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  • The American Heart Association actually began the Get With The Guidelines initiative about two years ago, in a pilot effort with the New England Affiliate. This program is a process in which we can close the gap from what we know in secondary prevention, and what we do when we take care of our patients. Dr. Sid Smith, Chief Science Officer of the American Heart Association, spoke about the treatment gap in his Presidential Address during the American Heart Association’s 1995 Scientific Sessions. And at the November 2000 Scientific Sessions, American Heart Association president, Dr. Rose Marie Robertson not only restated that we have a treatment gap, but that we now have a solution to the gap: implementation of Get With The Guidelines .
  • The American Heart Association established an ambitious organizational goal to reduce coronary heart disease, stroke and risk by 25% by the year 2010. Two strategies that will address this goal are establishing systems to implement the American Heart Association’s primary and secondary prevention guidelines, and to increase the number of patients (with two or more risk factors) to have risk factors managed to established goals. Get With The Guidelines will help us accomplish this goal.
  • This slide represents the HCFA data reported in an October 2000 JAMA article. Data was collected on 750 patients per state, and although that is a modest sample, it was a very rigorous chart review. These patients came into the hospital with an AMI, and all of them were screened so that all of these interventions should have occurred in each of these patients. The right column indicates where we should be “optimally.” The left-column indicates where we are nationwide. As we consider the number of AMI’s annually, a 15% treatment gap for aspirin is far-reaching. Cholesterol was not measured in the HCFA survey, and the data comes from the National Registry for Myocardial Infarction. It represents about 100,000 patients and is from July 2000. At that time, it was reported that 37% of patients were leaving the hospital on a lipid-lowering intervention. We know that about 96% of patients leave the hospital with an elevated lipid level and would benefit from a cholesterol-lowering intervention. Again, a substantial gap in treatment.
  • This slide shows statistics for patients after they’ve had an event. (Speaker should relay the information.) Programs such as Get With The Guidelines can help change these statistics by getting these prudent therapies to our patients
  • *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
  • 256 AMI pts discharged in92/93 Pre-CHAMP- compared to 302 pts in 94/95 Post-CHAMP ASA 78% vs 92%; BetaBlocker12% vs 61%; ACEI 4% vs 56%; Statin 6%vs 86% Fonarow ,American Journal of Cardiology 2001(in press)
  • Let’s take a look at the hospital-setting with this next slide. It represents results from 50 hospitals, 5,000 patients. Only one in four patients left the hospital on ACE-I and Beta Blockers. And as mentioned earlier with the National Registry of Myocardial Infarction data, about 1/3 of patients are discharged on cholesterol-lowering therapy. So we went from 25% to 37% over a three-year period. That’s encouraging – but we cannot continue to go at this pace. Our job is to accelerate that pace.
  • We need to have consensus and agreement about the guidelines. (presenter should read through this slide and reference the study published in JAMA.) A good analogy is the process an airline pilot goes through before take-off and landing. They go through a “check list” to be sure they are not leaving anything to “chance” or memory. When we consider which is more complicated: the airplane or the human body? But where do we use a checklist? Do we want to go to a hospital where we don’t use a check list to be sure everything we do, those routine things that we know work, aren’t being used.
  • Patients can also be advocates for treatment. They are learning more about treatments and effects (through reading, the Internet, etc.) and they are asking questions about their treatment. They are becoming “partners” in their treatment. Environmental issues are becoming big issues for hospitals. Managed care health plans and the Health Care Finance Administration (HCFA) are developing value-based reimbursement systems. The Massachusetts Blue Cross health plan has a pilot program that will reward hospitals by paying them more in reimbursement if they perform better in these prevention processes. HCFA will reimburse hospitals at a higher level for by-pass patients who are discharged on specified secondary prevention therapies. That’s compelling and makes good business sense.
  • So how can we improve and implement these interventions. What’s the solution?
  • The program was a collaborative effort with peer review organizations, medical association, insurers and financial support from Merck & Co., Inc. More than 70 of the region’s 160 acute care hospitals are currently (January 2001) in the program.
  • Why should we implement the program? Prevention is cost-effective. We will be rewarded with economic incentives as stated earlier. Accreditation agencies will require. Our patients will ask tough questions and demand this quality of care. Most importantly, as the studies show, it’s the right thing to do!
  • Brent James, MD from Intermountain Health points out that you manage what you measure. The process of continuous quality improvement requires the feedback of performance data to refine the process. The American heart association has created an internet -based data tool to help hospitals obtain the data they need.
