Update in Hospital Medicine

Quality Processes of Inpatient Care

Question: Is hospital adherence to guideline-recommended processes of care associated with reduced mortality rates for patients with non–ST-segment elevation acute coronary syndrome (ACS)?

Study Design: Cross-sectional analysis using hospital quality improvement registry data.

Patients: 64 775 patients with non–ST-segment elevation ACS. Patients who died during the first 24 hours were excluded from the denominator for assessment of acute care processes, and those who died during hospitalization were excluded from the discharge care assessment.

Setting: 350 U.S. academic and nonacademic centers.

Outcomes: Use of guideline-recommended treatments (aspirin, β-blocker, heparin, and intravenous glycoprotein IIb/IIIa inhibitors within the first 24 hours, and prescription of aspirin, β-blocker, clopidogrel, angiotensin-converting enzyme inhibitor, and lipid-lowering medication at discharge) and death.

Results: Care adhered to guideline recommendations in 74% of treatment opportunities, although medical centers varied greatly in guideline adherence. Composite guideline adherence correlated significantly with in-hospital death, with mortality rates decreasing from 6.31% for hospitals in the lowest quartile of adherence to 4.15% for those in the highest quartile (P < 0.001). After adjustment for several clinical factors, a patient's odds of dying was reduced by 10% for every 10% increase in a hospital's composite adherence (adjusted odds ratio, 0.90 [95% CI, 0.84 to 0.97]; P < 0.001).

Conclusion: Hospital-level adherence to guideline recommendations for care is statistically significantly associated with a reduced risk for death among patients with non–ST-segment elevation ACS.

Commentary: Care process measures are increasingly used to measure and report hospital quality despite limited data showing that they are associated with clinical outcomes. This study demonstrated an association with the single but clinically significant diagnosis of non–ST-segment elevation ACS; however, it did not establish a causal relationship between the processes and the outcomes …