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© American Heart Association 2001
© American Heart Association 2001
Get With The Guidelines--Reaching our 2010 Impact Goal
Overview of the Secondary Prevention Challenge
Get with the Guidelines Program Overview
The New England Affiliate Pilot and Results
National Roll-out
What would we like from you today?
Understand and communicate objectives of this Bold Initiative
Identification of strategic partner contacts
Recruitment of key champions across the country
Ken LaBresh, M.D., FACCAssociate Medical Director
Mass PRO
President, New England Affiliate
Get with the Guidelines-CVD and Stroke
AHA / ASA’s Program for Saving Lives Through Effective Implementation of
Secondary Prevention Guidelines
AHA GOALSAHA GOALS
By 2010, we will reduce coronary heart disease, stroke and
risk by 25%
The Healthcare Continuum
HealthyPopulation
Undiagnosedor Untreated
In Treatment
AcuteEvent
PostEvent
Implement Guidelines HERE
HealthyPopulation
Undiagnosedor Untreated
In Treatment
AcuteEvent
PostEvent
Status Report
AHA Guidelines• Smoking Cessation
• Lipid Management
• Physical activity
• Weight management
• Asprin/other Antithrombotic agents
• ACE inhibitors
• Beta blockers
• Blood pressure control
• Diabetes Management
• Stroke Specific: Atrial Fibrillation Management, Drug and Alcohol Abuse Management
Adapted from Smith, Circulation 92:3, 1995Adapted from Smith, Circulation 92:3, 1995
Implementation Statistics
Indicator Rate Optimal
ASA 85%* 100%
Beta Blocker 72%* 100%
ACE-I 71%* 100%
Smoking Cessation 40%* 100%
Lipid Lowering 37%** 96%
*HCFA, 1998 **NRMI 2nd Q 2000
Mortality Statistics• Over 450,000 people suffer from recurrent coronary attacks
each year.
• Within 1 year of a recognized MI 25% of men and 38% of women will die
• 100,000 recurrent strokes occur each year
• Within 1 year of a stroke 22% of men and 25% of women will die
• 14% of stroke survivors will experience a recurrent stroke within 1 year.
AHA 200 Heart and Stroke Statistical Update
Saving Lives:
Real Results
CHAMP:
Cardiac
Hospitalization
Atherosclerosis
Management
Program
CHAMP:
• UCLA- Gregg Fonarow, MD• Hospitalizations are a captured patient
encounter• Expedient one page algorithm for:
ASA, Beta Blocker, ACE inhibitor, Lipid Rx, Aerobic Exercise, Dietary guidelines, Smoking cessation
• Lipid Goal: LDL < 100 mg/dl
CHAMP: Cardiac Hospitalization Atherosclerosis Management Program
CAD Patient Treatment Rates*
*Fonarow, G. et al. “Improved Treatment of Cardiovascular Disease by Implementation of a Cardiac Hospitalization Atherosclerosis Management Program: CHAMP,” Abstract from the 70th Scientific Sessions, American Heart Association, November, 1997.
NRMI Registry Discharge Medications at UCLA compared to 1437 NRMI Hospitals
Sustained Impact of CHAMP on Secondary Prevention Treatment Rates
UCLA Data
64
12
68
88
52
68
9289
64
72
91 90
70
94
78
0
20
40
60
80
100
ASA Beta Blocker ACEI Statin
92/93
94/95
96/97
98/99
77
59
41
28
NRMIData98/99
Improvement in Treatment Utilization is Associated With A Marked Reduction in Clinical Events
14.8%
6.4%
0
5
10
15
20
Pre-CHAMP Post-CHAMP
Death or Recurrent MI%RR0.43p<0.01
256 AMI pts discharged in92/93 Pre-CHAMP- compared to 302 pts in 94/95 Post-CHAMPASA 78% vs 92%; BetaBlocker12% vs 61%; ACEI 4% vs 56%; Statin 6%vs 86%
Fonarow ,American Journal of Cardiology 2001(in press)
Bridging the Gap
• Systems to Translate Efficacy Effectiveness
SYSTEMS• Outcomes associated
with an intervention under ideal circumstances– Clinical trial
reported in literature
– Benchmarking
EFFICACY EFFECTIVENESS
• Outcomes associated with an intervention in the real world – Hospital– Outpatient– Across
Continuum
Bridging the Gap Between Efficacy and Effectiveness
The Gap
L-TAP survey showed– 95 % of PCPs are aware of NCEP guidelines– 18 % of their CAD patients at goal
* Treatment Patterns and Distribution of Low-Density Lipoprotein Cholesterol Levels in Treatment-Eligible United States Adults, Hoerger et. al. American Journal of Cardiology 1998; 82: 61-65
The Gap
NHANES III data* reveals– 28 % are eligible for treatment based on NCEP II– 82 % of those with CHD are not at NCEP II goal
for LDL– 65 % of patients eligible for treatment are not
receiving therapy
* Treatment Patterns and Distribution of Low-Density Lipoprotein Cholesterol Levels in Treatment-Eligible United States Adults, Hoerger et. al. American Journal of Cardiology 1998; 82: 61-65
The Gap
QAP Data - Community based Cardiologists– 30-40 % Documented Treatment Rate Treatment Gap of 61 % Provider awareness does not result in
successful implementation
* Treatment Patterns and Distribution of Low-Density Lipoprotein Cholesterol Levels in Treatment-Eligible United States Adults, Hoerger et. al. American Journal of Cardiology 1998; 82: 61-65
The Gap
ACC Evaluation of Preventive Therapeutics (ACCEPT) Data– 20-25 % Documented Treatment Rate – Treatment Gap of 80 %
- Hospital data (N=50) 1996-97
NRMI 3 Data - 6/00 37 % of Post-MI patients discharged on a statin
(N = 101, 294)
The Barriers
Physician Barriers• Attitudes
Agreement with specific guidelines Agreement with guidelines in general Outcome expectancy (performance of recommendations will not
lead to desired outcome) Self-efficacy (physician believes he cannot carry out
recommendations) Motivation (habits/routines)
From Cabana et al. JAMA. 1999; 282:1458-1465.