  • The tool can be accessed with a palm pilot and used as care is given. Some hospitals have chosen to place a paper version of the tool on chart to collect data and enter at the time of discharge. Hospital performance can be accessed at any time and compared to AHA benchmarks and overall program performance. There is also the potential to use the tool to collect ORYX performance measures for the AMI and CHF core measure requirements.
  • 5191

    1. 1. © American Heart Association 2001 Nathan D. Wong, PhD, FACC
    2. 2. Get with the Guidelines- CVD and Stroke AHA / ASA’s Program for Saving Lives Through Effective Implementation of Secondary Prevention Guidelines
    3. 3. AHA GOALS <ul><li>By 2010, we will reduce </li></ul><ul><li>coronary heart disease, stroke and risk by 25% </li></ul>
    4. 4. Implement Guidelines HERE Healthy Population Undiagnosed or Untreated In Treatment Acute Event Post Event
    5. 5. AHA Guidelines <ul><li>Smoking Cessation </li></ul><ul><li>Lipid Management </li></ul><ul><li>Physical activity </li></ul><ul><li>Weight management </li></ul><ul><li>Asprin/other Antithrombotic agents </li></ul><ul><li>ACE inhibitors </li></ul><ul><li>Beta blockers </li></ul><ul><li>Blood pressure control </li></ul><ul><li>Diabetes Management </li></ul><ul><li>Stroke Specific: Atrial Fibrillation Management, Drug and Alcohol Abuse Management </li></ul>Adapted from Smith, Circulation 92:3, 1995
    6. 6. Implementation Statistics <ul><li>Indicator Rate Optimal </li></ul><ul><li>ASA 85%* 100% </li></ul><ul><li>Beta Blocker 72%* 100% </li></ul><ul><li>ACE-I 71%* 100% </li></ul><ul><li>Smoking Cessation 40%* 100% </li></ul><ul><li>Lipid Lowering 37%** 96% </li></ul><ul><li>*HCFA, 1998 **NRMI 2nd Q 2000 </li></ul>
    7. 7. Mortality Statistics <ul><li>Over 450,000 people suffer from recurrent coronary attacks each year. </li></ul><ul><li>Within 1 year of a recognized MI 25% of men and 38% of women will die </li></ul><ul><li>100,000 recurrent strokes occur each year </li></ul><ul><li>Within 1 year of a stroke 22% of men and 25% of women will die </li></ul><ul><li>14% of stroke survivors will experience a recurrent stroke within 1 year. </li></ul><ul><li>AHA 200 Heart and Stroke Statistical Update </li></ul>
    8. 8. CHAMP : C ardiac H ospitalization A therosclerosis M anagement P rogram CAD Patient Treatment Rates*
    9. 9. Sustained Impact of CHAMP on Secondary Prevention Treatment Rates 77 59 41 28 NRMI Data 98/99
    10. 10. Improvement in Treatment Utilization is Associated with A Marked Reduction in Clinical Events RR0.43 p<0.01
    11. 11. <ul><li>Outcomes associated with an intervention under ideal circumstances </li></ul><ul><ul><li>Clinical trial reported in literature </li></ul></ul><ul><ul><li>Benchmarking </li></ul></ul>EFFICACY EFFECTIVENESS <ul><li>Outcomes associated with an intervention in the real world </li></ul><ul><ul><li>Hospital </li></ul></ul><ul><ul><li>Outpatient </li></ul></ul><ul><ul><li>Across Continuum </li></ul></ul>Bridging the Gap Between Efficacy and Effectiveness <ul><li>Systems to Translate Efficacy Effectiveness </li></ul>SYSTEMS
    12. 12. The Gap <ul><li>L-TAP survey showed </li></ul><ul><ul><li>95 % of PCPs are aware of NCEP guidelines </li></ul></ul><ul><ul><li>18 % of their CAD patients at goal </li></ul></ul><ul><ul><li>* 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 </li></ul></ul>
    13. 13. The Gap <ul><li>NHANES III data* reveals </li></ul><ul><ul><li>28 % are eligible for treatment based on NCEP II </li></ul></ul><ul><ul><li>82 % of those with CHD are not at NCEP II goal for LDL </li></ul></ul><ul><ul><li>65 % of patients eligible for treatment are not receiving therapy </li></ul></ul><ul><ul><li>* 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 </li></ul></ul>
    14. 14. The Gap <ul><li>QAP Data - Community based Cardiologists </li></ul><ul><ul><li>30-40 % Documented Treatment Rate </li></ul></ul><ul><ul><li>Treatment Gap of 61 % </li></ul></ul><ul><ul><li>Provider awareness does not result in successful implementation </li></ul></ul><ul><ul><li>* 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 </li></ul></ul>
