In-hospital Initiation of Cardiovascular Protective Therapies to Improve Treatment Rates and Clinical Outcomes

Abstract

Despite the scientific evidence that secondary prevention medical therapies reduce mortality in patients with established atherosclerosis, these therapies continue to be underused in patients receiving conventional care. To address this issue, the University of California, Los Angeles, Cardiovascular Hospitalization Atherosclerosis Management Program was implemented in 1994. This hospital-based system focused on initiation of antiplatelet therapy, beta-blocker, angiotensin-converting enzyme inhibitor, and statin therapy (irrespective of baseline low-density lipoprotein cholesterol) in conjunction with diet and exercise counseling in patients hospitalized with coronary artery and other atherosclerotic vascular disease. Preprinted orders, critical pathways, discharge forms, physician and nursing education, pocket cards, patient educational material, and treatment utilization reports facilitated program implementation. Statin use at the time of discharge increased from 6% before initiation of the program to 86% after the Cardiovascular Hospitalization Atherosclerosis Management Program was implemented (P < 0.001). Improved use of aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors was also observed. Importantly, in-hospital initiation of cardiovascular protective therapies had a dramatic effect on long-term treatment rates and patient compliance. The improved use of cardiovascular protective therapies was associated with a significant reduction in clinical events the first year after discharge: the death and nonfatal myocardial infarction rate decreased from 14.8% to 6.4% (odds ratio, 0.43; 95% confidence interval, 0.27-0.59; P < 0.01). These improved treatment rates have been sustained over an 8-year period. Compared with conventional care, the Cardiovascular Hospitalization Atherosclerosis Management Program has been associated with a significant increase in treatment utilization of evidence-based medications, more patients achieving low-density lipoprotein cholesterol less than 100 mg/dL, and improved clinical outcomes in patients hospitalized for cardiovascular disease. Hospital-based atherosclerosis treatment systems are an important step to help eliminate the cardiovascular treatment gap and dramatically reduce the death and disability caused by atherosclerotic vascular disease.