Clinical governance of patients with acute coronary syndromes
Sergio Leonardi, Claudio Montalto, Greta Carrara, Gianni Casella, Daniele Grosseto, Marco Galazzi, Alessandra Repetto, Lorenzo Tua, Monica Portolan, Filippo Ottani, Marcello Galvani, Leandro Gentile, Laura Sofia Cardelli, Stefano De Servi, Andrea Antonelli, Gaetano Maria De Ferrari, Luigi Oltrona Visconti, Gianluca Campo, ACS Clinical Governance Programme Investigators, Rasheed Gazmawi, Filippo Andrea Valenza, Francesco Alfio Russo, Sebastiano Carli, Francesco Matteo Dioniso, Alberto Barengo, Chiara Castelli, Federico Fortuni, Anna Peschiera, Pamela Candito, Marco Scorza, Mauro Acquaro, Rita Camporotondo, Ilaria Costantino, Massimiliano Gnecchi, Stefania Guida, Rossana Totaro, Alessandra Repetto, Marco Ferlini, Alessandro Mandurino Mirizzi, Barbara Marinoni, Maurizio Ferrario, Arianna Elia, Stefano Perlini, GianMarco Secco, Chiara Manzalini, Veronica Lodolini, Elisa Mosele, Filippo Flamigni, Giulia Sammarini, Emanuele Daniello, Roberto Carletti, Elisa Conficoni, Roberto Franco Enrico Pedretti, Tiziana Staine, Sergio Leonardi, Claudio Montalto, Greta Carrara, Gianni Casella, Daniele Grosseto, Marco Galazzi, Alessandra Repetto, Lorenzo Tua, Monica Portolan, Filippo Ottani, Marcello Galvani, Leandro Gentile, Laura Sofia Cardelli, Stefano De Servi, Andrea Antonelli, Gaetano Maria De Ferrari, Luigi Oltrona Visconti, Gianluca Campo, ACS Clinical Governance Programme Investigators, Rasheed Gazmawi, Filippo Andrea Valenza, Francesco Alfio Russo, Sebastiano Carli, Francesco Matteo Dioniso, Alberto Barengo, Chiara Castelli, Federico Fortuni, Anna Peschiera, Pamela Candito, Marco Scorza, Mauro Acquaro, Rita Camporotondo, Ilaria Costantino, Massimiliano Gnecchi, Stefania Guida, Rossana Totaro, Alessandra Repetto, Marco Ferlini, Alessandro Mandurino Mirizzi, Barbara Marinoni, Maurizio Ferrario, Arianna Elia, Stefano Perlini, GianMarco Secco, Chiara Manzalini, Veronica Lodolini, Elisa Mosele, Filippo Flamigni, Giulia Sammarini, Emanuele Daniello, Roberto Carletti, Elisa Conficoni, Roberto Franco Enrico Pedretti, Tiziana Staine
Abstract
Aims: Using the principles of clinical governance, a patient-centred approach intended to promote holistic quality improvement, we designed a prospective, multicentre study in patients with acute coronary syndrome (ACS). We aimed to verify and quantify consecutive inclusion and describe relative and absolute effects of indicators of quality for diagnosis and therapy.
Methods and results: Administrative codes for invasive coronary angiography and acute myocardial infarction were used to estimate the ACS universe. The ratio between the number of patients included and the estimated ACS universe was the consecutive index. Co-primary quality indicators were timely reperfusion in patients admitted with ST-elevation ACS and optimal medical therapy at discharge. Cox-proportional hazard models for 1-year death with admission and discharge-specific covariates quantified relative risk reductions and adjusted number needed to treat (NNT) absolute risk reductions. Hospital codes tested had a 99.5% sensitivity to identify ACS universe. We estimated that 7344 (95% CI: 6852-7867) ACS patients were admitted and 5107 were enrolled-i.e. a consecutive index of 69.6% (95% CI 64.9-74.5%), which varied from 30.7 to 79.2% across sites. Timely reperfusion was achieved in 22.4% (95% CI: 20.7-24.1%) of patients, was associated with an adjusted hazard ratio (HR) for 1-year death of 0.60 (95% CI: 0.40-0.89) and an adjusted NNT of 65 (95% CI: 44-250). Corresponding values for optimal medical therapy were 70.1% (95% CI: 68.7-71.4%), HR of 0.50 (95% CI: 0.38-0.66), and NNT of 98 (95% CI: 79-145).