    15. 15. The Gap <ul><li>ACC Evaluation of Preventive Therapeutics (ACCEPT) Data </li></ul><ul><ul><li>20-25 % Documented Treatment Rate </li></ul></ul><ul><ul><li>Treatment Gap of 80 % </li></ul></ul><ul><ul><li>- Hospital data (N=50) 1996-97 </li></ul></ul><ul><li>NRMI 3 Data - 6/00 </li></ul><ul><ul><li>37 % of Post-MI patients discharged on a statin </li></ul></ul><ul><ul><li>(N = 101, 294) </li></ul></ul>
    16. 16. Physician Barriers <ul><li>Attitudes </li></ul><ul><ul><li>Agreement with specific guidelines </li></ul></ul><ul><ul><li>Agreement with guidelines in general </li></ul></ul><ul><ul><li>Outcome expectancy (performance of recommendations will not lead to desired outcome) </li></ul></ul><ul><ul><li>Self-efficacy (physician believes he cannot carry out recommendations) </li></ul></ul><ul><ul><li>Motivation (habits/routines) </li></ul></ul><ul><ul><li>From Cabana et al. JAMA. 1999; 282:1458-1465. </li></ul></ul>
    17. 17. Physician Barriers <ul><li>Behavior </li></ul><ul><ul><li>Patient factors (patient preferences vs. recommendations) </li></ul></ul><ul><ul><li>Guideline factors (complexity, conflicting recommendations) </li></ul></ul><ul><ul><li>Environmental Factors </li></ul></ul><ul><ul><ul><li>Lack of time resources </li></ul></ul></ul><ul><ul><ul><li>Financial disincentives </li></ul></ul></ul><ul><ul><ul><li>Organizational constraints </li></ul></ul></ul><ul><ul><ul><li>From Cabana et al. JAMA. 1999; 282:1458-1465. </li></ul></ul></ul>
    18. 18. The Solution
    19. 19. Get With The Guidelines <ul><li>Prospective intervention process in the hospital setting, designed to significantly increase CHD and Stroke discharge treatment rates. </li></ul><ul><li>1. Supports system improvements for CHD and Stroke patients </li></ul><ul><li>2. Encourages links between cardiologist/ </li></ul><ul><li>neurologists and primary care physicians </li></ul><ul><li>3. Provides resources to build consensus and establish and execute protocols </li></ul>
    20. 20. <ul><li>Implement discharge protocols in hospital setting </li></ul><ul><li>Implemented by AHA Staff/Volunteers who will mobilize networks at the Local level </li></ul><ul><li>Implement CME-driven educational programs </li></ul><ul><li>Identify best practices for AHA recognition awards </li></ul><ul><li>Develop and disseminate reports and publications </li></ul><ul><li>Measure changes and report outcomes data </li></ul><ul><li>Drive impact into communities </li></ul>What is Get With The Guidelines ?
    21. 21. Best Practice - Pilot 1999 - New England Affiliate of the AHA launches “Get With the Guidelines” Pilot 1996 - QAP participant 1997 - Nurse based lipid clinic 1998 - QI initiative at Memorial Hospital American Journal of Cardiology - February 10, 2000
    22. 22. Get With The Guidelines - Pilot <ul><li>AHA New England Affiliate - Merck, PRO Partnership </li></ul><ul><li>85 of the regions’ 160 acute care hospitals currently participating </li></ul><ul><li>All three of the PRO’s using the process for 6th scope of work implementation of AMI, CHF, Atrial Fibrillation indicators </li></ul>
    23. 23. 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
    24. 24. What are Hospital Teams Agreeing to do? <ul><li>Identify/create the hospital implementation team </li></ul><ul><li>Attend a Get With The Guidelines Meeting </li></ul><ul><li>Agree to implement the AHA discharge protocol </li></ul><ul><li>Measure baseline performance level </li></ul><ul><li>Assess level of consensus within the hospital </li></ul>
    25. 25. What are Hospital Teams Agreeing to do? <ul><li>Implement program </li></ul><ul><li>F/u recovery plan for non-participating and lagging hospitals </li></ul><ul><li>Routine follow-up with all participants to get new data & assess progress every 3-months </li></ul><ul><li>Best practice sites for advocates and preceptorships </li></ul><ul><li>Receive recognition -- add to “Buzz” </li></ul>
