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

April 2021:

Pratyaksh K. Srivastava, MD
Cardiology Fellow
UCLA Medical Center
Los Angeles, CA

Data Registry: Get With The Guidelines®-Stroke

Published Study: Acute Ischemic Stroke in Patients With COVID-19: An Analysis From Get With The Guidelines-Stroke; Stroke

When you started this study, what were you aiming to learn? 
"The COVID-19 pandemic has created significant challenges in the delivery of acute stroke care. We sought to evaluate the clinical impact of the pandemic on those presenting with acute ischemic stroke (AIS)".

Who was your target patient population and how did you study them? 
"We evaluated the clinical characteristics, treatment patterns, and outcomes of 41,971 patients from 458 hospitals in the Get With The Guidelines-Stroke registry with a diagnosis of acute ischemic stroke between February 4th, 2020 and June 29th, 2020. Of this population, 1,143 patients were also positive for COVID-19 (AIS/COVID-19)."

Did the study results turn out as you had expected or were you surprised with what you found? 
"We found that patients with AIS/COVID-19 were more likely to be non-Hispanic Black, Hispanic, or Asian, had a greater proportion of large vessel occlusions, and presented with higher National Institutes of Health Stroke Scale scores compared to patients with AIS/no COVID-19. While rates of thrombolysis and thrombectomy were similar between the two groups, door to computed tomography, door to needle, and door to endovascular therapy times were all longer in the AIS/COVID-19 cohort. In adjusted models, patients with AIS/COVID-19 had decreased odds of discharge with a modified Rankin Scale score ≤2, and increased odds of in-hospital mortality when compared to those with AIS/no COVID-19."

How do you see this study impacting the future of medicine and patient care? 
"These findings demonstrate the challenges associated with delivering acute stroke care to those with COVID-19, and highlight a potential need for enhanced protocols and interventions for those who present with AIS and a simultaneous diagnosis of COVID-19. " 


March 2021:

Ying Xian, MD, PhD, FAHA
Associate Professor of Neurology and Medicine
Duke University
Durham, NC

Data Registry: Get With The Guidelines®-Stroke

Published Study: Clinical Characteristics and Outcomes Associated With Oral Anticoagulant Use Among Patients Hospitalized With Intracerebral Hemorrhage; JAMA Network Open

When you started this study, what were you aiming to learn? 
"Factor Xa (FXa) inhibitors such as apixaban, rivaroxaban, and edoxaban have increasingly gained popularity as first-line agents for stroke prevention in high-risk individuals with atrial fibrillation. Despite their improved safety profiles over warfarin, up to 0.7% of patients taking FXa inhibitors still experience an intracranial bleeding event with each year of treatment. Because of the low rate of bleeding events, there remains limited experience with FXa inhibitors-related intracerebral hemorrhage (ICH), the most feared complication of oral anticoagulation therapy (OAC)".

Who was your target patient population and how did you study them? 
"Using data from the Get With The Guidelines® Stroke program, the largest stroke registry in the nation, we studied patients who experienced a non-traumatic ICH. We compared patients with preceding use of FXa inhibitors against those on warfarin or those without any OAC."

Did the study results turn out as you had expected or were you surprised with what you found? 
"We found 27% ICH patients with preceding use of FXa inhibitors died during hospitalization. Although the mortality rates were higher than ICH with no OAC, patients on FXa inhibitors had 24% lower odds of death than ICH due to warfarin use. In addition, individuals on FXa  inhibitors were more likely to be discharged home and have better functional outcomes at discharge than those treated with warfarin. Concomitant OAC and antiplatelet therapy were quite common among ICH patients. Among ICH on warfarin, both single and dual antiplatelet therapy were associated with worse outcomes as compared with those on warfarin alone. To our surprise, such incremental risk was not found in patients taking FXa inhibitors. This is clinically relevant because some patients may be required to take both anticoagulant and antiplatelet agents for a short period of time in certain clinical scenarios such as atrial fibrillation with recent PCI."

How do you see this study impacting the future of medicine and patient care? 
"Although quite rare, FXa inhibitor-related ICH remains a devastating complication of oral anticoagulation. Having said that, many patients are required to take OAC to prevent thromboembolic events. Our findings suggest that FXa inhibitors may be a better choice than warfarin when OAC is warranted.  Additionally, further study is warranted to identify the best treatment strategies, such as the anticoagulation reversal treatment, for FXa inhibitor-related ICH." 


February 2021:

Daniel J. Friedman, MD
Assistant Professor of Medicine (Cardiology)
Yale New Haven Hospital
New Haven, CT

Data Registry: Get With The Guidelines®- AFIB

Published Study: Procedure characteristics and outcomes of atrial fibrillation ablation procedures using cryoballoon versus radiofrequency ablation: A report from the GWTG-AFIB registry; Journal of Cardiovascular Electrophysiology

When you started this study, what were you aiming to learn? 
"Radiofrequency ablation had long been the standard for catheter ablation of atrial fibrillation. However, over the last decade, cryoballoon ablation has increasingly gained popularity, particularly for paroxysmal atrial fibrillation. Despite this, there was relatively little real-world data on use of cryoballoon ablation, as compared to radiofrequency ablation. We sought to describe patterns of use and periprocedural outcomes associated with use of radiofrequency and cryoballoon ablation in the US. ".

