Patient, provider, and environmental factors associated with adherence to cardiovascular and cerebrovascular clinical practice guidelines in the ED

Abstract

Objectives: Myocardial infarction and stroke are two of the leading causes of death in the U.S. Both diseases have clinical practice guidelines (CPGs) specific to the emergency department (ED) that improve patient outcomes. Our primary objectives were to estimate differences in ED adherence across CPGs for these diseases and identify patient, provider, and environmental factors associated with adherence.

Methods: Design: Retrospective study at 3 hospitals in Colorado using standard medical record review.

Population: Consecutive adults (≥18) hospitalized for acute coronary syndrome (ACS), ST-elevation myocardial infarction (STEMI), or acute ischemic stroke (AIS), who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment.

Outcome: ED adherence to the CPG (primary); in-hospital mortality and length-of-stay (secondary).

Analysis: Multivariable logistic regression using generalized estimating equations was used.

Results: Among 1053 patients, ED care was adherent in 84% with significant differences in adherence between CPGs (p<0.001) and across institutions (p=0.04). When patients presented with atypical chief complaints, the odds of receiving adherent care was 0.6 (95% CI 0.4-0.9). When the primary ED diagnosis was associated but not specific to the CPG, the odds of receiving adherent care was 0.5 (95% CI 0.3-0.9) and 0.3 (95% CI 0.2-0.5) for unrelated primary diagnoses.

Conclusions: Adherence to ED CPGs for ACS, STEMI and AIS differs significantly between cardiovascular and cerebrovascular diseases and is more likely to occur when the diagnosis is highly suggested by the patient's complaint and acknowledged as the primary diagnosis by the treating ED physician.