Translating Efficacy into Effectiveness: AHA’s Get With The Guidelines Program

Nathan D. Wong, PhD, FACC, FAHAAssociate Professor and Director

Heart Disease Prevention ProgramUniversity of California, Irvine, CA USA

What is Clinical Effectiveness?….. The application of interventions

which have been shown to be efficacious to appropriate patients in a timely fashion to improve patients’ outcomes and value for the use of resources….

Batstone and Edwards, 1996. J Clin Effect 1996; 1: 19-21.

Process for Using Research-Derived Evidence to Help Solve a Clinical Problem:

• Identify a question which needs to be answered

• Search for the best evidence with which to answer the question

• Critically appraise that evidence for validity and applicability

• Apply the results of the appraisal to practice• Evaluate your performance

Get with the Guidelines-CVD and Stroke

AHA / ASA’s Program for Saving Lives Through Effective Implementation of Secondary

Prevention Guidelines© American Heart Association 2001

AHA GOALSAHA GOALS

By 2010, we will reduce coronary heart disease, stroke and

risk by 25%

Implement Guidelines HERE

HealthyPopulation

Undiagnosedor Untreated

In Treatment

AcuteEvent

PostEvent

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 OptimalASA 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

CHAMP: Cardiac Hospitalization Atherosclerosis Management Program

CAD Patient Treatment Rates*‘92-’93 ‘95-’96

Hospital discharge: Aspirin Beta-Blocker ACEI Statin12-month follow-up: Statin LDL < 100 mg/dL

78%12% 4% 6%

10% 6%

92%61%56%86%

91%58%

*Fonarow, G. et al. “Improved Treatment of Cardiovascular Disease by Implementation of a Cardiac Hospitalization Atherosclerosis Management Program: CHAMP,” Abstract from the 70th ScientificSessions, American Heart Association, November, 1997.

Sustained Impact of CHAMP on Secondary Prevention Treatment Rates

UCLA Data

6412

68

88

52

68

9289

64

72

91 90

70

94

78

0

20

40

60

80

100

ASA Beta Blocker ACEI Statin

92/9394/9596/9798/99

77

59

41

28

NRMIData98/99

NRMI Registry Discharge Medications at UCLA compared to 1437 NRMI Hospitals

Improvement in Treatment Utilization is Associated With A Marked Reduction in Clinical Events

14.8%

6.4%

05

101520

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)

• Systems to Translate Efficacy Effectiveness

SYSTEMS• Outcomes associated

with an intervention under ideal circumstances– Clinical trial

reported in literature

– Benchmarking

EFFICACY

• Outcomes associated with an intervention in the real world – Hospital– Outpatient– Across

Continuum

Bridging the Gap Between Efficacy and Effectiveness

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)

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 GuidelinesProspective 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 programs! Identify best practices for AHA recognition

awards! Develop and disseminate reports and

publications! Measure changes and report outcomes data! Drive impact into communities

What is Get With The Guidelines?

Best Practice - Pilot

1999 - New England Affiliate of the AHA launches “Get With the

Guidelines” Pilot

1997 - Nurse based lipid

clinic

1998 - QI initiative at Memorial

Hospital

1996 - QAP participant

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 IdentifiesAreas 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 Meeting" Agree to implement the AHA discharge

protocol" Measure baseline performance level" Assess level of consensus within the hospital

What are Hospital Teams Agreeing to do?" Implement program" F/u recovery plan for non-participating and

lagging hospitals" Routine follow-up with all participants to get

new data & assess progress every 3-months !Best practice sites for advocates and

preceptorships!Receive recognition -- add to “Buzz”

Find an opportunity to improveAn opportunity exists to improve use of evidence based treatmentguidelines for CAD prior to hospital discharge.

Organize a teamA team was organized with representatives from Cardiology, Internal Medicine, Emergency Medicine, Family Medicine, Case Management, Nursing, Rehab Services, Pharmacy, Performance Improvement, Product Line Development, Information Services.

Clarify the knowledge of the processThere is a shift from interventional treatment to a diagnostic and therapeutic focus, addressing underlying atherosclerotic disease. Patients should be treated with therapies that alter the naturalhistory of atherosclerosis, decrease cardiac events, and improvesurvival. Regardless of treatment, every patient should be treated for smoking cessation, exercise and weight management, BP control, lipid and diabetes management, antiplatelet agents, ACE inhibitors, and beta blockers. Patients placed on treatment protocols in the hospital have better long term compliance and lower costs per discharge.

Understand the causes of variationDespite compelling scientific evidence and national treatment guidelines supporting the use of secondary prevention medical therapies, therapies (smoking cessation, weight management, patient education in sodium restricted Step II AHA diet and exercise, rehab services, Ace Inhibitors and lipid lowering agents) continue to be underutilized at UCIMC. The AHA’s Get With the Guidelines program provides a framework for change.

Select the process improvementThe team selected improvements in: • ED algorithm and admitting order sets• Focused lectures and discharge process• Patient Education and prospective clinical measure benchmarking

Plan the improvement• Measure baseline then ongoing results• Communicate program with benchmark data• Identify champions and organize team• Educate providers and staff• Implement guidelines and develop algorthms and order sets• Standardize patient education process

Do the improvement• UHC projects; CHF, AMI, PCI 2001• Inpatient Guidelines• Outcomes Sciences SoftwareContract 8/15/01, audit tool 8/17/01• Champions identified 5/01; Team organized 7/15/01• ED Chest Pain Algorithm 8/22/01• Medicine Grand Rounds 7/3/01; AHA conf 4/01, 8/01; Nursing

Skills Lab 7/01; Manager Forum 8/21/01• Cardiology Pilot Project 9/1/01• CAD baseline data collection for discharges 7/01

Check the results• Press Ganey Satisfaction Surveys

• Readmission Case Reviews of Chest Pain, AMI, CHF, CAD,

Unstable Angina, & Acute Coronary Syndrome

• AHA Data Benchmarking

• June 2002 ORYX

Act to hold the gain• Chart analysis and feedback to providers and staff

• Poster Presentations

• Ongoing by the Performance Improvement

Committee

www.americanheart.org/getwiththeguidelines

GWTG: Secondary Prevention of CAD

Performance Improvement 9/01

Team was launched in April 2001

UCI Medical CenterUCI Medical CenterUCI Medical Center

Secondary Prevention Guidelines Indicators '00

26% 29%

50%

88%95%

0%

20%

40%

60%

80%

100%

ASA BetaBlocker ACE I Statin SmokingCessation

UCI AMI UHC AMI

NRMI CHAMP '99

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 AssociationData 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

+ ++ ++++

Demographics6 clicks

Clinical/Lab8 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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20%

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100%

Smoking ACE BB ASA LDL BP REHAB Lipid0%

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80%

100%

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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Risk S

mok

eDisA

CE

DisBB

DisASA

AHA-

LDL

AHA-

BPAH

A-Reh

abAH

A-Lipi

d

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!