Overview of the American Heart Association “Get With the Guidelines” Programs

Despite recent advances in scientific knowledge about and improvement of treatment and prevention (primary and secondary) for heart disease and stroke, these conditions remain the number one and 3 causes of death in the United States. 1 Every year, there are nearly 500, 000 deaths from coronary heart disease and over 160, 000 from stroke in the country. An estimated 700, 000 Americans have new coronary heart disease (CHD) every year and an additional 500, 000 have recurrent CHD events. The corresponding numbers for stroke are 500, 000 and 200, 000. The burden of heart failure in the society is also substantial. Deaths attributable to heart failure as the primary or secondary cause total 265, 000 per year. In addition, there are one million annual heart failure discharges from hospitals. The combined annual direct and indirect cost for CHD, stroke, and heart failure exceeds 225 billion. 1 This enormous burden of disease is also associated with numerous data collection efforts in hospitals to assess the quality of care delivered in coronary artery disease (CAD), heart failure, and stroke. These include the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) ORYX and the Centers for Medicare & Medicaid Services (CMS) measure sets for acute myocardial infarction and heart failure, 2–4 the National Registry of Myocardial Infraction, 5 GRACE for acute coronary syndromes, 6 The Paul Coverdell National Acute Stroke Registry, 7 and ADHERE for heart failure. 8Table 1 presents data from several of these sources that demonstrate, despite wide dissemination of these guidelines, recommended interventions are frequently not initiated during hospitalization for acute cardiac events, heart failure, and stroke. 4, 6–8TABLE 1: Hospital Performance Data for Myocardial Infarction, Heart Failure, and StrokeBarriers to the Use of Guidelines Barriers to the routine use of evidence-based care fall into 3 general categories: knowledge, attitudes, and behavior9 (Table 2). Knowledge barriers include absence of knowledge of new or updated guidelines or, if known, insufficient familiarity with the guidelines to be willing or able to use them. For example, one hospital seeking to extend CAD prevention measure use to patients with peripheral vascular disease engaged vascular surgeons to initiate lipid and angiotensin-converting enzyme (ACE) inhibitor therapies before hospital discharge. Resistance to the plan was substantial until a medical consultant offered to select and initiate these therapies in appropriate patients. On further discussion, the initial unwillingness to participate centered on unfamiliarity with specific agents and doses. Guidelines and evidence may be known but not adhered to because of a lack of belief in the concept of evidenced medicine or lack of belief that the benefits seen in clinical trials really occur in the “real world. ” These attitudinal barriers may mask knowledge barriers as illustrated presently or may represent concerns about autonomy and control. TABLE 2: Barriers to Adoption Addressed by Get With the GuidelinesThe final category, behavioral factors related to patients, guidelines, and the organizational environment. Patient preferences may not be consistent with guideline recommendations. Guidelines from multiple organizations may be contradictory causing confusion. The most common issues relate to the environment such as organizational constraints in culture, priorities, resources, and systems. Even if physicians know, believe, and intend to use the guidelines every time, this may not result in higher treatment rates. Davis and colleagues have demonstrated that typical didactic presentations may improve knowledge but do not produce increased use of evidence-based therapies. 10 In a chart review of primary care practices, selected as practices that were high prescribers of statins, knowledge of the National Cholesterol Education Program (NCEP) guidelines for lipid treatment and the intention of practitioners to use these guidelines were assessed. Although 95% of the physicians could demonstrate complete and accurate knowledge of the guidelines and 65% stated that they used the guidelines most or all of the time, only 18% of their CAD population had low-density lipoprotein (LDL) cholesterol levels of 100 mg/dL or who enter the hospital on lipid-lowering agents. Measurement of LDL cholesterol for all patients within the first 24 hours of admission is also tracked. The blood pressure measure assesses the percent of patients with the last recorded hospital blood pressure 100 mg/dL or on therapy on and smoking cessation counseling for all patients who have within of Performance Measures for Stroke and measures for are the heart failure discharge measurement of left ventricular ACE inhibitor at discharge for patients with left ventricular in the absence of documented contraindications or intolerance to both an additional blocker use at discharge for patients with in the absence of documented contraindications or intolerance (Table Performance Measures for Heart Each GWTG module offers The first hospitals as those that have a multidisciplinary a physician orders or that include the GWTG measures, and of data from at patients. The Performance the of performance for each of the modules of performance measures at for each of the performance measures is also on an annual basis for of have been used as a to engage hospital leadership, and the hospital's in support of the They have an important role in the goals of the GWTG modules into the strategic plan and help to to maintain the program over time. In were into the for quality of the resulting in participation in the CAD Get With the Guidelines Results There are more than hospitals in the GWTG-CAD program. The GWTG collaborative approach was demonstrated to produce improvement in several measures in the initial pilot by the of (Fig. 2). of 10% to with in many of the acute treatment and secondary prevention measures in less than a year of implementation have been seen in the larger with improvement through 2 in the Get With the Guidelines coronary artery disease pilot hospitals smoking cessation at angiotensin-converting angiotensin-converting enzyme inhibitor use at aspirin, use at use of lipid-lowering agents at low-density lipid measurement in the hospital for of low-density blood pressure blood pressure less than mm by the time of and to cardiac rehabilitation or exercise at discharge. based on with the Reprinted with permission from has more with more hospitals in less than The early results from the GWTG-Stroke has indicated nearly a in the use of rtPA with no in of and larger from performance in the prevention measures than seen in the CAD There has been adoption of the heart failure module as with nearly hospitals within the first 6 of the program. and The emphasis on data collection by a number of as previously, creates pressure on hospital that may from the ability to use the data to improve care. Although CMS provides process improvement through the quality improvement most of these efforts provide data feedback The design of some of these data collection chart review after care has been the of using that feedback to correct in the of care. Data collection without process change support also to poor but may not support improvement in that care. Although data feedback is a part of care time data not related to quality measures may from improvement in hospitals. of emphasis on culture change, and the adoption of along with process improvement support are key strategies to the care with potential change in system to the in these will an important role in the care of patients with stroke, and failure. GWTG medical and leadership, team approaches to care and and uses that can be used during the care process to produce process and change in hospitals. such as AHA/ASA also and support of systems of care. participation in such by such as the for Healthcare are progress to the of providing the care for every patient every time.