Get with the guidelines for cardiovascular secondary prevention: pilot results.

BACKGROUND: The use of Web-based technology and a collaborative model to improve hospital adherence to secondary prevention guidelines has not been previously evaluated. METHODS: Twenty-four hospitals in Massachusetts participated in a collaborative that met quarterly, with didactic and best-practice presentations and interactive multidisciplinary team workshops. A customized tool kit and interactive, Web-based management tool were used for data collection and on-line feedback. Data from 1738 patients admitted with coronary artery disease were collected by hospital staff from July 1, 2000, to June 30, 2001. Outcome measures included differences between baseline and 10- to 12-month follow-up measurements of use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, cholesterol measurement and treatment, smoking cessation counseling, blood pressure control, and cardiac rehabilitation referral. RESULTS: Clinically and statistically significant increases from baseline to 10- to 12-month follow-up were demonstrated in smoking cessation counseling (48% [95% confidence interval [CI], 36.6%-58.4%] to 87% [95% CI, 73.1%-100.7%]), lipid treatment (54% [95% CI, 46.6%-70.2%] to 79% [95% CI, 70.2%-88.3%]), lipid measurement (59% [95% CI, 51.5%-66.0%] to 81% [95% CI, 72.0%-89.5%]), and cardiac rehabilitation referral (34% [95% CI, 25.9%-39.7%] to 73% [95% CI, 63.2%-82.9%]). An improving trend was seen in blood pressure control (60% [95% CI, 55.3%-65.6%] to 68% [95% CI, 60.2%-76.1%]). High baseline use was maintained for use of aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors. CONCLUSION: Implementation of a collaborative quality improvement initiative, interactive training of hospital teams with physician champions, and the use of an interactive Web-based Patient Management Tool enhanced adherence to prevention guidelines in hospitalized patients with coronary artery disease.

Triage practice guideline for patients hospitalized with congestive heart failure: improving the effectiveness of the coronary care unit.

BACKGROUND: Decisions regarding the appropriate timing for transfer of patients hospitalized with congestive heart failure from the coronary care unit (CCU) to the medical ward are often not based on well-founded medical data. We investigated the potential safety and effectiveness of a practice guideline recommending early "step-down" transfer of low-risk patients with congestive heart failure. PATIENTS AND METHODS: We studied the use of a practice guideline for 384 patients hospitalized with congestive heart failure in a hypothetic experiment. The guideline stated that patients without any of the following conditions may be suitable for transfer to a nonmonitored bed 24 hours after admission: acute myocardial infarction or ischemia, complications, active or planned cardiac interventions, unstable comorbidity, worsening clinical status, or lack of response to diuretic therapy. Patients with any of the above conditions were classified as higher risk and potentially not suitable for early transfer. RESULTS: Life-threatening complications were 15.2 times more likely (95% confidence interval [CI] 2.2, 70, p = 0.001) and death 14.6 times more likely (95% CI 2.1, 68, p = 0.001) if the patient was classified as "high risk" rather than "low risk" by the guideline. The negative predictive value and sensitivity of the practice guideline for detecting patients who had life-threatening complications were 99.2% and 96.4%, respectively. Thirty-one percent of patients with congestive heart failure hospitalized in either the CCU or intermediate care unit were at low risk and potentially suitable for transfer to a nonmonitored bed 24 hours after admission. Use of the guideline would have reduced intermediate care unit lengths of stay from 2.91 days to 2.22 days and CCU length of stay from 2.06 to 2.04 days had it been used to triage patients with congestive heart failure. This reduction in length of stay would have resulted in 172 more intermediate care unit bed-days available per year to accommodate additional patients. On initial review, at least one cardiologist reviewer judged that use of the guideline may have adversely affected quality of care for 4% (95% CI 1%, 7%) of patients. After a consensus among the cardiologist reviewers, it was judged that the guideline may have adversely affected care for only 0.8% of patients (95% CI, 0%, 2.3%), and that no patient (95% CI 0%, 2.3%) would have had an unexpected life-threatening complication because of the guideline. CONCLUSIONS: Use of a practice guideline has the potential to reduce the intermediate care unit lengths of stay for selected low-risk patients with congestive heart failure.

Trends in the use of evidence-based treatments for coronary artery disease among women and the elderly: findings from the get with the guidelines quality-improvement program.

