Hospital performance recognition with the Get With The Guidelines Program and mortality for acute myocardial infarction and heart failure

Comparison of performance achievement award recognition with primary stroke center certification for acute ischemic stroke care

Background

Hospital certification and recognition programs represent 2 independent but commonly used systems to distinguish hospitals, yet they have not been directly compared. This study assessed acute ischemic stroke quality of care measure conformity by hospitals receiving Primary Stroke Center (PSC) certification and those receiving the American Heart Association's Get With The Guidelines‐Stroke (GWTG‐Stroke) Performance Achievement Award (PAA) recognition.

Methods and Results

The patient and hospital characteristics as well as performance/quality measures for acute ischemic stroke from 1356 hospitals participating in the GWTG‐Stroke Program 2010–2012 were compared. Hospitals were classified as PAA+/PSC+ (hospitals n=410, patients n=169 302), PAA+/PSC− (n=415, n=129 454), PAA−/PSC+ (n=88, n=26 386), and PAA−/PSC− (n=443, n=75 565). A comprehensive set of stroke measures were compared with adjustment for patient and hospital characteristics. Patient characteristics were similar by PAA and PSC status but PAA−/PSC− hospitals were more likely to be smaller and nonteaching. Measure conformity was highest for PAA+/PSC+ and PAA+/PSC− hospitals, intermediate for PAA−/PSC+ hospitals, and lowest for PAA−/PSC− hospitals (all‐or‐none care measure 91.2%, 91.2%, 84.3%, and 76.9%, respectively). After adjustment for patient and hospital characteristics, PAA+/PSC+, PAA+/PSC−, and PAA−/PSC+ hospitals had 3.15 (95% CIs 2.86 to 3.47); 3.23 (2.93 to 3.56) and 1.72 (1.47 to 2.00), higher odds for providing all indicated stroke performance measures to patients compared with PAA−/PSC− hospitals.

Conclusions

While both PSC certification and GWTG‐Stroke PAA recognition identified hospitals providing higher conformity with care measures for patients hospitalized with acute ischemic stroke, PAA recognition was a more robust identifier of hospitals with better performance.

Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association

BACKGROUND

Heart failure (HF) is an important contributor to both the burden and cost of national healthcare expenditures, with more older Americans hospitalized for HF than for any other medical condition. With the aging of the population, the impact of HF is expected to increase substantially.

METHODS AND RESULTS

We estimated future costs of HF by adapting a methodology developed by the American Heart Association to project the epidemiology and future costs of HF from 2012 to 2030 without double counting the costs attributed to comorbid conditions. The model assumes that HF prevalence will remain constant by age, sex, and race/ethnicity and that rising costs and technological innovation will continue at the same rate. By 2030, >8 million people in the United States (1 in every 33) will have HF. Between 2012 and 2030, real (2010$) total direct medical costs of HF are projected to increase from $21 billion to $53 billion. Total costs, including indirect costs for HF, are estimated to increase from $31 billion in 2012 to $70 billion in 2030. If one assumes all costs of cardiac care for HF patients are attributable to HF (no cost attribution to comorbid conditions), the 2030 projected cost estimates of treating patients with HF will be 3-fold higher ($160 billion in direct costs).

CONCLUSIONS

The estimated prevalence and cost of care for HF will increase markedly because of aging of the population. Strategies to prevent HF and improve the efficiency of care are needed.

Left Ventricular Ejection Fraction Assessment Among Patients With Acute Myocardial Infarction and Its Association With Hospital Quality of Care and Evidence-Based Therapy Use

Background—

The left ventricular ejection fraction (LVEF) has prognostic and therapeutic utility after acute myocardial infarction (AMI). Although LVEF assessment is a key performance measure among AMI patients, contemporary rates of in-hospital assessment and its association with therapy use have not been well characterized.

Methods and Results—

We examined rates of in-hospital LVEF assessment among 77 982 non–ST-elevation myocardial infarction patients and 50 863 ST-elevation myocardial infarction patients in Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines between January 2007 and September 2009, after excluding patients who died in-hospital or who were transferred to another acute care facility, discharged to end-of-life care, or had missing LVEF assessment status. LVEF assessment increased significantly over time, with higher rates among ST-elevation myocardial infarction than non–ST-elevation myocardial infarction patients (95.1% versus 91.6%; P <0.001). Excluding patients with prior heart failure did not alter these observations. Significant interhospital variability in LVEF assessment rates was observed. Compared with patients with in-hospital LVEF assessment, patients who did not have LVEF assessed were older and more likely to have clinical comorbidities. In multivariable modeling, lower overall hospital quality of AMI care was also associated with lower likelihood of LVEF assessment (odds ratio for failure to assess LVEF, 1.09; 95% confidence interval, 1.05–1.13 per 10% decrease in defect-free care). Patients with in-hospital LVEF assessment were more likely to be discharged on evidence-based secondary prevention medication therapies compared with paients without LVEF assessment.

Conclusions—

The assessment of LVEF among patients with AMI has improved significantly over time, yet significant interhospital variability exists. Patients who did not have in-hospital LVEF assessment were less likely to receive evidence-based medications at discharge. These patients represent targets for future quality improvement efforts.

Duration of hospital participation in Get With the Guidelines-Resuscitation and survival of in-hospital cardiac arrest

BACKGROUND

Get With the Guidelines (GWTG-R) is a data registry and quality improvement program for in-hospital cardiac arrest (IHCA). It is unknown if duration of hospital participation in GWTG-R is associated with IHCA outcomes.

METHODS

We analyzed adults with IHCA from 362 hospitals participating in GWTG-R between 2000 and 2009. Using logistic regression with generalized estimating equations to account for clustering on hospital, we determined the association between duration of hospital participation in GWTG-R and patient outcomes after IHCA, adjusted for patient and arrest characteristics and secular trend. Using these methods, we also evaluated the association between duration of participation and factors previously correlated with survival after IHCA, including ECG monitored status, after-hours arrest, and time to defibrillation.

RESULTS

Of 104,732 patients with IHCA, 17,646 patients (16.9%) survived to discharge. Duration of hospital participation in GWTG-R was associated with IHCA event survival (per year of participation, odds ratio [OR] 1.02; 95% CI 1.00-1.04; p=0.046) but not survival to discharge (OR 1.02; 95% CI 0.99-1.04; p=0.18). Among factors previously correlated with IHCA survival, duration of participation was associated with time to defibrillation ≤2 min (per year of participation, OR 1.06; 95% CI 1.03-1.10; p<0.001), but not ECG monitored status (OR 1.00; 95% CI 0.93-1.06; p=0.90) or survival of after-hours arrest (OR 1.01; 95% CI 0.99-1.03; p=0.41). Among ventricular tachycardia or ventricular fibrillation (VT/VF) arrests, time to defibrillation attenuated the association between duration of hospital participation and outcomes.

CONCLUSION

Duration of hospital participation in GWTG-R was significantly associated with survival of the IHCA event, but not with survival to discharge. In VT/VF arrests, this association may have been mediated by improvements in time to defibrillation.

Patient and hospital characteristics associated with traditional measures of inpatient quality of care for patients with heart failure

BACKGROUND

The purpose of this study was to determine patient and hospital characteristics associated with 4 measures of quality of inpatient heart failure care used by both the primary payer of heart failure care in the United States (Center for Medicare and Medicaid Services) and the main hospital accrediting organization (The Joint Commission).

METHODS

We used data from Get With The Guidelines Program for patients hospitalized with heart failure. Eligibility for receiving care based on the Center for Medicare and Medicaid Services performance measures was determined for assessment of left ventricular ejection fraction (LVEF; n = 60,601), use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) if LVEF<40% and no contraindications (24,130), discharge instructions (49,383), and smoking cessation counseling (10,152). Patient and hospital characteristics that were significantly associated with performance measures in univariate analyses were entered into multivariate logistic regression models.

