!"#$%&'()*+,-./0123
!"#$%&
1
!
3!
4!
4!
2 !"#$%&'()*+,-./01!)23&/456.789:;<=>?!)23 !"#$%&'()*+,-./012'(345678 !"#$%&'()*+,!-./0123456789:;<=>?@AB1CD-. !"#$%&'()*+,-./01#$23456789:;<=>?@A( ) !"#( ) !"#$%&'()*+,-2004100120050331 !" !"#$%&'()*+,- !"#$%&'()*+,-./0!15!"#$%&'()*+,- !"#$%7!"#$%&'()*+,- !"#$%&'() !"#$%&'(10 !"12 !"#$%&'( )*+,-./0123456 !"#$%&'()*+Aspirin !"#$%&'()Clopidogrel !"#$%&'() !"#$%&ST !"#$%&'()*Clopidogrel !ST !"#$%&'() !"#$%&'(Gp IIb/IIIa !"#$%&'()*+,90 !"#$%&'()*+ !"#$%&'()*+,-./0(/)45.5%44.3%72.3%56.8%100%0%3.9% 5.6%60.8%32.1%28.6%0%20.8%38.9% !"#$%&'()*+"#,$%(-./01234567!89+"#&'(-./ !"#$%&'()*AspirinHeparin !"#$%&'()*+,-./'(0123 !"#$%&'()*+$,-./01234567809:;<=>?@ABCDEFGH !"#$%&'()*+,-&./,012345ST !"#$%&'()*Clopidogrel Glycoprotein IIb/IIIa !"#$%&'()*!"#+,-.)*/0! !"#$%&'"()*+,"-. /"012
9515 !"#$9526
!"#1 !"#2 !"#$%3 !"#$%&'()*+,-4 !"#$ "%& !' !"#$%&'()*100 !"#$%&176635 !"#$%&'()*+,-.
(02)33228065
Institute of Medicine (IOM)2001 !"#$%&'((Crossing the Quality Chasm) !"#$%&'()*+,-./0 !"#$%&'()*+,-./012 !"#$%&'()*$+,(1) !" !"#$%&'()*+,-./01 !"#$%&'()*+ ,-./'0 !"#$%&'()*#+,-./01 !"#$%&'()*+,-./01! !"#$%&'()*+,-./0
!"#$%&'()!*(+,- !"#$%&'()*+,-"./01 !"#$%&'()*+,-"./0 !"#$%&' 1960 !"Donabedian !"# !"#$%&'()'*+,*-).(2) !"#$%&'()*+,-./0 !"#$%&'()*+,-./01(3,4) !"#$%&'()*+,-"#. !"#(5) !"#$%&'()*+,
(Joint Commission of American Healthcare Organization, JCAHO) !"#$%&'( !"#$%&'()*+,-.%/012 !"#$%&$'()*+,-./012 !"#$%&'() *+,-./01 !"#$%&'()*+!,-'./0 !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !"#$%&'()*+,-./# !"#$%&'()*+, !"-(TQIP)(6) !"#$%&'()*+,-./ !"(THIS)(7) !"#$%&'()*+,-./0 !"#$%&'()*+,-./0"# !"#$%&'() *+,-./0 !"#$%&'()*+,-./*0 !"#$%&'()*+,-./01 !"#$%&'$((8-12) !"#$% !"#$%&'()*+,-./012 !"#$%&'()*+,-./01) !"#$%&'()*+,-./01 !"#$%& '()*+,-./01 !"#$%&'()*+,-.$/ !"#$%&'()*+,-./.01 !"#$%&(acute coronary syndrome, ACS) !"#$%&'()*+,-./0 !"#$%&'()*+,-./01* !"#$%&'()*+,-(13) ! !"#$%&'()*+",-./01 !"#$%&'()*+,-./012 !"#$%&'()*+,-./'( !"#$%&'()*+ ,-./01 !"#$%&'()*$(14,15) !"# !"#$%&'()*+),-./0 !"#$%&'()*+,-./22%(16) !10% !"#$%&'()*+ 11%(17) !"#$%&'()*+,- !"#$%&'()*+,-!./01 !"#$%&'()*+,-./012 !"#$%&'()*+,-.%/0 !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !"#$%&'()*+,-.#/01 !"#$%&' !"()*+,- !"#$%&'()*+,-./012 !"#$%&'()*+(,-./ !"#$%&'()*+,-./0$1 !"#$%&'($)*+,-./01 !"
