Cardiovascular disease remains the leading cause of morbidity and mortality in both men and women in the United States (1). Patients hospitalized with myocardial infarction, heart failure, or stroke are at high risk for recurrent events, hospitalizations, and cardiovascular death. There are a number of evidence-based, highly effective, guideline-recommended therapies that can significantly improve acute long-term care outcomes and reduce recurrent events in these patients. While the American Heart Association (AHA), American College of Cardiology (ACC), American Stroke Association (ASA), and other organizations' guidelines provide evidence-based recommendations for cardiovascular care, adherence to these guidelines is incomplete and highly variable. To improve the quality of care for patients hospitalized with cardiovascular disease, the AHA launched the "Get With The Guidelines" (GWTG) Program in the year 2001 (2-4). Since that time, the program has produced a number of key findings and valuable lessons for measuring and improving the quality of cardiovascular care.
The GWTG Program was developed to provide hospitals with a systemic approach to measuring and improving the quality of care by utilizing evidence-based tools to help ensure that patients are initiated and discharged on appropriate medications and with risk modification counseling. Modules focused on patients with coronary artery disease, stroke, and heart failure have been implemented. GWTG facilitates performance improvement using a hospital-based system, a web-based Patient Management Tool (PMT)™ (Outcome, Cambridge, MA), and collaborative learning sessions in which hospital teams exchange best practices and learn rapid cycle improvement strategies (2-4). As part of an enhanced treatment and discharge plan, GTWG provides hospitals with guideline-based clinical pathways, standardized orders, best-practices algorithms, discharge checklists, educational tools for patients and care-givers, and a variety of other tools to assist hospitals in improving patient management. The collaborative learning model includes interactive learning sessions, teleconference, and electronic interaction between multidisciplinary teams from hospitals in a variety of settings (2-4). GWTG provides the opportunity for concurrent data collection and decision support, and also provides real-time quality reporting. On-line, on-demand reports provide continuous quality improvement feedback to the participating institutions and permit hospitals to compare their respective performance measure improvement with that of other hospitals. There is a modest annual charge for use of the PMT. Hospitals achieving the highest levels of performance are recognized by the AHA (3).
Since inception, there have been over 1,500 U.S. hospitals participating in one or more GWTG Program modules and over 1.1 million patient hospitalization episodes entered (see Table below). Participation in GWTG has been associated with statistically significant and clinically relevant improvements in the use of key evidence-based therapies in all three modules (1-4). For example, substantial improvements over time in the use of smoking cessation counseling (from 58.7% baseline to 94.7% post-intervention), lipid lowering medications (from 58.5% baseline to 84.6% post-intervention), and referral to cardiac rehabilitation (from 59.0% baseline to 72.9% post-intervention) were observed among the first 58,847 coronary artery disease (CAD) hospitalizations among 315 hospitals participating in GWTG (each P<0.0001). Improvements in acute care metrics such as early aspirin, beta blockers, and door-to-balloon time in acute coronary syndromes have also been observed (1-6). Among 141,449 patients hospitalized with stroke or transient ischemic attack at 778 GWTG-Stroke participating hospitals, use of thrombolytics in eligible acute ischemic stroke patients improved from 23.5% at baseline to 63.3% post-intervention and smoking cessation counseling from 38.8% at baseline to 83.8% post-intervention (each P<0.0001). Studies of each of the GWTG modules have suggested that this approach is associated with quality improvements at a rapid pace in a variety of hospital settings. Concurrent comparisons of performance in acute myocardial infarction (AMI) care between 225 GWTG-CAD hospitals and 3,487 other U.S. hospitals demonstrate statistically significant (albeit smaller) differences (for example, angiotensin converting enzyme inhibitor use at discharge in eligible AMI patients of 81.0% compared to 77.8% [P<0.0001]) (7). Readers interested in more details regarding the kinds of quality improvement seen are referred to peer-reviewed publications of the results (2-6). It is important to note that GWTG hospitals were self-selected and may represent hospitals that are more committed to quality improvement. The change in the performance measured observed over time could, in part, represent secular trends and a general improvement in care provided by U.S. hospitals as a whole.