    26. 26. <ul><li>Find an opportunity to improve </li></ul><ul><li>An opportunity exists to improve use of evidence based treatment guidelines for CAD prior to hospital discharge. </li></ul><ul><li>Organize a team </li></ul><ul><li>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. </li></ul><ul><li>Clarify the knowledge of the process </li></ul><ul><li>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. </li></ul><ul><li>Understand the causes of variation </li></ul><ul><li>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. </li></ul><ul><li>Select the process improvement </li></ul><ul><li>The team selected improvements in: </li></ul><ul><li>ED algorithm and admitting order sets </li></ul><ul><li>Focused lectures and discharge process </li></ul><ul><li>Patient Education and prospective clinical measure benchmarking </li></ul><ul><li>Plan the improvement </li></ul><ul><li>Measure baseline then ongoing results </li></ul><ul><li>Communicate program with benchmark data </li></ul><ul><li>Identify champions and organize team </li></ul><ul><li>Educate providers and staff </li></ul><ul><li>Implement guidelines and develop algorthms and order sets </li></ul><ul><li>Standardize patient education process </li></ul><ul><li>Do the improvement </li></ul><ul><li>UHC projects; CHF, AMI, PCI 2001 </li></ul><ul><li>Inpatient Guidelines </li></ul><ul><li>Outcomes Sciences SoftwareContract 8/15/01, audit tool 8/17/01 </li></ul><ul><li>Champions identified 5/01; Team organized 7/15/01 </li></ul><ul><li>ED Chest Pain Algorithm 8/22/01 </li></ul><ul><li>Medicine Grand Rounds 7/3/01; AHA conf 4/01, 8/01; Nursing </li></ul><ul><li>Skills Lab 7/01; Manager Forum 8/21/01 </li></ul><ul><li>Cardiology Pilot Project 9/1/01 </li></ul><ul><li>CAD baseline data collection for discharges 7/01 </li></ul><ul><li>Check the results </li></ul><ul><li>Press Ganey Satisfaction Surveys </li></ul><ul><li>Readmission Case Reviews of Chest Pain, AMI, CHF, CAD, </li></ul><ul><li>Unstable Angina, & Acute Coronary Syndrome </li></ul><ul><li>AHA Data Benchmarking </li></ul><ul><li>June 2002 ORYX </li></ul><ul><li>Act to hold the gain </li></ul><ul><li>Chart analysis and feedback to providers and staff </li></ul><ul><li>Poster Presentations </li></ul><ul><li>Ongoing by the Performance Improvement </li></ul><ul><li>Committee </li></ul><ul><li>www.americanheart.org/getwiththeguidelines </li></ul>GWTG: Secondary Prevention of CAD P Performance Improvement 9/01 Team was launched in April 2001 D C A F O C U S UCI Medical Center Performance Improvement
    27. 27. Incentives for Change <ul><li>Prevention is Cost Effective Quality Care </li></ul><ul><ul><li>Risk Sharing and Capitation provide economic incentives </li></ul></ul><ul><ul><li>Our patients will demand it </li></ul></ul><ul><ul><li>Accreditation agencies will require it </li></ul></ul><ul><li>It’s the right thing to do! </li></ul>
    28. 28. American Heart Association Data Tool
    29. 29. 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 + ++ ++++
    30. 30. 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
    31. 31. CHECKS PATIENT’S INFORMATION WITH AHA GUIDELINES
    32. 32. PRINT A NOTE FOR PATIENT EDUCATION OR AS A DISCHARGE SUMMATION EMPOWER PATIENTS WITH INFORMATION AND REINFORCEMENT
    33. 33. FAX LETTER TO REFERRING PHYSICIAN IMPROVE COMMUNICATION AND REINFORCE INTERVENTION
    34. 34. How it’s being used: <ul><li>On-line completion at discharge on the floor </li></ul><ul><li>Paper form follows patient on front of chart and entered on-line at discharge. </li></ul><ul><li>Used as a QI tool with frequent reports to relevant departments, (also meet include AMI and CHF JCAHO core measure requirements). </li></ul>
    35. 35. Hospital Baseline Data Examples From the New England AHA Data Tool Pilot Hospital A Hospital B Hospital C Hospital D AHA Benchmarks Hospital Data Click for larger picture
    36. 36. Percent of Patients Receiving Care Compared to AHA Goals in Quarter 4 NRMI comparison Measure
    37. 37. AHA Resources <ul><li>Large network of committed staff and volunteers with relationships in the community </li></ul><ul><li>Science - Guidelines development, data </li></ul><ul><li>Educational materials </li></ul><ul><li>Programs </li></ul><ul><ul><li>Get With the Guidelines </li></ul></ul><ul><ul><li>Operation Heart Beat </li></ul></ul><ul><ul><li>Operation Stroke </li></ul></ul><ul><ul><li>Call to Action </li></ul></ul><ul><ul><li>One of a Kind </li></ul></ul>
    38. 38. Join Us in Saving Lives! If Get With The Guidelines is implemented, more than 40,000+ lives could be saved every year!

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