Acute cardiac disease in the form of acute coronary syndromes (ACS) and congestive heart failure (CHF) remains the single largest cause of death in Australia, accounting for 197 000 hospitalisations per year at a cost of $579 million.1
Achieving optimal patient outcomes requires delivery of multiple forms of care by many clinicians over a care continuum spanning from presentation to emergency department to hospital discharge to general practice. Because of this complexity, several system failures can compromise quality and safety of care:2,3
delayed or incomplete diagnostic evaluation and risk-factor assessment;
omission, or delayed delivery, of effective treatments;
insufficient counselling of patients and carers about their condition and its management;
imperfect transfer of patient care information between hospital clinicians and general practitioners;
lack of timely, credible performance data for alerting health professionals to evidence–practice gaps; and
non-existent or underdeveloped methods for remediating identified deficiencies in care.
Audits of the quality of in-hospital care of patients with ACS and CHF admitted to three Brisbane teaching hospitals in late 2000 – early 2001 revealed opportunities for care improvement.2,3 Furthermore, after hospital discharge, patients with ACS do not always receive secondary prevention measures such as lipid-lowering therapy4 or cardiac rehabilitation,5 or achieve optimal control of risk factors.6 Population-based studies in Australia also suggest there are problems in ambulatory care of patients with CHF.7
The Brisbane Cardiac Consortium Clinical Support Systems Program (BCC-CSSP) sought to develop and implement a systematic, collaborative approach to achieving better in-hospital and after-hospital care of patients admitted with ACS or CHF, and to evaluate the impact of this program.
The Program involved three teaching hospitals (Royal Brisbane and Women’s [900 beds], Princess Alexandra [640 beds] and Queen Elizabeth II [165 beds]) and five Divisions of General Practice (Brisbane North, Brisbane Inner South, Brisbane Southside Central, Bayside, and Logan). The consortium undertook a 2-year quality improvement program coordinated by a multidisciplinary steering group of leading clinicians and supported by district health service managers, divisional boards, and senior executives of Queensland Health. Five working groups, each with hospital and general practice representation, undertook the following program tasks: decision support, performance measurement and feedback, clinical information systems, patient self-management (assisted by patient representation), and hospital–general practice integration.
Consecutive patients admitted to any of the three hospitals between 1 October 2000 and 31 August 2002, and who met the case definitions (Box 1), entered the program. Patients registered between 1 October 2000 and 17 April 2001 comprised the routine care (or baseline) group; those registered on or after 18 April 2001 and whose care involved the quality improvement program were the intervention group. Quality of in-hospital care was assessed in all patients; quality of after-hospital care was assessed in a subset of patients who met eligibility criteria (Box 2) and provided written informed consent.
The targeted professionals were all consultant physicians, medical registrars and residents, nurses, clinical pharmacists and allied health professionals (n ≈ 450) working in cardiology, general medicine and emergency departments of participating hospitals; and all GPs (n ≈ 1080) who were members of the participating Divisions.
Quality improvement interventions (QIIs) selected for implementation after reviewing published literature8 and expert opinion included the following (resource materials and technical reports are available from our website <www.heath.qld.gov.au/bcc>).
Locally endorsed, evidence-based, clinical-practice guidelines disseminated to hospital clinicians and GPs as full-text guidelines, flow-chart pocket cards, laminated desktop guides, wall posters, and computer-based formats.
Guideline-based reminders such as management checklists attached to hospital observation charts and chart stickers invoking consideration of specific treatments in eligible patients.
Clinical pathways for chest pain assessment and management in the emergency department.
Discharge summaries and practice evaluation forms issued to GPs, which acted to reinforce key management recommendations.
Periodic educational presentations (eg, “grand rounds”, seminars, and workshops), hospital newsletter articles (eg, hospital drug and therapeutics bulletins, and divisional newsletters), case-based unit and departmental meetings.
Academic detailing of hospital clinicians by trained clinical pharmacists, and of GPs, individually or in small groups (about 4–5), by trained detailers with no links to pharmaceutical companies.
Feedback to target clinicians of quality indicators (see below) for in-hospital care every 6 months, and for after-hospital care at 8, 16 and 24 months after program commencement.