Conclusion: A comprehensive approach to quality for patients with ACS may promote equitable access of care and inform implementation of health care delivery.
Registration: ClinicalTrials.Gov ID NCT04255537.
Keywords: acute coronary syndromes; clinical governance; quality improvement.
Conflict of interest statement
Conflicts of interest: S.L. reports grants and personal fees from Astra Zeneca, personal fees from Daiichi Sankyo, personal fees from Bayer, personal fees from Pfizer/BMS, personal fees from ICON, personal fees from Chiesi, personal fees from Novonordisk, all outside the submitted work. C.M. has nothing to disclose. G.Carrara reports personal fee from Advice Pharma during the conduct of the study. G.Casella has nothing to disclose. D.G. reports he has participated in advisory boards for Amgen and for Sanofi, outside the submitted work. M.G., A.R., L.T., M.P., F.O., M.G., L.G., L.S.C., Dr. S.D.S., and A.A. have nothing to disclose. G.M.D.F. serves as member of the steering committee for Amgen and consultant for UCB. L.O.V. reports personal fees from Eli Lilly; personal fees from Daiichi Sankyo, personal fees from AstraZeneca; personal fees from Menarini; personal fees from Bayer; personal fees from Pfizer; personal fees from BMS; personal fees from Boehringer Ingelheim, all outside the submitted work. Prof. Campo reports grants from SMT; grants from Siemens; Grants from MEDIS; grants from Boston Scientific, grants from GE Healthcare, all outside the submitted work.
© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.
Figures
References
- Hunter DJ. The complementarity of public health and medicine - achieving “the highest attainable standard of health”. N Engl J Med 2021;385:481–484.
- Scally G, Donaldson LJ. Looking forward: clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61–65.
- Leonardi S, Montalto C, Casella G, Grosseto D, Repetto A, Portolan M, Fortuni F, Ottani F, Galvani M, Cardelli LS, De Servi S, Rubboli A, De Ferrari GM, Oltrona Visconti L, Campo G.. Clinical governance programme in patients with acute coronary syndrome: design and methodology of a quality improvement initiative. Open Heart 2020;7:e001415.
- Peterson ED, Roe MT, Chen AY, Fonarow GC, Lytle BL, Cannon CP, Rumsfeld JS.. The NCDR action registry-GWTG: transforming contemporary acute myocardial infarction clinical care. Heart 2010;96:1798–1802.
- Grambsch PM, Therneau TM. Proportional hazards tests and diagnostics based on weighted residuals. Biometrika 1994;81:515–526.
- Altman DG, Andersen PK. Calculating the number needed to treat for trials where the outcome is time to an event. BMJ 1999;319:1492–1495.
- Herrett E, Smeeth L, Walker L, Weston C, MINAP Academic Group. The myocardial ischaemia national audit project (MINAP). Heart 2010;96:1264–1267.
- Miller FG, Emanuel EJ. Quality-improvement research and informed consent. N Engl J Med 2008;358:765–767.
- Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, Brindis RG, Douglas PS.. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010;362:886–895.
- Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health 1999;89:1322–1327.
- Schiele F, Aktaa S, Rossello X, Ahrens I, Claeys MJ, Collet JP, Fox KAA, Gale CP, Huber K, Iakobishvili Z, Keys A, Lambrinou E, Leonardi S, Lettino M, Masoudi FA, Price S, Quinn T, Swahn E, Thiele H, Timmis A, Tubaro M, Vrints CJM, Walker D, Bueno H.. 2020. Update of the quality indicators for acute myocardial infarction: a position paper of the association for acute cardiovascular care: the study group for quality indicators from the ACVC and the NSTE-ACS guideline group. Eur Heart J Acute Cardiovasc Care 2021;10:224–233.
- Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, Leaming JM, Gavin LJ, Pacella CB, Hollander JE.. CT Angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 2012;366:1393–1403.
Source: PubMed