Get With The Guidelines® Advances Health Services and Outcomes Research
Pub Date: Friday, May 15, 2009
Author: Paul Heidenreich, MD, MS
The Get With The Guidelines® (GWTG) program was initiated in 2000 by the American Heart Association and American Stroke Association with the primary goal of improving outcomes for patients with heart disease and stroke.[1,2] Additional goals of the program are the elimination of disparities and advancing the science of quality of care research. Approximately 1,500 hospitals, or about one-third of all US hospitals, have enrolled in at least one of three program modules (heart failure, stroke, or coronary artery disease). The GWTG program has now collected data on more than 1 million hospitalizations across all modules that include clinical characteristics of patients and their quality of care. Such a wealth of quality and quantity of data has allowed investigators to use the GWTG program to answer many questions related to the quality of care for heart disease. This commentary discusses six recently published studies that have used GWTG data.
In the study addressing male-female disparities in care, Reeves (Michigan State University) and colleagues examined the quality of care for women with ischemic stroke. Past studies have indicated that women have worse outcomes following a stroke, although it has been unclear if this outcome difference is explained by differences in quality of care. The investigators used data on 383,318 patients hospitalized with acute ischemic stroke from 1,139 hospitals. They found that women were slightly, but significantly, less likely to receive appropriate care compared with men. When seven stroke performance measures were examined, defect-free care (use of all measures where appropriate) was only 66% in women compared with 71% for men. Women were also less likely to be discharged home. Additional studies should examine if participation in the GWTG program has narrowed these gender differences in care. Presumably, as a hospital improves care toward defect-free care, disparities will be eliminated.
Gender disparities in care were also noted in a study of warfarin therapy for secondary stroke prevention among patients with atrial fibrillation. This study by Lewis from the MetroHealth Campus of Case Western Reserve University examined adherence to warfarin treatment at discharge for patients with stroke in those with a history of atrial fibrillation. Women and the elderly were less likely to receive warfarin regardless of whether atrial fibrillation was electrocardiogram (ECG)-documented or based on history alone. In general, warfarin was more likely to be used for those in whom an ECG documented the atrial fibrillation (79%) compared with those with only a medical history of atrial fibrillation (49%). Over time, participation in the GWTG program led to an increase in appropriate warfarin use, but only in those patients with an ECG-documented atrial fibrillation (from 74% at enrollment to 89% after participation). Atrial fibrillation was relatively common with 10% of stroke patients having either ECG documentation or a history of atrial fibrillation. The study highlights that although there are disparities in the quality of atrial fibrillation care, all patients could have better care.
Several other recent studies from the GWTG program have examined patient and hospital predictors of quality of care. In a study led by Shah of the Duke Clinical Research Institute , a large variation in guideline-recommended hospital use or planned use of implantable cardioverter defibrillators (ICDs) was demonstrated (1% to 35% at the hospital level). Use of ICDs was more common in larger facilities and in those that performed bypass surgery, heart transplant, and percutaneous coronary interventions compared with hospitals without those characteristics. However, much of the variation in ICD use across hospitals remained unexplained.
One of the goals of quality improvement programs such as GWTG is to expand use of interventions beyond ideal candidates to all patients where the benefit outweighs the harm. A classic example is the use of beta blockers following an acute coronary syndrome in patients with reactive airway disease. Although some of these patients may not tolerate beta blockers, numerous studies have shown that the vast majority do tolerate beta blockers and have improved outcome with its use. In a GWTG study lead by Olenchock from the TIMI Study Group of Brigham and Women’s Hospital, use of beta blockers in those with an acute coronary syndrome but with a history of reactive airways disease was only 66% at admission and 77% at discharge. Receipt of a beta blocker was associated with improved outcome. Although it is not expected that 100% of these patients can tolerate a beta blocker, the study demonstrates there is clear room for improvement in this population. One of the future goals of quality improvement programs should be to target populations that are not optimal candidates but that will still benefit from treatment.
Increased financial stress has led hospitals to shorten length of stay wherever possible. For patients hospitalized with heart failure, length of stay has dropped by about 1 day over the last 5 years. Concerns have been raised that with the rush to discharge patients, quality of care may suffer. Krantz and colleagues from Denver Health Medical Center examined a possible impact of shorter length of stay on quality of care in the GWTG-heart failure population. They found high levels of adherence to recommended therapies (beta blocker and angiotensin-converting enzyme inhibitor use) and education regardless of length of stay.
Although the primary goal of the GWTG program is to improve quality of care and outcomes, the data collected can be used for traditional clinical research by providing insights into new risk factors and disease associations. In a study by Horwich from the Ahmanson-UCLA Cardiomyopathy Center , the association of cholesterol levels and inhospital mortality for patient with heart failure was examined. In general, those with lower cholesterol values were older and sicker. About half of all patients were treated with cholesterol-lowering agents ranging from 58% in the lowest to 34% in the highest cholesterol quartile. Inhospital mortality was greatest for those with the lowest cholesterol levels (3.3% vs. 1.3% for the highest cholesterol quartile) and remained significantly higher after adjustment for other patient characteristics. These findings highlight the need for additional studies to determine whether low cholesterol is just a marker of illness or if lowering cholesterol in this population is somehow harmful.
These recent studies are indicative of the abundance of knowledge gained from the GWTG program. In particular, these studies have advanced our understanding of gender disparities in outcome and determinants of quality of care. The studies highlighted in this issue also demonstrate the wide range of scientific questions that can be answered through the GWTG program. These contributions to health services, outcomes, and clinical research extend the impact of GWTG well beyond the enrolled hospitals to the rest of society.
- LaBresh KA, Gliklich R, Liljestrand J, et al. Using "Get With The Guidelines" to improve cardiovascular secondary prevention. Jt Comm J Qual Saf 2003;29:539-550.
- Smaha LA. The American Heart Association Get With The Guidelines program. Am Heart J 2004;148:S46-S48.
- Reeves MJ, Fonarow GC, Zhao X, et al. Quality of care in women with ischemic stroke in the GWTG program. Stroke 2009;40:1127-1133.
- Lewis WR, Fonarow GC, LaBresh KA, et al. Differential use of warfarin for secondary stroke prevention in patients with various types of atrial fibrillation. Am J Cardiol 2009;103:227-231.
- Shah B, Hernandez AF, Liang L, et al. Hospital variation and characteristics of implantable cardioverter-defibrillator use in patients with heart failure: data from the GWTG-HF (Get With The Guidelines-Heart Failure) registry. J Am Coll Cardiol 2009;53:416-422.
- Olenchock BA, Fonarow GG, Pan W, et al. Current use of beta blockers in patients with reactive airway disease who are hospitalized with acute coronary syndromes. Am J Cardiol 2009;103:295-300.
- Krantz MJ, Tanner J, Horwich TB, et al. Influence of hospital length of stay for heart failure on quality of care. Am J Cardiol 2008;102:1693-1697.
- Horwich TB, Hernandez AF, Dai D, et al. Cholesterol levels and in-hospital mortality in patients with acute decompensated heart failure. Am Heart J 2008;156:1170-1176.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --