Quality of Care for Non-ST-Segment Elevation Acute Coronary Syndromes: What Should Be the Status Quo?

Nearly 13 million people in the United States have coronary artery disease (CAD), and more than 750,000 deaths are attributed to this disease each year [1]. Although there have been substantial therapeutic advances in the treatment of CAD in the past decade, these new therapies and approaches to care are not being systematically applied across the health system. Guidelines developed by the American College of Cardiology/American Heart Association (ACC/AHA) promote the systematic application of an evidence-based approach to the management of patients with suspected acute coronary syndrome (ACS). Clinical practice guidelines written by expert panels synthesize research findings from randomized clinical trials and observational studies as well as consensus opinion. Such guidelines can be useful for the practitioner because they distill a large and potentially overwhelming body of research and knowledge into clinically practical and relevant approaches to care. Through explicit statements that a therapy is “useful and effective” (ie, a class I recommendation), guidelines provide one framework for defining quality medical care. Importantly, the practice of evidence-based medicine, facilitated by clinical practice guidelines, has been associated with better patient outcomes [2–4]. However, resistance to adoption of guidelines in daily medical practice remains. Guidelines may be construed by physicians as a threat to their autonomy by placing “cookbook” constraints on the art of medicine [5,6]. Agrowing body of scientific literature, including the Institute of Medicine’s (IOM) report Crossing the Quality Chasm [7], reports that deviations from evidence-based guideline recommendations are common in daily practice, particularly among sociodemographic subgroups of patients. As the following case study illustrates, these nationwide gaps in treatment always begin with an individual patient.