Get With the Guidelines Program Improves Quality of Care for CAD Patients

Charlene Laino

November 11, 2003

Nov. 11, 2003 (Orlando) — Get With the Guidelines (GWTG), a national performance improvement initiative of the American Heart Association (AHA) to improve guidelines adherence in patients hospitalized with coronary artery disease (CAD), significantly improved the quality of care for patients hospitalized with CAD within one year of the program's implementation.

Three studies on the program, presented here at the American Heart Association Scientific Sessions, demonstrate that compliance with treatment guidelines "is a systems issue and that by employing the system, we can dramatically reduce hospitalizations and impact mortality," said Gregg C. Fonarow, MD, the Eliot Corday chair in cardiovascular medicine and science at the University of California at Los Angeles.

"Very often the most basic aspects of treatment — from beta-blocker use to smoking cessation counseling — are not done," said Kenneth A. LaBresh, MD, clinical associate professor of medicine at Brown University in Providence, Rhode Island and director of hospital projects at MassPro, Inc., in Waltham, Massachusetts. There is a strong need to "bring healthcare workers up to date with guidelines and protocols," Dr. LaBresh told Medscape.

As part of the GWTG program, a secure Internet-based patient management tool — with guidelines embedded in it — is used to gather information about patients. Checklists prompt the healthcare worker to follow proven treatment options to enhance secondary prevention, with electronic reminders sent out whenever basic care strategies are skipped, he said. Collaborative learning sessions, teleconferences, and e-mail support round out the offerings.

The studies, all of which used data on 27,825 patients at the first 123 hospitals to use the system from late 2001 to the end of 2002, show that the AHA's initiative is working.

The first study, a one-year overall effectiveness study conducted in geographically diverse hospitals and led by Dr. LaBresh, showed that by six months, there were significant improvements from baseline in nine of 10 quality-of-care measures, from beta-blocker and early aspirin use to smoking cessation counseling and cardiac rehabilitation.

Among the findings:

  • Early use of aspirin increased from 75% at baseline to 89% less than one year later ( P < .001).

  • Beta-blocker use within the first day of hospitalization improved, from 62% at baseline to 85% in the fourth quartile ( P < .001).

  • Beta-blocker use at discharge also increased, from 79% to 91% ( P < .001).

  • Angiotensin-converting enzyme (ACE) inhibitor use increased slightly, but significantly, from 63% to 68% ( P < .05).

  • Cholesterol treatment improved from 67% to 74% ( P < .001).

"By the fourth quartile, the results were striking," Dr. LaBresh said, noting that at baseline 65% of patients were sent to cardiac rehabilitation compared with 88% in the fourth quarter.

A second study confirmed Dr. LaBresh's findings, reporting that the quality of care for patients hospitalized with CAD was significantly improved in hospitals using the GWTG program, regardless of hospital teaching status.

Until now, studies documenting that quality improvement programs improve the care of such patients have been performed predominantly at teaching hospitals, Dr. Fonarow said. "This study is the first to document that the benefits extend to nonteaching hospitals as well."

Significant improvement from baseline to the fourth quarter occurred in both teaching hospitals and nonteaching hospitals for all 10 quality indicators studied, with the exception of ACE inhibitor use and low-density lipoprotein cholesterol lowering below 100 mg/dL at nonteaching hospitals, Dr. Fonarow reported.

Fifty of the 123 hospitals were nonteaching institutions, and 29 were teaching institutions. For 44 hospitals, teaching status was unknown.

The third analysis, led by Gray Ellrodt, MD, chair of medicine at Berkshire Medical Center in Lenox, Massachusetts, compared how male and female patients were treated in five core secondary prevention areas at hospital discharge.

At baseline, women discharged from the hospital were, "for no apparent reason," less likely than men to receive the five basic therapies: aspirin, beta-blockers, ACE inhibitors, cholesterol-lowering drugs, and smoking cessation counseling, Dr. LaBresh, a coauthor of the study, told Medscape.

"But once hospitals put the system in place, all these differences went away," he said.

The improvement was most striking with regard to cholesterol treatment, according to Dr. LaBresh. "At the start of the study, four in 10 women, but only three in 10 men, left the hospital without the drugs, so the difference was 10%," he said.

By the fourth quartile, 73% of women and 74% of men ( P < .01) were getting the drugs — "a difference of only about 1%," Dr. LaBresh said.

In fact, sex differences were significantly reduced during the study period for all five interventions except smoking cessation. However, the disparity in smoking cessation rates did not reach statistical significance, Dr. LaBresh said.

Although some physicians have criticized system-based programs as cookbook medicine, more physicians are realizing its benefits, said Richard Pasternak, MD, chief of preventive cardiology at Massachusetts General Hospital in Boston and moderator of a press conference at which the findings were discussed.

"It's partly a generational thing, with older physicians who have never used it feeling uncomfortable," he said.

But most important, "we now have data showing such programs work," Dr. Fonarow said. "Hard data changes behavior."

Based on the findings, GWTG has already been expanded to 400 hospitals in all 50 states, carrying the potential to save tens of thousands of lives a year, Dr. LaBresh said.

Merck, Inc., and the AHA funded the research.

AHA 2003 Scientific Sessions: Abstracts 3269, 3270, presented Nov. 9, 2003; abstract 2051, presented Nov. 10, 2003.

Reviewed by Gary D. Vogin, MD


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