© American Heart Association 2001 Nathan D. Wong, PhD, FACC

Get with the Guidelines- CVD and Stroke AHA / ASA’s Program for Saving Lives Through Effective Implementation of Secondary Prevention Guidelines

AHA GOALS By 2010, we will reduce coronary heart disease, stroke and risk by 25%

Implement Guidelines HERE Healthy Population Undiagnosed or Untreated In Treatment Acute Event Post Event

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, 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

CHAMP: Cardiac Hospitalization Atherosclerosis Management Program CAD Patient Treatment Rates*

Sustained Impact of CHAMP on Secondary Prevention Treatment Rates NRMI Data 98/99

Improvement in Treatment Utilization is Associated with A Marked Reduction in Clinical Events RR0.43 p<0.01

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 – % 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 – % Documented Treatment Rate – Treatment Gap of 80 % - Hospital data (N=50) 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:

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:

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 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?

New England Affiliate of the AHA launches “Get With the Guidelines” Pilot Best Practice - Pilot QAP participant Nurse based lipid clinic 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 Rates Analyze Discharge Rates Evaluate Assessment GWTG Team Reviews Summary Reports Refine Protocol GWTG Team Identifies Areas for Improvement Implement Refined Protocol GWTG Team Coordinates Implementation of Refined Protocol Find & Support a Champion

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 OBest practice sites for advocates and preceptorships OReceive recognition -- add to “Buzz”

Find an opportunity to improve An opportunity exists to improve use of evidence based treatment guidelines for CAD prior to hospital discharge. Organize a team A 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 process There 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 natural history of atherosclerosis, decrease cardiac events, and improve survival. 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 variation Despite 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 improvement The 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 GWTG: Secondary Prevention of CAD Performance Improvement 9/01 Team was launched in April 2001

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 (where it can still improve clinical decision making) Near the Point of Care Distant from the Point of Care

Demographics 6 clicks Clinical/Lab 8 clicks Discharge meds and interventions 7 clicks Interactively checks patient’s data with the AHA guidelines AHA TOOL: SIMPLE, ONE PAGE, ON-LINE FORM

CHECKS PATIENT’S INFORMATION WITH AHA GUIDELINES

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

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).

Hospital Baseline Data Examples From the New England AHA Data Tool Pilot Hospital A Hospital B Hospital CHospital D AHA Benchmarks Hospital Data Click for larger picture

Percent of Patients Receiving Care Compared to AHA Goals in Quarter 4 NRMI comparison Measure

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!