Get With The Guidelines: Improving Patient Outcomes One Hospital at A Time
Disclosure: Honoraria relationship with Reliant Pharmaceuticals and a modest consulting/advisory board relationship with Medtronic.
Pub Date: Monday, December 15, 2008
Author: William R. Lewis, MD
In 1998, the American Heart Association (AHA) board of directors set a goal of reducing death due to heart attack and stroke by 25%. Achieving such a goal would rely on various initiatives. Over the years, many scientific discoveries have been made, many through funding from the AHA. Periodically, the AHA and the American College of Cardiology (ACC) painstakingly review this scientific literature and develop guidelines. These guidelines are published and are available to physicians to apply the therapies to their patients. Unfortunately, these guidelines are not universally adhered to. The Institute of Medicine in their book, "Crossing the Quality Chasm," demonstrated that guideline adherence is inadequate and highly variable. Guidelines that are not followed are of no value.
Knowledge of the guidelines is not the problem. The barriers to adherence are related to the complexity of the health care-delivery system. The Get With The GuidelinesSM (GWTG) program was developed to improve adherence to evidenced-based medicine. This program uses local physician champions, multidisciplinary teams, didactic sessions, collaborative learning, preprinted orders, and monthly conference calls to support rapid-cycle improvement in a plan-do-study-act approach. In addition, GWTG uses a web-based Patient Management Tool with online decision support and report generation to allow national bench marking.
The pilot program for GWTG was implemented in 2000 and published by LaBresh and colleagues in 2003. They evaluated the records of 1,738 patients admitted with coronary artery disease to 24 hospitals. Improvement in adherence to guidelines was demonstrated over a 1-year period in smoking-cessation counseling, lipid treatment, and referral to cardiac rehabilitation. The AHA implemented this program nationally by recruiting local champions in major metropolitan areas. The result of this implementation was reported by LaBresh, et al. The records of 45,988 patients admitted with coronary artery disease were reviewed from 92 hospitals. Over a period of 1 year, improvement was demonstrated in 10 of 11 measures including aspirin on admission, beta blocker on admission and discharge, angiotensin-converting enzyme inhibitor therapy for left ventricular dysfunction, lipid treatment, and smoking-cessation counseling. The remarkable thing about this program is that this improvement occurred over a 1-year period of time, much faster than would be expected from a quality-improvement program. Thus, it became very clear that implementing GWTG can improve guideline adherence over time. However, do GWTG hospitals perform better than nonGWTG hospitals? Lewis and colleagues compared GWTG hospitals to those not participating, using the Centers for Medicare and Medicaid Services (CMS) website, Hospital Compare. They evaluated a composite of measures for acute myocardial infarction (AMI) in 233 GWTG hospitals and 3,407 nonGWTG hospitals and found that GWTG hospitals performed better even when the data were corrected for hospital characteristics such as the volume of AMI treated, teaching status, number of beds, or region of the country. In addition, the authors found that GWTG hospitals did not fare better in the treatment of pneumonia, and thus, the improved adherence appeared to be specific to participation in the program.
The success of the coronary artery disease program led to development of programs to enhance the adherence to guidelines in the treatment of stroke and congestive heart failure. LaBresh and colleagues studied 18,410 patients admitted with stroke or transient ischemic attack to 99 hospitals. Measures such as use of antithrombotic medications, lipid treatment, and smoking-cessation counseling were evaluated. Over a 1-year period, the adherence to all 13 measures increased from 50.2% to 58%. The administration of thrombolytic therapy when patients present within 2 hours of stroke increased from 23.5% to 40.8%. Additionally, the improvement observed in the GWTG-stroke program was sustainable. Schwamm and his coworkers demonstrated this in a recent publication. In the study, they evaluated the performance of 790 academic and community hospitals over a 5-year period. This involved 322,847 patients admitted with a diagnosis of TIA and stroke. The use of thrombolytic medication increased from 42% to 73%. The use of antithrombotic medications increased on admission (91% to 97%) and on discharge (96% to 99%). Improvement was also seen in smoking-cessation counseling and prescription of lipid agents. Multivariate analysis confirmed that GWTG was associated with improved adherence to guidelines for TIA and stroke. In this study, most of the improvement in adherence occurred within the first 2 years; however, with each measure, the benefit was sustained over time. Thus, each of the GWTG modules, coronary artery disease, stroke, and heart failure, have been demonstrated to increase adherence to evidence-based guidelines.
