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Geriatrics: ••Winter 2003/Vol. 7, No. 1 |
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Putting
Heart Disease Guidelines Into Practice: Kaiser Permanente Leads the Way
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Introduction In their 2001 update of the 1995 clinical guidelines for prevention of heart attack and death in patients with atherosclerotic cardiovascular disease, the American Heart Association (AHA) and the American College of Cardiologists (ACC) incorporated findings from numerous clinical trials and other consensus statements.1 In summary, the new guidelines call for
The guidelines no longer call for use of estrogen replacement therapy in postmenopausal women due to recent findings.7,8 Figure 1 (figure web link no longer availble) lists the updated guidelines for secondary prevention of heart attack and death in patients with coronary and other vascular diseases. Recommendations and goals that differ from the 1995 guidelines are listed in Table 1. Use of Practice Guidelines Improves Patient Outcomes Because the guidelines are derived from numerous clinical trials, hospitals that have implemented earlier iterations of the AHA/ACC guidelines for management of acute myocardial infarction (AMI) have found improved patient outcomes. The UCLA Medical Center's Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) instituted a systematic approach to increasing use of the AHA/ACC guidelines. Before CHAMP, 14.8% of MI patients had recurrent MI or died; after CHAMP, rates of death or recurrent MI fell to 6.4%.9 Similarly, Peterson recently presented data from the NRMI-4 Registry that documented a strong relationship between the processes used by hospitals for MI care and patient outcomes. Specifically, hospitals that more closely followed AHA/ACC guidelines had significantly lower overall in-hospital mortality than did hospitals that delivered care less consistent with the guidelines (Eric Peterson, MD, MPH, personal communication, October 15, 2002).a A pilot
study from the Cooperative Cardiovascular Project provided additional
support for the observation that patient outcomes improve when clinical
guidelines are implemented in medical practice. That study showed a decrease
in long-term mortality for a sample of elderly patients with myocardial
infarction treated in hospitals that participated in a quality improvement
program using evidence-based forms of therapy.10 Need for Wider Implementation of Evidence-Based Clinical Guidelines Despite evidence that following these guidelines will improve patient outcomes, overall implementation nationally is far from optimal (Figure 2) (figure web link no longer availble).12 However, this shortfall in implementation cannot be attributed to a lack of physician awareness of the guidelines. For example, in a large-scale study,13 95% of clinicians were aware of the National Cholesterol Education Program (NCEP) guideline for lipid management, yet only 18% of their patients with coronary heart disease were treated to LDL goal. The more likely explanation for poor implementation of evidence-based guidelines is that the guidelines are generally not well integrated into the health care delivery system. Recently, at least four documented efforts were implemented to solve this problem: the UCLA Medical Center's Cardiac Hospitalization Atherosclerosis Management Program (CHAMP),9 the American Heart Association's Get With the Guidelines (GWTG) program,14 the American College of Cardiology's Guidelines Applied to Practice (GAP) program,15 and Kaiser Permanente Northern California's (KPNC) Cardiovascular Disease Management Program.16,17
ASA = acetylsalicylic
acid (aspirin); ACE-I = angiotensin-converting enzyme inhibitor; HCFA
= Health Care Financing Administration (renamed Centers for Medicare &
Medicaid Services (CMS) in July 2001); NRMI = National Register of Myocardial
Infarction. Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) The CHAMP program, begun in 1994 and still in use, focuses on implementing guidelines that call for prescribing aspirin, cholesterol-lowering medication, beta-blockers, and ACE inhibitors in conjunction with counseling about diet and exercise before CAD patients are discharged from the hospital. Implementation of this program includes use of focused treatment guidelines, standardized admission orders, educational lectures, and tracking and reporting of adherence to the evidence-based treatment guidelines. Compared with the two-year period preceding implementation of the program, CHAMP increased adherence to treatment guidelines (Table 2). These improvements were also sustained at one-year follow-up--a finding demonstrating that therapies begun in the hospital are more likely to be continued. CHAMP patients also had better clinical outcomes (Table 3).9 Although these findings are impressive, they must be interpreted with regard to the fact that the study was observational only and lacked a concurrent control group.
