Get With The Guidelines-Coronary Artery Disease Research Articles

Abstract 14627: Machine Learning Based Models for Imputing Heart Failure on First Medical Contact From the Get With The Guidelines®- Coronary Artery Disease (GWTG-CAD) Registry

Introduction: The American Heart Association Get With the Guidelines - Coronary Artery Disease (GWTG-CAD) Registry is a quality improvement program with over 2600 participating U.S. hospitals. Among the collected data elements is the yes-no variable “Heart failure documented on First Medical Contact” (HF-FMC), an important clinical predictor of in-hospital mortality. Before 2018, the missing rate of HF-FMC exceeded 60% in some years, significantly limiting its utility as a predictor of in-hospitality mortality. We compared machine learning (ML)-based with traditional statistical methods to accurately impute missing HF-FMC values. Methods: We utilized admission records from the GWTG CAD Registry data from 2018 to 2021, including both STEMI and NSTEMI patients. We removed missing HF-FMC, using complete data as ground truth. The data was split into training and test datasets in a 3:1 ratio. Imputation was framed as a prediction task. For evaluation, we masked HF-FMC in the test set and compared the imputed values against the ground truth. For traditional methods, mode imputation, K-nearest neighbor imputer (KNN), and Multiple Imputation by Chained Equations (MICE) were applied. For ML models, we applied logistic regression, random forest and XGBoost. Shapley Additive exPlanations (SHAP) values were utilized to identify key features contributing to the ML models. Results: The study included 223,074 individuals (12.2% HF-FMC = “yes”), with mean (SD) age 64.9 (13.4) years (33.8% Female; and 77.3% White and 13.8% Black). Machine Learning models achieved higher AUROC scores compared to traditional models in imputing HF-FMC (Table 1). Top features for predicting HF-FMC are shown (Figure 1). Conclusions: Machine learning models outperformed traditional methods in imputing missing HF-FMC, a critical predictor of in-hospital mortality. SHAP values can identify key features in imputing clinically important variables with high degree of missingness.

Abstract 11426: Processes and Outcomes for 121,576 Patients With ST Elevation Myocardial Infarction in the AHA Get With the Guidelines®-Coronary Artery Disease (GWTG-CAD) Registry, 2018-2021

Introduction: Timely treatment of ST elevation myocardial infarction [STEMI] requires ongoing coordinated care between emergency departments, paramedics, and primary percutaneous coronary (PCI) intervention facilities. Methods: To provide a current view and a national benchmark, we examined 121,576 patient records submitted by 648 hospitals participating the GWTG-CAD registry from Q2 2018 through Q3 2021 [median age 63, women 29%, Black 11%, Hispanic 8%, admission cardiac arrest 5%, shock 7%, heart failure 7%, Covid 0.2%, presentation EMS 47%, walk in 27%, transfer 22%] Results: Reperfusion method for all patients included primary PCI 87%, fibrinolysis 5%, and no reperfusion 8% [increasing from 7 to 9% during the study period]. Median time from symptom onset to reperfusion was shortest for EMS patients 148 minutes, followed by walk-in 195 minutes, ground transferred 238 minutes, and air transferred 247 minutes. Process times did not improve during the study period. First medical contact to device times increased by 5 minutes for EMS and ground transferred patients in Q2 2020 corresponding with the pandemic onset, and adjusted mortality was significantly higher in the final 3 quarters compared to Q2 2018 [OR, 95% CI 1.28(1.07-1.53); 1.35(1.13-1.61); 1.23(1.03-1.48)]. Patients treated within guideline goals had significantly lower mortality [Figure]. Conclusions: These data reaffirm the association between process times and lower mortality for STEMI patients. They also identify concerning trends and opportunities for improved care. Increasing delays in treatment, particularly for hospital transfer, greater numbers of untreated patients, and increased risk-adjusted in-hospital mortality all provide strong impetus for renewed focus on STEMI systems. Regional collaborative efforts led by coordinators and informed by a common data system have the potential to reverse these trends and improve survival.

