1. Kayyali, Andrea MSN, RN

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IF Highlights head: According to this study:


* Discharge planning was given less often to women.


* The one-year mortality rate was lower among women given discharge planning.


* Standardized orders and discharge tool confer benefit to both men and women.



A recently published study reports that the use of a standardized discharge tool in patients with acute myocardial infarction (MI) can promote greater use of evidence-based medication. In addition, women who received the intervention had a lower mortality rate at one year, although they received it less frequently than men did.


Using its own guidelines and those of the American Heart Association, the American College of Cardiology developed the Guidelines Applied in Practice (GAP) program, which incorporates standardized orders and a standardized discharge document, and "systems that reinforce the use of evidence-based [acute MI] care that is often omitted." Studies have shown the GAP program, which has been implemented in numerous hospitals in Michigan, to be effective. The present study was designed to determine whether the GAP program was used equally among men and women and whether its use yielded the same results in both sexes.


Designed to promote the use of evidence-based care, the GAP program involves standardized physician orders and a discharge document encompassing education on heart disease, medication instructions, goals for controlling cholesterol levels and for smoking cessation, counsel in diet and exercise, and instructions for follow-up with the primary care physician.


The researchers randomly selected a baseline sample of at least 20 Medicare patients with acute MI at each hospital in Michigan participating in the GAP program during a one-year "pre-GAP" period, and a second sample was obtained during a four-month period after implementation of the GAP program. Data on presentation, treatment, comorbidities, diagnostic testing, the use of standardized orders and discharge tools, outcomes, and other patient variables were collected in both groups. The primary end points of the study were the mortality rates at 30 days and one year.


Among the women (mean age, 75 years), there were greater rates of a history of MI and previous coronary artery bypass grafting (CABG) in those in the "post-GAP" sample, compared with those in the pre-GAP sample; women in the post-GAP group were also more likely to have received aspirin within 24 hours of hospitalization and at discharge, b-blockers at discharge, and discharge planning according to a discharge tool. Among the men (mean age, 69 years), there were higher rates of hypertension but lower left ventricular ejection fractions in those in the post-GAP sample, compared with those in the pre-GAP sample. They were also more likely to have received aspirin, b-blockers, angiotensin-converting enzyme (ACE) inhibitors, and antilipidemic agents at discharge, as well as discharge planning according to the discharge tool.


A comparison between men and women in the post-GAP samples revealed higher rates of previous MI and CABG among men (despite a significantly younger mean age) and higher rates of hypertension and congestive heart failure among women. In addition, men received aspirin, ACE inhibitors, antilipidemic agents, and b-blockers within 24 hours of admission, and discharge planning at higher rates than women did. That women didn't receive the standardized discharge planning as often as men did was of particular concern because those women in whom the discharge tool had been used had a statistically significant lower one-year mortality rate compared with the women who didn't. The study authors suggest that the greater age of the women (on average, six years older than the men) might be part of the reason women received the standardized discharge tool less often; they write, "It is possible that as patient age increases, so does uncertainty of physicians as to the potential benefits of evidence-based therapies."


The study demonstrates that while differences based on sex exist in the treatment of acute MI, both men and women can benefit from the use of evidence-based medication as promoted by standardized orders and discharge planning instruments, and that greater use of such instruments in female patients should be encouraged in light of the lower one-year mortality rate observed in the study.


Jani SM, et al. Arch Intern Med 2006;166(11):1164-70.