Background Many hospitals enrolled in the American Heart Association's Get With The Guidelines (GWTG) Program achieve high levels of recommended care for heart failure, acute myocardial infarction ...(MI) and stroke. However, it is unclear if outcomes are better in those hospitals recognized by the GWTG program for their processes of care. Methods We compared hospitals enrolled in GWTG and receiving achievement awards for high levels of recommended processes of care with other hospitals using data on risk-adjusted 30-day survival for heart failure and acute MI reported by the Center for Medicare and Medicaid Services. Results Among the 3,909 hospitals with 30-day data reported by Center for Medicare and Medicaid Services 355 (9%) received GWTG achievement awards. Risk-adjusted mortality for hospitals receiving awards was lower for both heart failure (11.0% vs 11.2%, P = .0005) and acute MI (16.1% vs 16.5%, P < .0001) compared to those not receiving awards. After additional adjustment for hospital characteristics and noncardiac performance measures, the reduction in mortality remained significantly lower for GWTG award hospitals for acute myocardial infraction (−0.19%, 95% CI −0.33 to −0.05), but not for heart failure (−0.11%, 95% CI −0.25 to 0.02). Additional adjustment for cardiac processes of care reduced the benefit of award hospitals by 28% for heart failure mortality and 43% for acute MI mortality. Conclusions Hospitals receiving achievement awards from the GWTG program have modestly lower risk adjusted mortality for acute MI and to a lesser extent, heart failure, explained in part by better process of care.
Background Lipid levels among contemporary patients hospitalized with coronary artery disease (CAD) have not been well studied. This study aimed to analyze admission lipid levels in a broad ...contemporary population of patients hospitalized with CAD. Methods The Get With The Guidelines database was analyzed for CAD hospitalizations from 2000 to 2006 with documented lipid levels in the first 24 hours of admission. Patients were divided into low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), and triglyceride categories. Factors associated with LDL and HDL levels were assessed along with temporal trends. Results Of 231,986 hospitalizations from 541 hospitals, admission lipid levels were documented in 136,905 (59.0%). Mean lipid levels were LDL 104.9 ± 39.8, HDL 39.7 ± 13.2, and triglyceride 161 ± 128 mg/dL. Low-density lipoprotein cholesterol <70 mg/dL was observed in 17.6% and ideal levels (LDL <70 with HDL ≥60 mg/dL) in only 1.4%. High-density lipoprotein cholesterol was <40 mg/dL in 54.6% of patients. Before admission, only 28,944 (21.1%) patients were receiving lipid-lowering medications. Predictors for higher LDL included female gender, no diabetes, history of hyperlipidemia, no prior lipid-lowering medications, and presenting with acute coronary syndrome. Both LDL and HDL levels declined over time ( P < .0001). Conclusions In a large cohort of patients hospitalized with CAD, almost half have admission LDL levels <100 mg/dL. More than half the patients have admission HDL levels <40 mg/dL, whereas <10% have HDL ≥60 mg/dL. These findings may provide further support for recent guideline revisions with even lower LDL goals and for developing effective treatments to raise HDL.
Anticoagulation therapy significantly reduces the incidence of thromboembolic events in patients with atrial fibrillation (AF), and warfarin therapy at discharge is a class I–indicated drug in ...patients with ischemic stroke with persistent or paroxysmal AF without contraindications. The aim was to determine whether participation in the Get With The Guidelines-Stroke (GWTG-S) quality improvement program would be associated with improved adherence to anticoagulation guidelines for patients with all types of AF. Adherence to warfarin treatment at hospital discharge was assessed in eligible patients with AF who presented with stroke or transient ischemic attack, based on type of AF. Of patients with stroke, 10.5% presented with some form of AF. When AF was documented using electrocardiography or telemetry (ECG) during the present admission, eligible patients were more likely to receive warfarin compared with patients for whom AF was reported using medical history only (78.8% vs 49.4%; p <0.0001). Improvement after GWTG-S participation in warfarin use was observed in patients with ECG-documented AF (73.8% at baseline vs 88.5% after the intervention; p <0.0001), but not patients using history only. Women and elderly patients were less likely to receive warfarin, and these gaps in treatment did not narrow during the quality improvement program for patients with ECG-documented AF and those with history only. In conclusion, anticoagulation for stroke prevention was underused in general for patients with AF, even in such high-risk groups as patients with stroke. GWTG-S was associated with improved adherence for patients with ECG-documented AF, but patients with a history of AF alone were largely untreated.
