Health resource variability in the achievement of optimal performance and clinical outcome

Background-An evidence-practice gap in acute coronary syndromes (ACS) is commonly recognized. System, provider, and patient factors can influence guideline adherence. Through using guideline facilitators in the clinical setting, the uptake of evidence-based recommendations may be increased. We hypothesized that facilitators of guideline recommendations (systems, tools, and workforce) in acute cardiac care were associated with increased guideline adherence and decreased adverse outcome. Methods and Results-A cross-sectional evaluation of guideline facilitators was conducted in Australian hospitals. The population was derived from the Acute Coronary Syndrome Prospective Audit (ACACIA) and assessed performance, death, and recurrent myocardial infarction (death/re-MI) at 30 days and 12 months. Thirty-five hospitals and 2392 patients participated. Significant associations with decreased death/re-MI were observed with hospital strategies to facilitate primary percutaneous coronary intervention for ST-elevation MI patients (38/428 [8.9%] versus 30/154 [19.5%], P<0.001) and after adjustment (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.24 to 0.90], P<0.023), electronic discharge checklists (none: 233/1956 [11.9%], integrated; 43/251[17.1%], P=0.069, electronic; 6/124 [4.8%], P<0.001) and after adjustment (integrated versus none: OR, 1.66 [95% CI, 0.98 to 2.80], P=0.057 and electronic versus none: OR, 0.49 [95% CI, 0.35 to 0.68], P<0.001), and intensive cardiac care unit (ICCU) staff-to-patient ratios (neither: 200/1257 (15.9%), CCU: 135/1051 (12.8%), ICCU: 8/84 (9.5%), P=0.049 and after adjustment (CCU versus neither: OR, 0.74 [95% CI, 0.47 to 1.14], P=0.172 and ICCU versus neither: OR, 0.55; [95% CI, 0.38 to 0.81] P=0.003). Conclusions-Facilitating uptake of evidence in clinical practice may need to consider quality improvement systems, tools and workforce to achieve optimal ACS outcomes.