The First Two Million Patients in the Get With The Guidelines® Program: From Early Adoption to Spread
Disclosure:Get With The Guidelines® is sponsored by the American Heart Association with financial support from Merck-Schering Plough and GlaxoSmithKline. Dr. Schwamm is Chair of Get With the Guidelines steering committee (unpaid volunteer).
Pub Date: Monday, October 26, 2009
Author: Lee H. Schwamm, MD, FAHA, on behalf of the Get With The Guidelines Steering Committee and Hospitals
Cardiovascular disease, comprising coronary heart disease, heart failure, high blood pressure, and stroke, remains the leading cause of morbidity and mortality in both men and women in the United States. Patients hospitalized with a cardiovascular event are at particularly high risk for recurrent events, hospitalizations, and cardiovascular death. Fortunately, there are a number of evidence-based and highly effective therapies that can significantly improve acute long-term care outcomes and reduce recurrent events. Although the AHA, American College of Cardiology (ACC), and American Stroke Association Guidelines provide evidence-based recommendations for cardiovascular and stroke care, adherence to these guidelines is both incomplete and highly variable.[2-7] To improve the quality of care for patients hospitalized with coronary artery disease, heart failure, or stroke, the AHA launched the Get With The Guidelines (GWTG) program in 2000.[8,9] As we observe the 2 millionth patient being entered into the GWTG program database, there is an important opportunity to reflect on the transition from early adoption of the program at a forward-thinking group of hospitals, to the spread of GWTG into mainstream hospitals across the country.
The GWTG program was developed to provide hospitals with a systematic approach to measure and improve the quality of care they deliver. Evidence-based tools help ensure that patients receive appropriate interventions and are initiated and discharged on appropriate medications with risk modification counseling where needed. Modules focused on patients with coronary artery disease, stroke, and heart failure have been implemented. GWTG facilitates performance improvement using a hospital-based system, a Web-based Patient Management Tool (Outcome, Cambridge MA), and collaborative learning sessions in which hospital teams exchange best practices and learn rapid cycle improvement strategies.[8,9] As part of an enhanced treatment and discharge plan, GTWG provides hospitals with guideline-based clinical pathways, standardized orders, best-practices algorithms, discharge checklists, educational tools for patients and caregivers, and a variety of other tools to assist hospitals in improving patient management. The collaborative learning model includes interactive learning sessions-teleconference and electronic interaction between multidisciplinary teams from hospitals in a variety of settings.[8,9] GWTG provides the opportunity for concurrent data collection and decision support and also provides on-demand real-time quality reporting against a vast array of benchmarks, including similar hospitals across the state, region, or country. The electronic case report forms facilitate documentation of important patient demographic and disease state information as well as performance measure compliance into the GWTG database. Individual hospitals are responsible for data collection and input. Hospitals achieving the highest levels of performance are recognized by the AHA through a set of awards reflecting increasingly sustained high levels of compliance. There are no financial reward incentives directly attributable to participation.
Since inception, more than 1,400 U.S. hospitals have participated in one or more GWTG program modules and more than 2 million patients have been entered (Table 1). A number of key findings and important lessons have emerged. Participation in GWTG has been associated with statistically significant and clinically relevant improvements in the use of key evidence-based medications or interventions spanning all three modules. These include many publicly reported or National Quality Forum (NQF)-endorsed interventions, such as use of aspirin, antithrombotic agents, lipid-lowering agents, and smoking cessation to reduce recurrent vascular events; blood pressure control with beta blockers or angiotensin-converting enzyme inhibitors/angiotensin-receptor antagonists; prevention of deep vein thrombosis; and use of cardiac rehabilitation among patients with coronary artery disease (Tables 2-4).[1,8-12] Improvements in acute care metrics, such as early aspirin and beta blockers, as well as door-to-balloon time in acute coronary syndromes and intravenous thrombolytic therapy for acute ischemic stroke have also been observed (Tables 2, 3).[1,8,13,14] Studies of each of the GWTG modules have suggested that this collaborative approach and an Internet-based clinical management and decision-support tool rapidly extend the significant improvements seen in smaller studies  to patients in a variety of hospital settings and to multiple hospitals simultaneously.
A composite of the individual performance measures for each module reveals that a very high reliability in the quality of care provided to patients has been achieved at those hospitals participating in GWTG. Data in GWTG-Stroke also suggests that all hospitals benefit to some degree from time spent in the program over and above any secular trends in care improvement. As of July 2009, among GWTG-participating hospitals, the composite performance measure for GWTG-Coronary Artery Disease (CAD) was 92.7%, for GWTG-Stroke 92.3%, and for GWTG-HF 92.5% (Tables 2-4). Analyses of GWTG data have shown similar improvements among participating hospitals that are large and small, teaching and nonteaching, and in all regions of the country. Improvements in care have been observed in both men and women, older and younger patients, and in all major categories of race/ethnicity, although not all groups have benefited equally, and ongoing analyses of these differences in care continue.[8,16-18] It is important to note that GWTG hospitals were self-selected and may represent hospitals that are more committed to quality improvement. However, now that hospitals from every state in the United States are participating in GWTG, the sample becomes increasingly representative of U.S. cardiovascular care.
The change in the performance measures observed over time could, in part, represent secular trends and a general improvement in care provided by U.S. hospitals as a whole. Other cardiovascular performance improvement programs that have also been associated with improvements in the quality of cardiovascular care over time include the ACC Guideline Applied into Practice program and the CRUSADE Initiative.[19,20]
Many potential barriers to improving adherence to guideline recommendations have been identified, including issues related to patients, physicians, and health care systems. The GWTG program recognizes these barriers, incorporates approaches that take them into account, and as a result, helps to overcome them. Active physician involvement in the program, use of multidisciplinary teams, and ongoing administrative support are keys to the success of continuous quality improvement programs such as GWTG. Multiple strategies have been integrated into GWTG to encourage physician participation, share best practices, and overcome barriers. The growing movement for public reporting of hospital performance on quality of care and outcomes, as well as center of excellence disease-specific certification, has also helped to drive participation in GWTG.
