Quality of care of patients presenting with acute coronary syndrome in Taiwan

(1)

Original Research

Quality of care of patients presenting with acute coronary syndrome in

emergency departments in Taiwan

Dong Jin Hsieh, Wei-Kung Chen

*

Department of Emergency Medicine, Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan, ROC Received 26 March 2011; accepted 8 June 2011

Available online 16 November 2011

Abstract

Background: Acute coronary syndrome (ACS) represents one of the most common causes of acute medical admission at Taiwan hospitals. Clinical practice guidelines have been developed to provide physicians with evidence-based approaches to the patient’s daily care. However, data have suggested the presence of a large widespread gap between the medical care provided and the evidence-based recommendations. This report should help us to understand the management of ACS in emergency departments based on quality of care indicators and adherence to rec-ommended practice behaviors and international guidelines in Taiwan.

Methods: A retrospective patient chart review was undertaken in 14 participating hospitals from July 1, 2006 to June 30, 2007. A random sample of 2388 patients treated at the emergency rooms of these hospitals with the discharge code of ACS was identified. The data captured included final diagnosis, the acute therapies used, the in-hospital revascularization procedures used and the time to initiation of the various procedures. Results: Among the 2388 patients sampled, the mean age was 66.4 years old of which 67.9% were male. Overall, 42.0% of the patients had a history of coronary artery disease (CAD) including 17.0% with a prior myocardial infarction, 23.0% with a prior percutaneous coronary intervention, and 5.5% who had had a prior coronary artery bypass graft. Final diagnoses reported consisted of 29% (n¼ 701) with ST segment elevation myocardial infarction (STEMI), 30% (n¼ 718) with unstable angina, 24% (n ¼ 578) with nonSTEMI, 14% (n ¼ 335) with CAD/stable angina and 2.3% (n¼ 56) with another diagnosis. Out of all STEMI patients, 77.5% (n ¼ 543) received early catheterization and only 4.7% (33/ 701) were given thrombolytic agent treatment. In addition, among STEMI patients who received an early interventional strategy, only 41.7% received urgent cardiac catheterization within 90 minutes. The average time until a 12-lead electrocardiogram was obtained was 20.6 minutes, and only 52% of the patients had the electrocardiogram completed within 10.0 minutes.

Conclusion: Only 42% of patients who underwent an interventional strategy had catheterization intervention within 90 minutes after arriving at the emergency room. There were significant variations in practice between hospital types and across geographic areas. Further stricter implementation of the guidelines is needed to improve the quality of care provided to Taiwanese ACS patients.

Keywords: Acute coronary syndrome; Emergency room; Taiwan

1. Introduction

Acute chest pain is one of the most common reasons for presentation at an emergency department (ED). Acute coro-nary syndromes (ACS) represent a clinical spectrum that extend all the way from unstable angina (UA), through nonST segment elevation myocardial infarction (NSTEMI) to ST

segment elevation myocardial infarction (STEMI).1 ACS is a major cause of morbidity and mortality in most industrial-ized countries2,3including Taiwan.

Symptoms of coronary artery disease (CAD) include chest pain, referred pain and diaphoresis; however, on some occa-sions patients may present with atypical symptoms such as nausea, vomiting, dyspnea, light headedness, nervousness, and syncope. When patients present at an ED, a history of chest pain (ischemia-type) discomfort and a 12-lead electrocardio-gram (ECG) examination are the primary tools used during initial ACS screening. If an initial ECG shows a nonspecific * Corresponding author. Number 2, Yude Road, Taichung, Taiwan, ROC.

E-mail address:[email protected](W.-K. Chen).

