CRUSADE registry: Adherence to guidelines increasing

Better-performing hospitals have built multidisciplinary teams to focus on quality and process of care.

DALLAS — Analysis of data from the CRUSADE registry is revealing improvements over recent years in the care of patients with non ST-segment elevation acute coronary syndromes, as well as some shortcomings in that care.

E. Magnus Ohman, MD, Duke University Medical Center and CRUSADE executive committee co-chair, reviewed the American Heart Association 2005 Scientific Sessions’ array of oral and poster presentations about the registry. In an interview, Ohman said that CRUSADE is a national quality-improvement initiative designed to increase the practice of evidence-based medicine for patients diagnosed with NSTE ACS.

Treating to guidelines

Since CRUSADE’s inception in 2001, investigators have been collecting performance feedback data in a continuous cycle from more than 400 U.S. participating hospitals, with information from 150,000 patients currently available.

The good news, Ohman said, is that adherence to evidence-based medicine in NSTE ACS treatment, as reflected by compliance with ACC/AHA guidelines, has increased. In 2001 overall adherence was 65% for all hospitals; in the second quarter of 2005 it was 82%.

Furthermore, indirect evidence shows that patients treated according to guidelines benefit. For example, women with high-risk NSTE ACS who undergo coronary catheterization procedures within 48 hours of admission are significantly more likely to get ACC/AHA guideline-driven drugs on admission and at discharge, and they are significantly more likely to survive their hospitalization.

CRUSADE analyses also show that invasive management with cardiac catheterization is associated with lower mortality for all patients with severe CAD. Despite that, only about half of patients with moderate to high risk within the larger severe CAD category are actually managed invasively.

CRUSADE also revealed that hospitals with consistently better outcomes are not just following guidelines and using newer treatments. What seems to characterize better-performing hospitals, Ohman said, is the formation of multidisciplinary teams to focus on quality and process of care.

“The key to success is multidisciplinary quality improvement initiatives that generate excitement and ‘chemistry’ around doing the right thing. Team care is what improves care in medicine today,” Ohman said.

Guidelines not always followed

As expected, CRUSADE uncovered important departures from recommended practice. Ohman said that although guidelines recommend two antiplatelet agents for NSTE ACS patients — clopidogrel and low-dose aspirin — the majority of patients are assigned higher doses of aspirin. Elderly patients, in whom renal dysfunction is common, can end up with overdoses leading to bleeding, said Ohman.

“It’s not enough to get the medications right; we have to get the right medications in at the right level,” he said.

Awareness of findings from CRUSADE has led pharmacists at participating centers to become more proactive. “They’re the ones who adjust dosing and understand these issues better.”

Guidelines also state that no more than 10 minutes should transpire between hospital arrival and the first ECG for NSTE ACS patients. The average, however, is 35 minutes, Ohman said. This discovery “… got hospitals to look at their ER staffing and ask ‘what staff do I need to do this?’”

Weaknesses in guidelines

CRUSADE also uncovered weaknesses in guidelines. The recommended practice of giving IV morphine to high-risk NSTE ACS patients, it turns out, is associated with worse outcomes.

“We think that when you give patients morphine, it dulls their senses, which are really the warning system that tells them when they are in trouble. … That blunts the physician’s sense of urgency, as well,” Ohman said.

A medical student first brought attention to the issue by asking why morphine was given in this situation. “Then we looked at the data,” he said. – by Walter Alexander