Efforts to improve the quality of care for ACS through specific programs in Western countries and in China are also described.

Keywords: Acute coronary syndrome; Quality of care; Quality indicators


How to cite this article:
Zhao D, Smith Jr. SC. Quality of Care for Patients with Acute Coronary Syndrome. Cardiol Plus 2021;6:202-9

How to cite this URL:
Zhao D, Smith Jr. SC. Quality of Care for Patients with Acute Coronary Syndrome. Cardiol Plus [serial online] 2021 [cited 2022 Jan 21];6:202-9. Available from: https://www.cardiologyplus.org/text.asp?2021/6/4/202/334403




  Introduction Top


Ischemic heart disease (IHD) is a leading cause of death in China and worldwide.[1],[2] Despite systematic, comprehensive, and evidence-based strategies for IHD prevention and treatment being well established in clinical guidelines, substantial discrepancies between guideline recommendations and daily clinical practice have been recognized in both developed and developing countries.[3],[4],[5] The failure to implement evidence-based strategies for IHD prevention and treatment implies certain deficiencies in the quality of care for patients with IHD provided by health services.

Acute coronary syndrome (ACS) is a severe clinical manifestation of IHD and is associated with a high risk of death. Therefore, the quality of care for patients with ACS is a high priority in the efforts to improve the quality of care for patients with cardiovascular disease (CVD) worldwide.

This review will provide an overview of important issues in the quality of care for patients with ACS, including current standards of quality evaluation for ACS, specific strategies to improve the quality of patient management, and important quality improvement programs for ACS in developed countries and in China.

Assessing the quality of care of patients with acute coronary syndrome

A widely used definition of the quality of care was proposed by the US Institute of Medicine in 1990. According to this definition, the quality of care provided by health service is “the degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”[6]

To assess the quality of care of patients with ACS in clinical practice, it is necessary to design a standardized performance measure or an index system with measurable quality indicators, (QIs). The selected QIs are generally based on strongly recommended treatment or management strategies for ACS by the clinical guidelines with the high level of evidence. The QIs should be periodically updated considering new evidence or accumulating experience in the management of the disease. Many professional CVD societies in different countries have developed and issued metrics to assess the quality of care for ACS or acute myocardial infarction (AMI).[7],[8],[9],[10]

The latest published metrics to assess the quality of care for ACS are the “2020 Update of the Quality Indicators for AMI issued by the European Society of Cardiology (ESC), Association of Acute Cardiovascular Care (ACVC).[7] The updated ESC ACVC QIs system includes nineteen primary QIs and eight secondary QIs that are distributed in the seven domains of AMI care.

The seven domains of AMI care and nineteen primary QIs in the ESC ACVC QIs system are briefly explained below:

  1. Central Organization. The three main QIs in this domain are: (a) the center should participate in a regular registry or program for quality assessment with written protocols for rapid and efficient management; (b) the hospital/center uses hs-cTn; and (c) prehospital interpretation of electrocardiography should be available
  2. Reperfusion/invasive strategy. Four main QIs are in this domain: (a) the proportion of patients with ST-segment elevation myocardial infarction (STEMI) who receive reperfusion; (b) the proportion of STEMI patients who receive timely reperfusion; (c) the proportion of NSTEMI patients who undergo invasive coronary angiography within 24 h of their diagnosis; and (d) radial access for invasive strategy
  3. In-hospital risk assessment. Two QIs are in this domain: (a) the proportion of patients who receive an assessment of left ventricular ejection fraction (LVEF) before hospital discharge; and (b) performance of low-density lipoprotein-cholesterol assessment during hospitalization
  4. Anti-thrombotic treatment during hospitalization. Two main QIs are in this domain: (a) the proportion of patients with “adequate P2Y12 inhibition” defined as: (the number of patients discharged with prasugrel, ticagrelor, or clopidogrel)/(the number of eligible patients); (b) use of parenteral anticoagulant at admission
  5. Secondary prevention discharge treatments. Three main QIs in this domain: (a) the proportion of patients discharged from hospital on high intensity statins (defined as atorvastatin ≥40 mg or rosuvastatin ≥20 mg) unless contraindicated; (b) use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers if LVEF is <40%; and (c) use of beta-blockers if LVEF is <40%
  6. Patient Satisfaction. Three main QIs in this domain: (a) feedback regarding the patient's experience, which is systematically collected from all patients, including attendance at an educational program, explanations provided by doctors and nurses, discharge information regarding what to do in case of recurrence of symptoms and timing of the visit, and pain control. (b) cardiac rehabilitation; and (c) quality of life
  7. Composite QI (CQI) and outcome QI. The CQI is an accumulating calculation of six individual primary QIs selected from primary QIs in the previous six domains in patients with an LVEF of ≥40%. The six main QIs that comprise the CQI are as follows: (a) the center should participate in a regular registry or program for quality assessment; (b) the proportion of STEMI patients with reperfusion and the proportion of NSTEMI patients receiving invasive coronary angiography within 24 h; (c) assessment of LVEF before hospital discharge; (d) discharge on adequate P2Y12 inhibition; (e) discharge on high-intensity statins; (f) systematically collected feedback on the patient's experience systematically collected. The outcome QI is the risk-adjusted 30-day mortality rate.[7]