Journal of Acute Medicine 1 (2011) 33e40

www.e-jacme.com

(2)

ST change, ST depression or T inversion, a repeat ECG and serum cardiac marker assessment should be performed regu-larly. However, if the initial or repeat ECG showed a ST segment elevation, an acute myocardial infarction (MI) workout should be started immediately to evaluate whether reperfusion is needed. Time to reperfusion is another key factor. The goal of medical care is to facilitate the rapid recognition and treatment of patients with STEMI, such that the door-to-needle time for initiation of fibrinolytic therapy is within 30 minutes, alternatively that the door-to-balloon or percutaneous coronary intervention (PCI) is within 90 minutes.4 Despite the best evidence-based recommendations, early diagnosis and timely treatment of patients with ACS remains an everyday challenge in EDs.

Over the past 25 years, despite great progress in the fields of acute and chronic care of coronary heart diseases, which together with findings generated from clinical trials have helped to provide evidence-based treatment strategies for managing ACS patients, there is still a large lag in clinical practice when numerous real world studies are examined. The Global Registry of Acute Coronary Events has provided important and reliable information on quality of care (QoC) during ACS management, and has identified areas where further improvements can be made.5,6 Likewise, the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) study found that up to 25% of types of care recommended by the guidelines were missed based on current nonST elevation ACS management.7 In spite of all of the medical advances that have occurred through our understanding of the concepts needed when managing ACS, the quality of current ACS management in ED across Taiwan remains unexplored. Furthermore, no informa-tion is available on the practice gap between different geographical areas and between the various hospital types. Compared with regional hospitals, medical centers usually have a higher number of beds, more catheterization rooms, and larger resources in terms of trainees, physicians, ED special-ists, and so on. As such, their clinical care has been accredited at a higher grade by the government audit system. In addition to quality concerns, improvements in QoC, including short-ening the time to urgent PCI, is no doubt a big challenge when trying to meet today’s quality of medical care standards. 2. Methods

2.1. Study design and population

This was a retrospective randomized patient chart review study. Data were collected from 14 participating hospitals in Taiwan covering the period from July 1, 2006 to June 30, 2007. The study was approved by the ethics committee at each center. A total of 2388 patients treated at the EDs of these hospitals with a discharge international classification of disease (ICD) code of acute coronary (ICD-9: 411.8), acute myocardial infarction (ICD-9: 410), intermediate coronary syndrome (ICD-9: 411.1) and/or angina pectoris (ICD-9: 413)

were randomly sampled from each hospital. Eligible patients had to be at least 20 years of age and alive at the time of presenting at the EDs. Patients transferred from another hospital within the study, or with the qualifying ACS precip-itated or accompanied by a significant comorbidity (i.e., motor vehicle accident, trauma, severe gastrointestinal bleeding or surgical procedures), were not eligible for enrollment in this study. The 2388 patient charts were analyzed to record various types of data including age, gender, style of arriving at the ED (walk, ambulance, transfer or other), triage, underlying diseases, medications given and final diagnoses. No morbidity or mortality data were investigated.

2.2. Measurements

We collected and analyzed performance in EDs using various QoC indicators for ACS as the main evaluation criteria. The performance indicators were the following:

(1) a 12-lead ECG obtained within 10 minutes;

(2) repeated serum cardiac marker determinations (troponin T or I, creatinine kinase-MB isoenzyme);

(3) repeated 12-lead ECGs; (4) oxygen;

(5) nitrate; (6) aspirin; (7) beta-blocker; (8) clopidogrel;

(9) glycoprotein IIb/IIIa inhibitor; (10) heparin;

(11) a door-to-catheter laboratory time of less than 90 minutes for STEMI patients; and

(12) a thrombolytic agent given within 30 minutes to STEMI patients.

To investigate geographical variation and performance by various different hospital types, this study included medical centers and regional hospitals and these were divided geographically into Northern, Central and Southern Taiwan.

