Adherence to Guidelines Doesn't Ensure ACS Inpatient Safety

Many regulatory and professional organizations monitor hospitals and health care organizations for compliance to treatment guidelines, equating the use of evidence-based processes to high-quality care.

However, the Institute of Medicine notes that many clinicians select therapies recommended by guidelines, but make “errors of commission,” such as incorrect dosing or use in patients with contraindications to the treatments. These errors of commission can cause adverse events.

Investigators from the Duke Clinical Research Institute and Duke University Medical Center recently looked at adherence to guidelines and appropriate drug dosing in patients with acute coronary syndrome (ACS). Their study, which was published ahead of print in the journal Circulation, hypothesized that hospitals with good adherence to guidelines would also have better patient safety records.

This large study examined data from 39,291 patients from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) trial. All patients had non-ST-segment elevation ACS.

The investigators evaluated 3 things:

• To assess adherence, they considered hospital compliance with ACC/AHA guideline-recommended therapies.
• To assess safety, they determined the proportion of patients treated with a recommended dose of heparins or glycoprotein IIb/IIIa antagonists.
• To determine outcomes, they looked at the association with risk-adjusted, in-hospital mortality and bleeding.

The results were surprising. Hospitals that were most likely to show proof of adhering to evidence-based therapies did not necessarily have good safety records. The opposite was also true in that some institutions that did not adhere to guidelines had good safety records.

However, hospital with consistently high adherence to guidelines and good safety profiles had fewer in-hospital deaths. Additionally, patients treated in hospitals with low safety scores were more likely to develop non-CABG-related major bleeding.

Institutions with mixed performance metrics—high adherence and low safety, or low adherence and high safety—had intermediate risk-adjusted mortality rates.

In light of their data, the authors recommended that hospitals avoid focusing solely on guideline-based therapies to improve quality scores. Appropriate dosing—an area in which pharmacists can be a primary resource—is also critical.