Who was your target patient population and how did you study them? 
"We studied all patients in the GWTG-AFIB Registry who underwent ablation of atrial fibrillation with either a radiofrequency catheter or a cryoballoon. Our study included patients with paroxysmal and persistent atrial fibrillation, including those undergoing de novo and repeat procedures."

Did the study results turn out as you had expected or were you surprised with what you found? 
"The study demonstrated that reassuringly, rates of phrenic nerve injury, which was a concern with use of the cryoballoon, were significantly less common in the real world compared to the pivotal FIRE and ICE trial. However, phrenic nerve injury was still more common with cryoablation compared to radiofrequency ablation. We did observe that radiofrequency ablation cases, which use catheters that emit saline to prevent overheating and clot formation, more commonly had issues associated with this, including more issues with periprocedural volume overload. There were no differences in major complications like pericardial tamponade, stroke, or death. Overall, cryoballoon ablation was associated with fewer complications, although this finding was largely driven by fluid overload related complications in patients with persistent atrial fibrillation.

We were overall surprised to find that although the cryoballoon was initially studied for achieving pulmonary vein isolation in paroxysmal atrial fibrillation, it was being used very frequently in the setting of more advanced forms of atrial fibrillation and in the context of extra-pulmonary vein ablation."

How do you see this study impacting the future of medicine and patient care? 
"This study demonstrates that the cryoballoon has an excellent safety profile and that rates of phrenic nerve injury are even lower in the real world than what were observed in the pivotal FIRE and ICE trial. These data are particularly important in light of the recent STOP-AF and EARLY-AF trials, which compared cryoballoon ablation with medical therapy for recently diagnosed paroxysmal atrial fibrillation. The safety data from our study suggests that, in the current era, both radiofrequency and cryoballoon ablation demonstrate excellent safety among patients with paroxysmal atrial fibrillation." 


December 2020:

Frederik Dalgaard, MD, PhD
Herlev & Gentofte Hospital, Copenhagen, Denmark
Duke Clinical Research Institute, Durham, NC, USA

Data Registry: Get With The Guidelines®- AFIB

Published Study: Management of Atrial Fibrillation in Older Patients by Morbidity Burden: Insights From Get With The Guidelines‐Atrial Fibrillation; JAHA

When you started this study, what were you aiming to learn? 
"As clinicians, treating multimorbid patients is a complex and growing challenge. Older patients with atrial fibrillation(AF) often present with a high number of comorbidities and receive a higher number of prescriptions. Furthermore, multimorbidity increases the risk of stroke in patients with AF. These multiple comorbidities, which are indicative of an increasingly complex patient population, may influence therapeutic choices and quality of care. With sparse guidelines, it is unknown how multimorbid older AF patients are managed. We had two main objectives. Firstly, we wanted to investigate if the prevalence of patients with atrial fibrillation and multimorbidity was growing. Secondly, we wanted to investigate if the comorbidity burden affected the treatment decisions for patients with atrial fibrillation".

Who was your target patient population and how did you study them? 
"We investigated hospitalized patients with AF who were more than 65 years old from the Get With The Guidelines®-Atrial Fibrillation registry from 2013 to 2019. The patients had to be eligible for oral anticoagulation therapy. We used a temporal trend analysis to conclude if the multimorbidity was growing in patients with AF and we used logistic regression models to determine whether multimorbidity was associated with oral anticoagulant treatment at discharge.."

Did the study results turn out as you had expected or were you surprised with what you found? 
"We found that multimorbidity was extremely common and prevalent in almost two thirds of the patients with AF over 65 years of age. During the study period, multimorbidity increased with 4.9% which was more than we had expected. The most common comorbidities were hypertension, heart failure, coronary artery disease, and diabetes. The overall prescription rate of oral anticoagulants was quite high, 8 out of 10 received oral anticoagulation at discharge. However, having a high multimorbidity burden was associated with fewer prescription of oral anticoagulation at discharge. To our surprise, the most common reason for non-prescription was frequent falls and frailty. Reasons that research have shown for non-use of oral anticoagulants, in particular in the era of novel oral anticoagulants, are rarely good. The very high rates of oral anticoagulation used in this study may not reflect other healthcare settings, since the patients in this study was recruited in a quality of care database that aims to improve stroke prevention in patients with AF. This could potentially limit the generalizability of the results.."

How do you see this study impacting the future of medicine and patient care? 
"Healthcare workers and physicians should be aware that multimorbidity in AF is common and rising in prevalence. Furthermore, our study highlights a gap between current knowledge of atrial fibrillation management and clinical misperceptions regarding the benefits and risks of oral anticoagulation therapy. The study implies the need for initiatives that can close this gap between knowledge and clinical practice to improve the use of oral anticoagulation therapy in patients with high multimorbidity, mitigating the high stroke risk in this population." 


October 2020:

Feras Akbik, MD, PhD
Assistant Professor, Neurology and Neurosurgery
Emory University School of Medicine

Data Registry: Get With The Guidelines®-Stroke

Published Study: Trends in Reperfusion Therapy for In-Hospital Ischemic Stroke in the Endovascular Therapy Era; JAMA Neurology(link opens in new window)

When you started this study, what were you aiming to learn? 
"As a resident physician, I often found that inpatient stroke alerts were a frustrating mixture of confusion and delay, while strokes in the emergency department were routine. I wanted to better understand whether this was a more widespread experience, and if so, what the impact of these delays were on patient outcomes.  The hope was to identify tractable targets to guide efforts to improve stroke therapy for patients already under our care in the hospital".

Who was your target patient population and how did you study them? 
"Leveraging the national Get With The Guidelines-Stroke registry, we found that the in-hospital onset strokes are increasingly reported from 2008-2018.  Our target population was patients who received reperfusion therapy, either with mechanical thrombectomy and or intravenous thrombolysis.  We dichotomized these patients by site of stroke onset, either in or out of the hospital, and then compared quality metrics as well as functional outcomes."

Did the study results turn out as you had expected or were you surprised with what you found? 
"We predicted that the use of intravenous thrombolytics would be fairly constant throughout the study period, while endovascular therapy would significantly increase in 2015 (after publication of the pivotal clinical trials).  We did see a significant increase in endovascular therapy starting in 2015, but we were surprised to see a steady, year-over-year increase in intravenous thrombolysis, more than doubling over the 10-year period."

How do you see this study impacting the future of medicine and patient care? 
"Hospitals that have acknowledged the importance and morbidity of inpatient strokes have developed and practiced inpatient stroke protocols, minimizing the disparities in treatment and outcomes after in-hospital onset strokes.  We hope that by highlighting the persistence of these disparities nationwide helps our colleagues around the country revisit their inpatient stroke protocols.  If they do not have one, this is a call to develop and implement one.  If they do have one, our data highlight the importance of reevaluating and practicing the protocol to maximize patient outcomes.  Triage will always be faster in the emergency department; it's what they do all day, every day.  But we can do better upstairs." 


September 2020:

Madeline Sterling, MD, MPH, MS
Associate Professor of Medicine
Weill Cornell Medicine, New York, NY

Data Registry: Get With The Guidelines®-Heart Failure

Published Study: Home Health Care Use and Post-Discharge Outcomes After Heart Failure Hospitalizations JACC: Heart Failure

When you started this study, what were you aiming to learn? 
"There have been a few studies to suggest that home health care (HHC) use has been increasing among older adults discharged home after a heart failure (HF) hospitalization, but few contemporary studies have investigated this at the national level. HHC provides patients with home-based personal and skilled medical care after discharge, so our team wanted to understand how these services were being used and how they influenced post-discharge outcomes among HF patients. In that context, we had two main objectives. First, we aimed to describe utilization patterns of HHC among Medicare beneficiaries after a HF hospitalization. Second, we aimed to examine associations among HHC and post-discharge outcomes, including short-term readmission and mortality.

Who was your target patient population and how did you study them? 
"We studied Medicare beneficiaries hospitalized at American Heart Association’s Get With The Guidelines-HF (GWTG-HF) centers between 2005 and 2015 with a primary discharge diagnosis of HF, who had Medicare-linked data available, and were discharged home alive. Propensity score matching and Cox proportional hazards models were used to evaluate the associations between HHC and post-discharge outcomes."

Did the study results turn out as you had expected or were you surprised with what you found? 
"We found that more than one third of Medicare beneficiaries hospitalized for HF in the US were discharged home with HHC; this is equivalent to an absolute increase of 5% from 2005 to 2015. HHC recipients were older, more likely to be female, and had more comorbidities than those who did not receive HHC after discharge. We found that HHC recipients had a higher risk of 30 and 90-day all-cause and HF-specific readmission and a higher risk of all-cause mortality than those who did not receive HHC. This surprised us, as we hypothesized that HHC would be associated with a decrease in the risk of these outcomes. However, we urge readers to interpret the results cautiously, as the allocation of HHC was not random, and unmeasured confounding may have persisted. That is, while we adjusted for many covariates in our analyses, we were unable to account for some important ones (such as patients’ functional needs and cognition, HF severity, and social support) which may affect HHC and post-discharge outcomes.

How do you see this study impacting the future of medicine and patient care? 
"Health care providers and health systems should be aware of the increasing utilization of HHC among older adults discharged home after a HF hospitalization in the US. Further research is needed to determine the intensity and type of services patients received with their HHC, something we were unable to do in this study, but which may impact outcomes. Additionally, research is needed to understand the appropriateness and preventability of readmissions among patients with HF sick enough to receive HHC after discharge." 


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."