Physician Barriers
• Behavior Patient factors (patient preferences vs. recommendations) Guideline factors (complexity, conflicting recommendations) Environmental Factors
• Lack of time resources• Financial disincentives • Organizational constraints
From Cabana et al. JAMA. 1999; 282:1458-1465.
The Solution
Get With The Guidelines
Prospective intervention process in the hospital setting, designed to significantly increase CHD and Stroke discharge treatment rates.
1. Supports system improvements for CHD and Stroke patients
2. Encourages links between cardiologist/
neurologists and primary care physicians
3. Provides resources to build consensus and establish and execute protocols
Implement discharge protocols in hospital setting
Implemented by AHA Staff/Volunteers who will mobilize networks at the Local level
Implement CME-driven educational programsIdentify best practices for AHA recognition
awardsDevelop and disseminate reports and
publicationsMeasure changes and report outcomes dataDrive impact into communities
What is Get With The Guidelines?
1999 - New England Affiliate of the AHA launches “Get With the
Guidelines” Pilot
Best Practice - Pilot
1996 - QAP participant
1997 - Nurse based lipid
clinic
1998 - QI initiative at Memorial
Hospital
American Journal of Cardiology - February 10, 2000
Get With The Guidelines - Pilot
• AHA New England Affiliate - Merck, PRO Partnership
• 85 of the regions’ 160 acute care hospitals currently participating
• All three of the PRO’s using the process for 6th scope of work implementation of AMI, CHF, Atrial Fibrillation indicators
Assess CHD Treatment RatesAnalyze
Discharge Rates
Evaluate AssessmentGWTG Team Reviews
Summary Reports
Refine ProtocolGWTG Team Identifies Areas for Improvement
Implement Refined ProtocolGWTG Team Coordinates Implementation of Refined
Protocol
Find & Support a Find & Support a ChampionChampion
What are Hospital Teams Agreeing to do?Identify/create the hospital implementation
team Attend a Get With The Guidelines MeetingAgree to implement the AHA discharge
protocolMeasure baseline performance levelAssess level of consensus within the hospital
What are Hospital Teams Agreeing to do?Implement programF/u recovery plan for non-participating and
lagging hospitalsRoutine follow-up with all participants to get new
data & assess progress every 3-months Best practice sites for advocates and
preceptorshipsReceive recognition -- add to “Buzz”
Incentives for Change
• Prevention is Cost Effective Quality Care Risk Sharing and Capitation provide
economic incentives Our patients will demand it Accreditation agencies will require it
• It’s the right thing to do!
American Heart Association
Data Tool
Information at the Point of Care
IMPACT:
Point of Care Point of Care (where it can still improve clinical decision making)
Near the Near the Point of CarePoint of Care
Distant from Distant from the Point of Carethe Point of Care
+ ++ ++++
Demographics 6 clicks
Clinical/Lab 8 clicks
Dischargemeds and interventions 7 clicks
Interactivelychecks patient’sdata with theAHA guidelines
AHA TOOL: SIMPLE, ONE PAGE, ON-LINE FORMAHA TOOL: SIMPLE, ONE PAGE, ON-LINE FORM
CHECKS PATIENT’S INFORMATION WITH AHA GUIDELINES CHECKS PATIENT’S INFORMATION WITH AHA GUIDELINES
PRINT A NOTE FOR PATIENT EDUCATION OR AS A DISCHARGE SUMMATION EMPOWER PATIENTS WITH INFORMATION AND REINFORCEMENT
PRINT A NOTE FOR PATIENT EDUCATION OR AS A DISCHARGE SUMMATION EMPOWER PATIENTS WITH INFORMATION AND REINFORCEMENT
FAX LETTER TO REFERRING PHYSICIAN IMPROVE COMMUNICATION AND REINFORCE INTERVENTION
FAX LETTER TO REFERRING PHYSICIAN IMPROVE COMMUNICATION AND REINFORCE INTERVENTION
How it’s being used:
• On-line completion at discharge on the floor
• Paper form follows patient on front of chart and entered on-line at discharge.
• Used as a QI tool with frequent reports to relevant departments, (also meet include AMI and CHF JCAHO core measure requirements).
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Smoking ACE BB ASA LDL BP REHAB Lipid
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Smoking ACE BB ASA LDL BP REHAB Lipid
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Smoking ACE BB ASA LDL BP REHAB Lipid0%
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Smoking ACE BB ASA LDL BP REHAB Lipid
Hospital Baseline Data Hospital Baseline Data ExamplesExamples From the New England AHA Data Tool PilotFrom the New England AHA Data Tool Pilot
Hospital A Hospital B
Hospital C Hospital D
AHA Benchmarks Hospital Data
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20
40
60
80
100
Goal
Quarter 4
Percent of Patients Receiving Care Compared to AHA Goals in Quarter 4
NRMI comparisonNRMI comparisonMeasure
AHA Resources
• Large network of committed staff and volunteers with relationships in the community
• Science - Guidelines development, data
• Educational materials
• Programs Get With the Guidelines Operation Heart Beat Operation Stroke Call to Action One of a Kind
Join Us in Saving Lives!
If Get With The Guidelines is
implemented, more than 40,000+
lives could be saved every year!