2.3. Statistical analysis

Data were entered and stored on a database via Fox Pro 9.0 (Microsoft, Washington, USA). A data backup process was established as routine by the data management personnel. All statistical analyses were performed via SAS version 9.1 (SAS Institute Inc., Cary, USA). During the analysis, categorical variables (e.g., gender) were tabulated by frequencies and percentages, and continuous variables (e.g., age and timing of ECG examination) were summarized by the number of observations, mean, median, standard deviation and 95% confidence interval. For comparisons between groups a Chi-square test was used for the categorical variables and anal-ysis of variance was adopted for the continuous variables. All statistical tests were conducted as two-tailed tests with a significance level of 0.05. The hypothesis testing was

(3)

considered statistically significant if the derived p value was less than 0.05.

3. Results

During the 1-year study period, a total of 2388 patients’ charts from 14 hospitals in Taiwan were randomly selected and reviewed. In total, 83.9% (n¼ 2004) were from 10 medical centers and the other 16.1% (n¼ 384) were from four regional hospitals. The mean age of the patients was 66.4 years old and 67.9% were male. A higher proportion of patients were in the age range of 45 years to 65 years across all geographic areas. Methods of arrival at an ED included 67.4% (n¼ 1609) as walk in patients, 14.5% (n ¼ 346) by ambulance, 17.6% (n¼ 421) were transferred in from another hospital and 0.5% were (n¼ 12) out of hospital cardiac arrest. The majority of the studied population was Triage I or II (40% and 54%, respectively). Overall, 42.0% of the patients had a medical history of CAD, 17.0% had prior MI, 23.0% had undergone PCI previously and 5.5% had the coronary artery bypass graft procedure. Prior use of aspirin was reported in 25.4% of patients and prior use of clopidogrel was reported in 12.0% of the patients (Table 1).

Of the 2388 patients, 29% (n¼ 701) were diagnosed as STEMI, 30% (n¼ 718) as UA, 24% (n ¼ 578) as NSTEMI, 14% (n¼ 335) as CAD/stable angina and 2.3% (n ¼ 56) as other. Patients with ACS accounted for 83.2% (n¼ 1997)

of the patients. The percentage of patients with STEMI in Northern Taiwan hospitals (33%) was slightly higher than in the other geographical areas, whereas there were more patients with UA (42%) in Central Taiwan hospitals (Table 2).

A 12-lead ECG was carried out on almost all patients (99.3%). The ECG results showed ST elevation, ST depres-sion, and T inversion in 34%, 20% and 14% of the patients respectively, whereas 40% of the patients showed no ST change. Approximately half of the patients (52.4%) received 12-lead ECG within 10.0 minutes upon arriving at the ED with a mean time of 20.6 minutes. Repeated 12-lead ECG was only done in 69.1% of the patients after excluding STEMI patients based on the initial ECG results (nV230), and the repeat rate was higher in Northern Taiwan hospitals (76.5%) compared with hospitals in Central (65.9%) and Southern (62.4%) Tai-wan. Almost all patients (98.9%) were checked for serum cardiac markers. Positive results were found in 43% of the patients with no significant differences across the geographical areas. Repeat checks, however, were only done in 68.1% patients, after excluding the 350 STEMI patients whose initial results were positive. The rates of repeated 12-lead ECG and serum cardiac marker were both higher in Northern Taiwan (Table 2). During the early management of ACS, only 2% of ACS patients were treated with thrombolytic therapy, whereas 42% received an early catheterization procedure. Among STEMI patients, 77.5% (n¼ 543) received early catheteriza-tion and only 4.7% (n¼ 33/701) were given thrombolytic Table 1

Demographic data.

