# Presentation: 816373

## Get With The Guidelines-Heart Failure

**Get With The Guidelines-Heart Failure**

**Gregg C. Fonarow, MD**Eliot Corday** **Professor of Cardiovascular MedicineUCLA Division of CardiologyDirector, Ahmanson-UCLA Cardiomyopathy CenterAssociate Chief, UCLA Division of Cardiology
- Los Angeles, California

**Notes:**
Get With The Guidelines-Heart Failure

Gregg C. Fonarow, MDEliot Corday Professor of Cardiovascular MedicineUCLA Division of CardiologyDirector, Ahmanson-UCLA Cardiomyopathy CenterAssociate Chief, UCLA Division of Cardiology
Los Angeles, California

## Presenter and Program Disclosure Information

**GWTG-HF is sponsored by an**
**unrestricted educational grant from**
**GlaxoSmithKline**

**Gregg C. Fonarow, MD**
**AHA GWTG HF Program Presentation**

**FINANCIAL DISCLOSURE:**
**Research, Consultant, Honorarium: GSK, Pfizer, **
**Merck, Sanofi, Medtronic, Scios, AZ**

**UNLABELED/UNAPPROVED USES DISCLOSURE:**
**None**

**Notes:**
Presenter and Program Disclosure Information
Gregg C. Fonarow, MD
AHA GWTG HF Program Presentation
FINANCIAL DISCLOSURE:
Research, Consultant, Honorarium: GSK, Pfizer, Merck, Sanofi, Medtronic, Scios, AZ

UNLABELED/UNAPPROVED USES DISCLOSURE:
None

GWTG-HF is sponsored by an unrestricted educational grant from GlaxoSmithKline

## Opportunities to Improve Care for Patients With HF

- Despite overwhelming clinical trial evidence, expert opinion, national guidelines, and a vast array of educational conferences, evidence-based, life-saving therapies continue to be underutilized
- New approaches to improving the use of proven, guideline-recommended, life-prolonging therapies are clearly needed

**Fonarow GC.  *****Rev Cardiovasc Med.***** 2002;3:S2–S10. **

**Notes:**
Opportunities to Improve Care for Patients With HF

- Despite overwhelming clinical trial evidence, expert opinion, national guidelines, and a vast array of educational conferences, evidence-based, life-saving therapies continue to be underutilized
- New approaches to improving the use of proven, guideline-recommended, life-prolonging therapies are clearly needed

## Why a Hospital-based System forHF Management?

- Patients
- Patient capture point
- Have patient’s/family’s attention: “teachable moment”
- Predictor of care in community
- Hospital structure
- Standardized processes/protocols/orders/teams
- Accrediting bodies for standards of care
- Centers for Medicare and Medicaid Services—peer review organizations
- HEDIS (post-discharge)

**Fonarow GC.  *****Rev Cardiovasc Med.***** 2002;3:S2–S10. **

**Notes:**
Why a Hospital-based System for HF Management?
Patients
- Patient capture point
- Have patient’s/family’s attention: “teachable moment”
- Predictor of care in community
Hospital structure
- Standardized processes/protocols/orders/teams
- Accrediting bodies for standards of care
- Centers for Medicare and Medicaid Services—peer review organizations
- HEDIS (post-discharge)
Fonarow GC.  Rev Cardiovasc Med. 2002;3:S2–S10. 

Note to field personnel: with this slide, be sure to address positive CAD and Stroke experience thus far

## What is GWTG-HF?

- The American Heart Association’s in-hospital quality improvement program aimed at ensuring every heart failure patient receives the best care possible.

**Notes:**
What is GWTG-HF?

The American Heart Association’s in-hospital quality improvement program aimed at ensuring every heart failure patient receives the best care possible.

## GWTG-HF Program Objectives

- Improve medical care and education of patients hospitalized with heart failure
- Accelerate initiation of the HF evidence-based, guideline-recommended therapies by starting these life-saving therapies before hospital discharge in appropriate patients without contraindications
- Increase understanding of barriers to uptake of evidence-based therapies in this patient population

**Notes:**
GWTG-HF Program Objectives

- Improve medical care and education of patients hospitalized with heart failure
- Accelerate initiation of the HF evidence-based, guideline-recommended therapies by starting these life-saving therapies before hospital discharge in appropriate patients without contraindications
- Increase understanding of barriers to uptake of evidence-based therapies in this patient population 

## Methods: GWTG-HF 

**GWTG employs a collaborative model of care involving organizational stakeholders, AHA, physician/nurse champions, hospital teams**
**Web-based PMT providing decision support at he point of care, on-demand reporting, and patient education features**
**Hospital toolkit: Order sets, critical pathways, pocket cards, discharge checklists, patient educational materials**
**Ongoing real-time feedback of hospital data to support rapid cycle improvement**
**Learning sessions, Post meeting follow-up, teleconference and Internet based conferencing, Email community, and Hospital site visits**