Feedback of personalised quality indicators to individual in-hospital consultant units.
Provision of patient self-management kits, comprising educational booklets (with treatment-specific risk-reduction estimates), patient diaries, individualised management plans, and self-explanatory medication lists.
Pharmacist counselling of individuals about lifestyle changes, drug therapy, and risk-factor modification.
After-discharge telephone follow-up by clinical pharmacists of high-risk patients (more than five classes of drugs, admission within previous 6 months, non-compliance, multiple comorbidities, age > 75 years, social isolation, risk of drug–drug interactions).
Standardised discharge referral summaries with individualised treatment targets, advice on drug indications and monitoring, and follow-up arrangements.
Copies of medication lists forwarded to patients’ community pharmacists at discharge, with telephone call from hospital pharmacist in selected cases.
Telephone prompts to consenting patients to undertake follow-up visits to GPs.
Evidence-based, process-of-care indicators for in-hospital and after-hospital care were developed by consensus, as described elsewhere.2,3,9 In-hospital indicators were reported as the proportions of highly eligible patients (definite indication; no contraindication) who received specific care processes. Defining the indicator using eligibility criteria circumvented criticism from treating clinicians that indicators reported for their patients had not been adjusted for variation in casemix or risk. After-hospital care indicators were reported as overall rates, as detailed eligibility data could not be collected. In-hospital care data were abstracted retrospectively from patient records by trained nurses; after-hospital care data were obtained from GPs using standardised forms issued at 3, 6 and 12 months after discharge.
We assessed changes in the following indicators, measured on all patients, between routine care (1/10/00 – 17/4/01) and final intervention (15/2/02 – 30/8/02) cohorts:
proportions of inpatients receiving specific forms of care;
risk-adjusted, all-cause mortality at 30 days, 6 months and 12 months after discharge;
median length of index hospital stay; and
rates of same-cause readmission at 30 days.
Changes in after-hospital care were assessed by comparing indicators, measured at 3 and 6 months after discharge, between all evaluable routine care and intervention patients.
Proportions and medians were compared using χ2 and Mann–Whitney tests, respectively. Mortality rates were risk adjusted using logistic regression analysis models (C-statistic10 0.80 for ACS, and 0.75 for CHF).
Over a period of 23 months, 1594 patients with ACS and 904 patients with CHF met the case definitions and were registered. In-hospital data and all-cause mortality up to 12 months after discharge were collected for all patients. In all, 662 (42%) patients with ACS and 364 (40%) with CHF were eligible and consented to undergo follow-up to assess their after-hospital care. Evaluable data were obtained from 405 (61%) and 183 (50%) of these patients at 3 months, and from 344 (52%) and 151 (42%) at 6 months, respectively. Patient characteristics, risk factors and specialty of admitting clinician for both conditions were not significantly different between the routine care and the intervention groups (data not shown).
A brief summary of program effects follows; more detailed results are available at <www.health.qld.gov.au/bcc>.
In-hospital care (Boxes 3, 4): Compared with the routine-care group, significant increases were seen in the number of intervention patients with ACS receiving the following: timely electrocardiography after emergency department presentation; angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge; inpatient cardiac counselling; and referral to outpatient cardiac rehabilitation.
For patients with CHF, significant increases were seen in the numbers of intervention patients receiving the following: assessment for reversible, acute precipitants of cardiac decompensation; prophylaxis for deep venous thrombosis; requests for thyroid function tests (in those with atrial fibrillation); β-blocker prescription at discharge; and a recorded review of patient medications by clinical pharmacists. There was a trend towards increased use of imaging to assess left ventricular function.
After-hospital care: Relative to usual-care patients, more intervention patients with ACS were prescribed aspirin at 3 months (89% v 82%; P = 0.05), and, among those prescribed aspirin and β-blockers at discharge, more continued to receive these drugs at 3 months (92% v 84% [P = 0.03] and 85% v 76% [P = 0.05], respectively). For patients with CHF, more intervention than usual-care patients received β-blockers at 3 months (60% v 39%; P = 0.01) and at 6 months received ACE inhibitors (85% v 70%; P = 0.04); achieved ideal blood pressure levels (68% v 44%; P = 0.01); and were monitored for weight and salt/fluid intake (57% v 44%; P = 0.02).