!
!"#$%&'($)*+($,- !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !"#$%& '()*+,-./01 !"#$%&'()*+,-./012 !"#$%&'($)*+,-./01!"#$%&'()*+
ACC/AHA !"#$%&(18-20) !"#$%&'"#%()*'+,-. !"#$%&MEDLINE !"#$ (www.guideline.gov) !"#$%&' !"#$(21-24) !"#$%&'() !"#$%&'()*!"+,$%-. !"#$%&'(10 !"12 !"#ST !"#$%&'()"* !"C !(CRP) !"#$%&!"#$%&'()*+,-./01 !"#$%&'()*+,-./012 !"#$%&'()*+,-./01X !"#$%&'()*&+,-./01 !"#$%&'()*+,-./(NTG) !"#$%&'(Aspirin Aspirin !"#$%&'(Clopidogrel !" !"#$%&'()*+,-ST ! !"#$Clopidogrel !ST ! !"#$%&' ()*+,-.Gp IIb/ IIIa antagonist !"#$%&'Heparin !ST !"#$%&'()*90 !"#$%&'()*+ST !"# !"#$60 !"#$%&'()* 15 !"# !"#$%&'()*+,-.,/ !"#$%!&'()*+,-.&/ !"#$%&'Holloway et al(25)Cheng et al(26)Spertus et al(27) !"#$%&' !"#$%&'()*+&',-./0 !"#$%&'()*+,-./01 !"#$%&'(RAND appropriateness method !"#$%&'()*+,-. !"#$%&'()*%+,-./% !"#$%&'()*+,-,./ !"#$%&'()*+%,&-./ !"#$%& '"()*+,-. !"#$%&'(&)*+"#,-. !33 !"#$%&'()*+,- !"#$%!"&'()*+,-.%/ !"#$%&'()*+,-./01 !"#$%&'()*+$%,-.!/ !"#$%&'()*+,-+,./0 !"#$%&'()*+,-./'0 !"#$%& !"#'()*+,-. !"#RAND appropriateness method(28)
Holloway !"#$%(25) !"#$% !"#$%"&'()*+,-./0 1. !"#$%&'()*)7 !"# 2. !"#$%75% ( !"#$ ) !"789 !"#$% 3. !"#5 !"#$%&'()*+ !