The use of the GWTG database has also provided insight into areas where adherence to guideline-based therapy has been lagging. Jneid and coworkers evaluated in-hospital mortality and guideline adherence in 78,254 patients with AMI admitted to 420 GWTG hospitals. They demonstrated that women were less likely to receive aspirin and beta blocker on admission. In addition, reperfusion therapy was used less frequently (adjusted odds ratio: 0.75) and was delayed in women. Women also underwent cardiac catheterization and had revascularization therapy less often than men. The reasons for these treatment gaps were unclear. Thus, this study highlights an opportunity for improvement in the treatment of AMI in women. Reeves, et al. evaluated the treatment of stroke patients presenting during evenings and weekends (off hours) compared to those patients presenting during the work day. Slightly over half of ischemic strokes presented during off hours. They found that mortality was higher in patients presenting during off hours (5.8%) compared to workday hours (5.2%). This difference was maintained after adjusting for patient and hospital characteristics. Only slight differences were observed in guideline adherence. Fifty-six percent of patients received thrombolytic therapy during off hours compared to 59% of patients during work hours. Patients admitted during off hours were not lagging in any other quality measure. Thus, further study will be required to identify those factors which contribute to higher mortality among stroke patients who are admitted during off hours.
Analysis of the GWTG database has also provided insight into other aspects of medical care. In pay-for-performance programs by CMS, hospitals are ranked as to their adherence to reported measures. Hospitals are rewarded for higher performance by CMS. Hospitals in the top 10% receive a 2% bonus and hospitals in the second 10% receive a 1% bonus. On the other end of the spectrum, in the future, hospitals performing in the lower deciles are likely to be penalized by CMS. Mehta and colleagues hypothesized that adjusting for a given hospital's patient demographics and clinical characteristics would change their guideline-adherence ranking. They evaluated the adherence to AMI guidelines in 148,472 patients with AMI admitted to 449 GWTG hospitals. They found that hospital ranking changed on average by 22 ranks with adjustment (interquartile range: 9-40). In addition, 16.5% of hospitals changed ranks enough to alter their reimbursement status. Thus, without adjusting for case mix, hospital ranking is unlikely to accurately reflect differing demographic patterns. In summary, analysis of the GWTG database provides an opportunity to help guide reimbursement policy in the United States.
The GWTG database also is a source of clinical information that can be used to change medical care. Current guidelines for secondary prevention indicate that a low-density lipoprotein (LDL) less than 100 mg/dL is a class Ia indication for treatment, whereas a reduction in LDL to less than 70 mg/dL is a class IIa guideline. Sachdeva and coworkers evaluated admission lipids in 136,905 patients admitted with coronary artery disease. They found that the mean LDL of patients admitted was 104.9 mg/dL. This low LDL was surprising, given the fact that only 21% of patients were receiving lipid-lowering therapy on admission. Less than 25% of patients had an LDL greater than 130 mg/dL. On the other hand, LDL levels of less than 70 mg/dL were observed in only 17.6% of patients. The fact that so many patients present to the hospital with coronary artery disease and LDL levels that are near the Ia recommended level, is further evidence that the IIa recommended level of less than 70 mg/dL may be more appropriate.
