Improving quality of care for acute coronary syndromes in China - effectiveness of clinical pathways and barriers to improvements

Important gaps have been identified in the hospital treatment of people with heart attack or severe angina - commonly known as acute coronary syndromes, or “ACS” - in China. Clinical pathways are methods to streamline hospital care with the intention of guiding clinicians to provide timely, efficient and optimal care. In China, like most parts of the world, best treatment is not always delivered to patients with ACS.

Clinical Pathways in Acute Coronary Syndromes Phase 2 (CPACS-2) Study was designed to determine whether the use of clinical pathways would improve the quality of care for patients with ACS in China. As part of this study, an assessment was also performed to identify reasons why the pathways might or might not work in Chinese hospitals. The results of CPACS-2 were published in two papers in “Circulation: Cardiovascular Quality and Outcomes” today.

  • Click here to read the abstract of Hospital Quality Improvement Initiative for Patients With Acute Coronary Syndromes in China
  • Click here to read the abstract of System Barriers to the Evidence-Based Care of Acute Coronary Syndrome Patients in China

CPACS-2 study involved 15,141 patients in 75 hospitals. The primary findings of the study showed that after 12 months clinical pathways intervention, there was important improvements in the proportion of patients who left hospital on medications that should be used to help prevent another heart attack or episode of severe angina. However, for other treatments, the clinical pathways did not seem to improve care.

For example, in patients with more severe forms of heart attack, early treatment to remove clots that are blocking arteries is important. However, in CPACS-2, use of these treatments did not improve with the clinical pathways. The study found the presence of significant barriers to implementing change within hospitals and these barriers are likely to limit the impact of quality improvement efforts in China.

“Clinical pathways are management plans that advocate implementation of standardized strategies to deliver optimal care based on guideline recommendations and are commonly used for conditions of high volume and cost such as ACS. It is also one of a series of healthcare reform efforts endorsed by the Chinese government,” said Professor Yangfeng WU, Professorial Fellow at The George Institute for Global Health at Peking University Health Science Center. “However, there is no adequate data on how well they work for our country at the moment. Therefore we designed and implement the CPACS study, expecting to increase the use of recommended treatments and reduce the use of expensive and unnecessary investigations and treatment.”

“The CPACS-2 study found that the clinical pathways intervention was associated with improvement in some, but not all processes of care, and while there were trends towards reductions in repeat heart attack and death in hospital with the intervention, we were not able to definitively prove this," added Professor Wu.   

“Our barriers study, conducted in parallel, suggests the presence of multiple organizational and wider system factors which often prevented both the use of the clinical pathways and achieving the desired quality standards outlined by the pathway,” said Professor Runlin Gao, one of the co-Principal Investigator, ex-president of Chinese Society of Cardiology. He went on to describe the key findings from CPACS-2, “Our findings show that limited capacity of hospital emergency care services, high out–of-pocket expenses with the need for “upfront” payments, prolonged discussions with the patient and families for both obtaining consent and pooling funds, and the avoidance of treatments in patients with more severe illness are likely to be major contributing factors.”

The CPACS program has been independently conducted since 2004 through grants from Sanofi China. Phase 1 of the program (CPACS-1) evaluated the patterns of care in 2973 patients presenting with a suspected acute coronary syndrome (ACS) to 51 hospitals in 18 provinces across China. The main results (Heart 2008; 94:554-560) demonstrated important gaps between best treatment and current treatment for many of these patients.

Subsequently, under the auspices of the Chinese Society of Cardiology and involving representatives of the Ministry of Health in China (now, the National Health and Family Planning Commission of China), CPACS-2 was designed to improve the quality of care provided to hospitalized ACS patients.

To address the factors found in CPACS-2, the CPACS program entered into Phase 3 (CPACS-3), which is currently being conducted in 100 county hospitals in China. Evidence generated from CPACS program will be crucial for evidence-based police making.