Practice Makes Perfect: Lessons Learned While Implementing the Get With The Guidelines Quality Improvement Approach in an Outpatient Setting
|Disclosure:||Dr. Smith has nothing to disclose.|
|Pub Date:||Wednesday, May 14, 2014|
|Authors:||Eric E. Smith, MD, MPH, FAHA|
|Affiliation:||Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary|
Bufalino V, Bauman MA, Shubrook JH, Balch AJ, Boone C, Vennum K, Bradley S, Wender RC, Minners R, Arnett D; on behalf of the American Cancer Society, American Diabetes Association, and American Heart Association. Evolution of “The Guideline Advantage”: lessons learned from the front lines of outpatient performance measurement [published online ahead of print April 30, 2014]. Circ Cardiovasc Qual Outcomes. doi: 10.1161/HCQ.0000000000000003.
The American Heart Association (AHA)--sponsored Get With The Guidelines® quality improvement program has had an enormous impact on inpatient quality of care for cardiovascular diseases and stroke. Begun in 2003, the program has included modules for stroke, coronary artery disease, heart failure, cardiopulmonary resuscitation, and atrial fibrillation.1 The program includes data on more than 4.5 million hospital admissions. Approximately 30% of annual ischemic stroke admissions nationwide are captured in the program. The program elements include chart review with clinical case identification and data abstraction, a web-based Patient Management Tool for data entry, on-demand report generation with regional and national benchmarks, an award recognition program for high performing hospitals, and web- based access to seminars and repositories for sharing care pathways and decision support tools. Participating hospitals have seen dramatic and sustained improvements in many aspects of their quality of care.2
What could be a more obvious next step than to port this program from the inpatient setting to the outpatient primary care setting? Beginning in 2004 the AHA began planning to do exactly that. In a recent AHA Presidential Advisory paper, Bufalino et al described the planning, initiation, and subsequent modification of The Guideline Advantage program for outpatient primary care.3 In retrospect, it is clear that differences in the structure and timing of outpatient encounters versus inpatient encounters necessitate a different approach to performance measurement and quality improvement. Launched in 2011, The Guideline Advantage has already undergone several significant modifications. Despite this need for adaptation, The Guideline Advantage program has emerged as a major, growing quality improvement program with more than 56 sites encompassing more than 370,000 patients and 4,000,000 medical encounters.3
The inpatient encounter differs from the outpatient encounter in several significant ways. Inpatient care is often provided by a specialty service and focuses on the management of the acute medical event that prompted admission, as well as any complications. By contrast, outpatient primary care is holistic and must focus on screening, prevention, and management of many common diseases of which cardiovascular disease is only one, albeit highly prevalent and morbid. Inpatients are a captive audience, frequently admitted for days, providing a longer window for data capture and initiation of good quality care, whereas outpatient encounters may last only minutes, putting a premium on efficient data capture and rapid access to decision support. Inpatient quality measurement is based on measurement of independent individual discrete hospital admissions, whereas outpatient care is longitudinal, necessitating measurement of change over multiple visits.
In response to these differences between outpatient primary care and inpatient care, The Guidelines Advantage underwent several modifications to increase its utility for primary care physicians. These changes included adoption of a more functional data analytics platform capable of individual or aggregate data display and accessible at the point of care, alignment of quality measures with other national outpatient reporting initiatives such as the Physician Quality Reporting System (PQRS), and increased integration with electronic health records such that data entered into electronic systems would be culled and aggregated without the need for duplicate manual data entry. Perhaps most importantly, even prior to program launch the AHA recognized the need to broaden the program’s scope beyond cardiovascular care, and partnered with the American Cancer Society and American Diabetes Association to provide quality measurement for cancer and diabetes screening, prevention, and management.
One of life’s greatest lessons is to always be learning. The Guideline Advantage program has shown that it can learn and adapt. The future seems bright for this program.
- Ellrodt AG, Fonarow GC, Schwamm LH, Albert N, Bhatt DL, Cannon CP, Hernandez AF, Hlatky MA, Luepker RV, Peterson PN, Reeves M, Smith EE. Synthesizing lessons learned from get with the guidelines: the value of disease-based registries in improving quality and outcomes. Circulation. 2013;128:2447-2460.
- Schwamm LH, Fonarow GC, Reeves MJ, Pan W, Frankel MR, Smith EE, Ellrodt G, Cannon CP, Liang L, Peterson E, Labresh KA. Get With the Guidelines--Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009;119:107-115.
- Bufalino V, Bauman MA, Shubrook JH, Balch AJ, Boone C, Vennum K, Bradley S, Wender RC, Minners R, Arnett D; on behalf of the American Cancer Society, American Diabetes Association, and American Heart Association. Evolution of “The Guideline Advantage”: lessons learned from the front lines of outpatient performance measurement [published online ahead of print April 30, 2014]. Circ Cardiovasc Qual Outcomes. doi: 10.1161/HCQ.0000000000000003.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association. --