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

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.

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.

Objective The GWTG program is the largest hospital-based, national performance initiative that has shown to improve adherence to treatment guidelines over a one year period for participating hospitals. The purpose of the research is to evaluate whether the benefits of the GWTG program improved guideline adherence for patients hospitalized with CAD were sustained over time.

Methods The Centers for Medicare and Medicaid (CMS) Hospital was used to compare database 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-GWTG-CAD 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.

Results Compared with non-GWTG hospitals, the GWTG-CAD hospitals demonstrated higher guideline adherence for six 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 was also found for the composite measures. Although there was some narrowing between groups, GWTG-CAD 4 hospitals maintained superior guideline adherence than non-GWTG-CAD hospitals over the entire 3- year period (adjusted differences 1.8%, 1.6%, and 1.4%).

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.

Conclusion 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.