After 9 years and tens of millions of dollars, Get With the Guidelines—the American Heart Association's push for new standards of excellence for follow-up treatment of acute cardiovascular events—appears to have yielded murky gains at best in terms of saving lives, according to a new analysis.
A total of 3,909 medical centers participated in the Get With the Guidelines (GWTG) program. Of these, 355 hospitals (9%) received a nonmonetary achievement award for either heart failure or acute myocardial infarction (AMI) follow-up care. The report compared the risk-adjusted 30-day mortality figures for the top 355 hospitals with those of the remaining participating centers, and found no statistically significant difference in heart failure mortality. A modest 0.19% superiority in the top hospitals' survival rates following AMI was reduced by 43% after the data were adjusted for confounding factors (Am. Heart J. 2009;158:546–53).
Dr. Paul A. Heidenreich of the Veterans Affairs Palo Alto (Calif.) Health Care System and his coauthors, all from the GWTG steering committee, acknowledged that the best-performing hospitals tended to be ones that were exceptionally well funded before the program began. Overall, “it is unclear if outcomes are better in those hospitals recognized by the GWTG program for their processes of care,” they wrote.
Further, differentials in the 30-day mortality for the third component of GWTG—follow-up-care for stroke—were unclear. Recognition on all three measures of excellence, the core aim of the GWTG program, was achieved by 15 of the 3,909 participating hospitals.
The program now costs as much as $12 million per year. At the AHA scientific sessions in 2005, Dr. Gray Ellrodt, lead author of an interim review of the initiative, said the program was the start of a new era of systematic excellence in cardiovascular care. “Men and women, young and old, showed dramatic improvements in care,” said Dr. Ellrodt, an internist at Berkshire Medical Center, Pittsfield, Mass.
In an interview, Dr. Heidenreich called this claim “an accurate statement. The improvements in process of care were dramatic given that many quality interventions have no improvement.”
Yet despite dramatic changes in care—including greater assessment of left ventricular function, use of ACE inhibitors, and rigorous discharge counseling for heart failure patients; rapid onset of thrombolytics for MI patients and emergency percutaneous coronary intervention where necessary; and more consistent use of aspirin and beta-blockers at every stage—the benefits in terms of improved mortality remained small.
But Dr. Heidenreich defended the program's worth, particularly citing evidence that it encouraged hospitals to more widely prescribe ACE inhibitors.
“Hospitals enrolled in the GWTG program have demonstrated steady improvement in their process of care,” Dr. Heidenreich and his colleagues wrote. “These results are consistent with prior studies indicating better survival at hospitals with better processes of care for acute myocardial infarction and heart failure.”
The authors noted that even marginal reductions in 30-day risk-adjusted mortality of 0.1%–0.2% as achieved by the top hospitals in this comparative, nonrandomized analysis could potentially save 1,800–3,500 lives if optimum standards were made the rule nationwide.