!"#$%&'()*+
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spirin!"#$%&'()*+,- !"#$%&' Clopidogrel !"#$%&'()*+
!"#$ST !"#$%&'()* Clopidogrel !ST !"#$%&'( !"#$%&'()Gp IIb/IIIa ST !"#$%&'()*+90 !"# !"#$ !"#$%&'()*+,-./0 !"#$%&'()*+4 !"#$ !"#$%&'()*+,-. /01 !"#$%&'()*+Aspirin ! !"#Heparin !"#ST !" !"#$%60 !"#$%&'( !"#$%&'()*+,-.$/ !"#$255 !"#$%&'()* 161 !"#$!"%&'() *+,- !"#$%&'()*+,229*+,- ! !"#$%&'157 !"#$%&' !"#$%&'()$%&*+,-. !"#$%&'()*+,-./012 !"#$%&'(179 !"#$107 !"#$%&'()*+,-./I !"#$%&'()*+,- ./01 !"#$%&'()*+,-./01" !"#$%&'()*+,-.+/01 !"#$%&'()*+,-./01 !"#$%&93 !"94 !"#$%&'()*+,-.*/01 10 !"#$%&'()*+,-./ 93 !"#$%&12 !"#$%&' 13 94 !"#$%12 !"#$ 93 !"#$%11 94 !"# 16.5 !"#$%&'()*+,-./93 !"#1 !"#$%&'()* ST !"#$%&94 !"6 6 !"#$ST !"#$%1 !"#$%&1 !"#$%3 !"#$%1 !"#$%93 ! 2 !"#$%&'(%)*+,-./0 ST !"#$%&94 !"4 !"#$%&ST !"#$%3 !"1 !"#$%&'()*+,-.93 !"#$%&'()*&'+,150 94 !"#$%&"#'268 !"#$ 93 !"#$%&'()*+'(,97 94 !"#$%&'160 !"#$%&'(Aspirin !" !"#$Clopidogrel !ST ! !"#$%&'Clopidogrel !"# !"#$%&'(p0.05) !"#$ !"#$%&'()*+,-./0 90 !"#$%&'()*+,-./01 !
!"#$%&'()*+,-./0 !"#$%&'()*+,-./01 !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 ( !"#) !"( !) !"#( !) !"#$%&'( !"#$%&'(')*+,-./01 !"#$%&'()*+),-$./ !"#$%&'()*+,-./0(29) !"#$"% !&'()*+,- !"#$%&'()*+,-./012 !"#$%&'()*+,-./01 !"#$%11 !"#$%&'() !"#$%&'()*+,-()+./ !"#(30-33) !"#$%&'()* !"#$%&10 !"#$%&'( !Scott !"#$%&'()*+, !"#$%&'()*+, -./#$ !"#$%&'()*+,-./012 Aspirin !"#$%&'()*+,-. ( !"#$%&) !"#$%& !"#$ClopidogrelGlycoprotein IIb/IIIa !Heparin !"#$%&'()*%
!"#$%&'()*+,&-. !" !" 93 94 93 94 () 97 82 179 53 54 107 !() 66 67 66* 60 65 62* (/) 73/24 58/24 131/48 46/7 39/15 85/22 !() I 55 46 101 40 31 71 II 40 34 75 10 20 31 III 2 2 3 3 2 5 !() ! 86 70 156 42 46 88 119 11 12 23 11 8 19 CAD() 63 47 110* 12 12 24* !() STEMI 20 17 37* 9 16 25* NSTEMI 20 20 40 23 21 44 UA 30 14 44 7 3 10 ACS 23 16 49 12 12 24 Angina 3 2 5 1 0 1 CAD 1 3 4 1 2 3 !(){Median(IQR)} 343(832) 450(862.75) 390(822)* 260(506) 210(290.5) 240(402.5)* STEMI 150(118.25) 268(485) 204(161) 97(86) 160(121.5) 144(144) NSTEMI 682(800) 658(833.5) 671(833.5) 355(477) 355(288) 355(434.75) UA 727(1212.25) 704(1140) 727(1262) 309(592) 435(158.5) 404(433.5) ACS 244(474) 380(958.5) 337(671) 251(261.25) 154(77.25) 210(241.75) Angina 499(636) 1005(919) 499(1272) 910(0) N/A 898(0) CAD 2741(0) 419(319.5) 605(926.25) 898(0) 834(763.5) 855(736.5) *P0.05