Risk-adjusted mortality rates for patients with ACS trended downward from 5.0% to 3.8% at 30 days from 9.8% to 7.4% (P = 0.06) at 6 months and from 13.4% to 10.1% (P = 0.06) at 12 months. More notable reductions were seen for patients with CHF — 8.2% to 5.3% (P = 0.04), 22.8% to 15.2% (P < 0.001) and 32.8% to 22.4% (P = 0.005), respectively.
The median length of hospital stay for patients with ACS reduced by one day (from 7.0 to 6.0 days; P = 0.01), while that for patients with CHF remained unchanged (7.0 days). Same-cause readmission rates were not statistically different: 7.4% v 4.9% in ACS; 5.0% v 5.8% in CHF.
Focus-group discussions and surveys suggested that clinicians welcomed regular performance feedback and felt it had influenced their practice. Clinical guidelines and patient management plans were also regarded positively.
Program attributes which interviewed patients (n = 36) regarded very positively included provision of self-management materials and pharmacist counselling, support from relatives and GPs, empowerment in making care choices, and therapeutic relationship with clinicians based on good communication. Suggested further improvements included deferring education to a later time after hospital discharge, greater customisation of health information according to individual circumstances, and more psychosocial support. The BCC-CSSP heart failure patient information booklet was rated as one of the best four resources of its kind in Australia in a review recently conducted by the National Institute for Clinical Studies.11
Our results may be subject to bias, as the study was unblinded, used historical controls, and achieved follow-up of after-hospital care in only 50% of registered patients. However, the mortality end-points at 6 and 12 months were ascertained for all patients and were risk-adjusted; in-hospital data were obtained for the entire cohort; and the total intervention period of less than 18 months minimised the effects of secular trends.
Better care of patients with ACS or CHF can be achieved by implementing systems of decision support, targeted provider education and performance feedback, patient self-management, and hospital–community integration. The BCC-CSSP was unique in seeking to optimise patient care across two sectors of healthcare.
It is impossible to attribute specific process-of-care changes to specific QIIs within a multifaceted program. Systematic reviews reveal no singularly successful QII, and instead recommend deployment of multiple interventions.8
Processes of care directly controlled by individual clinicians (eg, drug prescribing) are readily amenable to behavioural change. Those more dependent on multilevel interactions within care systems (eg, emergency department triage or treatment responses, and timely access to complex modalities such as stress testing and cardiac rehabilitation) require interdisciplinary collaboration and/or work practice redesign, and hence change more slowly.
Our experience suggests the following pre-requisites: identification of problematic areas of care from practice audits; multidisciplinary quality improvement teams; multifaceted change strategies; ongoing performance feedback; and support of both managerial and clinical leaders. Various inhibiting factors will need to be overcome using locally designed solutions (Box 5).
The methods of BCC-CSSP have been extended into multihospital collaborations throughout Queensland targeting cardiac care, renal medicine and acute stroke care under the auspices of the Collaboratives for Healthcare Improvement instigated by Queensland Health (details available at <http://www.health.qld.gov.au/chi/default.asp>).
We are currently collecting data on long-term outcomes, readmissions and hospital costs in an effort to assess return on investment of our program,12 and such analyses will be the topics of future reports.
1: Case definitions
Acute coronary syndromes (ACS): Patients with a recorded acute clinical diagnosis of ACS at 48 hours after presentation and elevated serum cardiac markers: creatine kinase level more than twice, or troponin level more than 1.5 times, upper normal reference range.
Congestive heart failure (CHF): Patients with a recorded acute clinical diagnosis of CHF at 48 hours after presentation and two or more of the following diagnostic features: raised jugular venous pressure; third or fourth heart sounds; bilateral chest crackles to mid-zones; dependent oedema; cardiomegaly or pulmonary oedema on chest x-ray.