As of October 2008, GWTG has been implemented by 1,566 unique U.S. acute care hospitals. More than 234 hospitals are implementing all three program modules and over 243 are implementing two of the three modules. To date, more than 1.5 million patient records have been entered. A key component to the GWTG is recognition through a program of Performance Achievement Awards, which are awarded at the bronze, silver, and gold level. A gold performance achievement award requires 85% adherence to each of the performance measures for a minimum of two consecutive 12 month intervals. Since the inception of the program, over 500 awards have been given in the coronary artery disease module, over 300 in the heart failure module, and over 650 in the stroke module. Thus, hospitals are not just participating, but they are striving to achieve higher adherence levels and improved patient care
In April 2008, the AHA and the ACC announced the merger of two of the most comprehensive resources for improving quality of care and outcomes for patients with coronary artery disease and acute coronary syndromes: The AHA's GWTGSM Coronary Artery Disease Program and the ACC's ACTION® RegistryTM. This newly formed performance improvement registry is now known as the ACTION Registry®-GWTGTM.
The AHA/ACC believe that combining the two programs will generate a comprehensive and robust database built on the strong foundation of a quality-improvement program. The synergy of these initiatives will drive better treatment and care of acute coronary syndrome patients in accordance with national science-based treatment guidelines. This alliance will allow hospitals the opportunity to collect a broader range of data under acute coronary syndrome, enabling them to deliver more scientifically proven care for improved patient outcomes.
GWTG began as a small pilot project in New England, intended to improve adherence to evidence-based medicine in the treatment of coronary artery disease. It has grown into three modules to treat patients not only with coronary artery disease but heart failure and stroke as well. This program has demonstrated improved adherence to guidelines on a national level. The program has worked in hospitals regardless of size, region, and teaching status. It has worked in urban and rural hospitals and public and private hospitals. Because of these accomplishments, this program is the recipient of the 2004 Heath and Human Services Innovation in Prevention award. GWTG is saving lives and is one program the AHA is using to reach its goal of reducing death due to coronary artery disease and stroke by 25% by the year 2010.
- Institute of Medicine (U.S.). Committee on quality of health care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press; 2001.
- LaBresh KA, Ellrodt AG, Gliklich R, et al. Get with the guidelines for cardiovascular secondary prevention: pilot results. Arch Intern Med 2004;164:203-209.
- LaBresh KA, Fonarow GC, Smith SC, et al. Improved treatment of hospitalized coronary artery disease patients with the get with the guidelines program. Crit Pathw Cardiol 2007;6:98-105.
- Lewis WR, Peterson ED, Cannon CP, et al. An organized approach to improvement in guideline adherence for acute myocardial infarction. Arch Intern Med 2008;168(16):1813-1819.
- LaBresh KA, Reeves MJ, Frankel MR, et al. Hospital treatment of patients with ischemic stroke or transient ischemic attack using the "Get With The Guidelines" program. Arch Intern Med 2008;168:411-417.
- Lee Schwamm. Get with the guidelines-stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or TIA. Circulation. DOI: 10.1161/CIRCULATIONAHA.108.783688.
- Jneid H, Fonarow GC, Cannon CP, et al. Sex differences in medical care and early mortality after acute myocardial infarction. Circulation. DOI: 10.1161/CIRCULATIONAHA.108.789800.
- Reeves MJ, Smith E, Yu Y, Schwamm LH. Off-hour admission and in-hospital stroke case fatality in the get with the guidelines-stroke program. Stroke. Published online before print November 6, 2008. DOI: 10.1161/STROKEAHA.108.519355.
- Mehta RH, Liang L, Karve AM, et al. Influence of patients case-mix on hospital process performance rankings and eligibility for financial incentives. JAMA 2008;300(16):1897-1903.
- Sachdeva A, Cannon CP, Deedwania PC, et al. on behalf of the GWTG Steering Committee and Hospitals. Lipid levels in patients hospitalized with coronary artery disease: an analysis of 136,905 hospitalizations in Get With The Guidelines. Am Heart J. DOI: 10.1016/j.ahj.2008.08.010.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association