CAD: Coronary Artery Disease ( !"#$%)
STEMI: ST Elevation Myocardial Infarction (ST !"#$%)
NSTEMI: Non-ST Elevation Myocardial Infarction (ST !"#$%) UA: Unstable Angina ( !"#$)
ACS: Acute Coronary Syndrome ( !") Angina:
!" !" 93 94 93 94 47/96 34/82 81/178 26/53 21/53 (48.96%) (41.62%) (45.51%) (49.06%) (39.42%) (44.34%) 35/48 30/46 65/94 13/19 6/18 19/37 (72.92%) (65.22%) (69.15%) (68.42) (33.33%) (51.35%) 36/48 32/46 68/94 13/19 8/18 21/37 (75.20%) (69.57%) (72.34%) (68.42%) (44.44%) (56.76%) 77/96 64/76 141/172 38/47 29/46 67/93 (80.21%) (84.21%) (81.98%) (80.85%) (63.04%) (72.04%) N/A 2/2 2/2 0/1 N/A 0/1 (100%) (100%)* (0.00%) (0.00%)* 1/97 6/82 7/179 2/53 4/54 6/107 (1.03%) (7.73%) (3.91%) (3.77%) (7.41%) (5.61%) 29/50 22/34 51/84 6/28 11/24 17/53 (58.00%) (64.71%) (60.71%)* (21.43%) (45.83%) (32.08%)* 0/2 2/5 2/7 0/9 0/5 0/14 (0.00%) (40.00%) (28.57%) (0.00%) (0.00%) (0.00%) 81/97 69/82 150/179 35/53 41/54 76/107 (83.51%) (84.15%) (83.80%)* (66.04%) (75.93%) (71.03%)* 5/14 0/10 5/24 4/8 3/10 7/18 (35.71%) (0.00%) (20.83%) (50.00%) (30.00) (38.89%)
N/A N/A N/A N/A N/A N/A !"#$%&'(%)*+,-./01 !" !"#$%&10 !"12 !"# !"#$%&'()*+,-. !"#$% !"#$%&'()*+,-. !"#$ !" !"#$%&Aspirin Aspirin !"#"$%&'( Clopidogrel !"#$%&'()*+,-ST !"#$%&'()*+ Clopidogrel ST !"#$%&'()*+" !"#$Glyprotein IIb/IIIa antagonist !"#$%&Heparin ST !"#$%&'()*90 !"#$%&'() ST !"#$%&'()*60 !"#$%&'() *P0.05 !"#$%&' !"#$%&'"#%()*+,- !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !10 !"#$%&'()*+,- !"#$%&'()*+,-.(Timely) (Effective) !"#$%&$'() !"#$%&'()*+,-./ACE !"#$%&'()*+,%-./01 !"#$%&!'()*+,-./01 !"#$%&'()* !"#$%&'()*+,-../ !"#$%&'()#*+,-+10 !"#$%&'()*+,-.Scott !( !61% !"70%) ! !"#$%&'()*+,-#./01 !" !"#$%1214 !Quali Health !"#$%&'19.5 !(34)
Burwen Scott JCAHO- NQF*1 2005*1 2003*2 2004*2 ORYX®*2 & & @ # # @ § § § !"#$%&'()*+ !