There are many similarities among the QI systems for ACS/AMI issued by different professional organizations in different countries. [Table 1] is a comparison of primary QIs for ACS/AMI issued by the ESC, the American Heart Association (AHA)/ACC, and two quality improvement programs of the Chinese Society of Cardiology (CSC).[7],[8],[9],[10] While the most major QIs are the same in this comparison, some QIs issued by different organizations may have some differences. There are two type of differences. One type of difference is that some QIs issued by ESC metrics are not listed as QIs in the metrics of the ACC/AHA or two Chinese programs. Another type of difference is the same QI with different explanations. For example, beta-blocker use is a major QI of secondary prevention in the metrics issued by the ESC, the AHA/ACC, and two quality improvement programs of the CSC. However, ESC recommends using beta-blocker only in ACS patients with LVEF <40%, and the AHA/ACC, CSC programs recommend using beta-blocker in all ACS patients without the contraindications of beta-blocker.[7],[8],[9],[10] Furthermore, most of the QIs assess the performance of medical providers and few QIs measure the performance of a health system and adherence of the patients.
Table 1: Comparison of main quality indicators issued by European Society of Cardiology, American College of Cardiology/American Heart Association, Chinese Society of Cardiology and China ST-segment elevation myocardial infarction Care Project*

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Main strategies of quality improvement for acute coronary syndrome patient care

Many studies have demonstrated a notable gap between guideline recommendations and the clinical practice of ACS management both in the acute period and chronic period.[3],[4],[5],[11],[12] How to improve the quality of care for ACS in a community or a country? In 2020, WHO proposed a conceptual framework for strategies of improving the quality of care of CVD.[13]

The proposed strategies point out clearly the sharing responsibilities for the quality of care of CVD from multi-sectors of a community, included policymakers, health care system, health providers, and patients. In light of this framework, the specific areas for ACS quality care improvement are summarized as follows.

Strategies for improving quality of care for patients with acute coronary syndrome in the acute phase

The acute management of ACS includes prehospital care, emergency care and hospital care.

Health system strategies

The development of health system strategies depends on policymakers, administrators of the health system for a whole community, a city or even a country. Specific strategies are listed as follows.

  1. Improve the population awareness of acute symptoms of ACS, and of the importance of getting timely emergency medical help in hospitals with the capacity of ACS management
  2. Improve the availability and accessibility of hospitals with the capacity of primary percutaneous coronary intervention (PCI) for patients with STEMI or timely revascularization for patients with NSTE-ACS
  3. Improve the ambulance service and reduce the time from onset to proper medical treatment for ACS patients
  4. Strategically and reasonably locate hospitals to reduce treatment delays
  5. Develop and disseminate clinical guidelines and standards of evidence-based cares and train the care providers to deliver high-quality care for ACS.


Care provider strategies

Care providers include mainly the doctors, nurses and medical technicians who provide direct care for patients with ACS.

  1. Implement clinical practice guidelines in ACS management according to standardized clinical pathway algorithms
  2. Strengthen in-hospital education for ACS patients to increase their adherence to secondary prevention included unhealthy lifestyle modification and medical treatment
  3. Evaluate and monitor the quality of care for ACS patients by evidence-based and feasible metrics of QIs developed and updated by authoritative professional society.


Strategies for improving long term quality of care for acute coronary syndrome patients after discharge

Health system strategies

  1. Increase awareness of ACS patients discharged from hospitals for standardized long-term treatment of secondary prevention
  2. Improve availability and accessibility to health care and medications of secondary prevention for these patients
  3. Train care providers, especially the primary care providers to improve their ability of secondary prevention care for patients with a history of ACS
  4. Provide financial support for the quality improvement program
  5. Improve infrastructure, including health-care facilities and communication facilities.


