The Effect of a Disease Management Algorithm and Dedicated Postacute Coronary Syndrome Clinic on Achievement of Guideline Compliance: Results from the Parkland Acute Coronary Event Treatment Study
Yorio, Jeffrey T.
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BACKGROUND: The application of disease management algorithms by physician extenders has been shown to improve therapeutic adherence in selected populations. It is unknown whether this strategy would improve adherence to secondary prevention goals after acute coronary syndromes (ACSs) in a largely indigent county hospital setting. METHODS: Patients admitted for ACS were randomized at the time of discharge to usual followup care versus the same care with additional visits with physician extenders in a dedicated post- ACS clinic. Physician extender visits were conducted according to a treatment algorithm based on contemporary practice guidelines. Groups were compared using the primary end point of achievement of low-density lipoprotein treatment goals at 3 months after discharge with key secondary endpoints including the achievement of additional evidence-based practice goals with up to 1 year of follow up assessment. RESULTS: One hundred forty consecutive patients were randomized. Rates of use of all evidencebased therapies assessed were high at the time of hospital discharge, and similar between the study groups. A similar proportion of patients returned for study follow-up in both groups at 3 months (54 [79%]/68 in the usual care group vs. 57 [79%]/72 in the intervention group; P = 0.97). Among those completing the 3-month visit, a low-density lipoprotein cholesterol level less than 100 mg/dL was achieved in 37 (69%) of the usual care patients compared with 35 (57%) of those in the intervention group (P = 0.43). There was no statistical difference in implementation of therapeutic lifestyle changes (smoking cessation, cardiac rehabilitation, or exercise) between groups. Prescription rates of evidence-based therapeutics at 3 months were similar in both groups. CONCLUSION: The implementation of a post-ACS clinic run by physician extenders applying a disease management algorithm did not measurably improve adherence to evidence-based secondary prevention treatment goals. Despite initially high rates of evidence-based treatment at discharge, adherence with follow-up appointments and sustained implementation of evidence-based therapies remains a significant challenge in this high-risk cohort.