2: Patient eligibility criteria for interventions after discharge
Patients meeting the case definition whose usual GP practised in Greater Brisbane, and who had none of the following exclusion criteria: inability to participate in self-care due to mental or physical incapacity; resident of nursing home; terminal non-cardiac illness with life expectancy < 6 months.
3: Changes in process-of-care indicators for patients with acute coronary syndromes after quality improvement interventions (QIIs)
Baseline |
After QII |
||||||||||
(1/10/00 – 17/4/01) |
(15/2/02 – 31/8/02) |
||||||||||
Indicator |
n = 428 |
n = 435 |
P |
||||||||
ECG within 10 minutes of hospital arrival |
|
|
|
||||||||
No. (%) of patients presenting directly to ED |
145/238 (61%) |
170/243 (70%) |
0.05 |
||||||||
Thrombolysis |
|
|
|
||||||||
No. (%) of highly eligible patients presenting directly to ED |
49/49 (100%) |
39/39 (100%) |
na |
||||||||
Thrombolysis within 30 minutes of hospital arrival |
|
|
|
||||||||
No. (%) of patients receiving thrombolysis |
17/49 (35%) |
16/39 (41%) |
0.59 |
||||||||
Lipid status documented |
|
|
|
||||||||
No. (%) of all patients |
311/428 (73%) |
335/435 (77%) |
0.12 |
||||||||
β-Blockers prescribed at discharge* |
|
|
|
||||||||
No. (%) of highly eligible patients |
212/251 (84%) |
202/239 (85%) |
0.97 |
||||||||
No. (%) of all patients |
284/351 (81%) |
298/371 (81%) |
0.90 |
||||||||
Antiplatelet agents prescribed at discharge* |
|
|
|
||||||||
No. (%) of highly eligible patients |
301/318 (95%) |
321/334 (96%) |
0.39 |
||||||||
No. (%) of all patients |
319/351 (91%) |
344/371 (93%) |
0.30 |
||||||||
ACE inhibitors prescribed at discharge* |
|
|
|
||||||||
No. (%) of highly eligible patients |
105/143 (73%) |
113/139 (81%) |
0.12 |
||||||||
No. (%) of all patients |
222/351 (63%) |
261/371 (71%) |
0.04 |
||||||||
Lipid-lowering agents prescribed at discharge* |
|
|
|
||||||||
No. (%) of highly eligible patients |
165/202 (82%) |
197/223 (89%) |
0.04 |
||||||||
No. (%) of all patients |
254/351 (72%) |
293/371 (79%) |
0.03 |
||||||||
Early coronary angiography (during admission or within 30 days of discharge) |
|
|
|
||||||||
No. (%) of highly eligible patients |
41/45 (91%) |
43/46 (93%) |
0.82 |
||||||||
No. (%) of all patients |
223/428 (52%) |
236/435 (54%) |
0.53 |
||||||||
Non-invasive stress testing (during admission or within 30 days of discharge) |
|
|
|
||||||||
No. (%) of highly eligible patients |
17/57 (30%) |
17/55 (31%) |
0.89 |
||||||||
No. (%) of all patients |
72/428 (17%) |
86/435 (20%) |
0.27 |
||||||||
Cardiac counselling before discharge* |
|
|
|
||||||||
No. (%) of all patients |
168/351 (48%) |
212/371 (57%) |
0.009 |
||||||||
Referral to outpatient cardiac rehabilitation* |
|
|
|
||||||||
No. (%) of all patients |
28/351 (8%) |
64/371 (17%) |
<0.001 |
||||||||
*Denominator is number of patients discharged alive and not transferred. ECG = electrocardiogram. ED = emergency department. na = not applicable. ACE = angiotensin-converting enzyme. Highly eligible patients are those with definite indication and no contraindication to the stated intervention. |
|||||||||||
4: Changes in process-of-care indicators for patients with congestive heart failure after quality improvement interventions (QIIs)
Baseline |
After QII |
||||||||||
(1/10/00 – 17/4/01) |
(15/2/02 – 31/8/02) |
||||||||||
Indicator |
n = 220 |
n = 235 |
P |
||||||||
Assessment of acute reversible triggers |
|
|
|
||||||||
No. (%) of all patients |
166/220 (75%) |