EKG within 10min of presentation Cardiac markers follow-up more than 6hr EKG follow-up more than 6hr
Aspirin at arrival
Clopidogrel use if allergy to Aspirin
β-blocker at arrival
Clopidogrel on NSTEMI patients
Gp IIb/IIIa inhibitor on NSTEMI patients with PCI
Heparin use
PCI within 90min of arrival
Thrombolytic agent within 60min of arrival Aspirin at discharge
β-blocker at discharge ACEI for LVSD
Smoking cessation advice Lipid-lowing agents at discharge Inpatient mortality
*1: for Acute Coronary Syndrome ( !") *2: for Acute Myocardial Infarction ( !"#) &: on day 1 or 2
@: Median time to procedure #: PCI within 120min
§: Thrombolytic agent within 30min
NQF: National Quality Forum
NSTEMI: Non-ST Elevation Myocardial Infarction (ST !"#$%) PCI: Percutaneous Coronary Intervention ( !"#$%&')
ACEI: Angiotensin-converting enzyme inhibitors (ACE ) LVSD: Left ventricular systolic dysfunction ( !"#$%&)
!"# !"#$%&'()*+, !"#$%&'()*+,-./0 ! !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !"#$%&'()*+,-. /01 !"#$%&'()*+,-./01 ! !"#$%&'()*+,&-./ (30,35) !"#$%&'()*+,-. !"Aspirin !"#$%&'() !"#$%&'()&*+,-./0) !"#$%&'()*+,-.!" !"#$%&'()*+&,-GAP (The Guidelines Applied in Practice) !"#$%
!"#$%&'()*+,-./01 !"#$%&'()*+,-."%&/ !"#$%&'()*+,-./012 !"#$%&'()#*+,-./0 !"#$%&'()*+,-./012 !"#$%&'()*+,$%&'- !"#$%&' ST !"#$%&'()*+" !"#$%&'()*+120 !"# !"#$%&'()*+,-./012 !"#$%&'()*+,-.(/0* !"#$%&'()*+,-./012 !"#$%&'()*+,-./01 !"#$%&'()*"+,-./01 ! !"#$%&Clopidogrel !" !"#$%&'()*+,-./012 !"#$"%&'()*+,-./01 !"#$%&'()*+,-Clopidogrel Aspririn !"#$%&'(Aspirin Aspirin !"#$%&'()*+,-./ !"#$%&'()*+,#-. !"#$%&'()*+,-./012 !Aspirin !"#$%&'()*ST !" !"#$%Glycoprotein IIb/IIIa ! !"#$%&'(#$)*+,-./ !"#$%&'()*+,-%./01 GRACE(36) 11.9% (868/7286) ! !"#$%&'()*+,'-./01 !"#$% !"#$%&'()*+,-./0 !"#$%&'()*+,-./012 !"#$%&'()#*+,-./0 !"#$%&'()*+,-./012 !"#"$%&'()*+&,-./0 !"#$%&'()*+,-./01 !"#$%&'()*+,-."/(0 !"#$%&'()*+,-./0" !"#$%&'()*+,-./0 !"#$%&'()*+,-./0 !"#$%&%'()*+,-./0( !"#$%&'()*+,-./"01 !"#$%&'()*+,-./012 !"#$%&'()*+,-./01 !"#$%&'()*+,-./012 !"#$%&'()*+,-./0"1 !"#$%&'()*+,-./#01 !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !"#$%&'()*+,&-./01 !"#$%&'()$%*+,-./ !"#$%&'()*+,-./%01 !"#$%&'()* !"#$%&'()*+,-./0 !"#$%&'()*+,-./%0 !"#$%&'()*+,(%)
! GAP target Mehta 2002 Burwen 2003 (n178) (n107) (n914)* (n31331)*
Aspirin at arrival 82 72 95§ 81§ 76+
β-blocker at arrival 4 6 78§ 65§ 51+
PCI within 120min of presentation 29 56 NA NA NA PCI within 90min of presentation 21 39 NA NA 28 Median time to PCI(min) 182 99 60-120 130 120
* !" + !"# §24
