A new study has shown that US hospitals participating in the
American Heart Association (AHA) Get With the Guidelines--Coronary
Artery Disease (GWTG-CAD) program provide superior quality of care
in acute myocardial infarction (AMI), resulting in better clinical
outcomes [1]. Dr Wiliam R Lewis (Case Western Reserve University,
Cleveland, OH) and colleagues report the first head-to-head
comparison of care between GWTG and non-GWTG hospitals in the
September 8, 2008 issue of the Archives of Internal Medicine.


Senior author Dr Gregg C Fonarow (Ahmanson-UCLA Cardiomyopathy
Center, University of California, Los Angeles) told heartwire that
although prior studies have shown that hospitals participating in
GWTG-CAD have had progressive improvements in quality of care for
AMI over time, the question remained as to whether these
improvements would have occurred anyway. "This study allowed us to
compare, in a concurrent time frame, the quality of care being
provided in hospitals and look at whether it was participation in
GWTG-CAD per se that was influencing the quality of care provided vs
just some other characteristic of the hospital," he explained.

They found that participation per se was a defining factor in how
well the hospitals perform. "We believe these data show that GWTG-
CAD works and will be helpful in improving quality of care for the
nation's hospitals. We hope this will encourage participation in
GWTG-CAD, and we're hopeful that now the study is published in the
peer-reviewed literature, it will serve as a call to action for more
hospitals to join with this effort."

GWTG Program Itself Responsible for Success

Lewis et al used the Hospital Compare database to look at 223
hospitals participating in GWTG-CAD and contrasted them with 3407
nonparticipating hospitals. Adherence to eight national measures,
including the use of aspirin and beta blockers early and at
discharge, was analyzed, and a composite score was also calculated.
The researchers also compared the two groups of hospitals on a
noncardiovascular performance measure, pneumonia care, as a form of
control.

They found clinically relevant and statistically significant
differences in a number of the quality-of-care measures between the
two hospital groups, "and GWTG was independently associated with a
better quality of care," Fonarow said.

Adherence to the overall Hospital Compare composite measure was
higher in GWTG-CAD hospitals than in non-GWTG-CAD institutions:
89.7% vs 85.0% (p<0.001). Adherence to the GWTG-CAD performance-
measures composite was also higher among those participating in the
program: 89.5% vs 83.0% (p<0.001).

Larger AMI volume by quartile, geographic location in the Northeast,
and teaching-hospital status were also associated with improved
adherence to the performance-measures composite.

To rule out selection bias, they also looked at pneumonia-care
outcomes but found that for this variable, hospitals in GWTG-CAD
performed worse than those not in the program (74.8% adherence for
quality measures for pneumonia compared with 76.5% among non-GWTG
hospitals; p=0.005).

"It appeared to be the GWTG program itself that was influencing the
higher rate of performance on these very important AMI process
measures," Fonarow explained to heartwire. This proves that by
virtue of participating in the program, hospitals can provide higher
quality of care, he added.

Data Can Help Overcome Barriers to Participation

He explained that there are a number of potential barriers to taking
part in such programs: "It takes time and resources and is a matter
of identifying individual physicians and nurses within hospitals who
want to take this on and lead the effort. Hospitals faced with a
number of these [programs] may gravitate toward doing the minimum
that is required to be nationally mandated."

He hopes that "data like this can help to overcome the barriers to
show that active participation in GWTG-CAD allows for a meaningful
differential in quality of care. Research such as this is important
in encouraging further participation."

Fonarow disclosed receiving research grants from GlaxoSmithKline,
Medtronic, Pfizer, and the National Institutes of Health; having
been on the speaker's bureau for or having received honoraria from
AstraZeneca, GlaxoSmithKline, Merck, Pfizer, Sanofi-Aventis,
Schering-Plough, Novartis, and King; and having been a consultant
for GlaxoSmithKline, Schering-Plough, AstraZeneca, Scios, and Amgen.
Disclosures for the coauthors are listed in the paper.


Lewis WR, Peterson ED, Cannon CP, et al. An organized approach to
improvement in guideline adherence for acute myocardial infarction.
Results with the get with the guidelines quality improvement
program. Arch Intern Med 2008; 168: 1813-1819.