BACKGROUND: Significant disparities have been reported in the application of evidence-based guidelines in the treatment of coronary artery disease (CAD) in women and the elderly. We hypothesized that participation in a quality-improvement program could improve care for all patients and thus narrow treatment gaps over time. METHODS AND RESULTS: Treatment of 237 225 patients hospitalized with CAD was evaluated in the Get With the Guidelines-CAD program from 2002 to 2007. Six quality measures were evaluated in eligible patients without contraindications: aspirin on admission and discharge, beta-blockers use at discharge, angiotensin-converting enzyme inhibitor or angiotensin receptor antagonist use, lipid-lowering medication use, and tobacco cessation counseling along with other care metrics. Over time, composite adherence on these 6 measures increased from 86.5% to 97.4% (+10.9%) in men and 84.8% to 96.2% (+11.4%) in women. There was a slight difference in composite adherence by sex that remained significant over time (P<0.0001), but this was confined to patients <75 years. Composite adherence in younger patients (<75 years) increased from 87.1% to 97.7% (+10.6%) and from 83.0% to 95.1% (+12.1%) in the elderly (>or=75 years) over time. CONCLUSIONS: Among hospitals participating in Get With the Guidelines-CAD, guideline adherence has improved substantially over time for both women and men and younger and older CAD patients, with only slight age and sex differences in some measures persisting.

Improved treatment of hospitalized coronary artery disease patients with the get with the guidelines program.

Adherence to evidence-based interventions for hospitalized cardiovascular disease patients is not optimal. This study assesses the impact of a national quality improvement program on adherence to guidelines in these patients. Data from 92 hospitals from across the United States participating in the Get With The Guidelines program for at least 1 year for 11 acute and secondary prevention measures from a preintervention baseline period and the subsequent 4 quarters of a quality improvement intervention were analyzed. A patient group of 45,988 patients with acute myocardial infarction, unstable angina, revascularization, or peripheral vascular disease was included in this evaluation. Significant improvement from baseline was seen in 10 of 11 measures by the fourth quarter: use of early aspirin for acute myocardial infarction, 76.4% to 88.0% (P < 0.0001); early beta-blocker for acute myocardial infarction, 64.4% to 79.5% (P < 0.0001); beta-blocker at discharge, 75% to 82.1% (P < 0.0001); smoking cessation counseling, 58.7% to 74.3% (P < 0.0001); angiotensin-converting enzyme inhibitor use for acute myocardial infarction, 64.5% to 69.9% (P < 0.0001); lipid treatment, 58.5% to 63.4% (P < 0.0001); lipid treatment for low-density lipoprotein > or =100 mg/dL, 60.4% to 67.0% (P < 0.0001); low-density-lipoprotein measurement, 48.8% to 53.2% (P < 0.0001); discharge blood pressure <140/90 mm Hg, 65.9% to 68.0% (P = 0.03); and referral to cardiac rehabilitation or exercise counseling, 65.0% to 88.3% (P < 0.001). Discharge aspirin use at 89.9% did not change. Statistically and clinically significant improvement in 10 of 11 quality-improvement measures for the treatment of patients hospitalized for cardiovascular disease was seen in hospitals participating in Get With The Guidelines.

Using "get with the guidelines" to improve cardiovascular secondary prevention.

BACKGROUND: "Get With The Guidelines (GWTG)" was developed and piloted by the American Heart Association (AHA), New England Affiliate; MassPRO, Inc.; and other organizations to reduce the gap in the application of secondary prevention guidelines in hospitalized cardiovascular disease patients. Collaborative learning programs and technology solutions were created for the project. THE PATIENT MANAGEMENT TOOL (PMT): The interactive Web-based patient management tool (PMT) was developed using quality measures derived from the AHA/American College of Cardiology secondary prevention guidelines. It provided data entry, embedded reminders and guideline summaries, and online reports of quality measure performance, including comparisons with the aggregate performance of all hospitals. LEARNING SESSIONS: Multidisciplinary teams from 24 hospitals participated in the 2000-2001 pilot. Four collaborative learning sessions and monthly conference calls supported team interaction. Best-practices sharing and the use of an Internet tool enabled hospitals to change systems and collect data on 1,738 patients. SUMMARY AND CONCLUSIONS: The GWTG program, a template of learning sessions with didactic presentations, best-practices sharing, and collaborative multidisciplinary team meetings supported by the Internet-based data collection and reporting system, can be extended to multiple regions without requiring additional development. Following the completion of the pilot, the AHA adopted GWTG as a national program.