Seasonal and circadian variations of acute myocardial infarction: Findings from the Get With The Guidelines–Coronary Artery Disease (GWTG-CAD) program

Seasonal variation with winter preponderance of myocardial infarction incidence has been described decades ago, but only a few small studies have classified myocardial infarction based on ST-segment elevation. It is unclear whether seasonal and circadian variations are equally present in warmer and colder regions. We investigated whether seasonal and circadian variations in acute myocardial infarction (AMI) are more prominent in colder northern states compared with warmer southern states. We also investigated the peak time of admission to better understand the circadian rhythm. Data from the GWTG-CAD database were used. We analyzed 82,971 consecutive acute myocardial infarction (AMI) patients treated at 276 US centers from 2003 to 2008. The country was geographically divided into warmer southern and colder northern states using latitude 35 degrees for this purpose. Overall, acute myocardial infarction (AMI) admissions varied across seasons (P < .01), and were higher in winter (winter vs. spring n = 21,483 vs. 20,291, respectively). When stratified based on type of AMI, non-ST-segment elevation myocardial infarction (NSTEMI) admissions varied across seasons (P < .01) and were highest in winter and lowest in spring. Seasonal variation was not significant in STEMI admissions (P = .30). Seasonal variation with winter predominance was noted in AMI patients in warmer southern states (P < .01), but not in colder states. The distributions of length of stay for AMI patients and door to balloon times for STEMI patients were minimally different across all four seasons (P < .01) with longest occurring in winter. Most patients with AMI presented during daytime with a peak close to 11 am and a nadir at approximately 4 am. Seasonal variation with winter predominance exists in AMI admissions and was significant in NSTEMI admissions but not in STEMI admissions. Seasonal variation was only significant in warmer southern states.

Compliance with guideline-directed therapy in diabetic patients admitted with acute coronary syndrome: Findings from the American Heart Association's Get With The Guidelines–Coronary Artery Disease (GWTG-CAD) program

To evaluate and compare baseline characteristics, outcomes and compliance with guideline based therapy at discharge among diabetic and non-diabetic patients admitted with acute coronary syndromes (ACS). Study population consisted of 151,270 patients admitted with ACS from 2002 through 2008 at 411 sites participating in the American Heart Association's Get with the Guidelines (GWTG) program. Demographic variables, physical exam findings, laboratory data, left ventricular ejection fraction, length of stay, in-hospital mortality and discharge medications were compared between diabetic and non-diabetic patients. Temporal trends in compliance with guidelines directed therapy were evaluated. Of 151,270 patients, 48,938 (32%) had diabetes. Overall, diabetic patients were significantly older and more likely non-white. They had significantly more hypertension, atherosclerotic disease, CKD, and LV dysfunction and were more likely to present as NSTEMI. They had longer hospital stay and higher hospital mortality than non-diabetic patients. Diabetic patients were less likely to get LDL checks (65% vs 70%) and less frequently prescribed statins (85% vs 89%), RAAS blockers for LV dysfunction (80% vs 84%) and dual-antiplatelet therapy (69% vs 74%). Diabetic patients were less likely to achieve BP goals before discharge (75% vs 82%). Fewer diabetic patients met first medical contact to PCI time for STEMI (44% vs 52%). Temporal trends, however, showed continued progressive improvement in most performance measures from 2002 to 2008 (all P<.001). These data from a large cohort of ACS patients demonstrate gaps in compliance with guidelines directed therapy in diabetic patients but also indicate significant and continued improvement in most performance measures over time. Concerted efforts are needed to continue this positive trend.

Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG-CAD) Registry.

BackgroundTimely reperfusion after ST‐elevation myocardial infarction (STEMI) improves survival. Guidelines recommend primary percutaneous coronary intervention (PPCI) within 90 minutes of arrival at a PCI‐capable hospital. The alternative is fibrinolysis within 30 minutes for those in those for whom timely transfer to a PCI‐capable hospital is not feasible.Methods and ResultsWe identified STEMI patients receiving reperfusion therapy at 229 hospitals participating in the Get With the Guidelines—Coronary Artery Disease (GWTG‐CAD) database (January 1, 2003 through December 31, 2008). Temporal trends in the use of fibrinolysis and PPCI, its timeliness, and in‐hospital mortality outcomes were assessed. We also assessed predictors of fibrinolysis versus PPCI and compliance with performance measures. Defect‐free care was defined as 100% compliance with all performance measures. We identified 29 190 STEMI patients, of whom 2441 (8.4%) received fibrinolysis; 38.2% of these patients achieved door‐to‐needle times ≤30 minutes. Median door‐to‐needle times increased from 36 to 60 minutes (P=0.005) over the study period. Among PPCI patients, median door‐to‐balloon times decreased from 94 to 64 minutes (P<0.0001) over the same period. In‐hospital mortality was higher with fibrinolysis than with PPCI (4.6% vs 3.3%, P=0.001) and did not change significantly over time. Patients receiving fibrinolysis were less likely to receive defect‐free care compared with their PPCI counterparts.ConclusionsUse of fibrinolysis for STEMI has decreased over time with concomitant worsening of door‐to‐needle times. Over the same time period, use of PPCI increased with improvement in door‐to‐balloon times. In‐hospital mortality was higher with fibrinolysis than with PPCI. As reperfusion for STEMI continues to shift from fibrinolysis to PPCI, it will be critical to ensure that door‐to‐needle times and outcomes do not worsen.

