The American Stroke Assocation's GWTG–Stroke is an in-hospital acute stroke treatment and ischemic stroke prevention program. It focuses on providing an infrastructure for better care to ensure that patients are treated and discharged appropriately.
"We and others have found that missed opportunities to provide preventive stroke care reflect a systems problem, not an expertise problem," said Lee H. Schwamm, M.D., co-investigator of the GWTG-Stroke pilot and an author of both studies.
"Get With The Guidelines is like a pre-flight check list. A person wouldn't want to get on an airplane that didn't have systems to help the crew make sure the plane is ready for take-off. Similarly, Get With The Guidelines provides a kind of check list to review while patients are being treated, and especially before they are discharged from the hospital," he said.
GWTG–Stroke uses inter-hospital collaborative meetings, best-practice sharing and an Internet tool for data collection, reporting and decision support.
"When people operate in isolation, they are not as effective as when they interact in groups," said Schwamm, an associate professor of neurology at Harvard Medical School and associate director of Acute Stroke Services at Massachusetts General Hospital in Boston. "This collaborative model brings people together -- colleagues and competitors alike -- who are interested in improving stroke care quality."
Both studies analyzed stroke treatment in the same group of 21,563 ischemic stroke patients at 99 participating hospitals.
One study, which was led by Kenneth A. LaBresh, M.D., vice president of Medical Affairs and Quality Improvement at MassPRO in Waltham, Mass., the health care quality improvement organization for Massachusetts, focused on a broad range of patients with ischemic stroke or TIAs and reported the use of and improvement in eight secondary preventive measures.
In terms of prevention, they monitored the percentage of discharged patients who received anticoagulation for atrial fibrillation; treatment with aspirin-like drugs or anticoagulants; cholesterol measurement; treatment for low-density lipoprotein (LDL) cholesterol levels of 100 or higher, or continued therapy for those already on cholesterol-lowering drugs; medications to control diabetes; counseling/drug therapy for smoking cessation; and recommendations for lifestyle changes to control obesity.
Clinically meaningful and statistically significant improvement occurred in all these areas. Certain aspects of care, such as providing treatment with aspirin-like drugs or anticoagulants, had a high baseline compliance (90.7 percent) and continued to improve by the fourth quarter (97 percent). Others, such as treatment with tPA, had low baseline compliance (32.3 percent) and improved substantially (61.1 percent).
"Our data suggest a broad range of baseline rates of compliance on these measures, and there are abundant opportunities for improvement," Schwamm said. "We would consider many of these measures routine and expect them to be performed in all patients. These data provide evidence that system change improves hospital-based compliance with these acute treatment and secondary prevention strategies."
LaBresh added: "The ability of our hospitals to significantly improve the use of secondary prevention measures is particularly exciting because these measures apply to a broad range of patients. Their use will help prevent future strokes and cardiovascular events and are most effective when started in the hospital."
The second study, led by Schwamm, examined clot-buster and early aspirin use in patients presenting with acute ischemic stroke. Researchers monitored the percentage of eligible stroke patients arriving within two or three hours of symptom onset who received timely treatment with intravenous tPA, the standard FDA-approved clot-busting therapy. They also monitored how many patients were treated with aspirin-like drugs or anticoagulants within 48 hours, and the number documented as ineligible for intravenous tPA treatment.
The researchers emphasized the use of tPA within 60 minutes, and monitoring symptomatic systemic or intracranial hemorrhage. Data were documented at baseline and for four subsequent quarters.
Results showed that GWTG–Stroke implementation was associated with a dramatic 89 percent improvement in rates of intravenous tPA use in eligible patients who came in within two hours of symptoms, without an increase in bleeding complications. By the fourth quarter, 85 percent of all acute stroke patients who did not receive IV tPA had a documented reason for ineligibility. The study also showed that reducing door-to-needle time remains a challenge, but Schwamm said that the GWTG-Stroke program addresses the type of "rapid cycle improvement" needed to target this problem.
"It's the first program that has been able to show this much improvement in stroke care so rapidly across this scope and scale of patients and hospitals," he said.
"Guidelines by themselves are not successful in changing practice. However, guidelines tied to individual patients at the point of care can have an impact. This program helps bridge the gap between what we know and what we do."
Co-authors for both studies are Dawn G. Albright; Michael Frankel, M.D.; Irene Katzan, M.D.; Ali Malek, M.D.; Mathew Reeves and Scott E. Kasner, M.D.
GWTG-Stroke is not a certification program. It is a voluntary in-hospital, quality improvement recognition program.
Editor's note: The American Heart Association's Get With The GuidelinesSM quality improvement program received the 2004 Innovation in Prevention Award from Tommy Thompson, Secretary of Health and Human Services. The award recognized GTWG as "the premiere hospital-based healthcare improvement program for cardiac and stroke patients."
Statements and conclusions of study authors that are published in the American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect association policy or position. The American Heart Association makes no representation or warranty as to their accuracy or reliability.
Abstracts P84, 93
NR05-1003 (ISC05/Schwamm)
Note: Abstract P84 will be presented at 5:30 p.m. CST, Wednesday, Feb. 2, 2005.
Abstract 93 will be presented at 10:02 a.m. CST, Friday, Feb. 4, 2005.