RESULTS

Overall, documentation for LVEF assessment was noted in 95%, ACEi/ARB use in 87%, discharge instruction in 82%, and smoking cessation counseling in 91% of eligible patients. In adjusted analyses, older patients and those with evidence of renal failure were significantly less likely to receive each care measure except for discharge instructions (no age effect). Patients with higher body mass index were more likely to receive ACEi/ARB and discharge instructions but less likely to have LVEF documented or to receive smoking cessation counseling. Small hospitals (<200 beds) were less likely to provide each of the performance measures compared with larger hospitals.

CONCLUSION

Recommended heart failure care is less likely in patients with certain characteristics (older age and abnormal renal function) and those cared for in smaller hospitals. Programs to improve evidence-based care for heart failure should consider interventions specifically targeting and tailored to smaller facilities and patients who are older with comorbidities.

Get With The Guidelines program participation, process of care, and outcome for Medicare patients hospitalized with heart failure

BACKGROUND

Hospitals enrolled in the American Heart Association's Get With The Guidelines Program for heart failure (GWTG-HF) have improved their process of care. However, it is unclear if process of care and outcomes are better in the GWTG-HF hospitals compared with hospitals not enrolled.

METHODS AND RESULTS

We compared hospitals enrolled in GWTG-HF from 2006 to 2007 with other hospitals using data on 4 process of heart failure care measures, 5 noncardiac process measures, risk-adjusted 30-day mortality, and 30-day all-cause readmission after a heart failure hospitalization, as reported by the Center for Medicare and Medicaid Services (CMS). Among the 4460 hospitals reporting data to CMS, 215 (5%) were enrolled in GWTG-HF. Of the 4 CMS heart failure performance measures, GWTG-HF hospitals had significantly higher documentation of the left ventricular ejection fraction (93.4% versus 88.8%), use of angiotensin-converting enzyme inhibitor or angiotensin receptor antagonist (88.3% versus 86.6%), and discharge instructions (74.9% versus 70.5%) (P<0.005 for all). Smoking cessation counseling rates were similar (94.1% versus 94.0%; P=0.51). There was no significant difference in compliance with noncardiac process of care. After heart failure discharge, all-cause readmission at 30 days was 24.5% and mortality at 30 days after admission was 11.1%. After adjustment for hospital characteristics, 30-day mortality rates were no different (P=0.45). However, 30-day readmission was lower for GWTG hospitals (-0.33%; 95% CI, -0.53% to -0.12%; P=0.002).

CONCLUSIONS

Although there was evidence that hospitals enrolled in the GTWG-HF program demonstrated better processes of care than other hospitals, there were few clinically important differences in outcomes. Further identification of opportunities to improve outcomes, and inclusion of these metrics in GTWG-HF, may further support the value of GTWG-HF in improving care for patients with HF.

Chronic heart failure: we are fighting the battle, but are we winning the war?

Heart failure represents an end-stage phenotype of a number of cardiovascular diseases and is generally associated with a poor prognosis. A number of organized battles fought over the last two to three decades have resulted in considerable advances in treatment including the use of drugs that interfere with neurohormonal activation and device-based therapies such as implantable cardioverter defibrillators and cardiac resynchronization therapy. Despite this, the prevalence of heart failure continues to rise related to both the aging population and better survival in patients with cardiovascular disease. Registries have identified treatment gaps and variation in the application of evidenced-based practice, including the use of echocardiography and prescribing of disease-modifying drugs. Quality initiatives often coupled with multidisciplinary, heart failure disease management promote self-care and minimize variation in the application of evidenced-based practice leading to better long-term clinical outcomes. However, to address the rising prevalence of heart failure and win the war, we must also turn our attention to disease prevention. A combined approach is required that includes public health measures applied at a population level and screening strategies to identify individuals at high risk of developing heart failure in the future.