Background Although hospital admissions during weekends have been associated with worse quality of care and worse outcomes in some but not all medical conditions, the impact of weekend versus weekday ...admission and discharge for heart failure (HF) has not been well studied. This study investigates the association of (1) weekend compared to weekday HF admissions and discharges with quality of care and (2) weekend versus weekday HF admissions with length of stay (LOS) and mortality in the hospital. Methods Data were analyzed for 81,810 HF admissions at 241 sites participating in Get With the Guidelines (GWTG)–HF from January 2005 to September 2008. The cohort was stratified by weekend versus weekday admission and discharge. Generalized estimating equations adjusted for patient and hospital characteristics and clustering. Results Mean age was 72 ± 14 years; left ventricular ejection fraction (LVEF) was 39±17%. Inhospital mortality was 3.0% and median LOS 4 days. Weekend admission was associated with decreased odds of LVEF documentation. Weekend discharge was associated with decreased odds of LVEF documentation and completed discharge instructions. Weekend HF admission compared to weekday admission was associated with slightly higher risk-adjusted odds of longer inhospital LOS (1.03 1.01-1.05 and increased inhospital mortality (1.13 1.02-1.27). Conclusions Among GWTG-HF hospitals, weekend admission and discharge for HF were associated with similar quality of care in many but not all measures. Risk-adjusted LOS was slightly longer and mortality moderately higher for weekend HF admissions.
Background Both heart failure (HF) and chronic kidney disease (CKD) are highly prevalent conditions that often coexist; however, the quality of care received by hospitalized patients with both is not ...known. Methods The Get With the Guidelines—HF registry and performance improvement program prospectively collects data on patients hospitalized with HF. Performance measures to improve treatment of patients with HF and inhospital mortality were examined by kidney function based on glomerular filtration rate (GFR) categorized as normal (GFR ≥ 90), mild (60 ≤ GFR < 90), moderate (30 ≤ GFR < 60), severe (15 ≤ GFR < 30), and kidney failure (GFR < 15 or dialysis). Results Nearly two thirds of hospitalized patients with HF (15,560 patients from 137 hospitals) also had CKD: moderate CKD (43.9%), severe CKD (14.2%), and kidney failure (6.6%). Inpatient mortality was higher for patients with more severe renal dysfunction. Those with kidney failure were significantly less likely to receive nearly all guidelines-based therapies. In contrast, those with moderate or severe CKD often received similar care when compared with those with normal kidney function, except for lower use of angiotensin-converting enzyme inhibitors or receptor blockers (odds ratio 0.19 0.13-0.28 and 0.47 0.36-0.62, respectively) and lower proportions with blood pressure control (odds ratio 0.70 0.58-0.85 and 0.52 0.42-0.63, respectively). Conclusions In a large contemporary cohort of patients hospitalized with HF, we found that renal dysfunction was a highly prevalent comorbidity. Despite higher mortality rates, patients with increased severity of renal dysfunction were less likely to receive important guideline-recommended therapies. Further efforts are needed to improve the care of patients with HF and CKD.
Background Longitudinal data directly comparing the rates of death and rehospitalization of patients discharged after transient ischemic attack (TIA) versus acute ischemic stroke (AIS) are lacking. ...Methods Data were analyzed from 2802 patients (TIA n = 552; AIS n = 2250) admitted to 100 U.S. hospitals participating in the Get With The Guidelines–Stroke and the Adherence Evaluation of Acute Ischemic Stroke–Longitudinal registry. The primary composite outcome was the adjusted rate of all-cause death and rehospitalization over 1 year after discharge. Four additional single or combined outcomes were explored. Results Compared with AIS, TIA patients were older (median 69 v 66 years; P = .007) and more likely female (53.3% v 44.2%; P < .0001). Secondary prevention medication use after hospital discharge was less intensive after TIA, with underuse for both conditions. All-cause death or rehospitalization at 1 year was similar for TIA and AIS patients (37.7% v 34.6%; P = .271); the frequency for TIA patients was higher after covariate adjustment (hazard ratio HR 1.19; 95% confidence interval CI 1.01-1.41). One-year all-cause mortality was similar among those with TIA compared to AIS patients (3.8% v 5.7%; P = .071; adjusted HR 0.86; 95% CI 0.52-1.42). All-cause rehospitalizations were higher for TIA compared to AIS patients (36.4% v 33.0%; P = .186; adjusted HR 1.20; 95% CI 1.02-1.42), but similar for stroke rehospitalizations (10.1% v 7.4%; P = .037; adjusted HR 1.38, 95% CI 0.997-1.92). Conclusions Patients with TIA have similar or worse 12-month postdischarge risk of death or rehospitalization as compared with those with AIS. Outcomes after TIA and AIS might be improved with better adherence to secondary preventive guidelines.
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