Transcript Document

Are Quality Improvements Associated with the GWTG-Coronary Artery
Disease (GWTG-CAD) Program Sustained Over Time?
A Longitudinal Comparison of GWTG-CAD Hospitals vs.
non--GWTG-CAD Hospitals
Ying Xian, MD; Wenqin Pan, PhD; Eric D. Peterson, MD, MPH; Paul A.
Heidenreich, MD, MS; Christopher P. Cannon, MD; Adrian F. Hernandez, MD, MHS;
Bruce Friedman, PhD, MPH; Robert G. Holloway, MD, MPH;
Gregg C. Fonarow, MD
Xian et al. Am Heart J 2010;159(2):207-214
© 2010, American Heart Association. All rights reserved.
Background
Previous reports have demonstrated that
participation in Get With The Guidelines-Coronary Artery Disease (GWTG-CAD), a national
quality initiative of the American Heart
Association, is associated with improved
guideline adherence for patients hospitalized with
CAD. We sought to establish whether these
benefits from participation in GWTG-CAD were
sustained over time.
Xian et al. Am Heart J 2010;159(2):207-214
© 2010, American Heart Association. All rights reserved.
Introduction
The American Heart Association (AHA) and the American
College of Cardiology (ACC) have developed treatment
guidelines for patients with coronary artery disease (CAD).
Despite widely available evidence-based therapies that
have been shown to improve clinical outcomes for
patients with coronary artery disease (CAD), a treatment
gap exists between clinical practice and use of
guideline-recommended therapies.
GWTG-CAD quality improvement program has shown
significant improvements in guideline adherence for
patients hospitalized with CAD.
© 2010, American Heart Association. All rights reserved.
Xian et al. Am Heart J 2010;159(2):207-214
Objective
The GWTG program is the largest hospital-based,
national performance initiative that has shown to
improve adherence to treatment guidelines over a 1-year
period for participating hospitals. The purpose of this
paper was to evaluate whether guideline adherence for
patients hospitalized with CAD was sustained over time.
Xian et al. Am Heart J 2010;159(2):207-214
© 2010, American Heart Association. All rights reserved.
Methods
• The Centers for Medicare and Medicaid (CMS) Hospital
Compare Database was used to examine six performance
measures and one composite score over 3 consecutive
12-month periods including aspirin and β-blocker on
arrival/discharge, ACE-I for LVSD, and adult smoking
cessation counseling.
• The differences in guideline adherence between the
GWTG-CAD hospitals (n=440, 439, 429) and non--GWTGCAD hospitals (n=2438, 2268, 2140) were evaluated for
each 12-month period.
• A multivariate mixed-effects model was used to estimate
the independent effect of GWTG-CAD over time adjusting
for hospital characteristics.
© 2010, American Heart Association. All rights reserved.
Xian et al. Am Heart J 2010;159(2):207-214
Results
•
Compared with non--GWTG hospitals, the GWTG-CAD hospitals
demonstrated higher guideline adherence for 6 performance measures.
•
The largest differences existed for
(1) aspirin at arrival (2.3%, 2.1%, and 1.6% for each 12-month period,
respectively)
(2) aspirin at discharge (3.4%, 2.2%, and 2.3%)
(3) β-blocker at arrival (3.4%, 2.9%, and 2.6%), and
(4) β-blocker at discharge (2.8%, 1.8%, 1.5%).
•
In multivariate analysis, the GWTG-CAD hospitals were independently
associated with better adherence for 4 of the 6 measures (the
exceptions were ACE-I for LVSD and smoking cessation counseling).
•
Superior performance also was found for the composite measures.
Although there was some narrowing between groups, GWTG-CAD 4
hospitals maintained superior guideline adherence than non--GWTGCAD hospitals over the entire 3-year period (adjusted differences 1.8%,
1.6%, and 1.4%).
Xian et al. Am Heart J 2010;159(2):207-214
© 2010, American Heart Association. All rights reserved.
Limitations
•
Too few hospitals newly joined the GWTG-CAD during the study period
to allow a pre-and-post evaluation of performance changes after the
GWTG-CAD implementation using the CMS Hospital Compare
Database.
•
This study did not control for the patient case mix; however
performance measure assessment was confined only to eligible
patients without contraindications.
•
Because program participation is voluntary it was hard to establish if
participation in the GWTG-CAD program resulted in improved
adherence or if higher quality hospitals participate in GWTG-CAD.
•
Other factors such as pay for performance, public reporting, or other
quality initiatives may have influenced the performance measures
because information on these factors was not available in the CMS
Hospital Compare Database.
Xian et al. Am Heart J 2010;159(2):207-214
© 2010, American Heart Association. All rights reserved.
Conclusions
Hospitals participating in GWTG-CAD had
modestly superior acute cardiac care and
secondary prevention measures performance
relative to non--GWTG-CAD. These benefits of
GWTG-CAD participation were sustained over time
and independent of hospital characteristics. As
substantial
care opportunities
in
patients
hospitalized with coronary artery disease remain
unfulfilled, expanding GWTG-CAD participation
nationwide has the potential to increase guideline
adherence and enhance patient outcomes.
Xian et al. Am Heart J 2010;159(2):207-214
© 2010, American Heart Association. All rights reserved.