Effectiveness of a Simplified Checklist to Overcome the Inertia of Treatment Implementation in ACS Patients with High Comorbidity Burden

Abstract

Background/Objective: High-risk subsets of patients with acute coronary syndrome (ACS) experience decreased access to optimal care and have poor clinical outcomes, reflecting an inertia to the delivery of guideline-directed and evidence-based therapy and implementation of critical care pathways. We aim to investigate the clinical effectiveness of a simplified implementation checklist to counter treatment inertia in patients with high comorbidity burden. Methods: An ACS critical care pathway was simplified and reduced to a minimalistic checklist including only items on GDMT and invasive strategy. A total of 2005 consecutive patients with ACS were evaluated including 1499 patients receiving standard care and 506 patients managed with the checklist. Patients with STEMI undergoing primary percutaneous coronary interventions and patients receiving upfront cardiovascular intensive care were excluded. Multivariate regression spline models were used to study the relationship between comorbidity, expressed as the Charlson Comorbidity Index (CCI) and a management strategy including guideline-directed medical therapy (GDMT) and an early invasive approach. Inverse probability of treatment weighting (IPTW) was used to address confounding factors. The use of GDMT and early invasive therapy were compared in patients receiving standard care and checklists. The 90-day composite outcome of all-cause mortality, recurrent ACS and stroke were compared between patients receiving standard care and those receiving checklists. Results: High CCI was associated with decreased GDMT, invasive strategy and the utilization of critical care pathway. Checklist utilization was unaffected by high CCI and led to sustained and higher use of GDMT and invasive approach in patients despite high CCI. Checklist managed patients have >10% higher rates of prescription of each class of GDMT (p < 0.0001) and more than twice the rate of early invasive approach (51.0% vs. 20.7%, (p < 0.0001) compared to patients receiving standard care. The 90-day composite outcome was lower in checklist management patients compared to patients receiving standard care, adjusted hazard ratio 0.61 (95% CI 0.46–0.81), log-rank p = 0.0006, especially in patients with high CCI, adjusted hazard ratio 0.60 (95% CI 0.38–0.97), log-rank p = 0.035 for CCI 5–6; adjusted hazard ratio 0.53 (95% CI 0.35–0.84), log-rank p = 0.0057 for CCI 7 or more. Conclusions: The use of a simplified checklist is associated with better implementation of GDMT and invasive strategy as well as better 90-day clinical outcomes in ACS patients with high comorbidity burden