Myocardial infarction classification and its implications on measures of cardiovascular outcomes,quality, and racial/ethnic disparities

Heart disease continues to be the leading cause of death in the United States, with approximately 805 000 cumulative deaths from myocardial infarctions (MI) from 2005 to 2014. Gender and racial/ethnic disparities in MI diagnoses are becoming more evident in quality review audits. Although recent changes in diagnostic codes provided an improved framework, clinically distinguishing types of MI remains a challenge. MI misdiagnoses and health disparities contribute to adverse outcomes in cardiac medicine. We conducted a literature review of relevant biomedical sources related to the classification of MI and disparities in cardiovascular care and outcomes. From the studies analyzed, African Americans and women have higher rates of mortality from MI, are more probably to be younger and present with other comorbidities and are less probably to receive novel therapies with respect to type of MI. As high-sensitivity troponin assays are adopted in the United States, implementation should account for how race and sex differences have been demonstrated in the reference range and diagnostic threshold of the newer assays. More research is needed to assess how the complexity of health disparities contributes to adverse cardiovascular outcomes. Creating dedicated medical quality teams (physicians, nurses, clinical documentation improvement specialists, and medical coders) and incorporating a plan-do-check-adjust quality improvement model are strategies that could potentially help better define and diagnose MI, reduce financial burdens due to MI misdiagnoses, reduce cardiovascular-related health disparities, and ultimately improve and save lives.     

Improving compliance with diabetes care using a novel mnemonic: A quality improvement project in an urban primary care clinic

AimThe aim of this quality improvement project was to improve compliance with the delivery of multidimensional patient-centered diabetes care using a streamlined mnemonic based on established diabetes guidelines.MethodsUsing the Institute for Healthcare Improvement (IHI) model for improvement, four rapid plan-do-study-act cycles primarily implemented different tests of change over eight weeks using a streamlined mnemonic – the LLaVES (lifestyle, laboratory tests, vaccination, examination, social/psychosocial) bundle for screening and case management of patients with diabetes. Secondary to the LLaVES bundle, tests of change were also conducted for clinic team members and patients. Team member engagement utilized a best-practice toolkit for effective communication. Patient engagement implemented validated models to evaluate knowledge of diabetes and stage of change. Data were analyzed using run charts to evaluate the impact of interventions on outcomes. Overall compliance was measured as the diabetes management compliance rate (DMCR), composed of LLaVES implementation, team engagement, and patient engagement scores.ResultsThe diabetes management compliance rate increased by 72.2%, from a baseline of 49% to 84.4% in eight weeks. Team engagement increased from 76.6% to 92% while patient engagement increased from 70.4% to 87.4%.ConclusionsDiabetes management is complex and requires team and patient engagement to implement a structured and multidimensional process. Composed of established, high-level evidence interventions, the LLaVES bundle is one approach to systematize complex care while taking into account the specific and unique challenges of a health care organization.