**Notes:**
Methods: GWTG-HF

- GWTG employs a collaborative model of care involving organizational stakeholders, AHA, physician/nurse champions, hospital teams
- Web-based PMT providing decision support at he point of care, on-demand reporting, and patient education features
- Hospital toolkit: Order sets, critical pathways, pocket cards, discharge checklists, patient educational materials
- Ongoing real-time feedback of hospital data to support rapid cycle improvement
- Learning sessions, Post meeting follow-up, teleconference and Internet based conferencing, Email community, and Hospital site visits

## GWTG-HF Data Collection

**GWTG-HF Data Collection**

- Relevant medical history
- Smoking within the last 12 months
- HF History
- Symptoms (closest to admission)
- Vital Signs
- Exam (closest to admission)
- Labs (closest to admission; peak to troponin)
- Admission medications (taken prior to admission)
- Parenteral therapies
- Procedures during this hospital stay
- Ejection Fraction

- Discharge Status
- If patient expired, primary cause of death
- Symptoms (closest to discharge)
- Vital Signs (closest to discharge)
- Exam (closest to discharge)
- Labs (closest to discharge)
- Discharge medications
- Smoking cessation counseling
- Discharge instructions
- Date of discharge
- Process of care improvement
- Highlighted items are optional

**Notes:**
GWTG-HF Data Collection

Relevant medical history
Smoking within the last 12 months
HF History
Symptoms (closest to admission)
Vital Signs
Exam (closest to admission)
Labs (closest to admission; peak to troponin)
Admission medications (taken prior to admission)
Parenteral therapies
Procedures during this hospital stay
Ejection Fraction
Discharge Status
If patient expired, primary cause of death
Symptoms (closest to discharge)
Vital Signs (closest to discharge)
Exam (closest to discharge)
Labs (closest to discharge)
Discharge medications
Smoking cessation counseling
Discharge instructions
Date of discharge
Process of care improvement

## GWTG-HF Recognition Program Performance Measures

- 1.  HF Discharge instructions provided to all eligible patients
- 2.  Measurement of LV function in all eligible patients
- 3.  ACE inhibitor and/or ARB at discharge provided to eligible patients with   LVEF < or = 0.40, in absence of documented contraindications or intolerance
- 4.  Beta blocker at discharge provided to eligible patients with LVEF < or = 0.40, in absence of documented contraindications or intolerance
- 5.  Smoking cessation counseling provided to all eligible patients (current or recent smokers)

**Notes:**
GWTG-HF Recognition Program Performance Measures

1.  HF Discharge instructions provided to all eligible patients
2.  Measurement of LV function in all eligible patients
3.  ACE inhibitor and/or ARB at discharge provided to eligible patients with   LVEF < or = 0.40, in absence of documented contraindications or intolerance
4.  Beta blocker at discharge provided to eligible patients with LVEF < or = 0.40, in absence of documented contraindications or intolerance
5.  Smoking cessation counseling provided to all eligible patients (current or recent smokers) 

To reach Performance Achievement Award Status, Hospitals must reach and sustain 85% adherence in all five of the above measures for the designated time period for each recognition level. 

## Emerging Performance Measures

** ****Anticoagulation in eligible patients with current or paroxysmal atrial fibrillation and no documented contraindications, intolerance, or other reason**
** ****Aldosterone antagonists in eligible patients with LVSD and no contraindications, intolerance, or other reason**
** ****Hydralazine/Nitrates in eligible Black patients with LVSD and no contraindications, intolerance, or other reason **
** ****Evidence based beta blocker use (carvedilol, bisoprolol or metoprolol succinate) in eligible patients with LVSD**
** ****ICD in eligible patients with LVEF **_**<**_**30 and no contraindication or other reason documented**

**Notes:**
Emerging Performance Measures

- Anticoagulation in eligible patients with current or paroxysmal atrial fibrillation and no documented contraindications, intolerance, or other reason
- Aldosterone antagonists in eligible patients with LVSD and no contraindications, intolerance, or other reason
- Hydralazine/Nitrates in eligible Black patients with LVSD and no contraindications, intolerance, or other reason 
- Evidence based beta blocker use (carvedilol, bisoprolol or metoprolol succinate) in eligible patients with LVSD
-  ICD in eligible patients with LVEF <30 and no contraindication or other reason documented