Total (n¼ 2388) Northern Taiwan (n¼ 984) Central Taiwan (n¼ 600) Southern Taiwan (n¼ 804) p

Age (y), mean SD 66.4 13.8 65.3 14.4 67.2 14.1 67.2 12.6 0.004 *

20e45 y 6.2% 6.6% 7.0% 5.1% <0.0001 * 46e65 y 38.5% 43.3% 36.0% 34.5% 66e75 y 24.3% 19.7% 22.7% 31.2% 76e85 y 23.0% 22.1% 23.8% 23.4% >85 y 8.0% 8.3% 10.5% 5.9% Male 67.9% 68.3% 65.7% 69.2% 0.364

Time spent in ED (h), mean SD 8.7 14.1 7.1 10.5 7.4 10.1 11.8 19.2 <0.0001 *

Style of ED arrival <0.0001 *

Walk 67.4% 70.9% 60.8% 67.9%

Ambulance 14.5% 20.7% 6.5% 12.8%

Transfer 17.6% 7.3% 32.3% 19.2%

OHCA 0.5% 0.9% 0.3% 0.1%

Taiwan DOH triage <0.0001 *

I 40.4% 35.6% 53.5% 36.6% II 53.7% 56.7% 42.8% 58.2% III 5.8% 7.6% 3.7% 5.2% IV 0.04% 0.1% 0.0% 0.0% Medical history CAD 41.8% 44.5% 42.0% 38.3% 0.030 * Prior MI 17.0% 18.9% 12.3% 18.2% 0.002 * Prior PCI 22.6% 18.2% 25.2% 26.1% <0.0001 * Prior CABG 5.5% 5.1% 6.7% 5.1% 0.340

Prior use of aspirin 25.4% 22.8% 23.7% 29.9% 0.002 *

Prior use of clopidogrel 11.9% 12.4% 8.2% 14.2% 0.002 *

CABG¼ coronary artery bypass graft; CAD ¼ coronary artery disease; DOH ¼ Department of Health; ED ¼ emergency department; MI ¼ myocardial infarction; OHCA¼ out of hospital cardiac arrest; PCI ¼ percutaneous coronary intervention.

(4)

agents. The percentage of STEMI patients receiving early thrombolytic therapy was significantly higher in Southern Taiwan hospitals (12.4%) compared with the hospitals in other areas. As for the door-to-balloon time, only 41.7% received urgent cardiac catheterization within 90 minutes, with the rates being 36.7%, 50.9% and 43.2%, respectively, in Northern, Central and Southern Taiwan hospitals (Table 3).

Analyzing other QoC indicators showed that the rates for oxygen, nitrate, aspirin, clopidogrel and heparin treatment were 94%, 76%, 79%, 62% and 61%, respectively. Further analysis of antiplatelet agents, including clopidogrel and glycoprotein IIb/ IIIa, in patients receiving early catheterization or PCI, showed that clopidogrel was prescribed for 83% of patients, with the highest rate being in Northern Taiwan (94%), followed by Table 2

Diagnosis, 12-lead ECG and serum cardiac enzyme analyses by geographic areas.

Total (n¼ 2388) Northern Taiwan (n¼ 984) Central Taiwan (n¼ 600) Southern Taiwan (n¼ 804) p

Diagnosis <0.0001 STEMI 29.4% 33.1% 23.5% 29.1% NSTEMI 24.2% 28.1% 18.3% 23.9% UA 30.1% 23.0% 42.2% 29.7% CAD/Stable angina 14.0% 15.0% 11.2% 14.9% Others 2.3% 0.8% 4.8% 2.4%

12-lead ECG examination

Yes 99.3% 99.1% 99.8% 99.1% 0.184

Timing of ECG (min), mean SD 20.6 72.7 22.7 86.8 18.1 33.6 19.9 75.0 0.439

Conducted within 10 min 52.4% 54.3% 50.3% 51.6% 0.264

Repeat 12-lead ECGa _69.1% _76.5% _65.9% _62.4% _<0.0001

Result

- ST elevation 34.2% 38.1% 29.2% 33.3% 0.001

- ST depression 19.7% 22.7% 11.5% 22.2% <0.0001

- T inversion 13.6% 15.6% 7.5% 15.8% <0.0001

- No ST change 40.0% 33.5% 54.3% 37.1% <0.0001

Serum cardiac marker determination

Yes 98.9% 98.7% 99.7% 98.5% 0.097

Repeating determinationb 68.1% 75.0% 62.2% 63.4% <0.0001

Result

- positive 43.5% 43.6% 40.0% 46.2% 0.112

- negative 56.4% 56.4% 60.0% 53.7%

CAD¼ coronary artery disease; ECG ¼ electrocardiogram; NSTEMI ¼ nonST segment elevation myocardial infarction; STEMI ¼ ST segment elevation myocardial infarction; UA¼ unstable angina.