Abstract 17419: Sex and Race Related Disparities in Care and Outcomes After Hospitalization for Coronary Artery Disease Among Older Adults

Background: It is unclear to what extent following a standard performance protocol will help reduce gaps in cardiovascular health among sexes, racial/ethnic groups, and geographic regions in United States hospitals. Method: Based on the Get With The Guidelines Coronary Artery Disease (GWTG-CAD) registry linked with Medicare inpatient data, we included 49,358 patients, age 65 years or older, from 366 US hospitals from 2003 to 2009. Our primary outcome was 3-year all-cause mortality. Exposures included sex, race/ethnicity, and geographic region. Our mediator was a composite score of quality of care, defined as the total number of performance measures the patient received divided by total number of performance measures the patient was eligible for. Logistic regression with generalized estimating equations and mediation analysis were used. Results: During 3 years of follow-up, 16,130 deaths were identified. Compared with men, women were less likely to receive optimal care at discharge (adjusted odds ratio (aOR)=0.92, 95% Confidence Interval (CI): 0.88-0.95, p&lt;0.0001). We identified a significant interaction between sex and quality of care measures (p for interaction=0.04). Compared with men, women had higher odds of mortality (aOR=1.23, 95%CI: 0.99-1.54, p=0.06) if they received sub-optimal care, though the sex disparity disappeared with optimal care (aOR=0.97, 95%CI: 0.92-1.01, p=0.13). There was no difference in terms of quality of care across racial/ethnic groups or geographic regions. Compared with whites, blacks had higher mortality (aOR=1.36, 95%CI: 1.24-1.50, p&lt;0.0001), and the disparity persisted regardless of the quality of care received. We did not identify a significant mortality difference based on geographic region. Conclusion: Compared with men, women were less likely to receive optimal care at discharge which was associated with higher mortality. The observed sex disparity in mortality could potentially be reduced or even eliminated by providing equitable and optimal care. In contrast, the higher mortality observed in black patients could not be accounted for by differences in the quality of care measured in this study. We did not observe differences in care or outcomes by geographic region.

Quality of Care for Patients With Acute Coronary Syndromes as a Function of Hospital Revascularization Capability: Insights From Get With The Guidelines‐CAD

Revascularization availability at US hospitals varies and may impact care quality for acute coronary syndrome patients. The hypothesis of this study was that there would be differences in care quality at Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) hospitals based on revascularization capability. For acute coronary syndrome patients admitted to GWTG-CAD hospitals between 2000 and 2010, care quality at hospitals with or without revascularization capability was examined by assessing conformity with performance and quality measures. This study included 95 999 acute coronary syndrome patients admitted to 310 GWTG-CAD hospitals. There were 89 000 patients admitted to 226 revascularization-capable hospitals and 6999 patients admitted to 84 hospitals without revascularization capability included. Adjusted multivariate analysis demonstrated that 8 of the 19 measures were more frequently performed in the revascularization cohort: aspirin (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.04-1.92), clopidogrel (OR: 2.31, 95% CI: 1.78-3.00), lipid-lowering therapies at discharge (OR: 1.39, 95% CI: 1.04-1.87), lipid-lowering therapies for low-density lipoprotein >100 mg/dL (OR: 1.85, 95% CI: 1.23-2.77), achievement of blood pressure <140/90 mm Hg (OR: 1.20, 95% CI: 1.03-1.40), LDL recorded (OR: 1.47, 95% CI: 1.05-2.06), and recommendations offered for physical activity (OR: 3.82, 95% CI: 2.23-6.55) or weight management (OR: 1.74, 95% CI: 1.12-2.69). The GWTG-CAD revascularization hospitals were associated with better performance in some, but not all, measures assessed. Although the difference in conformity between hospital types was modest for performance measures but more variable for quality measures, room for improvement exists in key aspects of care.