211/235 (90%) |
<0.001 |
||||||||
Prescribing of explicit fluid orders |
|
|
|
||||||||
No. (%) of all patients |
89/220 (40%) |
128/235 (54%) |
0.002 |
||||||||
Weighed daily for first 3 days of hospitalisation |
|
|
|
||||||||
No. (%) of all patients |
121/220 (55%) |
148/235 (63%) |
0.59 |
||||||||
DVT prophylaxis |
|
|
|
||||||||
No. (%) of highly eligible patients |
31/104 (30%) |
94/128 (73%) |
<0.001 |
||||||||
No. (%) of all patients |
57/220 (26%) |
148/235 (63%) |
<0.001 |
||||||||
Request for thyroid function tests |
|
|
|
||||||||
No. (%) of highly eligible patients |
16/31 (52%) |
41/52 (79%) |
0.01 |
||||||||
No. (%) of all patients |
124/220 (56%) |
165/235 (70%) |
0.002 |
||||||||
Imaging of left ventricular function |
|
|
|
||||||||
No. (%) of all patients |
135/220 (61%) |
164/235 (70%) |
0.06 |
||||||||
Scheduled clinic follow-up within 30 days of discharge* |
|
|
|
||||||||
No. (%) of all patients |
87/191 (46%) |
130/219 (59%) |
0.005 |
||||||||
Clinical pharmacist review before discharge* |
|
|
|
||||||||
No. (%) of all patients |
105/191 (55%) |
142/219 (65%) |
0.04 |
||||||||
ACE inhibitors prescribed at discharge* |
|
|
|
||||||||
No. (%) of highly eligible patients |
58/71 (82%) |
61/71 (86%) |
0.68 |
||||||||
No. (%) of all patients |
136/191 (71%) |
163/219 (74%) |
0.46 |
||||||||
β-Blocker prescribed at discharge* |
|
|
|
||||||||
No. (%) of highly eligible patients |
47/135 (35%) |
88/152 (58%) |
<0.001 |
||||||||
No. (%) of all patients |
61/191 (32%) |
113/219 (52%) |
<0.001 |
||||||||
Warfarin prescribed at discharge* |
|
|
|
||||||||
No. (%) of highly eligible patients |
22/50 (44%) |
27/63 (41%) |
0.68 |
||||||||
No. (%) of all patients |
46/191 (24%) |
41/219 (19%) |
0.19 |
||||||||
Avoidance of deleterious agents† at discharge* |
|
|
|
||||||||
No. (%) of all patients |
180/191 (94%) |
214/219 (98%) |
0.79 |
||||||||
*Denominator is number of patients discharged alive and not transferred to other institutions. † Agents that are negatively inotropic, proarrhythmic or engender fluid retention (non-dihydropyridine calcium antagonists, non-steroidal anti-inflammatory agents, tricyclic antidepressants, class 1 antiarrhythmic agents). DVT = deep venous thrombosis. ACE = angiotensin-converting enzyme. Highly eligible patients are those with a definite indication and no contraindication to the stated intervention. |
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5: Program inhibitors and solutions
Potential inhibitor |
Solution adopted |
||||||||||
Failure to engage all key participants on equal terms |
|
||||||||||
Failure to articulate a clear and agreed vision and operational plan |
|
||||||||||
Failure to formulate quality targets and measures for evaluating program effects over time |
|
||||||||||
Lack of timely, credible and interpretable performance data |
|
||||||||||
Lack of program effects on clinical practice |
|
||||||||||
Failure to forge collaboration between hospital units and between hospitals and general practice |
|
||||||||||
Failure to gain support from senior office-holders in challenging current culture |
|
||||||||||
Failure to gain and maintain interest and involvement of practising clinicians |
|
||||||||||
- Ian A Scott1
- Annabel C Hickey2
- Daniela C J Sanders3
- Mark A Jones4
- Charles P Denaro5
- Cameron J Bennett6
- Alison M Mudge7
- Justine M Thiele8
- Judy L Flores9
- Beres Wenck10
- John W Bennett11
- 1 Clinical Services Evaluation Unit, Princess Alexandra Hospital, Brisbane, QLD.
