Get With the Guidelines-Stroke Linked to Improved Care for Stroke and TIA Patients

Susan Jeffrey

December 23, 2008

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December 23, 2008 — Adherence to evidence-based guidelines implemented through the Get With the Guidelines-Stroke (GWTG-Stroke) program resulted in significant improvements in hospital performance measures related to the care of stroke or transient-ischemic-attack (TIA) patients, including thrombolysis, smoking cessation, and early antithrombotics, the researchers report.

Get With the Guidelines is a quality-improvement program first developed and implemented in coronary heart disease care. The program, a voluntary-participation project involving hospitals across the United States, has been adapted to improve adherence to guidelines in the area of stroke and TIA.

"The big picture is that care improved dramatically — orders of magnitude more than has been seen in other projects that have attempted to improve quality of care," Lee H. Schwamm, MD, from Massachusetts General Hospital, in Boston, and a steering committee member for GWTG-Stroke, told Medscape Neurology & Neurosurgery.

"We saw absolute improvements on the order of 20% to 30% — not relative, but absolute improvements," he added.

Their report is published online December 16 in Circulation.

Guidelines Not Sufficient to Improve Care

In response to evidence that stroke patients often do not receive recommended interventions, organizations such as the American Academy of Neurology, the American Heart Association (AHA), the Joint Commission, and the Centers for Disease Control and Prevention (CDC) have in the past decade promoted efforts such as dedicated stroke units and increased adherence to guidelines, the authors write. "However, publication of national guidelines alone has generally not been sufficient to produce substantial changes in physician behavior or patient treatment," they note.

In 2001, the AHA had finished piloting Get With the Guidelines for coronary disease, Dr. Schwamm said in an interview. "Ken LaBresh [MD, from Masspro, Waltham, Massachusetts], who is the senior author on the paper with me, was 1 of the architects of that effort," he said. They developed a new GWTG module for stroke and were successful in getting funding from the CDC to pilot their model in Massachusetts.

"This paper, then, reflects the implementation of that model in a cohort of hospitals nationwide, I think broadly representative of the US population of hospitalized patients," Dr. Schwamm said. The report looks at 7 prespecified performance measures before and after implementation of the improvement program. A total of 790 US academic and community hospitals participated voluntarily from 2003 to 2007. Information was available on 322,847 hospitalized stroke patients, making it 1 of the largest samples of stroke patients available to date, he said.

The 7 performance measures are those for which there is level 1, class A evidence in patients with stroke or TIA and about which there should be little controversy, he said. These included intravenous thrombolysis, early antithrombotics, deep vein thrombosis prophylaxis, discharge antithrombotics, anticoagulation in the setting of atrial fibrillation, lipid treatment for low-density lipoprotein (LDL) cholesterol > 100 mg/dL, and smoking-cessation efforts with either medication or counseling.

They also included a composite measure (calculated by dividing the total number of interventions provided in eligible patients by the total number of care opportunities among eligible patients) and examined factors that were associated with improvement over time.

"We saw really dramatic improvements across the board on all of the measures," Dr. Schwamm said.

Change in Performance Measures at Baseline and After 5 Years of Participation in GWTG-Stroke

Measures Baseline (%) 5 Y (%) P
Intravenous thrombolytics 42.09 72.84 < .0001
Early antithrombotics 91.46 97.04 < .0001
Deep vein thrombosis prophylaxis 73.79 89.54 < .0001
Discharge antithrombotics 95.68 98.88 < .0001
Anticoagulation for atrial fibrillation 95.03 98.39 < .0001
Lipid treatment for LDL > 100 mg/dL 73.63 88.29 < .0001
Smoking cessation 65.21 93.61 < .0001
Composite 83.52 93.97 < .0001

Improvements were even seen in care processes that had already been in the 90% range at baseline, he noted, a challenging task. "It's much easier in some ways when you shine a spotlight on something to get it to go from say, 40% or 50% to 60% or 70%, but to go from 91% to 97% starts to mean you're getting to the point where you're not missing anybody, a measure of high reliability."

Improvements were seen not only in large or teaching hospitals, he added, but also in smaller community settings. Multivariate analysis showed that time in the program was associated with a 1.18-fold annual increase in the odds of fulfilling care opportunities independent of secular trends, he said, "meaning about an 18% increase in the odds of giving this care for every year of participation in the program, so a very powerful effect."

Because the GWTG-Stroke program collaborated with the CDC from the outset, he said, "at the end of this process we actually sat down with the AHA, the Joint Commission, and the Centers for Disease Control and created a consolidated set of performance measures, which is now what has been approved by the National Quality Forum and will likely be incorporated in some form into the [Center for Medicare and Medicaid Services] CMS for next year," Dr. Schwamm noted.

The program is voluntary, so the performance reported in this paper may be better than would be seen if every hospital joined the program, he acknowledged. If the performance measures are adopted by the CMS in the coming year, though, "we'll have essentially a controlled sample, where we can see what happens when large numbers of hospitals attempt to do this in or out of the program."

There is "nothing revolutionary" about Get With the Guidelines, he concluded. Pilots go through a safety checklist every time they take off and every time they land, every day of their career, in an attempt to limit the chance of catastrophe. "It should be the same for patients in hospitals. We need to build highly reliable systems to help prompt and remind physicians, nurses, and other healthcare professionals to do the right thing."

GWTG-Stroke is funded by the AHA and the American Stroke Association. The program is also supported in part by unrestricted educational grants to the AHA by Pfizer and the Merck-Schering Plough Partnership, which did not participate in the study design, analysis, manuscript preparation, or approval. Dr. Schwamm reports he has consulted on economic models of thrombolytic therapy for Research Triangle Institute. He has provided expert medical opinions in 4 malpractice lawsuits and is a consultanton stroke systems development to the Massachusetts Department of Public Health. He also serves as a member of the AHA's GWTG Steering Committee.

Circulation. Published online December 15, 2008. Abstract


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