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A recent publication by a group
from the MGH and BWH sheds additional light on the value of clinical practice
guidelines. Using guidelines originally developed and published by the
Agency for Health Care Policy and Research (AHCPR) in 1994, the researchers
examine the relationship between concordance with treatment guidelines
and outcomes at 1 year in patients with unstable angina.1 A
total of 275 patients admitted with the diagnosis of unstable angina were
included in this retrospective study.
Of the 95 recommendations contained with the AHCPR guideline2, the authors chose 8 which they believed to most likely have a clinical effect. |
| One hundred eighty-nine patients
were found to have been treated in a manner consistent with the 8 highlighted
AHCPR recommendations. Eighty-six patients were not. Patient characteristics
for both groups were similar. Notable exceptions were: patients treated
outside the guidelines tended to be older, have a history of heart failure,
demonstrate heart failure on admission have renal insufficiency and a
Charlson comorbidity index of 2 or more.
Here are the Kaplan-Meier survival curves: |
Some important findings associated with 100% concordance
to the 8 recommendations:
Moreover, improved outcomes were seen in those patients at highest risk of death or myocardial infarction. Patients over age 65 years who presented with unstable angina and congestive heart failure who did not receive treatment in concordance with the 8 recommendations had the poorest one year outcomes. Similar patients treated within the recommendations had similar outcomes to those at lower risk. Ironically, those patients over age 65 years with unstable angina and congestive heart failure were least likely to be treated concordant with the 8 recommendations. While there are some methodological issues with the study, it does strongly support the use of AHCPR guidelines in the management of unstable angina, especially in patients over age 65 years with congestive heart failure. The MGH now has over 60 clinical practice pathways developed locally by 16 teams. Here is the hotlink to the Operations Improvement Clinical Pathways Home Page (http://is.partners.org/pathways). References:
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