a

Excluded patients who were diagnosed as STEMI by initial ECG results (total: 2158; North: 890; Central: 535; South: 733).

b _{Excluded STEMI patients with positive result by initial determination (total: 2038; North: 877; Central: 507; South: 654).}

Table 3

Reperfusion therapy among total patients and STEMI patients by geographic area.

Total Northern Taiwan Central Taiwan Southern Taiwan p

No. of patients 2388 984 600 804

Early PCI

Yes 35.1% 40.0% 43.7% 22.8% <0.0001

Timing of early PCI (min), median 124.0 131.0 130.0 109.0 <0.0001

Thrombolytic agent

Yes 1.7% 0.3% 1.2% 3.7% <0.0001

Timing of thrombolytic agent (min), median 92.5 339.5 294.0 76.5 0.011

No. of STEMI patients 701 326 141 234

Early PCI

Yes 77.5% 85.0% 85.8% 62.0% <0.0001

Timing of early PCI (min), median 102.0 112.0 87.5 96.0 0.002

Thrombolytic agent

Yes 4.7% 0.6% 1.4% 12.4% <0.0001

(5)

Southern Taiwan (86%) and Central Taiwan (63%) hospitals. Glycoprotein IIb/IIIa was administered to 31% of the patients on average, with the highest rate being seen in Southern Taiwan hospitals (49%). Among the recommended medications, acute b-blocker usage was the lowest at only 26% in the sampled population. The treatments recommended by the guidelines were underused in general, with relatively lower rates being seen most often in Central Taiwan hospitals (Fig. 1).

The data were next examined by hospital type and it was noted that the proportions of final diagnoses as UA, NSTEMI or STEMI were similar between medical centers and regional hospitals. The performance rates for acute procedures were good (99%) for initial ECG and serum markers, and there was little variation between hospital types. The percentage where ECG was obtained within 10 minutes was also similar, this being 52% at medical centers compared with 53% at regional hospitals. Repeat ECGs and repeat serum cardiac marker assessment were however, more commonly performed at medical centers (72.9% and 72.2%, respectively) than at regional hospitals (47.5% and 44.3%, respectively). Among STEMI patients, the rate of urgent cardiac catheterization within 90 minutes (Table 4) was higher at medical centers than at regional hospitals (43.7% vs. 27.9%). When medica-tions recommended by the guidelines were considered, the prescription rates for aspirin, nitrate and b-blocker were higher at medical centers whereas regional hospitals more commonly prescribed heparin and glycoprotein IIb/IIIa. Clopidogrel usage was similar (w62%) across the different hospital types (Fig. 2). The overall results indicated that there was an underutilization of therapies recommended by the guidelines among all geographical areas and hospital types in Taiwan.

4. Discussion

This QoC project is the first large registry in Taiwan that has collected data on ACS patients treated at EDs using a multicenter perspective. ACS was prospectively defined based on the guidelines established by the American College of Cardiology and the American Heart Association with the

following modifications. Possible or probable ACS required resting chest pain compatible with myocardial ischemia of more than 30 minutes duration within 12 hours of ED presentation. NSTEMI required there to be some type of clinical evidence of CAD and abnormal serial serum markers consistent with acute MI without ST elevation change. Confirmation of UA required a 70% epicardial coronary stenosis or true positive abnormal stress test performed during the index hospitalization or subsequently during the 6-week to 8-week follow-up period.8

