Acute Ischemic Heart Disease The impact of achieving perfect care in acute coronary syndrome: The role of computer assisted decision support Richard V. Milani, MD, a Carl J. Lavie, MD, a,b and Adriana C. Dornelles, ScD a New Orleans, and Baton Rouge, LA Background Attainment of every performance measure or perfect care (PC) is used as a tool for measuring hospital quality of care. We sought to describe the effect of achieving PC on subsequent outcomes in patients admitted with acute coronary syndrome (ACS) and to determine whether computerized physician order entry enabled with decision support (CPOE- DS) would enhance the likelihood of achieving PC and improvements in clinical outcomes. Methods Clinical inpatient data, performance measures and subsequent mortality was collected in 1,321 consecutive ACS patients admitted between January 1, 2009, to October 15, 2011, using either a standardized order set that followed consensus guidelines or orders generated via CPOE-DS. Results CPOE-DS generated orders were utilized in 642 (49%) patients while the remaining 679 (51%) of patients were admitted using standardized order sets. At baseline, CPOE-DS patients were younger (-3%, P = .006), had lower resting heart rates (-3%, P = .012), higher TIMI risk scores (+19%, P b .001), were less likely to have hypertension (85% vs. 90%, P = .014), and more likely to have ST-segment elevation myocardial infarction (17% vs 10%; P = .001) than patients admitted with standard orders. Patients admitted using CPOE-DS were 5.7 times more likely to achieve PC than those who were admitted with standard orders (P b .001). Independent predictors of survival included PC (HR, 0.45; P b .001), age ≥67 years (HR, 2.34; P b .001), and abnormal presenting heart rate (HR, 1.71; P = .046). Conclusions Achievement of PC is a valid measure of quality of care in the hospitalized ACS patient and is associated with improved survival. CPOE-DS is feasible in the care process for ACS and can increase attainment of PC. (Am Heart J 2012;164:29-34.) Acute coronary syndrome (ACS) constitutes approxi- mately 1.3 million hospital discharges per year in the United States at a cost of $35 billion in hospital charges. 1,2 In those patients who survive the index hospitalization, the risk of further cardiovascular complications including recurrent myocardial infarction (MI), sudden cardiac death, heart failure, and stroke are substantial. 1 There is clear evidence from randomized clinical trials and consensus guidelines that in-hospital initiation of key pharmacotherapies and interventions can substantially reduce short and long-term mortality and morbidity in ACS patients. 3 Yet despite promulgation of these recommendations, several studies have documented poor performance and a high degree of hospital and physician variability in meeting guideline standards, suggesting inadequacies in the organization and delivery of care. 4-10 Computerized physician order entry enabled with decision support (CPOE-DS) can present an attractive avenue for improving process of care and is well suited for the complex algorithms governing the ACS patient. Decision support software has established benefit in other disease states including venous thromboembolism and has demonstrated efficacy at reducing medication errors and adverse clinical outcomes. 11-14 To focus greater attention at deficiencies of care in ACS, the American Heart Association (AHA) and American College of Cardiology (ACC) have co-developed guide- line-based “performance measures” for ACS patients which has been adopted by various health agencies From the a Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School–The University of Queensland School of Medicine, New Orleans, LA, and b Pennington Biomedical Research Center, Baton Rouge, LA. Presented in part at the American College of Cardiology (ACC.11/i2) Summit, New Orleans, Louisiana, April 2011. Submitted November 4, 2011; accepted April 10, 2012. Reprint requests: Richard V. Milani, MD, FACC, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA, 70121. E-mail: rmilani@ochsner.org 0002-8703/$ - see front matter © 2012, Mosby, Inc. All rights reserved. doi:10.1016/j.ahj.2012.04.004 Clinical Investigations