Reperfusion Strategies and Quality of Care in 5339 Patients Age 80 Years or Older Presenting With ST‐Elevation Myocardial Infarction: Analysis from Get With The Guidelines‐Coronary Artery Disease

Data regarding reperfusion strategies, adherence to national guidelines, and in-hospital mortality in ST-elevation myocardial infarction (STEMI) patients age ≥80 years are limited. The aim of this study was to determine current reperfusion trends, medical treatment, and in-hospital mortality during STEMI in older adults. Among patients aged 80 or above presenting with STEMI, adherence to guidelines, length of stay, and in-hospital mortality would be better in those receiving reperfusion versus those who did not. Using the Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) database, we examined care and in-hospital outcomes of STEMI patients ≥80 years old. Use of evidence-based therapies and quality measures were analyzed by reperfusion strategies. A total of 5339 patients age ≥80 years hospitalized with STEMI were included. Of these, 42.8% (n = 2285) underwent primary percutaneous coronary intervention (PPCI), 4.8% (n = 255) underwent thrombolysis (TL), and 52.4% (n = 2799) received no reperfusion (NR). Patients with NR were more likely to be older, female, have lower body mass index, and higher prevalence of renal insufficiency and heart failure compared with PPCI or TL patients. During the last decade, there was a significant increase in the use of PPCI compared with TL as the main reperfusion strategy in this population. Adjusted in-hospital mortality in PPCI patients was lower compared with NR patients (odds ratio [OR]: 0.41, 95% confidence interval [CI]: 0.35-0.49); also, patients undergoing PPCI or TL had lower mortality compared with NR patients (OR: 0.47, 95% CI: 0.40-0.55). Among patients ≥80 years old admitted with STEMI to GWTG-CAD hospitals, less than half undergo mechanical or pharmacological reperfusion. However, the proportion of patients undergoing PPCI has increased substantially over the 8-year study period. Patients undergoing PPCI or TL had lower in-hospital mortality compared with the NR strategy.

Quality of Care and Outcomes Among Patients With Acute Myocardial Infarction by Level of Kidney Function at Admission: Report From the Get With The Guidelines Coronary Artery Disease Program

Many patients admitted for acute myocardial infarction (AMI) have chronic renal insufficiency. We studied the impact of chronic renal insufficiency on mortality and quality of inpatient care for AMI from the American Heart Association's Get With The Guidelines-Coronary Artery Disease Program. We hypothesized that mortality and quality of inpatient care would not vary with renal function. We examined in-hospital AMI performance measures by renal function based on glomerular filtration rate (GFR). Severity of renal insufficiency was categorized as normal (GFR ≥ 90 mL/min/1.73 m(2)), mild (GFR 60-90 mL/min/1.73 m(2)), moderate (GFR 30-60 mL/min/1.73 m(2)), severe (GFR 15-30 mL/min/1.73 m(2)), and kidney failure (GFR ≤ 15 mL/min/1.73 m(2) or dialysis). A total of 21721 patients from 291 sites were studied, with most data collected in 2008 to 2009. Multivariable regression analysis after adjusting for patient characteristics was performed and generalized estimating equations were used to account for within-hospital clustering. In-hospital mortality and quality of inpatient care were assessed. Renal insufficiency was present in 82.0 percent of AMI patients. The adjusted odds ratio vs normal renal function for mortality increased with worsening renal function: 1.45 for mild renal insufficiency (95% confidence interval [CI]: 1.03-2.05, P = 0.03); 3.36 for moderate renal insufficiency (95% CI: 2.31-4.89, P < 0.0001); 5.43 for severe renal insufficiency (95% CI: 3.70-7.95, P < 0.0001); and 6.35 for kidney failure (95% CI: 4.48-9.01, P < 0.0001). Patients with renal insufficiency received less inpatient and discharge guideline-recommended therapy for AMI. Among AMI patients, mortality and guideline-recommended inpatient therapy correlated inversely with renal function. Adjusted mortality was equally poor among patients with severe renal dysfunction and on dialysis.