The most common way for ACS patients to arrive at an ED in Taiwan is to walk in alone or to be transported to the hospital by their family. This often can result in under assessment of patients’ clinical conditions and severity. The capture of patients’ medical histories in detail, such as CAD history, medication usage, gender and age, is crucial to making appropriate clinical judgments, especially for male elderly patients with a CAD history. Our registry has shown that ACS patients in Northern Taiwan tend to be younger with better paramedical/medical services being provided (20.7% patients transported by ambulance, the triages for suspected CADs were mostly Level I or II and 12-lead ECG and serum cardiac marker checks were routinely arranged); the different degrees of urbanization in the various geographical areas may have been a contributory factor. According to our results, 12-lead ECG and serum cardiac markers were repeated in less than 70% of the patients during their stay at the ED and this begs the question as to whether one-time ECG examinations during ED management are really sufficient. Missing a diagnosis of ACS doubles the risk-adjusted mortality.9 Recent estimates have indicated that approximately 2% of patients with MI are inappropriately discharged home from EDs.9e11 Consistent with the vulnerable plaque hypothesis, the consequences of not detecting an UA could result in progression to MI after discharge from ED. Although troponin-negative patients seemed to be at lower risk, 12 many patients with UA do require urgent medical therapy or intervention.

The door-to-balloon time window recommended by the guidelines is less than 90 minutes.4 The CRUSADE study reported only 40% of STEMI patients received primary PCI

0% 20% 40% 60% 80% 100%

Oxygen Nitrate ββ–blocker Aspirin Clopidogrel GP IIb/IIIa Heparin

(LMWH/UFH)

Total NorthNorth CentralCentral South

(6)

within 90 minutes.13 In our registry, a similar proportion of 42% was also observed in Taiwan. Additionally, only 52% of initial 12-lead ECGs were obtained within 10 minutes. The mean time was approximately 20 minutes which is twice the time specified in the guidelines, and this result varied little across the different geographical areas or hospital types. These findings showed that there is significant room for improvement in ACS management in Taiwan. In a clinical setting, there are many factors that might lead to a delay in the door-to-balloon procedure; such events would include time to definitive diagnosis, time required to obtain the patient’s consent for an

urgent PCI, patient transfer, getting the catheterization room ready, and so on. To facilitate the overcoming of these hurdles, ED physicians should immediately perform a 12-lead ECG on patients who arrive at the ED with complaints of chest pain, or with symptoms related to CAD. Such a practice can help to shorten time to emergency PCI and this would ultimately translate into a mortality reduction. As for the use of throm-bolytic agents in STEMI patients, it was found to be higher in the hospitals, both medical centers and regional hospitals, in Southern Taiwan (12%). This difference across the geographic regions of Taiwan needs further investigation.

0% 20% 40% 60% 80% 100%

Oxygen Nitrate ββ–blocker Aspirin Clopidogrel GP IIb/IIIa Heparin

(LMWH/UFH)

Total Medical CenterMedical Center Regional Hospital

Fig. 2. Quality of care indicator analyzed by hospital type in Taiwan. GP¼ glycoprotein; LMWH/UFH ¼ low molecular weight heparin/unfractionated heparin. Table 4

Diagnosis, 12-lead ECG, serum cardiac enzyme and reperfusion results by hospital types.

Total (n¼ 2388) Medical center (n¼ 2004) Regional hospital (n¼ 384) p

Diagnosis <0.0001 STEMI 29.4% 29.4% 29.2% NSTEMI 24.2% 23.3% 29.2% UA 30.1% 30.6% 27.3% CAD/Stable angina 14.0% 15.0% 8.9% Others 2.3% 1.8% 5.5%