!"#$%&'()*+,-./01 !"#$%&'()*+,-./0() !"#$%&'()*+,-./01 !"#$%&'()*+,(-./01 !"# !"#$%&'()*&+,-./ !"#$%&'()*!+,-./0 !"#$%&'()*+,-./01 !"#$%&'()(37) !"#$% !"#$%&'()*+,-./01 !"#$%&'()*+,-./01 !"#$%#&'!"()*+,-./ !"#$%&'()*+,-./0 !"#$%&'()*+,-./&0 !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !"#$%&'()*+,-./0*+ !"#$%&'()*+,-./012 10 !"#$%&'()*+,-!".# !"#$%&'()*+,-./0"1 !"#$%&'()*+,-./012 !"#$%&'() *+,-./'0 !"#$% &'()*+,-./%0 !"#$%&'()*+, -./0 !"#$%&'()*+,-./01* !"#$%&'()*+, !"#$%&'()*+,-./0 !"#$%&'()*+,-./0&1 !"#$%&'()*+,-./012 !"#$%&'( )*+,-./01 !"#$%&'()*+,-./01! !"#$%&'()*+,-./0%1 !"#$%&'()*+,$-./0$ !"#$%&'()*+!,-./"# !"#$%&'()*+,-."/01 !"#$%&' !"#$%&'()*+,-./ !"#$%&'()*+,-./012 !"#$%&'()*+,-./&01 !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !"#$%&'()*+,-.#/01 !"#$%&'()*+,-./012 !"#$%&'()*+,-./0!1 !"#$%&'()*+,-./$%0 !"#$%&'()*+,- &./0 (38) !"#$%&'()*+,#- !" !"#$% &'()*+,-. !"#$%&'()*+,-./01' !"#$%&'()*+,-./012 !"#$%&'()*+,-./01 !"#$%&'()*+,-./012 !"#$%&'"#(%)"*+,-. !"#$%&'() !"#$*+,- !"#$%&'()*+,-./01 !"#$%&'()*+,-./012 !"#$%&'() !"#$%&'()*+,-./0 !"#$%&'()*+,-./0'( !"#$%&'()*+,-./012 !"#$%&'()*+,-./012 !"#$%&'()*+,-%./0 !"#$%&'()*+,-./01 !"#$%&'(%)*+
!
1. Institute-of-Medicine. Crossing the Quality Chasm: National Academy of Sciences; 2001. 2. Donabedian A. Evaluating the Quality of
Med-ical Care. Milbank Q 1966;44:166-206. 3. Campbell SM, Braspenning J, Hutchinsom A,
Marshall MN. Improving the Quality of Health Care_Research Methods Used in Developing and Applying Quality Indicators in Primary Care. BMJ 2003;326:816-9.
4. !"#$!%&'()*+,-./ ! 19993237-44
5. Mainz J. Defining and Classifying Clinical Indicators for Quality Improvement. Int J
Qual Health Care 2003;15:523-30. 6. !"#$%&"'()*+,-./ !"#$%(TQIP)In !"#$ !"#$%&'( 7. ! " # $ % & ' ( ) * + , - . (THIS)In !"#$%
8. Birkmeyer JD, Dimick JB, Birkmeyer NJO. Measuring the Quality of Surgical Care: Structure, Process, or Outcomes? J Am Coll Surg 2004;198:626-32.
9. Pronovost PJ, Nolan T, Zeger S, Miller M, Rubin HR. How Can Clinicians Measure Safety and Quality in Acute Care? Lancet 2004;363: 1061-7.
10. Rubin HR, Pronovost PJ, Diette GB. The Advantages and Disadvantages of Process-based Measures of Health Care Quality. Int J Qual Health Care 2001;13:469-74.
11. Bowers MR, Keife AI. Measuring Health Care Quality: Comparing and Contrasting the Medical and the Marketing Approaches. Am J Med Qual 2002;17:136-44.
12. Palmer RH. Process-Based Measures of Quality: The Need for Detailed Clinical Data in Large Health Care Databases. Ann Intern Med 1997; 127:733-8.
13. Wasserfallen JB, Berger A, Eckert P, et al. Impact of Medical Practice Guidelines on the Assessment of Patients with Acute Coronary Syndrome without Persistent ST Segment Elevation. Int J Qual Health Care 2004;16: 383-9.
14. Allen LA, O'Donnell CJ, Giugliano RP, Ca-margo CA, Lioyd-Jones DM. Care Concor-dant With Guidelines Predicts Decreased Long-Term Mortality in Patients With Unstable Angina Pectoris and Non-ST-Elevation Myo-cardial Infarction. Am J Cardiol 2004;93: 1218-22.
