For most of the 21st century, cardiology practice has focused on improving the quality of care and implementing evidence-based clinical guidelines. A study suggests those efforts have yielded a string of remarkable successes.
Published in Circulation in late 2014, the study, “Trends in Hospitalizations and Outcomes for Acute Cardiovascular Disease and Stroke: 1999-2011,” reviewed data regarding myocardial infarction, unstable angina, ischemic stroke and heart failure. Researchers examined mortality and hospital readmission rates, among other factors, for these conditions in all individuals age 65 and older who participated in the Medicare fee-for-service program. Results revealed significant improvements in outcomes, as evidenced by declining trends in mortality and hospitalization.
A Measure of Success
The goal of the research was to evaluate what had been achieved during a period when there were not many therapeutic breakthroughs for stroke and cardiovascular disease but rather an emphasis on quality and the translation of evidence to the bedside, according to Harlan M. Krumholz, MD, Director of the Center for Outcome Research and Evaluation at Yale University School of Medicine and lead author of the study.
Researchers evaluated medical records for nearly 34 million Americans receiving Medicare. Key factors considered for the four diagnoses included hospitalization rates, mortality rates at 30 days and one year post-hospitalization, and 30-day hospital readmission rates.
“To really measure the benefits of our work in trying to improve care, we have to look at what’s happening with the patients ...,” Dr. Krumholz says, “so we tried to focus on the patient experience.”
Analyzing data from such a broad pool of Medicare patients gave researchers an advantage over smaller studies that seek to quantify the national experience. They were able to produce a report card reflective of national trends that not only outlined progress in cardiology but also allowed for comparisons between some of the trends observed in cardiology and those seen in other medical specialties.
“If we decreased the [hospitalization] rates to the same extent as other specialties, we can’t claim special credit,” Dr. Krumholz explains. “We can just say this is representative of all other conditions. We wanted to make that comparison.”
Researchers were astounded by their findings.
Rates of hospitalization during the years covered by the study declined 38 percent for patients with myocardial infarction, 30.5 percent for patients with heart failure and 33.6 percent for those with ischemic stroke. The largest decline, however, occurred in the area of unstable angina, which saw an 83.8 percent reduction in hospitalization rates. By comparison, the decline in hospitalization rates across all other conditions averaged 10 percent.
Thirty-day readmission rates experienced the following declines: 18.6 percent for myocardial infarction, 32.3 percent for unstable angina, 9.7 percent for heart failure and 5.9 percent for ischemic stroke.
Mortality rates after 30 days decreased nearly 30 percent for myocardial infarction, 13.1 percent for angina, 4.7 percent for stroke and 16.4 percent for heart failure. Observed declines in one-year mortality rates were 23.4 percent for myocardial infarction, 21.1 percent for unstable angina, 13 percent for heart failure and 13.1 percent for ischemic stroke.
“Between 1996 and 1997, we began to fully appreciate that even though we were generating good evidence, it was being unevenly applied across the country,” Dr. Krumholz says. “Over the last decade, hospitals, doctors, professional societies and the government have all worked together to make sure the quality of care is increasing. The results are breathtaking — truly remarkable — and I think it shows they can be translated into other areas of medicine. We’ve made extraordinary progress, and it’s not due to an extraordinary medicine. We’ve done it because of better care, better communication and a focus on implementation.”