Get With The Guidelines Stroke

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Get With The Guidelines Stroke

• Improving the Quality of Care
• and Outcomes of Patients with Stroke and TIA

Gregg C. Fonarow, MD, Lee Schwamm MD, and AHA
staff on behalf of the GWTG Steering Committee
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Disclosures
The Get With The Guidelines Stroke Program is
sponsored by the American Heart Association and
American Stroke Association Funding, in part, has
been provided by, the Merck-Schering Plough
Partnership and Pfizer. Outcome Sciences, Inc. is
the data collection and coordination center for
GWTG. The Duke Clinical Research Institute
(DCRI) serves as the data analysis center for GWTG
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Get With The Guidelines is the American Heart
Association/American Stroke Associations suite
of award winning comprehensive programs which
improve acute and preventive care for patients
hospitalized with cardiovascular disease.
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Consequences of Stroke

• Stroke 3rd leading cause of death and a leading
  cause of disability.
• More than 795,000 new strokes each year, with
  200,000 recurrent strokes.
• Recurrent rates are high, despite well defined
  risk factors including atrial fibrillation,
  atherosclerosis and smoking.
• Medical complications in stroke patients occur
  at a high rate.
• The estimated direct and indirect costs of
  stroke exceed 68.9 billion in 2009.

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More than half of all heart disease and stroke
patients do not receive consistent preventive
instructions upon discharge from the hospital
Heart and Stroke Patient Treatment
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While evidence-based guidelines for stroke
and TIA care have been developed along with
improved diagnostic and treatment modalities,
there are gaps, variations, and disparities in
how these are applied. Furthermore many
hospitals may not have the systems, organization,
staff, and equipment to effectively diagnose and
treat acute stroke patients.
The Wall Street Journal, November 9, 2003,
Physicians Weekly, June 21, 2004, ADHERE Study
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Challenging Conventional Care
Proven, evidence-based treatment guidelines are
available, and should be part of
every hospitals routine
but sadly, this is not always the case.

• Treatment protocols
• Written discharge
• instructions
• Risk modification
• counseling
• Appropriate
• prescriptions

We now have a situation where medicine is by
memory. Busy clinicians try to recall for each
patient the appropriate evidence-based therapies,
all during the chaos of the day. If they don't
remember all of this there are repetitive
oversights. Gregg Fonarow, MD, FACC, FACP UCLA
Division of Cardiology
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AHA GWTG Program
GWTG is a national initiative of the AHA to
improve care quality and guidelines adherence in
patients hospitalized with cardiovascular
disease. GWTG uses collaborative learning
sessions, conference calls, e-mail and staff
support to assist hospital teams improve acute
and secondary prevention care systems. A
web-based Patient Management Tool is used for
point of care data collection and decision
support, on-demand reporting, communication and
patient education.
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The GWTG Stroke Program

• GWTG-CAD Program launched in 2000
• GWTG Stroke Program development from 2001-2003
  to identify best practices and mature the QI
  model
• Pilot testing in 24 hospitals from 2001-2003
• Regional implementation in 99 hospitals from
  2003-2004
• National implementation in 2004, currently in
  over 1,280 hospitals with 1,000,000 patients
  entered!

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Translating Guidelines into Practice

• Evidence shows that publishing guidelines is not
  sufficient to change practice
• To prevent underutilization or disparities in the
  use of therapies recommended in national
  guidelines, the guideline development and
  distribution process should recognize and
  incorporate strategies for increased
  implementation (Class I, Level of Evidence B)
• GWTG Stroke turns guidelines into practice!

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Bridging the Gap Between Knowledge and Routine
Clinical Practice
AHA/ACC Guidelines
Clinical Practice
Systems

• Implement evidence-based care
• Improve communications
• Ensure compliance

• Clinical trial evidence
• National guidelines

• Improve quality of care
• Improve outcomes

Adapted from the American Heart Association. Get
With The Guidelines 2001.
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AHA Support and Resources
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GWTG Program Support

• Volunteers
• Steering Committee
• Chair Dr. Lee Schwamm
• Past Chair Dr. Gregg Fonarow
• QII Sub Committee
• Chair Dr. Paul Heidenreich
• Past Chair Dr. Ken LaBresh
• Science Sub Committee
• Chair Dr. Deepak Bhatt
• Past Chair Dr. Chris Cannon
• Staff
• 8 Affiliate QII Teams (70 field staff)
• National Center Team (20 staff)