15. Iliadis EA, Klein LW, Vandenberg BJ, et al. Clinical Practice Guidelines in Unstable
Angi-na Improve Clinical Outcomes by Assuring Early Intensive Medical Treatment. J Am Coll Cardiol 1999;34:1689-95.
16. Alexander KP, Peterson ED, Granger CB, et al. Potential Impact of Evidence-Based Medi-cine in Acute Coronary Syndromes: Insights from GUSTO-IIb. J Am Coll Cardiol 1998; 32:2023-30.
17. Tanne JH. News Extra_Hospitals That Follow Heart Attack Guidelines Save Lives. BMJ 2004;328:664.
18. Antman EM, Anbe DT, Armstrong AW, et al. ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Inf-arction-Executive Summary. J Am Coll Cardi-ol 2004;44:671-719.
19. Antman EM, Kupersmith J, Beasley JW, et al. ACC/AHA Guidelines for the Management of Patients With Unstable Angiona and Non-ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2000;36:970-1062.
20. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA Guideline Update for the Manage-ment of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Inf-arction-2002:Summary Article. Circulation 2002;106:1893-900.
21. American-College-of-Emergency-Physicians. Clinical Policy: Critical Issues in the Evalua-tion and Management of Adult Patients Pre-senting With Suspected Acute Myocardial In-farction or Unstable Angina. Ann Emerg Med 2000;35:521-44.
22. Bertrand ME, Simoons ML, Fox KAA, et al. Management of acute coronary syndromes in patients presenting without persistent ST-seg-ment elevation. Eur Heart J 2002;23:1809-40. 23. Pollack CV, Roe MT, Peterson ED. 2002
Update to the ACC/AHA Guidelines for the Management of Patients With Unstabel Angi-na and Non-ST-Segment Elevation
Myocar-dial Infarction: Implications for Emergency Departmetn Practice. Ann Emerg Med 2003; 41:355-69.
24. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001;345:494-502. 25. Holloway RG, Vickrey BG, Benesch C, Hinchey
JA, Bieber J. Development of Performance Measure for Acute Ischemic Stroke. Stroke 2001;32:2058-74.
26. Cheng EM, Siderowf A, Swarztrauber K, Eisa M, Lee M, Vickrey BG. Development of Quality of Care Indicators for Parkinson's Disease. Mov Disord 2004;19:136-50.
27. Spertus JA, Eagle Ka, Krumholz HM, Mitch-ell KR, Normand S-LT. American College of Cardiology and American Heart Association Methodology for the Selection and Creation of Performance Measures for Quantifying the Quality of Cardiovascular Care. Circulation 2005;111:1703-12.
28. The RAND/UCLA Appropriateness Method User's Manual. RAND Corporation, 2001. (Accessed at http://www.rand.org/publications/ MR/MR1269/)
29. Powell C. The Delphi Technique: Myths and Realities. J Adv Nurs 2003;41:376-82.
30. Bruwen Dr, H.Galusha D, Lewis JM, et al. National and State Trends in Quality of Care for Acute Myocardial Infarction Between 1994-1995 and 1998-1999: The Medicare Health Care Quality Improvement Program. Arch In-tern Med 2003;163:1430-9.
31. Specifications Manual for National Hospital Quality Measures. The Joint Commission of
American Healthcare Organization. (Accessed at http://www.jcaho.org/pms/core+measures/ Ocintroduction.pdf)
32. Hospital Care National Performance Measure. The National Quality Forum for Halthcare Quality Measurement and Reporting. (Accessed at http://www.qualityforum.org)
33. Scott IA, Denaro CP, Hichey AC, et al. Optimising Care of Acute Coronary Syndromes in Three Australian Hospitals. Int J Qual Health Care 2004;16:275-84.
34. Emergnecy Deparment Study: Development of ED Quality Performance Measures Project. Qualis Health, 2004. (Accessed at http://www. q u a l i s h e a l t h . o r g / e d s t u d y / y e a r 2 d o c s / final_report_phaseii_edqpm.doc)
35. Mehta RH, Montoye CK, Gallogly M, et al. Improving Quality of Care for Acute Myocar-dial Infarction: The Guidelines Applied in Practice (GAP) Initiative. JAMA 2002;287: 1269-76.