Care provider strategies

  1. Educate providers and patients for the importance of secondary prevention and increase awareness of standardized treatment strategies
  2. Improve risk factors monitoring and management
  3. Improve adherence of patients to the recommended treatments
  4. Improve adherence of providers to recommendations of relevant clinical guidelines.


Quality of care programs for acute coronary syndrome/ischemic heart disease

As the concept of evidence-based medicine has become the cornerstone and basis of clinical practice, the issue that insufficient implementation of evidence-based treatment strategies by care providers in routine clinical practice was raised and recognized in the 1990s. Increasing efforts have been made to improving the quality of care for ACS and IHD by different professional organizations, medical societies, cardiologists, and policymakers. These programs may have different focuses on the strategies of improving the quality of care. Some programs of quality improvement focused on the performance of care providers for hospitalized ACS patients. Others covered prehospital care, care after discharge, and health system of the whole community.

The American Heart Association get with the guidelines

AHA get with the guidelines (GWTG) program started the pilot phase in the year 2000 as a national initiative of the AHA. The rationale of this program is that while evidence-based guidelines for AMI, HF, and Stroke care were developed along with improved diagnostic and treatment modalities, there were notable gaps or disparities in how these are applied.[14],[15],[16],[17] Many hospitals may not have the systems, organization, staff to provide highly reliable care at all times. The aim of GWTG is to improve care quality and guidelines adherence in patients hospitalized with CVD. Multiple strategies for quality improvement are used in the GWTG program. The strategies of the GWTG program for ACS include (a) a QI system based on the recommendations with strong evidence from updated guidelines. (b) QI relevant clinical data collected from the records of hospitalized patients with ACS; (c) continuous quality improvement efforts by a repetitive process of measurement and feedback on the QIs performance and sharing the goals of quality improvement among providers; (d) substantial administrative support for the quality improving efforts. GWTG program also uses collaborative learning sessions, conference calls, E-mail, and staff support to assist hospital teams to improve acute and secondary prevention care systems. A web-based Patient Management Tool is used for care data collection and decision support, on-demand reporting, communication, and patient education.[14],[15],[16],[17]

National Cardiovascular Data Registry (ACTION Registry–get with the guidelines)

National Cardiovascular Data Registry (NCDR) ACTION Registry-GWTG was established in 2007–2008 based on three large AMI registry programs in US, including AHA GWTG, National Registry of Myocardial Infarction and Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of ACC/AHA Guidelines (CRUSADE).[18]

The aims of NCDR ACTION Registry-GWTG were (a) serve as a national surveillance system to assess the characteristics, treatments, and outcomes of patients hospitalized with AMI, enrolling consecutive patients with ST-segment myocardial infarction (STEMI) and non-ST-segment myocardial infarction; (b) optimize the outcomes and management of AMI patients through the implementation of evidence-based guideline recommendations into clinical practice; (c) facilitate efforts to improve the quality and safety of AMI care through novel QI methods.[17] The important strategies of NCDR ACTION Registry-GWTG include that institution-specific performance feedback reports were sent to each hospital each quarter. The contents of the reports emphasize understanding what patients are entered into the registry, whether these patients received evidence-based care, and patient outcomes. Along with the site-specific data, there are some internal and external benchmarks as the visible comparative indicator for the quality of care in each center. Internal benchmarks include quality QIs changes over time. External benchmarks are (a) overall national benchmarks; (b) “like hospital” benchmarks (e.g., hospitals with similar invasive cardiac procedural facilities); and (c) an achievable benchmark of care that describes the composite guideline-recommended treatment provided at top-performing hospitals (e.g., “Top 10%”).[18],[19],[20]

European Society of Cardiology Euro Heart Survey acute coronary syndrome

Guideline adherence for ACS in Europe-wide was evaluated by regular cross-sectional surveys. ESC organized and sponsored the first largest survey named Euro Heart Survey ACS in the year 2000. The aims of this survey were to better delineate the characteristics, treatments, and outcomes of ACS patients treated in representative ESC-member countries, and particularly to examine the adherence to practice guidelines.[21] The initial survey included 10 484 patients from 25 ESC member countries with a final diagnosis of ACS. After the first survey in 2000, there were series surveys in 2004, 2006–2008, 2009, and 2015–2018 in European countries.[21],[22],[23],[24] A recent publication from the series survey summarized the substantial changes of quality of care for STEMI patients. The reperfusion therapy by PCI for STEMI patients in European countries increase from 21% in the first survey in 2000–2001 to 79% in the most recent surveys in 2015–2018. The proportions of STEMI patients without any reperfusion therapy decreased from 44% from the first survey in 2000–2001 to 8% in the most recent surveys in 2015–2018.[24]