Care and Outcomes of Asian-American Acute Myocardial Infarction Patients: Findings From the American Heart Association Get With The Guidelines-Coronary Artery Disease Program

Asian-Americans represent an important United States minority population, yet there are limited data regarding the clinical care and outcomes of Asian-Americans following acute myocardial infarction (AMI). Using data from the American Heart Association Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program, we compared use of and trends in evidence-based care AMI processes and outcome in Asian-American versus white patients. We analyzed 107,403 AMI patients (4412 Asian-Americans, 4.1%) from 382 United States centers participating in the Get With The Guidelines-Coronary Artery Disease program between 2003 and 2008. Use of 6 AMI performance measures, composite "defect-free" care (proportion receiving all eligible performance measures), door-to-balloon time, and in-hospital mortality were examined. Trends in care over this time period were explored. Compared with whites, Asian-American AMI patients were significantly older, more likely to be covered by Medicaid and recruited in the west region, and had a higher prevalence of diabetes, hypertension, heart failure, and smoking. In-hospital unadjusted mortality was higher among Asian-American patients. Overall, Asian-Americans were comparable with whites regarding the baseline quality of care, except that Asian-Americans were less likely to get smoking cessation counseling (65.6% versus 81.5%). Asian-American AMI patients experienced improvement in the 6 individual measures (P≤0.048), defect-free care (P<0.001), and door-to-balloon time (P<0.001). The improvement rates were similar for both Asian-Americans and whites. Compared with whites, the adjusted in-hospital mortality rate was higher for Asian-Americans (adjusted relative risk: 1.16; 95% confidence interval: 1.00-1.35; P=0.04). Evidence-based care for AMI processes improved significantly over the period of 2003 to 2008 for Asian-American and white patients in the Get With The Guidelines-Coronary Artery Disease program. Differences in care between Asian-Americans and whites, when present, were reduced over time.

Abstract P128: Get With the Guidelines Coronary Artery Disease Program Helps Attain Quality Care in Minority Population: 5 Year Experience in the Inner City Bronx

Background: Gender and race based disparities in health care delivery are reported. Our acute care, non interventional hospital serves a Bronx population comprising predominantly Hispanic/Latino and African Americans. Hypothesis: Get with The Guidelines Coronary Artery Disease (GWTG-CAD) Patient Management Tool helps providers adhere to guideline recommended secondary prevention therapies in hospitalized patients with acute myocardial infarction (AMI), irrespective of gender, ethnicity or race . Our objective was to verify that the program with a dedicated physician champion and staff cardiologists achieved and maintained a high level of adherence in this population by continued education and oversight. Methods: Patients admitted to coronary care unit with diagnosis of AMI were entered into GWTG database. Data entries were both concurrent and retrospective. Guideline recommended therapies were initiated prior to transfer to an interventional facility or discharge. No order sets or checklists were used; however written policy and procedure on AMI management was available as reference, in coronary care unit and Emergency Dept. The 5 year data from January 2004 to December 2008 were analyzed for “defect free care measures” (DFCMs) (% patients receiving all eligible interventions). Chi square testing was done with significance at p&lt;0.05. Results: 728 patient records reviewed, comprising 315 females, 379 males, 525 Hispanics (any race) and 157 non-Hispanics (includes blacks and whites). DFCMs achieved annually from 2004-2008 for sub groups as well as p values are listed in table . Conclusions: The analysis confirms that GWTG program with continuous education of providers helps impart high quality of care (DFCMS) in all subsets, including minority populations. VARIABLE 2004 2005 2006 2007 2008 Male 93.8% (75/80) 97% (65/67) 96.1% (73/76) 100% (93/93) 98.4% (62/63) Female 81.2% (52/64) 91.5% (54/59) 98.3% (58/59) 97% (65/67) 100% (66/66) p value 0.04 0.03 0.79 0.33 0.98 Hispanic (Any Race) 90.5% (86/95) 96.3%(105/109) 96.2%(102/106) 98.4%(125/127) 98.9% (87/88) Non Hispanic (Blacks / Whites) 81.1% (30/37) 84.2% (16/19) 100% (25/25) 97.3% (36/37) 100% (39/39) p value 0.23 0.11 0.73 0.65 0.50

Changes in Myocardial Infarction Guideline Adherence as a Function of Patient Risk: An End to Paradoxical Care?