Get With the Guidelines (GWTG) Program CHAMP results inspired the American Heart Association to develop Get With the Guidelines,14 an in-hospital program that standardizes discharge protocols for CAD patients. Its centerpiece is a Patient Management Tool that is available online as a one-page form. The form includes a checklist of medications recommended by the AHA/ACC guidelines and reminds the discharging clinician to refer the patient to smoking cessation, nutrition, and physical activity counseling as appropriate. The provider who is responsible for discharge clicks in the appropriate boxes to record medications and referrals given to the patient. The online Patient Management Tool also includes "pop-up" explanations and evidence-based justification of each recommendation in the guidelines. To increase the likelihood that when discharged from the hospital patients will follow a plan consistent with AHA/ACC guidelines, the AHA encourages health care practitioners to complete the online form immediately at discharge instead of retrospectively. To reinforce continuity of care, the Patient Management Tool can generate a discharge note for the patient and for the medical chart and can fax a discharge letter to the patient's primary care practitioner. The tool can also store data that the hospital can transmit to third parties, which can include the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to satisfy requirements for reporting core measures. The data collected by the Patient Management Tool can also be relayed back to clinicians and hospitals in a graphic format for convenient comparison with national performance on adherence to guidelines. Offering regular performance feedback using this benchmarking tool has been shown to drive improvements to systems of care. GWTG was piloted in four hospitals in New England, and results showed that the program improved smoking cessation, lipid measurement and treatment, blood pressure control, and referral to cardiac rehabilitation.12 The American Heart Association is introducing GWTG in California, beginning with the southern part of the state (in 2001). The Guidelines Applied to Practice (GAP) Program The ACC's GAP program for acute myocardial infarction provides another illustration of how adherence to clinical guidelines improves when the system is changed so that guidelines are integrated into the tools of practice and thus become institutionalized.15 GAP uses a toolkit which includes standard orders, a clinician pocket guide, a clinical pathway, patient education materials, chart reminders, and examples of how to report performance. GAP has increased use of aspirin (81% vs 87%, p = 0.02) and beta blockers (65% vs 74%, p = 0.04) at admission to the hospital; and use of aspirin (84% vs 92%, p = 0.002) and smoking cessation (53% vs 65%, p = .02) at discharge from the hospital. Adherence to other quality indicators was improved, although improvement did not reach statistical significance.15 KPNC Cardiovascular Disease Management Programs KPNC's approach toward development of clinical guidelines and critical pathways has been truly visionary. Systematic efforts to implement evidence-based cardiovascular guidelines have been in place at KPNC since the early 1990s to reduce mortality in CAD patients. The program is supported at each KPNC facility by a multidisciplinary team of champions including cardiologists, intensivists, emergency department physicians, internists, critical care nurses, and pharmacists. KPNC's horizontal and vertical integration of health care delivery facilitates systematic implementation of guidelines. Standing orders and preprinted discharge sheets promote adherence to secondary prevention guidelines during inpatient care. After patients are discharged from the hospital, MULTIFIT and the Cholesterol Management Program assure that patients continue to receive recommended care. MULTIFIT is an individualized, nurse-managed program intended to reduce risk through lifestyle changes and adherence to medications. Patients recovering from heart attack who choose to enroll in MULTIFIT receive their first consultation with the nurse-manager while still in the hospital. These patients receive counseling about smoking cessation, lipid management, medication use, proper nutrition, and other risk-reduction strategies. After patients return home, they receive continuous encouragement and guidance for making lifestyle changes at scheduled phone calls with the MULTIFIT nurse and by receiving written progress reports by mail. Patients participate with MULTIFIT for a period ranging from six months to a year, depending on progress. The MULTIFIT program currently serves approximately 3100 patients per year. Patients who have completed MULTIFIT or who declined enrollment in MULTIFIT can enroll in the Cholesterol Management Program (CMP), which addresses both primary and secondary prevention of CAD. Priority is given to four groups of patients: CAD patients whose plasma lipid levels are not at goal (plasma LDL level <100 mg/dL [2.59 mmol/L]); patients who have high triglyceride levels; MULTIFIT graduates; and diabetic patients whose plasma lipid levels are not at goal. Through phone calls, mailings, and referrals to health education programs, a nurse-manager or pharmacist-manager helps patients to change their lifestyles as needed. With the aid of a computer program, the case manager assesses each patient's risk and tracks results of lipid tests as well as medication use. The CMP currently serves 65,660 patients per year. Outreach is facilitated by the Patient Integrated Log and Outpatient Tracking (PILOT) system, which searches KPNC's CAD registry to identify (and mail letters to) patients who must return to the clinic for lipid tests, medication management, and other follow-up care. The CAD registry also supports a Population Care Registry, which generates a Member Summary Sheet for the clinician at the time of a patient visit. The summary sheet is placed on the face of the patient chart by the medical assistant and contains patient-specific information (eg, medication prescribed, dates of lipid tests taken and scheduled, smoking status) and prompts the clinician about needed tests and medication adjustment. The CAD registry is also one of the databases used to generate the Preventive Health Prompt, a patient-focused strategy in which patients registering for a health care visit are given a receipt that includes a record of screening examinations given and due. For patients listed in the CAD registry, the receipt shows the date when lipid levels should next be tested. These strategies have improved patient outcomes.16 For example, in KPNC, LDL control (ie, plasma LDL level <130 mg/dL [3.36 mmol/L]) in CAD patients improved from 22% (in 1996) to 81% (in 1999).17 In 1997, the rate was 97% among eligible patients recovering from myocardial infarction (MI) who received beta-blockers at discharge from the hospital.17 After adjustments are made for age and sex, mortality from heart disease is 30% lower in the KPNC population than in the non-KPNC population in California.17 Of the 16 Northern California hospitals recognized by the Office of Statewide Health Planning and Development as having significantly lower-than-expected rates of mortality from acute MI, nine were Kaiser Permanente facilities.18 Conclusions These programs share three important similarities. First, recognizing that system change must be driven by strong intent, each program uses in-hospital multidisciplinary teams led by at least one "champion." Second, each program uses prompts (eg, preprinted orders and checklists) to ensure that following guidelines is not dependent on clinicians' memory. Third, as part of continuous quality improvement, each program provides feedback to clinicians and hospitals regarding their performance. The KPNC model adds an outpatient component that assures patients continue recommended care.
Acknowledgments
References
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