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© American Heart Association 2001

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

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© American Heart Association 2001

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

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

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

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

  5. 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

  6. 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

  7. 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

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

  9. Sustained Impact of CHAMP on Secondary Prevention Treatment Rates 77 59 41 28 NRMI Data 98/99

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

  11. SYSTEMS • Systems to Translate Efficacy Effectiveness Bridging the Gap Between Efficacy and Effectiveness EFFECTIVENESS EFFICACY • Outcomes associated with an intervention under ideal circumstances • Clinical trial reported in literature • Benchmarking • Outcomes associated with an intervention in the real world • Hospital • Outpatient • Across Continuum

  12. 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

  13. 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

  14. 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

  15. 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)

  16. 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.

  17. 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.

  18. The Solution

  19. 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

  20. What is Get With The Guidelines? • 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

  21. Best Practice - Pilot 1997 - Nurse based lipid clinic 1998 - QI initiative at Memorial Hospital 1996 - QAP participant 1999 - New England Affiliate of the AHA launches “Get With the Guidelines” Pilot American Journal of Cardiology - February 10, 2000

  22. 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

  23. Find & Support a Champion Assess CHD Treatment Rates Analyze Discharge Rates Implement Refined Protocol GWTG Team Coordinates Implementation of Refined Protocol Evaluate Assessment GWTG Team Reviews Summary Reports Refine Protocol GWTG Team Identifies Areas for Improvement

  24. 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

  25. 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”

  26. UCI Medical Center Performance Improvement GWTG: Secondary Prevention of CAD • 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 F Team was launched in April 2001 • 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 P O C D U C A S Performance Improvement 9/01

  27. 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!

  28. American Heart AssociationData Tool

  29. Near the Point of Care Distant from the Point of Care Point of Care (where it can still improve clinical decision making) + ++ ++++ IMPACT: Information at the Point of Care

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

  31. CHECKS PATIENT’S INFORMATION WITH AHA GUIDELINES

  32. PRINT A NOTE FOR PATIENT EDUCATION OR AS A DISCHARGE SUMMATION EMPOWER PATIENTS WITH INFORMATION AND REINFORCEMENT

  33. FAX LETTER TO REFERRING PHYSICIAN IMPROVE COMMUNICATION AND REINFORCE INTERVENTION

  34. 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).

  35. Click for larger picture Hospital Baseline Data ExamplesFrom the New England AHA Data Tool Pilot Hospital Data AHA Benchmarks Hospital A Hospital B Hospital C Hospital D

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

  37. 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

  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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