The importance of consistent, high-quality acute myocardial infarction and heart failure care results from the American Heart Association's Get with the Guidelines Program

OBJECTIVES

This study examined the degree to which hospital performance for acute myocardial infarction (AMI) and heart failure (HF) care processes are correlated.

BACKGROUND

Although AMI and HF care processes may be amenable to similar quality improvement interventions, whether these are indeed correlated and whether hospitals with consistently superior performance for both care metrics have the best outcomes remains unknown.

METHODS

We compared hospital performance of the Centers for Medicare & Medicaid Services AMI and HF core measures in 283 hospitals submitting 10 or more patients to the Get With The Guidelines AMI and HF programs between January 2005 and April 2009.

RESULTS

Median hospital adherence to AMI and HF composite measures were 93% (interquartile range: 87% to 97%) and 92% (interquartile range: 85% to 96%), respectively, with only a modest correlation between hospital performance on these 2 composite metrics (r = 0.50; 95% confidence interval: 0.41 to 0.58). Hospitals with superior performance to both AMI and HF processes had significantly longer duration of Get With The Guidelines participation and lower adjusted in-hospital mortality (odds ratio: 0.79; 95% confidence interval: 0.63 to 0.99) for AMI and HF patients, whereas hospitals with superior adherence to either alone had similar mortality rates as hospitals with superior adherence to neither measure.

CONCLUSIONS

Hospitals that had consistent, superior performance for both AMI and HF care had significantly lower risk-adjusted mortality than those with superior performance either alone or for neither measure. Whether a single scoring system to assess global, rather than condition-specific, quality of cardiovascular care would facilitate care quality improvement more consistently and would optimize patient outcomes merits further investigation.

Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in the United States and is responsible for 17% of national health expenditures. As the population ages, these costs are expected to increase substantially.

METHODS AND RESULTS

To prepare for future cardiovascular care needs, the American Heart Association developed methodology to project future costs of care for hypertension, coronary heart disease, heart failure, stroke, and all other CVD from 2010 to 2030. This methodology avoided double counting of costs for patients with multiple cardiovascular conditions. By 2030, 40.5% of the US population is projected to have some form of CVD. Between 2010 and 2030, real (2008$) total direct medical costs of CVD are projected to triple, from $273 billion to $818 billion. Real indirect costs (due to lost productivity) for all CVD are estimated to increase from $172 billion in 2010 to $276 billion in 2030, an increase of 61%.

CONCLUSIONS

These findings indicate CVD prevalence and costs are projected to increase substantially. Effective prevention strategies are needed if we are to limit the growing burden of CVD.

Hospital-level variation in mortality and rehospitalization for medicare beneficiaries with acute ischemic stroke

BACKGROUND AND PURPOSE

stroke is the second leading cause of hospital admission among older adults in the United States. However, little is known regarding contemporary ischemic stroke mortality and rehospitalization rates for Medicare beneficiaries and how they vary by hospital.

METHODS

we analyzed outcome data from 91 134 Medicare fee-for-service beneficiaries treated at 625 Get With The Guidelines-Stroke hospitals between April 2003 and December 2006. Within each hospital, 30-day and 1-year death or all-cause readmission rates were calculated with and without risk adjustment.

RESULTS

in this cohort, mean age was 79.3 years, 58% were female, and 82% were white. In-hospital, 30-day, and 1-year unadjusted mortality from admission were 6.1%, 14.1%, and 31.1%, respectively, for participating hospitals. The median hospital-level 30-day unadjusted death or readmission rate after discharge was 21.4% (10th to 90th 14.4% to 28.6%). The overall rate of death or rehospitalization within 1 year of hospital discharge was 61.9%. Risk-adjusted rates varied widely by hospital at each time point. There were no improvements in death or rehospitalization from 2003 to 2006. Hospital-level performance in risk-adjusted outcomes did not significantly differ by size or primary stroke center designation, but academic hospitals and those in the Northeast or West had slightly more favorable outcomes.