European Action on Secondary and Primary Prevention by Intervention to Reduce Events

European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) is another large series of cross-sectional surveys for quality of care with extending scope that covered not only secondary prevention but also primary prevention of coronary heart disease (CHD). The first survey started in 1995–1996 in nine countries.[25] followed by second and third surveys in 1999–2000 in 15 countries and in 2006–2008 in 22 countries through the Euro Heart Survey program.[26],[27],[28] The fourth survey in 2012–2014 in 26 countries and the most recent fifth survey was in 2016–2017 among 131 centers in 27 countries.[29] The aim of EUROASPIRE surveys was to describe lifestyle and risk factors management in patients with CHD and people at high risk of developing CHD, and to see whether the practice of preventive cardiology had improved by comparison with the previous surveys. The levels of major risk factors and adherence to evidence-based treatments in the secondary prevention of CHD between The EUROASPIRE II (1999–2000), III (2006–2007), and IV (2012–2013) surveys were compared in one of the publications from this series study.[30] The study found during the period from 1999 to 2013, there were adverse lifestyle factors trends in patients surviving the development of coronary disease, characterized by high levels of persistent smoking and inexorable increases in obesity, central obesity, and diabetes. The deteriorated lifestyle risk factors reduced the gains made in improving blood pressure and lipid control. The researchers of EUROASPIRE appealed to deliver a comprehensive service addressing all aspects of lifestyle, medical risk factor control, and prescription of, and adherence with, evidence-based medications. All cardiovascular patients should be guaranteed access to modern preventive cardiology programs in every country to gain, beyond those initial lifesaving treatments, longer, healthier, and productive lives.

Improving care for cardiovascular disease in china project

Improving Care for Cardiovascular Disease in China (CCC) project is an ongoing program launched in 2014 as a collaboration with the AHA and the CSC.[9] The aims of the CCC ACS project were to improve patient care for ACS through evaluate the adherence of care providers to the guidelines recommended treatments for ACS patients and the effectiveness of quality improvement with timely feedback in China. Because hospital volumes and clinical capacities differ among geographic and economic regions, CCC recruited hospitals separately in different geographic-economic regions of mainland China. Total 150 tertiary hospitals and 84 secondary hospitals in nationwide were selected. The CCC-ACS project used modified performance measure metrics of ACC/AHA [Table 1] to evaluate the quality of care of ACS for the hospitals that joined this study. The program includes a circulated process of five key components, (a) to establish continuously registry of hospitalized ACS cases covered a wide range of hospitals in a country, (b) to assess the quality of care according to key QIs for individual patients, (c) to provide feedback for the quality assessment to the providers in each hospital and (d) to provide specific educational efforts that target on the deficient areas of quality of care; (e) provide recognition for providers or hospitals with high quality of care. Based on data of the CCC program, many problems in the quality of care for ACS in China have been identified.[31],[32],[33]

Clinical pathways for acute coronary syndromes in China

Clinical pathways for acute coronary syndromes in China (CPACS) is a prospective study of patients with suspected ACS admitted to tertiary and nontertiary urban hospitals throughout China. CPACS started in 2004 with an overall goal to maximize the use of evidence-based investigations and treatments in the management of patients admitted with suspected ACS to urban hospitals in China, and thereby improve clinical outcomes among such patients. It comprised three phases. CPACS-1 was a prospective survey to investigate the variation in management practices for patients with ACS admitted to both tertiary and nontertiary level hospitals throughout China. Nearly 3000 ACS patients from 51 hospitals across of China were included.[34] CPACS-2 aimed to evaluate the effects of the quality-of-care initiative after intensively promoting the implementation of a standardized clinical pathways for ACS care through multiple strategies. Totally 75 urban hospitals in China were included. The effects of the quality care initiative program were evaluated using both “before-after” comparison and a cluster randomized control trial. For the before-after comparison, the QIs of patient management were compared at each 6-month interval, including comparison with baseline and comparison with the previous 6 months. Furthermore, a cluster randomized control trial was conducted. One-half of the 75 participating hospitals were randomly allocated to commence the study in the 1st year of the full program while the remaining one-half were allocated to commence the study during the second year.[35] CPACS-3 was a stepped-wedge cluster randomized clinical trial that included 101 resource-constrained hospitals and 29 346 patients with ACS in China. The primary objective was to determine whether routinely using a clinical pathway–based, multifaceted quality of care initiative led to a measurable reduction in the number of in-hospital major adverse cardiovascular events in patients with ACS presenting to resource-limited hospitals in China. The criteria for resource-constrained hospitals were nontertiary centers with (1) more than 90 min taken to transfer a patient with ACS to the nearest large tertiary hospital with a cardiac catheterization laboratory, (2) no plans to develop the capacity for onsite PCI within the next 4 years.[36]

