Guideline adherence, safety don’t always go hand-in-hand at hospitals

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Cardiologists who want to improve patient outcomes need to strike a balance between evidence-based therapy and patient safety, according to a study published online Feb. 16 in Circulation.

Studies have shown a correlation between guideline-based therapies and patient outcomes, and between safety and improved patient outcomes. Together, guideline adherence and safety profiles have a significant effect on patient outcomes.

But the study, led by Rajendra H. Mehta, MD, associate consulting professor of clinical research at the Duke Clinical Research Institute in Durham, N.C., found a hospital or center that provides high quality of care doesn’t necessarily also provide a high level of patient safety.

Mehta and his team studied 39,291 patients from Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of ACC/AHA Guidelines (CRUSADE) with non-ST-segment elevation acute coronary syndromes. The team evaluated hospital variability in composite use of ACC/AHA guideline-recommended therapies and the proportion of treated patients with recommended dose of heparins or Gp IIb/IIIa antagonists and its association with risk-adjusted in-hospital mortality and bleeding.

Institutions that performed well on adherence to guideline recommendations and had better patient safety had a 42 percent decrease in odds of unadjusted overall in-hospital mortality. The reduction in unadjusted odds of mortality at institutions that excelled in either evidence-based treatment or patients safety, but not both, was 19 to 31 percent.

Among facilities with low or high adherence to guideline-based care, the risk of non-CABG major bleeding was lower in those with higher safety compared with those with lower safety. “Our data indicates that focusing only on guideline-based therapies (to improve ‘report-card’) without paying attention to safety could be potentially dangerous, as this often leads to increased risk of non-CABG major bleeding,” they wrote.

Dosage errors were made generally in patients who needed special consideration when dosage is prescribed. Often, physicians focused on prescribing the correct medicine but didn’t consider such factors as renal function, age of the patient, history of previous bleeding, history of stroke and more, Mehta told Cardiovascular Business.

If an institution’s mix of patients included people who were older, female, African-American, sick or frail, that institution tended to have lower safety marks, the study found.

Quality of patient care matrices should consider appropriate dosage prescribed, not just appropriate medications prescribed, the authors argued.

“The way hospitals are generally assessed is by the quality of care they provide,” Mehta said. “For example, the medication used, prescribing a certain lifestyle medication. But perhaps other things, such as medication usage in appropriate dosing, should also become a part of quality matrices. And hospitals should try to focus not only on appropriate medications but using them in the right dose to improve their outcomes.”