- 2 Internal Medicine Research Unit, Royal Brisbane Hospital, Brisbane, QLD.
- 3 Department of Medicine, Queen Elizabeth II Hospital, Brisbane, QLD.
- 4 Brisbane North Division of General Practice, Brisbane, QLD.
We gratefully acknowledge the efforts of Melodie Downey, Lisa Mitchell, Alison Ruiz, Katie Foxcroft, Karen Watson, Gabby Jones and the late Jane Davey for performing data abstraction and tracking patients; Nguyen Thinh for constructing the database; Neil Stewart for providing data management; and Professor Jeanette Ward for advice on guideline implementation. We also wish to acknowledge the quality improvement efforts made by the many doctors, nurses, allied health professionals and patient representatives involved in program activities.
The Brisbane Cardiac Consortium Clinical Support Systems Program was an initiative of the Royal Australasian College of Physicians. It was funded by the Australian Government Department of Health and Aged Care, and supported by Queensland Health.
The members of the Brisbane Cardiac Consortium Leadership Group are listed on the inside front cover.
- 1. Australian Institute of Health and Welfare. Heart, stroke and vascular diseases – Australian facts 2001. AIHW Catalogue No. CVD 13. Canberra: AIHW, National Heart Foundation of Australia, National Stroke Foundation of Australia, 2001. (Cardiovascular Disease Series No. 14.)
- 2. Scott IA, Denaro CP, Flores JL, et al. Quality of care of patients hospitalised with acute coronary syndromes. Intern Med J 2002; 32: 502-511.
- 3. Scott IA, Denaro CP, Flores JL, et al. Quality of care of patients hospitalised with congestive heart failure. Intern Med J 2003; 33: 140-151.
- 4. Mudge AM, Brockett R, Foxcroft KF, Denaro CP. Lipid-lowering therapy following major cardiac events: progress and deficits. Med J Aust 2001; 175: 138-140.
- 5. Scott IA, Lindsay K, Harden H. Utilisation of outpatient cardiac rehabilitation in Queensland. Med J Aust 2003; 179: 341-345. <MJA full text>
- 6. Vale MJ, Jelinek MV, Best JD, for the COACH study group. How many patients with coronary heart disease are not achieving their risk-factor targets? Experience in Victoria 1996–1998 versus 1999–2000. Med J Aust 2002; 176: 211-215. <MJA full text>
- 7. Krum H, Tonkin AM, Currie R, et al. Chronic heart failure in Australian general practice. The Cardiac Awareness Survey and Evaluation (CASE) study. Med J Aust 2001; 174: 439-444. <MJA full text>
- 8. Grimshaw JM, Eccles MP, Walker AE. Changing physicians’ behaviour: what works and thoughts on getting more things to work. J Contin Educ Health Prof 2002; 22: 237-243.
- 9. Hickey A, Scott I, Denaro C, et al. Using clinical indicators in a quality improvement programme targeting cardiac care. Int J Qual Health Care 2004; 16 Suppl 1: i11-i25.
- 10. Centor RM, Schwartz JS. An evaluation of methods for estimating the area under the receiver operator characteristic (ROC) curve. Med Decis Making 1985; 5: 149-156.
- 11. National Institute of Clinical Studies. Heart failure resources directory, 2004. Available at: www.nicsl.com.au/projects_projects_detail.aspx?view=15&subpage=19 (accessed Mar 2004).
- 12. Severens JL. Value for money of changing healthcare services? Economic evaluation of quality improvement. Qual Saf Health Care 2003; 12: 366-371.
Abstract
In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after-hospital care, patient self-care, and hospital–community integration.
A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF.
Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included:
clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways);
educational interventions (seminars, academic detailing);
regular performance feedback;
patient self-management strategies; and
hospital–community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs).
Using a before–after study design to assess program impact, significantly more program patients compared with historical controls received:
ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and β-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation.
CHF: Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, β-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels.
Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P = 0.06) and from 13.4% to 10.1% (P = 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P = 0.005) for patients with CHF.
Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.