## GWTG-HF PMT Form

**GWTG-HF ****PMT Form**

**Notes:**
GWTG-HF PMT Form

## GWTG-HF PMT Special Features:Guidelines

**GWTG-HF PMT Special ****Features:Guidelines**

**Notes:**
GWTG-HF PMT Special Features:Guidelines

## GWTG-HF PMT Special Features: Patient Ed

**GWTG-HF PMT Special Features: Patient Ed**

**Notes:**
GWTG-HF PMT Special Features: Patient Ed

## GWTG-HF PMT Report Output

**GWTG-HF PMT Report Output**

**Notes:**
GWTG-HF PMT Report Output

## GWTG-HF Cycle of Quality Improvement

_**Evaluate Assessment**_
- Hospital team reviews summary reports and current protocols

_**Refine Protocols**_
- Hospital team identifies
-  areas for improvement

_**Implement Refined Protocols**_
- Hospital team coordinates implementation of refined protocols

_**Find and Support a Champion**_

_**Assess HF Treatment Rates**_
- Measure current  treatment rates and process-of-care indicators

**GWTG-HF Cycle of Quality Improvement**

**Notes:**
GWTG-HF Cycle of Quality Improvement

The program success is based on the concept of “continuous quality improvement.”  Identifying program champions is critical to move the program forward.  Next, assessing our baseline treatment rates and communicating the data helps get buy-in.  We evaluate and refine our protocols, implement the protocols and then reassess the data.  This concept is based on rapid-cycle improvement.  We do not have to have a “perfect” process in place to begin implementation.  We continue to reassess and refine.  We will see improvement almost immediately.

## GWTG-HF Implementation Recognition

- GWTG-HF Quality Improvement Award Levels include:
- Initial GWTG-HF Performance Achievement Award
- Annual GWTG-HF Performance Achievement Award
- Sustaining GWTG-HF Performance Achievement Award

**Notes:**
GWTG-HF Implementation Recognition

GWTG-HF Quality Improvement Award Levels include:
- Initial GWTG-HF Performance Achievement Award
- Annual GWTG-HF Performance Achievement Award
- Sustaining GWTG-HF Performance Achievement Award

## GWTG-HF Initial Results

** ****Data analyzed from the first 97 hospitals participating in GWTG-HF and utilizing the web-based Patient Management Tool****TM**** for data collection and decision support (Outcome, Cambridge, MA).**
** ****Patient cohort: patients hospitalized with a primary or secondary heart failure diagnosis.**
** ****The first 30 pre-GWTG implementation “baseline” patient records were compared to post 4 quarters of patients entered immediately after the start of GWTG implementation to determine if guideline-driven care improved over time for 5 performance measures (PM).**

**Notes:**
GWTG-HF Initial Results

- Data analyzed from the first 97 hospitals participating in GWTG-HF and utilizing the web-based Patient Management ToolTM for data collection and decision support (Outcome, Cambridge, MA).
- Patient cohort: patients hospitalized with a primary or secondary heart failure diagnosis.
- The first 30 pre-GWTG implementation “baseline” patient records were compared to post 4 quarters of patients entered immediately after the start of GWTG implementation to determine if guideline-driven care improved over time for 5 performance measures (PM).

## Results: Patient Characteristics

| Characteristic | Level | Total Cohort
(N=18,516) |
| --- | --- | --- |
| Age  | Mean (STD) | 72.9 + 14.2 years |
| Gender | Male | 50.0% |
| Race/
Ethnicity | Caucasian
African American | 71.6%
16.3% |
| CAD-Ischemic | Yes | 49.8% |
| Diabetes | Yes | 43.7% |
| Atrial Fibrillation History | Yes | 31.1% |
| Hypertension History | Yes | 72.6% |

-  **18,516 hospitalized HF patients from January 2005 to March 2006**

**Notes:**
Results: Patient Characteristics

## Results: Patient Characteristics

| Characteristic | Level | Total Cohort
(N=18,516) |
| --- | --- | --- |
| Systolic Blood Pressure | Mean (STD) | 140.5 + 31.2 mmHg |
| Heart Rate | Mean (STD) | 85.6 + 21.0 bpm |
| LVEF  | Mean (STD)
LVEF < 40% | 38.7 + 17.1%
49.8% |
| Sodium | Mean (STD) | 137.1 + 9.5 mEq/L |
| Potassium | Mean (STD) | 4.1 + 0.7 mEq/L |
| Blood urea nitrogen (BUN) | Mean (STD) | 31.6 + 20.3 mg/dL |
| Creatinine | Mean (STD) | 1.8 + 1.9 mg/dL |
| BNP (n=11,844) | Median (IQR) | 873 (451-1701) pg/mL |

**Notes:**
Results: Patient Characteristics

## Results: Performance Measures

**p<0.0001**

**p<0.0001**

- Data from 97 GWTG-HF hospitals and 18,516 HF patients were collected from 1/05-3/06
- Fonarow GC, et al. *J Card Fail*. 2006;12:S130.