However, many challenges still remain. Hospital teams are facing an ever increasing array of data that they need to collect and report, and avoiding the need for duplicate entry is essential. Securing and maintaining resources, administrative support, and maintaining momentum when key team members relocate have been difficult for certain hospitals. This is why the AHA has focused considerable attention on harmonization efforts, wherever possible. This is reflected in the consensus process between the AHA, the Centers for Disease Control and Prevention, and The Joint Commission, which produced a set of stroke performance measures; these were submitted to the NQF. They are currently in use by all three organizations and will contribute to the JC hospital core measure set this fall. In addition, AHA and ACC recently merged their efforts to produce a single registry for quality improvement in CAD, the Action Registry-GWTG. This change in focus reflects the maturation of the AHA's cardiovascular quality improvement strategy, as it shifts from early adoption efforts to generalization and spread of innovation.
GWTG is among the largest national hospital-based programs dedicated to quality-of-care improvement for patients hospitalized with cardiovascular disease and stroke. Hospitals participating in GWTG have demonstrated greater adherence to national guideline-recommended therapies compared with other U.S. hospitals publicly reporting data at the same time. With more than 2 million patients entered into the program, the potential benefits of hospital participation have been substantial. However, further opportunities remain, including enhancing participation of U.S. hospitals and making further strides to achieve 100% performance in each measure for each disease state. Some of the planned enhancements to GWTG include providing personalized patient educational materials, program links to the ambulatory care setting, and interfaces with multiple electronic medical record systems. The results with GWTG and other health care improvement programs suggest that the quality of care provided to patients with cardiovascular disease and stroke can be further enhanced by the use of performance feedback, collaborative care models, and concentration on those processes of care proven to improve outcomes.
The author would like to acknowledge the tremendous contributions to the success of the GWTG program by its participating hospital champions, key volunteers and AHA staff, especially Drs. Chris Cannon, Gray Ellrodt, Gregg Fonarow, Rich Gliklich, Ken LaBresh, Eric Peterson, Rose Marie Robertson, Lynn Smaha, Eric Smith, Sidney Smith, Gayle Whitman, and Mr. Winfred Kao and Ms. Nancy Brown, Susan Dance, Meighan Girgus, Tammy Gregory, Laura Shuey, Robyn Landry ,and Louise Morgan.
- Lloyd-Jones W, Adams R, Carnethon M, et al. Heart disease and stroke statistics 2009 Update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119:e21-e181.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. Circulation 2004;110:e82-292.
- Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation 2006;113:2363-2372.
- McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-2645.
- 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: National Academy Press, 2001.
- Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med 2005;353:265-274.
- Fonarow GC, CW Yancy, Heywood JT. Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry. Arch Intern Med 2005;165:1469-1477.
- LaBresh KA, Ellrodt AG, Gliklich R, et al. Get with the guidelines for cardiovascular secondary prevention: pilot results. Arch Intern Med 2004;164(2):203-209.
- Smaha LA. American Heart Association Get With The Guidelines program. Am Heart J 2004;148(5 Suppl):S46-S48.
- Denton TA, Fonarow GC, LaBresh KA, Trento A. Secondary prevention after coronary bypass: the American Heart Association "Get With The Guidelines" program. Ann Thorac Surg 2003;75(3):758-760.
- Krantz MJ, Baker WA, Estacio RO, et al. Comprehensive coronary artery disease care in a safety-net hospital: results of get with the guidelines quality improvement initiative. J Manag Care Pharm 2007;13:319-324.
- Fonarow GC, Abraham WT, Albert NM, et al; for the OPTIMIZE-HF Investigators and Hospitals. Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Arch Intern Med 2007;167:1493-1502.
- LaBresh KA, Reeves MJ, Frankel MR, Albright D, Schwamm LH. Hospital treatment of patients with ischemic stroke or transient ischemic attack with "Get With The Guidelines" program. Arch Intern Med 2008;168(4):411-417.
- Schwamm LH, Fonarow GC, Reeves MJ, et al. Get With The Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or TIA. Circulation 2009;119:107-115.
- Fonarow GC, Gawlinski A, Cardin S, Moughrabi S, Tillisch JI. Improved treatment of cardiovascular disease by implementation of a cardiac hospitalization atherosclerosis management program: CHAMP. Am J Cardiol 2001;87:819-822.
- 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.
- Reeves MJ, Smith EE, Fonarow GC, Hernandez A, Pan W, Schwamm LH. Off-hour admission and in-hospital stroke case fatality in the get with the guidelines-stroke program. Stroke 2009;40(2):569-76. Epub 2008.
- Reeves MJ, Fonarow GC, Zhao X, Smith EE, Schwamm LH. Quality of care in women with ischemic stroke in the GWTG program. Stroke 2009;40(4):1127-1133.
- Methra RH, Roe MT, Chen AY, et al. Recent trends in the care of patients with non-ST-segment elevation acute coronary syndromes: insights from the CRUSADE initiative. Arch Intern Med 2006;166:2027-2034.
- Mehta RH, Montoye CK, Gallogly M, et al. Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative. JAMA 2002;287:1269-1276.
- Available at: http://www.jointcommission.org/CertificationPrograms. Accessed September 20, 2009.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --