Featured Quality Research

The American Heart Association's (AHA) Get With The Guidelines® (GWTG) is a hospital-based quality improvement program designed to close the treatment gap in cardiovascular disease, heart failure, resuscitation and stroke. Our suite of quality improvement programs collects millions of patient records that allow investigator-led research using this data. The AHA greatly values clinical investigators and their research.

Each month we will spotlight the author of the newest Quality Improvement Research coming from the Get With The Guidelines Data Registries.  

Questions with the Experts

August 2020:

Saket Girotra, MD, SM
Associate Professor of Medicine
University of Iowa Carver College of Medicine

Data Registry: Get With The Guidelines®- Resuscitation

Published Study: Association of Hospital-Level Acute Resuscitation and Post resuscitation Survival With Overall Risk-Standardized Survival to Discharge for In-Hospital Cardiac Arrest JAMA Network Open

When you started this study, what were you aiming to learn? 
"Prior work from GWTG-Resuscitation has shown that survival for survival for in-hospital cardiac arrest (IHCA) varies by more than 3-fold. We wanted to find out whether high survival at top-performing hospitals is because they excel in running codes, excel in post-resuscitation care, or both.

Who was your target patient population and how did you study them? 
"We used data from 290 hospitals participating in GWTG-R during 2015-2018. For each hospital in our study, we calculated risk-adjusted rates of acute resuscitation survival, defined as return of spontaneous circulation (ROSC) for at least 20 minutes, post-resuscitation survival, defined as survival to discharge, in patients who achieved ROSC and overall survival using a validated methodology. We examined the extent to which hospital rates of overall survival were correlated with rates of acute resuscitation and post-resuscitation survival."

Did the study results turn out as you had expected or were you surprised with what you found? 
"We found that a hospital’s overall risk-standardized survival rate (RSSR) was correlated with both acute resuscitation and post-resuscitation survival which was expected because in order for patients to survive, they must achieve ROSC and survive during the post-resuscitation phase. However, the strength of the correlation between overall RSSR and post-resuscitation survival was much stronger compared to its correlation with acute resuscitation survival (rho=0.90 vs. 0.50). Additionally, we found no correlation between acute resuscitation and post-resuscitation survival. This finding was rather unexpected and suggested that hospitals that excel in IHCA survival, either excel in acute resuscitation, or post-resuscitation survival but not consistently both phases.

How do you see this study impacting the future of medicine and patient care? 
"Our findings have important implications for quality improvement for resuscitation care. The current AHA GWTG-R quality measures that incentivize hospitals are focused only on acute resuscitation. Our findings suggest that in order for us to achieve continued improved in overall IHCA survival, there is an urgent need to identify best practices for post-resuscitation survival." 

July 2020:

Nancy Luo, MD, FACC
Advanced Heart Failure Cardiology
Dignity Health Heart and Vascular Institute
Sacramento, CA

Data Registry: Get With The Guidelines®-Heart Failure

Published Study: Outcomes and Cost Among Medicare Beneficiaries Hospitalized for Heart Failure Assigned to Accountable Care Organizations. American Heart Journal 2020 

When you started this study, what were you aiming to learn? 
"Accountable care organizations (ACO) were created in 2010 as a promising alternative payment and care delivery model that aimed to improve care for US patients and reduce costs. Programs continue to expand a decade later, but we didn’t know their specific effect on the quality of care for patients with HF. Heart failure continues to be a leading driver for the cost of care and cause of readmissions among Medicare beneficiaries. As quality is a primary focus of the AHA GWTG programs, we thought GWTG-HF would serve as the ideal platform to analyze the impact of an ACO on patient HF-related performance measures, patient outcomes, and cost." 

Who was your target patient population and how did you study them? 
"We targeted hospitalized Medicare patients with heart failure, as these are one of the most costly and high risk populations in Medicare. We linked GWTG-HF to CMS data and capitalized on quality metrics gathered within GWTG to evaluate patient outcomes."

Did the study results turn out as you had expected or were you surprised with what you found? 
"Our study showed that participation in an accountable care organization (ACO) was not associated with reduction in annual CMS cost or risk-adjusted readmission. However, we were very surprised that all-cause mortality risk over 1-year was 15% lower in the ACO group. This finding was especially surprising as there was no difference in hospitalization rates. Our analysis was risk adjusted for many defined underlying differences, but there may still be residual confounders that account for this mortality difference. For me, this finding highlights the important impact of social determinants of health on mortality and morbidity in HF, as those represented some of the major factors that differentiated the ACO and non-ACO patients." 

How do you see this study impacting the future of medicine and patient care? 
"Our study highlights the need to rigorously and continuously study policy changes so we understand intended and unintended effects. As the ACO program expands, i hope we will continue to learn from the programs that are successful so that we can implement the most efficacious interventions." 

June 2020:

Shumei Man, MD, PhD, FAHA
Director, Cleveland Clinic Fairview Hospital Stroke Center
Staff, Department of Neurology and Cerebrovascular Center
Neurological Institute
Cleveland Clinic

Data Registry: Get With The Guidelines®-Stroke

Published Study: Association between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients with Acute Ischemic Stroke. JAMA 2020

When you started this study, what were you aiming to learn? 
"We recognized that there has been a knowledge gap when it comes to intravenous thrombolytic therapy for acute ischemic stroke—the lack of understanding about long term outcomes. Randomized clinical trials have shown that intravenous thrombolytic therapy, if administered within 4.5 hours of stroke onset, can improve functional outcomes at 3 months. Furthermore, earlier administration of tPA was associated with reduced in-hospital mortality and better functional outcomes at discharge and 90 days. Door-to-needle time is directly under the control of the stroke care teams and has been used as a target for quality improvement by the American Heart Association Target: Stroke national quality initiative to shorten time to thrombolytic therapy. However, it remains unclear whether shorter door-to-needle (DTN) times translate to better long-term outcomes and survival benefit. This study aimed to examine the association of DTN times for intravenous thrombolytic therapy with all-cause mortality, all-cause readmission, the composite of mortality and readmission, and cardiovascular readmission, at one year after acute ischemic stroke. Recurrent stroke readmission was later added as a post hoc outcome which turned out to be a nice negative control."

Who was your target patient population and how did you study them? 
"The targeted patient population are patients who were treated with intravenous thrombolytic therapy for acute ischemic stroke within 4.5 hours of last known normal from 2006 to 2016. In order to obtain accurate door-to-needle times and clinical information, we used Get With The Guidelines (GWTG)-Stroke, an ongoing registry and quality initiative collecting patient level clinical data. GWTG-Stroke was launched by the American Heart Association/American Stroke Association (AHA/ASA) to support continuous quality improvement in hospital systems of care for patients with stroke and transient ischemic attack.  GWTG-Stroke includes a substantial proportion of all acute ischemic stroke patients in the US.  In order to obtain post discharge outcomes, GWTG-Stroke was linked with Medicare fee-for-service claims files which means that only patients aged 65 years and older who were covered by Medicare program were included in the final study. As a result, this study included 61426 Medicare beneficiaries aged 65 years and greater who were treated with intravenous thrombolytic therapy for acute ischemic stroke at GWTG-Stroke participating hospitals between January 1, 2006 and December 31, 2016.".

Did the study results turn out as you had expected or were you surprised with what you found? 
"Because there was no prior study showing that shorter DTN times were associated with better long-term outcomes, the results were a nice surprise. We were inspirited to see that shorter DTN times were associated with both lower mortality and readmission at one year, with the lowest mortality and readmission rates at DTN time of 45 minutes and less. The results were not unexpected. Prior studies have shown that earlier intravenous thrombolytic therapy was associated with lower hemorrhagic transformation and in-hospital mortality, and better functional outcomes at discharge and 3 months. It is possible that better and sooner functional recovery have enabled more physical activity and healthier lifestyle resulting in lower long-term mortality, readmissions, and cardiovascular events.".

How do you see this study impacting the future of medicine and patient care? 
"This retrospective study, with substantially more power and longer follow up period than clinical trials, found lower long-term mortality and readmission rates associated with shorter DTN times. The findings support further implementation of the strategies and goals of Target: Stroke national quality initiatives to shorten time to thrombolytic therapy. Although studies have shown that median DTN  times have decreased and the proportion of patients treated with DTN times within 45 minutes and 60 minutes have greatly increased since the launch of Target: Stroke in 2010, study has also shown that there were still opportunities in implementing the strategies that were most strongly associated with shorter DTN times, such as direct transport to CT/MRI scanner by EMS, premix of tPA ahead of time, protocol for routine premixing of tPA, initiation of tPA in the brain imaging suite, CT/MRI scanner physically located in the ED, and a timer or clock attached to track time. With the understanding that shorter DTN times can save lives and reduce readmissions in long term, health care professionals and stakeholders could be more motivated and determined to further shorten the time to thrombolytic therapy.".