36. Fox KAA, Goodman SG, Klein W, et al. Management of Acute Coronary Syndromes. Variations in Practice and Outcome_Finding form the Global Registry of Acute Coronary Events. Eur Heart J 2002;23:1177-89.
37. Walter LC, Davidoqitz NP, Heineken PA, Covinsky KE. Pitfalls of Convertiing Practice Guidelines Into Quality Measures_Lessons Learned From a VA Performance Measure. JAMA 2004;291:2466-70.
38. Weiner M, Stump TE, Callahan CM, Lewis JN, McDonald CJ. Pursuing Integration of Performance Measures into Electronic Medi-cal Records: Beta-adrenergic Receptor Antag-onist Medications. Qual Saf Health Care 2005; 14:99-106.
Development of Clinical Quality of Care Indicators for
Acute Coronary Syndrome in Emergency Departments and
a Current Performance Analysis at Two Northern Hospitals
CHIEH-MIN FAN1, KUO-PIAO CHUNG3, MATTHEEW HUEI-MING MA4,
WEN-JONE CHEN4, SHU-HSUN CHU2
Background: The issue of quality of health care has been discussed widely and is a topic of current concern. Early diagnosis and timely treatment of patients suffering from acute coronary syndrome (ACS) are always a challenge in an emergency department (ED). Currently, there are not indicators available to measure quality of care for ACS in EDs across Taiwan.
Method: As a first stage, we developed summaries for each potential quality indicator; these were modified from various evidence-based clinical guidelines for ACS. A multidisciplinary expert panel rated the potential indicators using two rounds of the Delphi technique. This involved five dimensions of quality, including validity of the evidence, feasibility, impact on outcomes, room for improvement, and controllability. In the second stage, from 1st Oct., 2004 to 31st Mar., 2005, we retrospectively measured by chart abstrac-tion using these indicators of ACS the performance at the EDs of two northern Taiwan hospitals, one medical center and one district teaching hospital.
Results: Seven indicators, made up of two evaluation indicators and five therapeutic indicators, were found to meet all five dimensions by the expert panel. These were rate of completion of an electrocardio-gram within 10 minutes of presentation, cardiac markers follow-up when the ED stay is more than 6 hours, the use of Clopidogrel if there is Aspirin allergy, the use of a β-blocker on arrival, the use of Clopidogrel on non-ST elevated myocardial infarction (NSTEMI) patients, the use of Glycoptotein IIb/IIIa inhibitor on NSTEMI patients with percutaneous coronary intervention (PCI) and PCI carried out within 90 minutes of arrival. The performances for these indicators at the two target hospitals were 45.5%/ 44.3%, 72.3%/56.8%, 100%/0%, 3.9%/5.6%, 60.8%/32.1%, 28.8%/0% and 20.8%/38.9%, respectively.
Conclusions: Both study hospitals need to improve their performance with respect to the evaluation indicators and the administration of a β-blocker. The performance for timely PCI after arrival was ideal at one of the study hospitals.
Key words: quality indicators, acute coronary syndrome, disease oriented, clinical guidelines, Delphi technique
Received: January 5, 2006 Accepted for publication: February 6, 2006
From the 1Department of Emergency Medicine, 2Division of Cardiovascular Surgery, Department of Surgery Far Eastern Memorial Hospital
3Graduate Institute of Health Care Organization Administration, National Taiwan University 4Department of Emergency Medicine, National Taiwan University Hospital
Address for reprints: Kuo-Piao Chung, Graduate Institute of Health Care Organization Administration, National Taiwan University Room 635, 6F, 17 Syujhou Road, Taipei City 100, Taiwan (R.O.C.)