The goals of this analysis were to determine: 1) whether guideline-based care during hospitalization for a myocardial infarction (MI) varied as a function of patients' baseline risk; and 2) whether temporal improvements in guideline adherence occurred in all risk groups. Guideline-based care of patients with MI improves outcomes, especially among those at higher risk. Previous studies suggest that this group is paradoxically less likely to receive guideline-based care (risk-treatment mismatch). A total of 112,848 patients with MI were enrolled at 279 hospitals participating in Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) between August 2000 and December 2008. We developed and validated an in-hospital mortality model (C-statistic: 0.75) to stratify patients into risk tertiles: low (0% to 3%), intermediate (3% to 6.5%), and high (>6.5%). Use of guideline-based care and temporal trends were examined. High-risk patients were significantly less likely to receive aspirin, beta-blockers, angiotensin-converting inhibitors/angiotensin receptor blockers, statins, diabetic treatment, smoking cessation advice, or cardiac rehabilitation referral at discharge compared with those at lower risk (all p < 0.0001). However, use of guideline-recommended therapies increased significantly in all risk groups per year (low-risk odds ratio: 1.33 [95% confidence interval (CI): 1.22 to 1.45]; intermediate-risk odds ratio: 1.30 [95% CI: 1.21 to 1.38]; and high-risk odds ratio: 1.30 [95% confidence interval: 1.23 to 1.37]). Also, there was a narrowing in the guideline adherence gap between low- and high-risk patients over time (p = 0.0002). Although adherence to guideline-based care remains paradoxically lower in those MI patients at higher risk of mortality and most likely to benefit from treatment, care is improving for eligible patients within all risk categories, and the gaps between low- and high-risk groups seem to be narrowing.

Quality of acute myocardial infarction care and outcomes in 33,997 patients aged 80 years or older: Findings from Get With The Guidelines-Coronary Artery Disease (GWTG-CAD)

To determine the adherence to national guidelines and in-hospital mortality of older patients with acute myocardial infarction (AMI) using a national database. Prior studies have demonstrated that older patients are less likely to receive evidence-based therapies. Using data from the GWTG-CAD, we examined care and in-hospital outcomes among AMI patients treated at 416 US centers from 2000 to 2009. Evidence-based medical therapy, other quality measures, and in-hospital post-AMI mortality were analyzed. A total of 156,677 patients were included in the study; 21.7% (n = 33,997) were aged ≥80 years, 33.0% (n = 51,773) 65 to 79 years, and 45.3% (n = 70,907) 18 to 64 years. Older patients had higher prevalence of comorbidities compared to younger patients. Overall, compliance with evidence-based medical treatment upon admission and discharge was high, but age-related differences in care were seen for most measures. After multivariate adjustment, the mortality of the patients aged ≥80 years was substantially higher compared to the youngest cohort (adjusted OR 3.4, 95% CI 3.2-3.8, P < .0001). There were substantial improvements in AMI quality measures over time in each age group. Among AMI patients aged ≥80 years, the use of evidence-based therapies was high and significant improvements over time have been observed in a national quality improvement program. Nevertheless, there remain important age-related gaps in care and outcomes, suggesting opportunities exist to improve prognosis in this high-risk population.

Performance Achievement Award Program for Get With The Guidelines Coronary Artery Disease Is Associated With Global and Sustained Improvement in Cardiac Care for Patients Hospitalized With an Acute Myocardial Infarction

Adherence to evidence-based guidelines for the treatment of coronary artery disease (CAD) is suboptimal. Our goal was to determine whether the performance achievement award program for Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) was associated with global and sustained adherence to evidence-based guidelines for acute myocardial infarction. Adherence to evidence-based guidelines was assessed in 170,061 hospitalized acute myocardial infarction patients from 418 US hospitals participating in GWTG-CAD from 2000 to 2008. Hospitals that received a performance achievement award by attaining 85% adherence with 6 GWTG performance measures for at least 12 consecutive months were compared with those that had enrolled in the GWTG-CAD and had not attained this level of adherence. The outcome measures were change in adherence for 6 GWTG performance measures, 9 GWTG quality measures, a composite score, and an all-or-none measure. Generalized estimating equations were used to provide valid inference accounting for the within site correlation. Hospitals that maintained 85% adherence with GWTG performance measures for at least 12 consecutive months had a higher composite score (94.78 +/- 15.99% vs. 89.72 +/- 21.37, P < 0.0001) and an all-or-none measure (87.17% vs. 75.15%, P < 0.0001) compared with hospitals that had not yet attained this level of adherence. Hospital adherence with performance and quality measures generally improved over time. In conclusion, the performance achievement award program for GWTG-CAD was associated with global and sustained adherence to evidence-based guidelines. Our data suggest that this tool is a useful component of a quality improvement initiative and should be considered for other similar programs.