12-lead ECG examination

Yes 99.3% 99.3% 99.5% 0.627

Timing of ECG (min), mean SD 20.6 72.7 20.3 76.1 22.3 51.8 0.615

Conducted within 10 min 52.4% 52.4% 52.6% 0.928

Repeat 12-lead ECGa _69.1% _72.9% _47.5% _<0.0001

Serum cardiac marker determinations

Yes 98.9% 99.0% 98.4% 0.382

Repeat determinationb _68.1% _72.2% _44.3% _<0.0001

Early PCI

Yes 35.1% 35.2% 34.6% 0.838

Conducted within 90 min 32.8% 34.8% 21.3% 0.006

In STEMI patients

- Yes 77.5% 79.0% 69.6% 0.031

- Conducted within 90 min 41.7% 43.7% 27.9% 0.014

Thrombolytic agent

Yes 1.7% 1.6% 2.3% 0.265

In STEMI patients

- Yes 4.7% 4.2% 7.1% 0.184

- Conducted within 30 min 10.3% 4.8% 25.0% 0.110

CAD¼ coronary artery disease; ECG ¼ electrocardiogram; NSTEMI ¼ nonST segment elevation myocardial infarction; PCI ¼ percutaneous coronary interven-tion; STEMI¼ ST segment elevation myocardial infarction; UA ¼ unstable angina.

a _{Excluded patients who were diagnosed as STEMI by initial ECG results (total: 2158; medical center: 1838; regional hospital: 320).} b _{Excluded STEMI patients with a positive result by initial determination (total: 2038; medical center: 1732; regional hospital: 306).}

(7)

We also found from this registry that there was a significant underutilization of the therapies recommended by the guide-lines, including b-blockers, aspirin, clopidogrel, glycoprotein IIb/IIIa inhibitors and heparin. It is important to note that only 26% of ACS patients were given an acuteb-blocker at the ED. Despite some well-known contraindications tob-blockers such as acute heart failure, asthma/chronic obstructive pulmonary disease, hypotension and/or bradycardia, which might result in some patients not receiving this therapy, there are still many eligible ACS patients who would benefit from treatment with an acute b-blocker. Again, physicians at EDs need to better assess the patient’s condition and then make a sound profes-sional judgment on this treatment accordingly.

Our study has a number of limitations inherent to its retrospective design. Historical medical record review is a method that has been widely used in the emergency medi-cine literature in the past.14,15 Gilbert et al16 proposed eight strategies for improving the quality of medical record review studies, which have since been considered to be the guidelines for medical record review reporting. We adhered to five of the eight methodological standards, namely a clear hypothesis, the training of the abstractors, defined inclusion and exclusion criteria, the definition of important variables and the use of standard abstraction forms. Random sampling of the eligible patients’ charts was done to minimize selection bias and ensure data quality. The number of regional hospitals was limited to four and included only the Northern and Southern Taiwan areas and this may have contributed to selection bias. Thus, our study may not be truly representative of the regional hospital ED ACS care in Taiwan. Future prospective studies are needed to determine whether the observed variations in care between hospital types in our registry are real.

Nevertheless, this retrospective study should reflect the real-world performance when managing ACS in Taiwan as measured by the QoC indicators. Substantial gaps exist between medical care in practice and recommendations derived from evidence-based researches. Variations between hospital types and geographical locations were also observed. After further data analysis of the CRUSADE database, Peterson et al17 re-ported a strong correlation between hospital care performance and patient outcomes. It was found that for every 10% increase in composite guideline adherence, there was an associated 10% decrease in the likelihood of in-hospital mortality.17 Raising awareness and providing adequate knowledge of ACS management by focusing on treatments recommended by the guidelines through continuous medical education is of the utmost importance when trying to improve ACS medical care and to promote better patient outcomes.

5. Conclusion

In Taiwan, therapies recommended by the guidelines for managing ACS patients were underused in EDs. Variations in practice existed between hospital types and across geographic areas. Although more than 80% of STEMI patients received early reperfusion therapy, only four out of 10 patients under-went catheterization intervention within the target timeframe

recommended by the guidelines. Every effort should be made for patients to have an ECG examination within 10 minutes of presenting at the ED with chest pain, especially those with a prior CAD history; this will allow an immediate decision to be made on treatment strategy. Further implementation of medical education initiatives is needed to improve the QoC of ACS patients in Taiwan.