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GWTG Program Delivery

• Stakeholder meetings
• On line GWTG CME Course
• Regional CME Workshops
• Webinars
• Regional and National
• Regional User Forums
• On site consultation
• On line/ point of care data tool

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Building the GWTG Hospital Team

• Physician Champion(s)
• Nurses
• Pharmacists
• Hospital Administrators
• Directors of Cardiac or Neurology Services,
  Quality Improvement and Case Management
• Stroke Rehab Team

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AHA Patient Education Materials Tailored to the
Individual Patient
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GWTG Program Implementation

• Physician Champion
• Administrative Champion
• Multidisciplinary Team
• Application of QI methods
• Patient Management Tool
• Supports data to drive change process
• Hospital Toolkit Library Standing Order Sets,
  Discharge Protocols, Care Paths
• Recognition Program
• Drives sustainable levels of compliance

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Improving Care Quality and Outcomes
Decreased risk of death or recurrent related
health problems
Patients have a 10-to-15 fold higher likelihood
of adhering to recommended prevention therapy
when it is started in the hospital.
Physicians Weekly, June 21, 2004
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GWTG Cumulative Progress-to-Date
As of July 17th, 2009
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GWTG Stroke Hospitals
1,272 Stroke Contracts Last updated 6/11/2009
ME (6)
VT (1)
WA (28)
ND (2)
MT (4)
NH (4)
MN (13)
NY (110)
OR (18)
WI (61)
MA (60)
ID (1)
SD (3)
RI (5)
MI (42)
WY (2)
CT (18)
PA (83)
IA (16)
NJ (39)
NE (10)
OH (44)
IL (45)
IN (23)
DE (4)
NV (9)
WV (5)
VA (28)
MD (35)
UT (10)
CO (37)
KY (16)
KS (6)
MO (22)
DC (4)
CA (88)
NC (19)
TN (26)
SC (11)
OK (9)
AR (8)
NM (3)
AZ (17)
MS (12)
AL (16)
GA (58)
LA (15)
TX (78)
1-9 GWTG-S Hospitals
AK (2)
FL (115)
10-19 GWTG-S Hospitals
20-49 GWTG-S Hospitals
HI (12)
50-99 GWTG-S Hospitals
gt100 GWTG-S Hospitals
PR (2)
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Stroke Achievement Measures(Aligned with
AHA/ASA, CDC, TJC Consensus Measures)

• Iv rt-PA 2 hour
• Early Antithrombotics
• DVT Prophylaxis
• Antithrombotics at discharge
• Anticoagulation for AF
• Lipid lowering therapy
• Smoking cessation

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GWTG-S Effectiveness Study

• N 322,847 patients from 790 hospitals
• Time 4.25 years of program participation
• GWTG population similar in many ways when
  compared to other large datasets
• racial make-up similar to the US pop 2000 census
• LOS (5.19 vs. 4.7 days) and in-hospital mortality
  (4.21 vs. 4.09) similar to the National
  Inpatient Sample NIS 2000

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GWTG-S Patient Characteristics
Schwamm LH et al. Circulation 2009119107-115
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GWTG-S Hospital Characteristics

• Hospitals from all regions of the country
  represented
• GWTG hospitals similar in many ways when compared
  to other large datasets
• Most GWTG-S hospital sample characteristics did
  not change significantly over the 4.5 years of
  the analysis except for regional contributions

Schwamm LH et al. Circulation 2009119107-115
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GWTG-Stroke Effectiveness Study Results

• Improvement in all 7 PMs over time 3.20 to
  30.75, p lt 0.0001 for all comparisons
• This was observed for composite and all-or-none
  scores
• IV rt-PA rates dramatically increased over time,
  ICH rates did not change significantly
• (4.49 at baseline, vs 5.95 5 years, p .41)