American Heart Association GWTG Program Overview*
||Hospitals Currently Utilizing
||Number of Records
||Number of Performance Measures & Quality Measures
|Get With The Guidelines
||6 performance; 11 quality
||Heart Failure Module
||5 performance; 5 quality
||7 performance; 17 quality
||18 performance; 23 quality
*as of 2/1/2008
** 1500 unique hospitals participating in one or more modules
(Source: American Heart Association)
Many potential barriers to improving adherence to guideline recommendations have been identified, including issues related to patients, physicians, and health care systems. The GWTG program recognizes these factors, incorporating approaches that take them into account, and, as a result, helps to overcome them. Active physician involvement in the program, use of multidisciplinary teams, and ongoing administrative support are keys to the success of continuous quality improvement programs such as GWTG. Multiple strategies have been integrated into GWTG to encourage physician participation, share best practices, and overcome barriers. The growing movement for public reporting of hospital performance on quality of care and outcomes, as well as center of excellence certification has also helped to drive participation in GWTG. However, many challenges still remain. Hospital teams are facing an ever increasing amount of data which they need to collect and report, and avoiding the need for duplicate entry is essential. Securing and maintaining resources and administrative support, and maintaining momentum when key team members relocate have been difficult for certain hospitals.
GWTG is among the largest national hospital-based programs dedicated to quality-of-care improvement for patients hospitalized with cardiovascular disease. Hospitals participating in GWTG have demonstrated greater adherence to national guideline-recommended therapies compared to other U.S. hospitals publicly reporting data at the same time. With over 1.1 million patients entered into the program, the potential benefits of hospital participation have been substantial. However, further opportunities remain including enhancing participation of U.S. hospitals and making further strides to achieve 100% performance in each measure for each cardiovascular disease state. Planned enhancements to GWTG include providing personalized patient educational materials, program links to the ambulatory care setting, and interfaces with multiple electronic medical record systems, among others.
Gregg C. Fonarow, MD
Los Angeles, CA
The views and opinions expressed are those of the author and do not necessarily state or reflect those of the National Guideline Clearinghouse™ (NGC), the Agency for Healthcare Research and Quality (AHRQ), or its contractor, ECRI Institute.
Potential Conflicts of Interest
Dr. Fonarow is Chair of the "Get With The Guidelines" Steering Committee. This is a volunteer position. The American Heart Association sponsors "Get With The Guidelines." The program is funded in part by GlaxoSmithKline and the Merck-Schering Plough Partnership. Dr. Fonarow has declared research, consultant, and honorarium relationships with GlaxoSmithKline, Pfizer, Merck Schering Plough, and Medtronic.
- Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics--2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007; 115:e69-171.
- LaBresh KA, Ellrodt AG, Gliklich R et al. Get with the guidelines for cardiovascular secondary prevention: pilot results. Arch Intern Med. 2004 Jan 26; 164:203-9.
- Smaha LA. American Heart Association Get With The Guidelines program. Am Heart J. 2004; 148(5 Suppl):S46-8.
- LaBresh KA, Reeves MJ, Frankel MR, Albright D, Schwamm LH. Hospital treatment of patients with ischemic stroke or transient ischemic attack using the "Get With The Guidelines" program. Arch Intern Med. 2008; 168:411-7.
- Krantz MJ, Baker WA, Estacio RO, et al. Comprehensive coronary artery disease care in a safety-net hospital: results of get with the guidelines quality improvement initiative. J Manag Care Pharm. 2007; 13:319-24.
- Fonarow GC, Abraham WT, Albert NM, et al; for the OPTIMIZE-HF Investigators and Hospitals. Influence of a Performance-Improvement Initiative on Quality of Care for Patients Hospitalized With Heart Failure: Results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Arch Intern Med. 2007; 167:1493-502.
- Lewis WR, Super DM, LaBresh KA, Queasy K, Fonarow GC. Does the AHA GWTG program improve the quality of care of patients with acute myocardial infarction? Circulation 2006; 113:4(abstract).