Acknowledgments

This study was supported by Sanofi-Aventis Taiwan Co. Ltd.

We acknowledge the following investigators at 13 other hospitals who participated in the QoC study: Ju-Chi Liu and Ming-Hsiung Hsieh, Wan Fang Hospital; Ming-Yuan Huang and Wen-Han Chang, Mackay Memorial Hospital; Chih-Hua

Chang, Shin Kong Wu Ho-Su Memorial Hospital;

Chao-Hsin Wu, Chung Shan Medical University Hospital; Wen-Huei Lee, Chang Gung Memorial Hospital-Kaohsiung; Ping-Rcng Kuo, Chi Mei Medical Center; Yao-I Huang, National Cheng Kung University Hospital; Chun-Yao Huang, Taipei Medical University Hospital; Chung-Hsien Liu, Chia-Yi Christian Hospital; Chu-Jen Lai, St. Martin De Porres Hospital; Chin-Fu Chang, Changhua Christian Hospital; Kuang-Chau Tsai, Far Eastern Memorial Hospital; Chen, Kuan-Chun and Wei-Hsien Yin, Cheng Hsin Rehabilitation Medical Center.

References

1. The GRACE Investigators. Rationale and design of the GRACE (Global Registry of Acute Coronary Events) project: A multinational registry of patients hospitalized with acute coronary syndromes. Am Heart J. 2001;141:190e199.

2. Howson CP, Reddy KS, Ryan TJ, Bale JR, eds. Control of Cardiovas-cular Diseases in Developing Countries: Research, Development and Institutional Strengthening. Washington, DC: National Academy Press; 1998.

3. Chockalingam A, Balaguer-Vintro I, Achutti A, et al. The world heart federation’s white book: impending global pandemic of cardiovascular diseases: challenges and opportunities for the prevention and control of cardiovascular diseases in developing countries and economies in transi-tion. Can J Cardiol. 2000;16:227e229.

4. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarc-tioneexecutive summary. A report of the American college of cardiology/ American heart association task force on practice guidelines. J Am Coll Cardiol. 2004;44:671e719.

5. Steg PG, Goldberg RJ, Gore JM, et al. Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the global registry of acute coronary events (GRACE). Am J Cardiol. 2002;90:358e363.

6. Fox KAA, Goodman SG, Anderson FA Jr, et al. From guidelines to clinical practice: the impact of hospital and geographical characteristics on temporal trends in the management of acute coronary syndromes. The global registry of acute coronary events (GRACE). European Heart Journal. 2003;24:1414e1424.

7. Bottorff MB, Nutescu EA, Spinler S. Antiplatelet therapy in patients with unstable angina and non-ST-segment-elevation myocardial infarction: findings from the CRUSADE national quality improvement initiative. Pharmacotherapy. 2007;27:1145e1162.

(8)

8. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable Angina/Non-ST-elevation myocardial infarction. J Am Coll Cardiol. 2007;50:e1ee157.

9. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163e1170. 10. Lee TH, Rouan GW, Weisberg MC, et al. Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Cardiol. 1987;60:219e224.

11. McCarthy BD, Beshansky JR, D’Agostino RB, et al. Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study. Ann Emerg Med. 1993;22:579e582.

12. Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med. 1996;335:1342e1349.

13. Q2 2006 CRUSADE STEMI data. http://clintrialresults.org/Slides/ CRUSADEResults2006Q2.

14. Badcock D, Kelly AM, Kerr D, et al. The quality of medical record review studies in the international emergency medicine literature. Ann Emerg Med. 2005;45:444e447.

15. Worster A, Bledsoe RD, Cleve P, et al. Reassessing the methods of medical record review studies in emergency medicine research. Ann Emerg Med. 2005;45:448e451.

16. Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305e308.

17. Peterson ED, Roe MT, Mulgund J, et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA. 2006;295:1912e1920.