CONCLUSIONS

nearly two thirds of the Medicare beneficiaries discharged after ischemic stroke died or were rehospitalized within 1 year, but hospital-level outcomes varied considerably. These findings underscore the need to better understand the patterns and causes of deaths and readmission after ischemic stroke and to develop strategies aimed at avoiding those that are preventable.

Hospital certification for optimizing cardiovascular disease and stroke quality of care and outcomes

Cardiovascular disease and stroke remain leading causes of mortality, disability, and rising healthcare expenditures in the United States. Although a number of organizations provide hospital accreditation, recognition, and certification programs, existing programs do not address cardiovascular disease and stroke care in a comprehensive way. Current evidence suggests mixed findings for correlation between accreditation, recognition, and certification programs and hospitals' actual quality of care and outcomes. This advisory discusses potential opportunities to develop and enhance hospital certification programs for cardiovascular disease and stroke. The American Heart Association/American Stroke Association is uniquely positioned as a patient-centered, respected, transparent healthcare organization to help drive improvements in care and outcomes for patients hospitalized with cardiovascular disease and stroke. As a part of its commitment to promoting high-quality, evidence-based care for cardiovascular and stroke patients, it is recommended that the American Heart Association/American Stroke Association explore hospital certification programs to develop truly meaningful programs to facilitate improvements in and recognition for cardiovascular disease and stroke quality of care and outcomes. Future strategies should standardize objective, unbiased assessments of hospital structural, process, and outcome performance while allowing flexibility as technology and methodology advances occur.

Benefits of statin therapy and compliance in high risk cardiovascular patients

Cardiovascular disease (CVD) remains the top cause of global mortality. There is considerable evidence that supports the mortality and morbidity benefit of statin therapy in coronary heart disease (CHD) and stroke, both in primary and secondary prevention settings. Data also exist pointing to the advantage of statin treatment in other high-risk CVD conditions, such as diabetes, CKD, CHF, and PVD. National and international clinical guidelines in the management of these CVD conditions all advocate for the utilization of statin therapy in appropriate patients. However, overall compliance to statin therapy remains suboptimal. Patient-, physician-, and economic-related factors all play a role. These factors need to be considered in devising approaches to enhance adherence to guideline-based therapies. To fully reap the benefits of statin therapy, interventions which improve long-term treatment compliance in real-world settings should be encouraged.

Trends in mortality of acute myocardial infarction after discharge from the hospital

BACKGROUND

We assessed trends in the prognosis of patients with acute myocardial infarction hospitalized in New Jersey hospitals. In recent decades, in-hospital mortality has declined markedly but the decline in longer-term mortality is less pronounced, implying that mortality after discharge has worsened.

METHODS AND RESULTS

Using the Myocardial Infarction Data Acquisition System (MIDAS), we examined the outcomes of 285 397 patients hospitalized for a first acute myocardial infarction between 1986 and 2007. Mortality at discharge decreased by 9.4% from 16.9% to 7.5% (annual change, -0.44; 95% confidence interval, -0.49 to -0.40), but the decrease at 1 year was less pronounced (6.4%) because of an increase in mortality from discharge to 1 year after discharge (from 12.1% to 13.9%; annual change, +0.15; 95% confidence interval, +0.10 to +0.20). Mortality from 30 days after discharge to 1 year, a measure not affected by length of stay, increased by 1.2% (annual change, +0.10; 95% confidence interval, +0.06 to +0.23). The effect was more evident in the older age groups and was due to noncardiovascular mortality, especially from respiratory and renal diseases, septicemia, and cancer. All effects remained statistically significant (P<0.0001) after adjustment for demographics, comorbidities, infarction type, complications, and interventions. Piecewise linear regressions confirmed these trends.

CONCLUSIONS

Postdischarge mortality of patients with acute myocardial infarction is increasing, primarily because of higher noncardiovascular mortality in the older age groups.