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Improvement Over Time in GWTG-Stroke
Schwamm LH et al. Circulation 2009119107-115
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Improvement Over Time in GWTG-Stroke
Schwamm LH et al. Circulation 2009119107-115
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Improvement Over Time in GWTG-Stroke
Schwamm LH et al. Circulation 2009119107-115
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Improvement Over Time in GWTG-S
Schwamm LH et al. Circulation 2009119107-115
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Schwamm LH et al. Circulation 2009119107-115
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Analyzing Improvement With Controlling for
Secular Trends

• Use the composite measure of performance to
  summarize improvement into 1 variable, and then
  examine the factors that were associated with
  improvement in that variable using logistic
  regression models controlling for changes in
  baseline pre-intervention data over time

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Analyzing the Effects of Time Spent in the GWTG-S
Program

• All hospitals improved over time, but some types
  of hospitals improved faster
• We identified those hospital characteristics that
  demonstrated a significant interaction with the
  time in GWTG-Stroke variable
• Factors included bed capacity, annual stroke
  discharge volume and teaching status

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GWTG-Stroke Effectiveness

• GWTG Stroke was associated with a significant
  and sustained improvement in adherence to acute
  hospital performance measures as well as
  secondary prevention for inpatient care of
  patients with ischemic stroke and TIA
• This improvement was independent of secular trends

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GWTG-S Effectiveness Discussion

• Largest cohort to date to report on this broad
  range of stroke quality measures from within a QI
  intervention.
• Improvements were sustainable and generalizable
  over gt4 years.
• Improvement over several domains of care not just
  limited to one intervention
• Hospital participation in the program has grown
  steadily

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GWTG-Stroke Performance Measures
Baseline Admissions Jan2003 Dec2003
April 2009 Current Admissions
Apr2008 Mar2009
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GWTG Publications

• 2008 Results
• 20 Published Manuscripts (5 HF, 10 CAD, 5 Stroke)
  
• 2007 Results
• 4 Published Manuscripts (1 HF, 3 CAD)
• Current Status Summary
• 11 Manuscripts in process to Journal submission
• 6 Manuscripts pending Journal decision
• 7 HF, 7 CAD, 2 HF/CAD, 1 Stroke
• 21 Abstracts in process to manuscript
• 5 HF, 7 CAD, 1 HF/CAD, 8 Stroke
• Upcoming Conference Activity
• ISC (Feb) 2009 10 Accepted Abstracts (4
  National, 5 Single Ctr, 1 AVAIL)
• ACC (Mar) 2009 6 Accepted Abstracts (All GWTG
  National)
• 34 Total Research Proposals in Queue

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AHA GWTG is Award Winning

• First hospital-based program to receive the
  prestigious Innovation in Prevention Award from
  U.S. Department of Health and Human Services.
• Recipient of Inaugural eHealth Initiative (eHI)
  Award Honoring Leadership in Health Care Quality
  through Health IT for Transforming Care Delivery

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Looking Ahead

• Stroke Measures will be incorporated next year
  into the Joint Commission Core Measure Set and
  the CMS Inpatient Prospective Payment System
• State-based stroke center initiatives are on the
  rise, and expect that performance measurement
  play an increasingly important role
• Start improving now before they start counting!

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GWTG-Stroke Summary

• GWTG-Stroke
• Represents a set of strategies for increased
  guideline implementation
• Associated with substantial improvements in care
  quality
• Findings suggest that a structured quality
  improvement program can benefit all types of
  hospitals
• Translates into better adherence across a bundle
  of evidence-based indicators

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Get With The Guidelines Works! Hospitals
Participating in GWTG Provide Higher Quality
Care1 with Better Clinical Outcomes than Other
Hospitals
The Bottom Line
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Its time to ask yourself, How does my
hospital measure up? Join GWTG now to find
out and start improving!
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Congratulations toThe AHA/ASA and Get With
The Guidelines HospitalsOne Million Stroke/TIA
Patients Entered into the Program!
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• High Quality Cardiovascular Care Making it a
  Reality
• A major CVD treatment gap still exists
• The hospital is the ideal capture point, provides
  a teachable moment, and predicts care in the
  community
• Get With The Guidelines can improve treatment
  rates and save lives. All hospitals should
  implement a prospective quality improvement
  system to improve CHD, Stroke, and HF patient
  care.
• Treatment rates should be measured and reported
  to ensure optimal care for all CVD and stroke
  patients.

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