China ST-segment elevation myocardial infarction Care Project

CSCAP was established by the Chinese Medical Doctor Association and supported by the National Health Commission of China in 2011. The aims of ongoing CSCAP are to improve the quality of care for STEMI patients through the development of localized regional STEMI care networks.[11] The main strategies of CSCAP are improving the population awareness of health and emergency service for patients with STEMI, establishing and optimizing patients' care process, providing quality feedback and evaluation system. The specific goals are increasing the ratio of reperfusion treatment, shortening the overall duration of myocardial ischemia, and increasing adherence to standardized secondary prevention. The experience from CSCAP will be valuable for extending the STEMI care networks in nationwide. CSCAP includes three phases. CSCAP-1, including 53 tertiary hospitals from 14 provinces/municipalities/autonomous regions of China. All hospitals in CSCAP-1 can provide high quality and full time (24 h/day and 7 days/week) primary PCI (PPCI) service. Therefore, these hospitals play a leading role in local STEMI care network construction. CSCAP-2 recruited 244 PCI hospitals with affiliated non-PCI hospitals from 24 provinces/municipalities/autonomous regions. CSCAP-3 includes seven large cities. These cities are expected to develop a whole-city STEMI care network. The main strategies of CSCAP include (1) 13 key performance indexes as a metric of the STEMI quality of care were selected; (2) an evaluation, feedback, and improvement system were established. (3) The quality improvement for PPCI hospitals focused on the PPCI capacity and efficiency, non-PPCI hospitals focused on rapid diagnosis, thrombolysis, and referral capacity to PPCI hospitals, and EMS focused on the improvement in information transmission to alert hospitals early for rapid and accurate transfer.[10]

National Chest Pain Centers Program

The National Chest Pain Centers Program (NCPCP), launched in 2016, is an ongoing nationwide, hospital-based, multifaceted, continuous quality improvement program.[37] The aims of NCPCP are to improve the quality of care for patients with acute chest pain in nationwide hospitals. ACS is the commonest disease with acute chest pain. Compared with previous programs of quality improvement introduced in above, NCPCP depends more on the system strategies of improving quality of care. The main strategy of NCPCP is to accredit the chest pain centers for hospitals that submit applications according to China Chest Pain Center Accreditation Criteria, a multi-dimension criterion issued by CSC in 2013. The China Chest Pain Center Accreditation Criteria have been widely issued. If the performance of the chest pain center in a hospital meets the China Chest Pain Center Accreditation Criteria, this center will be accredited as a qualified chest pain center. A qualified chest pain center can provide a higher quality of care for patients with ACS. Up to 2020, NCPCP recruited 4621 hospitals. Among the hospitals, 1507 hospitals have been granted certification of qualified chest pain centers.[37]


  Summary Top


ACS is a severe stage of IHD with high risk of death. The quality of care provided by the health system and medical providers to patients with ACS in daily clinical practice determines the likelihood of desired health outcomes or prognosis of these patients. This review provides an overview of some key issues in the quality of care for ACS, including how to assess the quality of care for ACS and the main strategies to improve the quality of care for ACS in both the acute and chronic phases. The important national programs of quality improvement in the care of patients with ACS conducted in the US, Europe, and China are introduced.

Assessment of quality of care is a basic strategy in any effort aiming to improve the quality of care for this disease. The development of authoritative and updating metrics of QIs is a premise of the assessment of the quality of care. Improvement of quality of care in a community should rely on systematic approaches using both health system strategies and care provider strategies. The quality improvement programs or initiatives introduced in this review provide invaluable experience and guidance to future efforts to improve the care of CVD or other diseases in worldwide.

Financial support and sponsorship

Nil.

Conflicts of interest

Dong Zhao is an Editorial Board member of Cardiology Plus. The article was subject to the journal's standard procedures, with peer review handled independently of this Editorial Board member and their research groups.



 
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