**P=0.046**

**P=0.036**

**P=0.127**

**Notes:**
Results: Performance Measures

## Results: Performance Measures

**Results: Performance Measures**

**Notes:**
Results: Performance Measures

## Results: Composite and Defect Free Measures Over Time

- P<0.0001

- P<0.0001

**Notes:**
Results: Composite and Defect Free Measures Over Time

## GWTG-HF  Results: Emerging Performance Measures

**P=0.0257**

**P=0.0017**

- Data from 97 GWTG-HF hospitals and 18,516 HF patients were collected from 1/05-3/06

**P=0.2477**

**P<0.0001**

**P=0.0498**

**Notes:**
GWTG-HF  Results: Emerging Performance Measures

## GWTG Findings

-  **The AHA GWTG-HF Program is associated with significant improvements in the quality of care for patients hospitalized with heart failure**** as indexed by specific performance measures and composites.**
** ****After initial increases from baseline, successive improvements over time in certain performance measures were observed.**
** ****Hospitals participating in GWTG-HF significantly improved evidence-based care of HF patients over time as reflected by the composite and defect free care performance measures. **

**Notes:**
GWTG Findings

- The AHA GWTG-HF Program is associated with significant improvements in the quality of care for patients hospitalized with heart failure as indexed by specific performance measures and composites.
- After initial increases from baseline, successive improvements over time in certain performance measures were observed.
- Hospitals participating in GWTG-HF significantly improved evidence-based care of HF patients over time as reflected by the composite and defect free care performance measures. 

## Gender-Related Disparity in Use of Evidence-Based HF Therapy at Discharge

**Eligible Patients Treated (%)**

**ACEI**

**ACEI/ARB**

******-Blocker**

**Warfarin**

**Statin**

**Aldosterone****Antagonist**

- Men (n=23,537)

- Women (n=25,075)

*P*=.5028

*P*=.1281

*P*=.0062

*P*.0001

*P*.0001

*P*=.0406

- ACEI/ARB, β-blocker, and aldosterone antagonist use in eligible patients with LVSD; statin in CAD, PVD, CVD, and/or diabetes; and warfarin use in patients with atrial fibrillation.
- Fonarow GC, et al. *J Am Coll Cardiol*. 2005;45:339A (Updated July 2005). The OPTIMIZE-HF Registry [database]. Final Data Report. Duke Clinical Research Institute. July 2005.

**Notes:**
Gender-Related Disparity in Use of Evidence-Based HF Therapy at Discharge

## Impact of Evidence-Based HF Therapy Use at Hospital Discharge on F/U Use: OPTIMIZE-HF

**60 to 90 Day Post-Discharge Follow-up**

- 34,057 HF patients hospitalized at 236 US hospitals participating in OPTMIZE-HF, f/u on 2500 with LVD.
- Fonarow GC. Paper presented at: Heart Failure Society of America Annual Meeting; September 12-15, 2004; Toronto Canada.

**Notes:**
Impact of Evidence-Based HF Therapy Use at Hospital Discharge on F/U Use: OPTIMIZE-HF

## In-Hospital and Follow-Up Outcomes by Process of Care Improvement Tool Use

**In-Hospital and Follow-Up Outcomes by Process of Care Improvement Tool Use**

*P*.0001

- PrCI Tool Use

- No PrCI Tool Use

- PrCI Tool Use

- No PrCI Tool Use

*P*<.017

- Patients (%)

- PrCI tool use (admission order set or discharge checklist) was reported during hospitalization in 45.3% of patients (n=22,017/48,612).
- Fonarow GC, et al. *Arch Intern Med*. 2007;167:14931502.

- In-Hospital Mortality

- 60- to 90-Day Mortality and Rehospitalization

**Notes:**
In-Hospital and Follow-Up Outcomes by Process of Care Improvement Tool Use

## Conclusions

**Large number of heart failure patients are having events that could be prevented with improved care**
**Hospital-based HF quality improvement is feasible on a national scale**
**GWTG-HF can help hospital teams to ensure use of evidence-based therapies in their eligible HF patients prior to hospital discharge**
**Recent  studies provide additional scientific evidence in support of the American Heart Association’s efforts through GWTG to improve the quality of cardiovascular care in the nation’s hospitals.**

**Notes:**
Conclusions

- Large number of heart failure patients are having events that could be prevented with improved care
- Hospital-based HF quality improvement is feasible on a national scale
- GWTG-HF can help hospital teams to ensure use of evidence-based therapies in their eligible HF patients prior to hospital discharge
- Recent  studies provide additional scientific evidence in support of the American Heart Association’s efforts through GWTG to improve the quality of cardiovascular care in the nation’s hospitals.

## Slide 29

**Notes:**
Logo