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Almost Getting With the Guidelines: Fame or Shame?

      To the Editor:
      I am uncomfortable with Vaishnava and Eagle's
      • Vaishnava P.
      • Eagle K.A.
      Almost getting with the guidelines.
      satisfaction to observe the clear improvement over time with more than 90% adherence for each performance measure (aspirin within 24 hours, discharge with aspirin and beta-blockers, patients with low ejection fraction discharged with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, smoking-cessation counseling, use of lipid-lowering medication) for patients discharged after acute myocardial infarction.
      • Kumbhani D.J.
      • Fonarow G.C.
      • Cannon C.P.
      • et al.
      Predictors of adherence to performance measures in patients with acute myocardial infarction.
      First, this has been too slow, and tens of thousands of patients were denied adequate treatment for too long. Claiming that “deviations (from the standard of care) are considered medical errors” may explain why. Chronic lack of implementation of basic care is more than error, it is a faulty and damaging behavior of the profession.
      Second, smoking-cessation counseling is a totally inadequate indicator. These patients deserve intensive interventions, not counseling.
      • Smith P.M.
      • Burgess E.
      Smoking cessation initiated during hospital stay for patients with coronary artery disease: a randomized controlled trial.
      Moreover, the term “performance indicator” is confusing; this is only process, and we need outcome. The Joint Commission raised the bar with a new tobacco-cessation measure set, effective on January 1, 2012.
      • Fiore M.C.
      • Goplerud E.
      • Schroeder S.A.
      The Joint Commission's new tobacco-cessation measures–will hospitals do the right thing?.
      Vaishnava and Eagle
      • Vaishnava P.
      • Eagle K.A.
      Almost getting with the guidelines.
      should have looked forward: What is the percentage of patients taking beta-blockers 6 months after discharge or benefiting from cardiac rehabilitation program? Quality of care needs humility and ambition, not satisfaction.

      References

        • Vaishnava P.
        • Eagle K.A.
        Almost getting with the guidelines.
        Am J Med. 2013; 126: 4-5
        • Kumbhani D.J.
        • Fonarow G.C.
        • Cannon C.P.
        • et al.
        Predictors of adherence to performance measures in patients with acute myocardial infarction.
        Am J Med. 2013; 126: 74.e1-74.e9
        • Smith P.M.
        • Burgess E.
        Smoking cessation initiated during hospital stay for patients with coronary artery disease: a randomized controlled trial.
        CMAJ. 2009; 180: 1283-1284
        • Fiore M.C.
        • Goplerud E.
        • Schroeder S.A.
        The Joint Commission's new tobacco-cessation measures–will hospitals do the right thing?.
        N Engl J Med. 2012; 366: 1172-1174

      Linked Article

      • Almost Getting With the Guidelines
        The American Journal of MedicineVol. 126Issue 1
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          Although the past several years have seen remarkable advances in the management of cardiovascular disease, acute myocardial infarction remains one of the leading causes of morbidity and mortality globally.1 Pivotal trials of proven therapies and emerging science have informed the best practices of what we should do to improve outcomes. Despite this knowledge, there remains disconnect with what we actually sometimes do.
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      • The Reply
        The American Journal of MedicineVol. 126Issue 7
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          Though we thank Braillon for his commentary, we do not find shame in the Get with the Guidelines-Coronary Artery Disease (GWTG-CAD) quality improvement initiative. To the contrary, we would congratulate the hospitals that participated in the GWTG-CAD registry and were able to achieve greater than 90% adherence for each of 6 core performance measures.1 This is not shameful. GWTG-CAD is a hospital-based initiative. The analysis from Kumbhani et al suggests that GWTG-CAD is almost meeting its objectives of promoting adherence to guideline and evidence-based care during hospitalization for acute myocardial infarction.
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