Linking the Hospital and the Office in Cardiovascular Secondary Prevention
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Am Fam Physician. 2005 Feb 1;71(3):430-433.
Cardiovascular disease and stroke cause 38.5 percent of all deaths in the United States.1 Despite the existence of guidelines for secondary prevention of cardiovascular disease from the American Heart Association (AHA) and the American College of Cardiology (ACC),2 many patients with acute events leave the hospital without these evidence-based therapies.3 Observations from primary care practices4 show that 95 percent of physicians questioned intended to treat patients with elevated cholesterol levels, but chart abstractions from their patients treated for coronary artery disease show that only 18 percent of patients reached their goal low-density lipoprotein cholesterol levels. These observations and other evidence of treatment gaps,5 despite significant opportunities to learn new clinical evidence and guidelines, suggest that the solution to closing the gap lies in changing systems of care. Technology initiatives such as the Physician Office Link from the National Committee for Quality Assurance and the Doctor's Office Quality-Information Technology program from the Centers for Medicare and Medicaid Services (CMS) help offices develop the technology infrastructure to help underlay systems of care.
The AHA's Get with the Guidelines (GWTG) program is designed to address the secondary prevention needs of patients at the highest risk—those hospitalized with cardiovascular events, transient ischemic attack, or ischemic stroke. GWTG addresses this need by providing a structured, inexpensive quality-improvement solution for cardiovascular care. The program conforms to the AHA/ACC secondary prevention guidelines, the CMS performance measures for acute myocardial infarction and heart failure, and the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) ORYX core measures for these conditions. The GWTG collaborative model uses AHA staff and volunteers to provide evidence-based measures and clinical science expertise, blended with system change solutions, such as preprinted orders, discharge protocols, and chart reminders, that are developed and shared by multidisciplinary hospital teams. The program features an Internet-based, point-of-service data-collection tool that includes decision support and performance feedback to hospitals, including comparison of their data to aggregate data from the entire project or a large group of similar hospitals.6
In addition, the GWTG program includes customized patient education materials that can be printed from the Internet before the patient is discharged. A summary letter that includes diagnosis, procedures, risk-profile information, and pharmacologic and lifestyle interventions can be generated by the data-collection tool and provided to all pertinent physicians at the time of discharge. This rapid communication provides a valuable and timely link for office follow-up and helps provide the necessary communication between hospitalists or subspecialists and primary care physicians.
This effort by the AHA is targeted at the hospital for several reasons. One of the strongest predictors of cardiovascular events is a prior event. Thus, the hospital is a logical point to identify patients with events who will be at risk for subsequent events. Risk and the need for prevention are often abstract and hard to personalize as a motivation for behavior change. Hospitalization represents an important teaching opportunity when the concept of risk suddenly becomes real for patients and their families. Initiation of secondary prevention measures in the hospital significantly increases adherence to preventive medications in the first year following an event.7 Hospitals have been required to measure and improve quality of care for many years and have infrastructure in place to address the requirements of JCAHO and CMS. Approximately 4,300 U.S. hospitals provide care for the highest risk group of patients with cardiovascular disease. Thus, from a systems perspective, the hospital is an appropriate place to begin improving cardiovascular secondary prevention. Building effective hospital systems is an important first step in improving outpatient secondary prevention by “getting it right” at a critical moment and reducing the burden in the office setting.
Published data from GWTG8 demonstrate significant improvement in the number of patients who receive guideline-recommended secondary prevention measures before post-hospital follow-up. Too often, time in the office is spent on the more difficult task of educating patients about the need to start medication that the subspecialist may have failed to start in the hospital. When patients already have received counseling and have been started on pharmacologic therapy such as aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and statins, valuable office time can be used to titrate medication and reinforce adherence to medication regimens and lifestyle changes.
Kenneth A. LaBresh, M.D., is vice president for medical affairs and quality improvement at MassPRO, Inc., Waltham, Mass., and associate professor of medicine at Brown Medical School, Providence, R.I.
Patricia A. Tyler, R.N., C.C.R.N., is senior manager for clinical effectiveness at the American Heart Association, Dallas.
Address correspondence to Kenneth A. LaBresh, M.D., MassPRO, 235 Wyman St., Waltham, MA 02451 (e-mail: firstname.lastname@example.org). Reprints are not available from the authors.
The Centers for Medicare and Medicaid Services provided resources for program development and analysis under contract 500-02-MA03. The conclusions and interpretation of results are the sole responsibility of the authors and do not necessarily reflect the position or policy of the U.S. government.
1. American Heart Association. Heart Disease and Stroke Statistics Update. Accessed online January 7, 2005, at:http://www.americanheart.org/presenter.jhtml?identifier=1928.
2. Smith SC Jr, Blair SN, Bonow RO, Brass LM, Cerqueira MD, Dracup K, et al. AHA/ACC scientific statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation. 2001;104:1577-9.
3. Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001 [published correction appears in JAMA 2003;289:2649]. JAMA. 2003;289:305-12.
4. Pearson TA, Laurora I, Chu H, Kafonek S. The lipid treatment assessment project (L-TAP): a multicenter survey to evaluate the percentages of dyslipidemic patients receiving lipid-lowering therapy and achieving low-density lipoprotein cholesterol goals. Arch Intern Med. 2000;160:459-67.
5. Sueta CA, Chowdhury M, Boccuzzi SJ, Smith SC Jr, Alexander CM, Londhe A, et al. Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease [published correction appears in Am J Cardiol 1999;84:1143]. Am J Cardiol. 1999;83:1303-7.
6. LaBresh KA, Glicklich R, Liljestrand J, Peto R, Ellrodt AG. Using “get with the guidelines” to improve cardiovascular secondary prevention. Jt Comm J Qual Saf. 2003;29:539-50.
7. Fonarow GC, Gawlinski A, Moughrabi S, Tillisch JH. Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol. 2001;87:819-22.
8. LaBresh KA, Ellrodt AG, Glicklich R, Liljestrand J, Peto R. Get with the guidelines for cardiovascular secondary prevention: pilot results. Arch Intern Med. 2004;164:203-9.
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