Racial and ethnic differences in the treatment of acute myocardial infarction: findings from the Get With the Guidelines-Coronary Artery Disease program.

Racial/ethnic differences in cardiovascular care have been well documented. We sought to determine whether racial/ethnic differences in evidence-based acute myocardial infarction care persist among hospitals participating in a national quality improvement program. We analyzed 142 593 acute myocardial infarction patients (121 528 whites, 10 882 blacks, and 10 183 Hispanics) at 443 hospitals participating in the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) program between January 2002 and June 2007. We examined individual and overall composite rates of defect-free care, defined as the proportion of patients receiving all eligible performance measures. In addition, we examined temporal trends in use of performance measures according to race/ethnicity by calendar quarter. Overall, individual performance measure use was high, ranging from 78% for use of angiotensin-converting enzyme inhibitors to 96% for use of aspirin at discharge. Use of each of these improved significantly over the 5 years of study. Overall, defect-free care was 80.9% for whites, 79.5% for Hispanics (adjusted odds ratio versus whites 1.00, 95% confidence interval 0.94 to 1.06, P=0.94), and 77.7% for blacks (adjusted odds ratio versus whites 0.93, 95% confidence interval 0.87 to 0.98, P=0.01). A significant gap in defect-free care was observed for blacks mostly during the first half of the study, which was no longer present during the remainder of the study. Overall, progressive improvements in defect-free care were observed regardless of race/ethnic groups. Among hospitals engaged in a national quality monitoring and improvement program, evidence-based care for acute myocardial infarction appeared to improve over time for patients irrespective of race/ethnicity, and differences in care by race/ethnicity care were reduced or eliminated.

Are quality improvements associated with the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) program sustained over time?: A longitudinal comparison of GWTG-CAD hospitals versus non–GWTG-CAD hospitals

Previous reports have demonstrated that participation in GWTG-CAD, a national quality initiative of the American Heart Association, is associated with improved guideline adherence for patients hospitalized with CAD. We sought to establish whether these benefits from participation in GWTG-CAD were sustained over time. We used the Centers for Medicare and Medicaid Services Hospital Compare database to examine 6 performance measures and one composite score for 3 consecutive 12-month periods including aspirin and beta-blocker on arrival/discharge, angiotensin-converting enzyme inhibitor (ACE-I) for left ventricular systolic dysfunction (LVSD), and adult smoking cessation counseling. The differences in guideline adherence between the GWTG-CAD hospitals (n = 440, 439, 429) and non-GWTG-CAD hospitals (n = 2,438, 2,268, 2,140) were evaluated for each 12-month period. A multivariate mixed-effects model was used to estimate the independent effect of GWTG-CAD over time adjusting for hospital characteristics. Compared with non-GWTG hospitals, the GWTG-CAD hospitals demonstrated higher guideline adherence for 6 performance measures. The largest differences existed for (1) aspirin at arrival (2.3%, 2.1%, and 1.6% for each 12-month period, respectively), (2) aspirin at discharge (3.4%, 2.2%, and 2.3%), (3) beta-blocker at arrival (3.4%, 2.9%, and 2.6%), and (4) beta-blocker at discharge (2.8%, 1.8%, and 1.5%). In multivariate analysis, the GWTG-CAD hospitals were independently associated with better adherence for 4 of the 6 measures (the exceptions were ACE-I for LVSD and smoking cessation counseling). Superior performance was also found for the composite measures. Although there was some narrowing between groups, GWTG-CAD hospitals maintained superior guideline adherence than non-GWTG-CAD hospitals for the entire 3-year period (adjusted differences 1.8%, 1.6%, and 1.4%). Hospitals participating in GWTG-CAD had modestly superior acute cardiac care and secondary prevention measures performance relative to non-GWTG-CAD. These benefits of GWTG-CAD participation were sustained over time and independent of hospital characteristics.