Intervention to Increase the Proportion of Acute Myocardial Infarction or Coronary Artery Bypass Graft Patients Receiving an Order for Aspirin at Hospital Discharge

BACKGROUND: Chronic aspirin therapy is recommended by the American College of Cardiology/American Heart Association (ACC/AHA) following acute myocardial infarction (AMI) and by the Society of Thoracic Surgeons (STS) following coronary artery bypass graft (CABG). Aspirin therapy at discharge following a hospitalization for AMI or CABG is a common pay-for-performance indicator used by third-party payers and was included as a quality measure in the Centers for Medicare and Medicaid Services (CMS)/ Premier Hospital Quality Incentive Demonstration initiated in 2003. A formal prescription for aspirin, such as required for other cardiovascular drugs, could serve as a reminder to all health care providers (doctors, nurses, and pharmacists) to include aspirin on a discharge medication list. OBJECTIVES: To evaluate if an aspirin prescription placed in the patient chart shortly after hospital admission would increase compliance with guidelines for aspirin use at discharge in patients with AMI or CABG. METHODS: This was a single-center prospective pre-intervention to postintervention comparison study in a 411-bed hospital. Patients admitted during the 3-month period from July through September 2008 with an AMI or undergoing CABG surgery served as the pre-intervention group, and patients admitted during the 3-month period from January through March 2009 were in the post-intervention group. The intervention included multiple educational sessions with clinical staff, conducted both prior to and during the pilot, and blank pre-printed aspirin prescriptions placed in the charts of patients for whom no contraindication to aspirin was present. The blank prescriptions were then completed by the attending physician (or physician extender), and the discharge nurse used the completed aspirin prescription, with other prescriptions and written orders, as a reference when creating the discharge medication list. The primary outcome measure was the percentage of patients who had aspirin documented on the discharge medication list. Differences in compliance rates in the comparison and pilot periods were assessed using the Pearson chi-square test. RESULTS: A total of 458 patients were identified with a CABG procedure and/or an admitting diagnosis of AMI; 447 met inclusion criteria, and 11 were excluded (1 patient in each of the groups had a contraindication to aspirin due to bleeding, and 9 died during hospitalization). The intervention was associated with an increase in the proportion of patients with aspirin documented on the discharge medication list, 266 of 269 patients (98.9%) compared with 169 of 178 patients (94.9%, P = 0.012) in the pre-intervention group. In the subsample of patients with CABG, 54 of 59 (91.5%) patients in the pre-intervention group had aspirin documented on the discharge medication list compared with 100% of 66 patients in the postintervention group (P = 0.016). In the subsample of patients with AMI, aspirin was documented in 115 of 119 (96.6%) patients in the pre-intervention group versus 200 of 203 (98.5%) in the post-intervention group (P = 0.263). CONCLUSIONS: A quality improvement initiative that included clinical staff education and placement of aspirin prescriptions in patient charts during the hospital stay was associated with an increase in the proportion of patients who had aspirin documented on the discharge medication list for the overall sample of patients with AMI or CABG and for patients with CABG alone but not for the quality measure for AMI patients.