Get with the Guidelines®: Using Our Data to Identify Disparities and Improve Outcomes
Pub Date: Wednesday, December 9, 2009
Author: Eric Edward Smith, MD, MPH, FRCPC, FAHA
At the heart of Get With The Guidelines® (GWTG) is an encounter between a patient and a set of hospital providers striving to fulfill every opportunity to provide the evidence-based care that we know saves lives. We know that GWTG helps providers do this. Studies show consistent improvement over time in provision of acute therapy, secondary prevention, and counseling on lifestyle modification. Our patients have had their lives improved by these performance measures. Heart failure, heart attacks, and strokes have been prevented, and our patients have enjoyed a better quality of life. Aggregated over the more than 1.6 million hospital admissions in the GWTG programs (Heart Failure, Coronary Artery Disease and Stroke), the cumulative benefit is almost mind-boggling. One of the societal benefits of the GWTG programs, perhaps not immediately apparent from the individual patient or hospital viewpoint but nonetheless extremely valuable, is the ability to look at the massive aggregate of data for the purposes of research. Researchers can now look at the GWTG data to get a good sense of how care is provided in a broad sample of hospitals across the United States. This data can be used to identify national trends in care, to identify patient groups at risk for under-utilization of guideline-based care, to describe the transition from the hospital to the community, and to determine the relationship between evidence-based, guideline-recommended care and patient outcomes in the real world setting. Several recent publications using GWTG data are highlighted here.
One of the ways that research can be helpful is by identifying groups of patients who are at risk for not receiving guideline-recommended care. Dr. Brilakis, a winner of a GWTG Young Investigator Award, and colleagues examined the quality of care provided to patients with acute coronary syndromes who had known atherosclerotic disease. These patients were older, and paradoxically were less likely to receive some guideline-based therapies despite being at higher risk for worse outcomes. Forman and associates showed similar findings in older patients hospitalized for congestive heart failure--namely, that older persons were less likely to receive some therapies despite being at higher risk. It must be recognized that, despite these disparities, in most cases, the patients did receive the appropriate therapy, and that, in some cases, the problem may have been related to failure to document appropriate age- or comorbidity-related contraindications to therapy in situations where the therapy was not actually indicated. Another report by Horwich and colleagues found that weekend discharge of heart failure patients was associated with lower rates of documentation of ejection fraction and provision of discharge instructions. Collectively, these studies allow us to improve care by targeting efforts to groups most at risk for missed care opportunities.
The transition from the acute care hospital to the community or rehabilitation setting is recognized to be a period in which care can become fragmented and disorganized. For example, Brown and associates looked at hospital-based referral for cardiac rehabilitation following admission for coronary artery disease and found that only 56% of eligible patients were referred to cardiac rehabilitation. Clearly, we need to rethink the role of cardiac rehabilitation in our systems of care for coronary artery disease. In stroke, a team of researchers has partnered with GWTG to prospectively study the adherence to stroke prevention medications as patients transition from the hospital to the community. In the Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) study, patients will be enrolled in the hospital (n = 2,900) and followed over 12 months to determine who stays on their medicines, who doesn't, and why.
Guideline recommendations for therapies are predominantly based on large, randomized, controlled trials. Although extremely informative, these trials are performed in selected groups of consenting patients in highly monitored settings that may not reflect the diversity of patients and practice settings in the real world. There is, therefore, a need to determine whether adherence to guideline-based therapies in the real world works as well as it should, based on the clinical trials. Wang and colleagues looked at door-to-balloon times in patients with acute myocardial infarction and found, surprisingly, that improving door-to-balloon times did not correlate with improvements in other processes of care, or with mortality. It is possible, at least in theory, that excessive efforts at improving one quality measure, such as door-to-balloon time, might delay progress in improving other measures. The lack of association with decreased mortality in the study is perhaps not of great concern because a lot of factors affect mortality, of which door-to-balloon time is only one. The authors conclude that improving outcomes following myocardial infarction may not be achieved by focusing on single process measures in isolation and will likely require comprehensive quality improvement efforts.
- Brilakis ES, Hernandez AF, Dai D, et al. Quality of care for acute coronary syndrome patients with known atherosclerotic disease: results from the Get With the Guidelines Program. Circulation 2009;120(7):560-567.
- Forman D, Cannon C, Hernandez A, et al. Influence of age on the management of heart failure: findings from Get With the Guidelines-Heart Failure (GWTG-HF). Am Heart J 2009;157(6):1010-1017.
- Horwich T, Hernandez A, Liang L, et al. Weekend hospital admission and discharge for heart failure: association with quality of care and clinical outcomes. Am Heart J 2009;158:451-458.
- Brown T, Hernandez A, Bittner V, et al. Predictors of cardiac rehabilitation referral in coronary artery disease patients: results from the American Heart Association's Get With The Guidelines Program. J Am Coll Cardiol 2009;54;515-552.
- Bushnell C, Zimmer L, Schwamm L, et al. The Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) Registry: Design, rationale, and baseline patient characteristics. Am Heart J 2009;157:428-435.e2.
- Wang T, Fonarow G, Hernandez A, et al. The dissociation between door-to-balloon time improvement and improvements in other acute myocardial infarction care processes and patient outcomes. Arch Intern Med 2009;169(15):1411-1419.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --