Copyright © 2003 by the European Society of Cardiology.
Regular Articles
From guidelines to clinical practice: the impact of hospital and geographical characteristics on temporal trends in the management of acute coronary syndromes
The Global Registry of Acute Coronary Events (GRACE)
a The University and The Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
b Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
c University of Massachusetts Medical School, Worcester, MA, USA
d Duke University Medical Center, Durham, NC, USA
e University of Michigan Health System, Ann Arbor, MI, USA
f Royal Brompton & Harefield NHS Trust, London, UK
g Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
* Corresponding author: Professor Keith A. A. Fox, Department of Cardiology, University of Edinburgh, Edinburgh EH3 9YW, UK. Tel.: +44-131-536-2742; fax: +44-131-536-2744
E-mail address: k.a.a.fox{at}ed.ac.uk
Received 19 December 2002; revised 22 April 2003; accepted 27 April 2003
Aims The extent to which hospital and geographic characteristics influence the time course of uptake of evidence from key clinical trials and practice guidelines is unknown. The gap between evidence and practice is well recognized but the factors influencing this disjunction, and the extent to which such factors are modifiable, remain uncertain.
Methods and results Using chronological data from the GRACE registry (n=12 666, July 1999 to December 2001), we test the hypothesis that hospital and geographic characteristics influence the time course of uptake of evidence-based guideline recommendations for acute coronary syndromes (ACS) with and without ST elevation. Certain therapies were widely adopted in both ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients (aspirin >94% of all patients; beta-blockers 85–95%) and changed only modestly over time. Significant increases in the use of low-molecular-weight heparins and glycoprotein IIb/IIIa inhibitors occurred in STEMI and NSTEMI patients in advance of published practice guidelines (September/November 2000) with marked geographical differences. The highest use of LMWH was in Europe in NSTEMI (86.8%) and the lowest in the USA (24.0%). Contrasting geographical variations were seen in the use of percutaneous coronary intervention (PCI) in NSTEMI: 39.5% USA, 34.6% Europe, 33.5% Argentina/Brazil, 25.0% Australia/New Zealand/Canada (July–December 2001). Theuse of PCI was more than five times greater in hospitals with an on-site catheterization laboratory compared to centres without these facilities, and geographic differences remained after correction for available facilities.
Conclusions Hospital and geographical factors appear to have a marked influence on the uptake of evidence-based therapies in ACS management. The presentation and publication of major international guidelines was not associated with a measurable change in the temporal pattern of practice. In contrast, antithrombotic and interventional therapies changed markedly over time and were profoundly influenced by hospital and geographic characteristics.
Key Words: Acute coronary syndromes • Low-molecular-weight heparin • Glycoprotein IIb/IIIa inhibitors • Percutaneous coronaryintervention • Catheterization laboratory • Temporal trends • Guidelines
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