Although stroke is the third leading cause of death and long-term disability in the United States, evidence suggests that stroke patients often do not receive interventions recommended by national guidelines. In response to the often suboptimal adherence to evidence-based guidelines, the American Heart Association (AHA) piloted “Get With the Guidelines-Stroke” (GWTG-Stroke), a national stroke program designed to ensure continuous quality improvements in the domains of acute stroke treatment and transient-ischemic attack (TIA). The program is a voluntary participation project that involves hospitals across the U.S. and focuses on care team protocols to ensure that patients are treated and discharged appropriately.
Components of the GWTG-Stroke Program
GWTG-Stroke is a comprehensive program that provides an online interactive assessment and report tool, resources, quarterly workshops, training, and feedback to staff at participating hospitals. The components include organizational stakeholder and opinion leader meetings, hospital recruitment, collaborative workshops for hospital teams, tool kits, and hospital recognition. Data collection, decision support, and hospital data feedback via multiple on-demand reports of performance on all key measures are performed with the internet-based Patient Management Tool. The Patient Management Tool is an online, interactive assessment and reporting system. It provides patient-specific guideline information and enables each facility to track its adherence to evidence-based recommendations individually as well as against national benchmarks over time.
“The cornerstone of GWTG-Stroke is the community of learners and quality improvement implementers who come together on a regular basis to share their experiences and their best practices,” says Lee. H. Schwamm, MD. “It was designed to help hospitals improve implementation of evidence-based interventions in stroke and TIA that are proven to reduce complications after these events and to decrease the chances of a subsequent stroke or heart attack. The program helps hospitals emphasize the changes that are necessary to implement guideline recommendations effectively and consistently.”
Prior to GWTG-Stroke, most quality improvement efforts in the hospital have relied on quarterly or annual evaluation of performance efforts through a long, complex acquisition of data. Dr. Schwamm says, “GWTG-Stroke focuses on managing patients in real-time. We want to accomplish this by using small tests of change and rapid cycles of improvement to optimize patient care quickly.”
Data Demonstrate Improved Care
In a 5-year study, the largest involving acute stroke care for hospitalized patients, Dr. Schwamm and his colleagues published a study in the January 6, 2009 issue of Circulation to evaluate whether broad hospital participation in the GWTG-Stroke program was associated with improvements in the quality of stroke care. It also aimed to identify factors that contribute to differences in performance between hospitals. “The study is among the first to characterize national patterns of stroke and TIA care in the context of contemporary guidelines,” says Dr. Schwamm. “It’s also the first to assess the influence of a national stroke quality improvement program on a set of seven predefined performance measures that were analyzed before and after implementation of the GWTG-Stroke program [Table 1].”
A total of 790 U.S. academic and community hospitals participated voluntarily from 2003 to 2007, all of which provided information on over 300,000 hospitalized stroke patients. According to the findings, participation in GWTG-Stroke was associated with increased adherence to all stroke performance measures. The seven performance measures were prospectively selected by the GWTG Steering Committee to measure the quality of inpatient stroke care on the basis of a combination of the strength of the evidence, clinical relevance, magnitude of the relationship between performance and outcome, and precision of definition, its construct content validity, and its feasibility.
Significant Ramifications
Among all hospital interventions for preventing another stroke or reducing stroke disability, the overall absolute percentage of interventions performed in eligible patients increased from 83.5% in the first year to 93.7% in the fifth year (Table 2). The researchers concluded that GWTG-Stroke participation was associated with a 1.18-fold yearly increase in the odds of fulfilling care opportunities that was independent of secular trends.
“Currently, there are almost 1,200 hospitals participating with GWTG-Stroke and 800,000 patients in the database tool,” explains Dr. Schwamm. “Participation in the GWTG-Stroke program enables hospitals to improve care at their facility while also contributing to a large dataset that helps drive system-wide improvements in stroke care across the U.S. Not only do participating hospitals improve quality of patient care within their own hospital, but they’re also contributing to a process that will ultimately improve care at hospitals across the nation. Participating hospitals make it possible for us to ask questions that we couldn’t answer in a single hospital alone.”
Lee H. Schwamm, MD, has indicated to Physician’s Weekly that he has consulted on economic models of thrombolytic therapy for Research Triangle Institute He has provided expert medical opinions in four malpractice lawsuits and is supported as a consultant on stroke systems development to the Massachusetts Department of Public Health. He also serves as a member of the American Heart Association’s “Get With the Guidelines” Steering Committee.
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