Presentation to: Council of State Governments Health Policy Forum

1. Addressing Systems Change for Heart Disease and Stroke Prevention through GWTG-Patient Management Tool Presentation to: Council of State Governments Health Policy Forum On Cardiovascular Health and Wellness September 28, 2006 Brian Boisseau Program Manager Heart Disease and Stroke Prevention Program Kentucky Department for Public Health

2. “Houston…we have a problem” • Kentucky has higher than national averages in heart disease and stroke. • Kentucky has higher rates of hypertension in whites and blacks than rest of the nation. • Kentucky has the highest smoking rate in the nation. • Kentucky average for cholesterol higher than nation. • No statewide network for system change. Cabinet for Health and Family Services

3. “Houston…we have a problem” • Health care costs increasing due to risk factors of heart disease and stroke. • Health care not always provided equally. • How do we get to the 2010 goals if we keep doing the same things the same way? • “If you always do what you always did, you’ll always get what you always got!” • See the need, do the deed! Cabinet for Health and Family Services

4. CDC—Mission Control Promote policy and system change to assure quality care through adherence to primary and secondary prevention guidelines. Cabinet for Health and Family Services

5. CDC—Mission Control • Hospitals • Implement American Heart Association’s Get With the Guidelines for coronary artery disease and stroke quality improvement; or Guidelines Applied in Practice (American College of Cardiology) to support implementation of ACC/AHA cardiovascular guidelines. • Chief partners are state QIO and AHA. • Similar strategies as listed in primary care. Cabinet for Health and Family Services

6. MISSION OUTCOMES • Increase the number of people who have high blood pressure under control • Increase the number of people with total blood cholesterol less than 200 mg/dL • Increase the number of people who know the signs and symptoms of heart attack and stroke, the risk factors for heart disease and stroke, and the importance of calling 9-1-1 • Improve Emergency Response Cabinet for Health and Family Services

7. MISSION OUTCOMES • Improve Quality of Care • Eliminate Disparities in terms of race, ethnicity, gender, geography, or socioeconomic status • Decrease mortality • Decrease health care costs Cabinet for Health and Family Services

8. WHAT WAS THE MISSION? • Implement Get With the Guidelines in 26 Kentucky Hospitals by the end of FY 2003. • Evidence based guidelines developed by AHA and ACC. • Provides guidelines based care to all patients, equaling the field for patients regardless of geography, race, socioeconomic status…eliminates disparities. Cabinet for Health and Family Services

9. “One Small Step for Man….” Cabinet for Health and Family Services

10. What is Get With The GuidelinesSM? WHAT IS GWTG? • The premier hospital-based quality improvement program for the American Heart Association • Leverages the “teachable moment” immediately after a patient has had an acute event • Tools that allow healthcare providers to concurrently assess treatment compliance Cabinet for Health and Family Services

11. What is Get With The GuidelinesSM? WHAT IS GWTG? • Provides a framework for Continuous Quality Improvement • Winner of the 2004 Health and Human Services, Innovation in Prevention Award Cabinet for Health and Family Services

12. WHAT IS GWTG? A prospective intervention process in the hospital setting, for coronary artery disease, heart failure, and stroke patients, designed to significantly increase compliance with secondary prevention treatment rates by the time of discharge Cabinet for Health and Family Services

13. WHAT DOES GWTG DO? Supports system improvements for coronary artery disease, heart failure, and stroke patients Encourages links between cardiologists, neurologists, intensivists, primary care physicians, and ancillary healthcare providers Provides resources to build consensus and establish and execute protocols Cabinet for Health and Family Services

14. WHAT DOES GWTG DO? Get With The Guidelines offers hospitals a Recognition Program which encourages hospitals to excel by achieving 85% compliance in the indicators for each module. Cabinet for Health and Family Services

15. WHAT DOES GWTG DO? Get With The Guidelines offers hospitals three (3) Performance Achievement Awards recognizing hospitals that maintain a consistent, high level of quality within the GWTG program. Cabinet for Health and Family Services

16. WHAT ARE THE MODULES? • GWTG-Coronary Artery Disease (KY 2003) • GWTG-Stroke (KY 2005) • GWTG-Heart Failure (KY 2006) Cabinet for Health and Family Services

17. What are the CAD performance measures that need 85% adherence for recognition? • Smoking Cessation counseling for current smokers or persons who have smoked within the last twelve (12) months • Aspirin on Discharge* • Beta-blocker on Discharge* • ACE-I on Discharge* • Lipid lowering therapy on Discharge* • *In eligible patients without contraindications (designated by CMS as “Ideal Patients”) Cabinet for Health and Family Services

18. What are the Stroke performance measures that need 85% adherence for recognition? • Percent of acute ischemic stroke patients who arrive at the ED at hospital within 120 mins of onset of stroke symptoms who receive IV t-PA within 180 mins of onset of stroke symptoms. • Percent of ischemic stroke or TIA patients who receive antithrombotic medication within 48 hours of hospitalization. • Percent of ischemic stroke or TIA patients discharged on antithrombotics. • Percent of ischemic stroke or TIA patients with atrial fibrillation who are discharged on anticoagulation therapy. Cabinet for Health and Family Services

19. Continued What are the Stroke performance measures that need 85% adherence for recognition? 5. Percent of patients at risk for DVT who received DVT prophylaxis by the 2nd hospital day. 6. Percent of ischemic stroke or TIA patients with LDL>100 mg/dL OR on cholesterol reducer prior to admission who are discharged on cholesterol reducing drugs. 7. Percent of smokers who receive smoking cessation advice or medication. Cabinet for Health and Family Services

20. What are the Heart Failure performance measures that need 85% adherence for recognition? • HF Discharge instructions provided to all eligible patients • Measurement of LV function in all eligible patients • ACE inhibitor and/or ARB at discharge provided to eligible patients with LVEF < or = 0.40. • Beta blocker at discharge provided to eligible patients. • Smoking cessation counseling provided to all eligible patients (current or recent smokers) Cabinet for Health and Family Services

21. What Did We Do? • Trained hospitals at statewide workshop with partners. • AHA provided training/education and we helped support the education materials and facilities for training. • KY CVH program served as facilitators. • Program was successful. • 26 Hospitals contracted to do GWTG. • Follow-up GWTG Quality Improvement Workshop in January 2004 Cabinet for Health and Family Services

22. Who Was Involved • American Heart Association • Kentucky Hospital Association • Health Care Excel (Kentucky Medicare QIO) Cabinet for Health and Family Services

23. What Happened After? • Through the continuance of implementing GWTG w/ Stroke module, formed partnership with the University of Louisville Stroke Team. • Partnership developed into contract for services. • U of L provided provider education, nursing symposium, EMS education, and community education in Louisville DMA, to affect the stroke systems of care. Cabinet for Health and Family Services

24. What Happened After? • Heart Disease and Stroke Program Manager invited to speak to Get Healthy Kentucky Board about state of stroke in Kentucky. • Manager invited Dr. Remmel to attend and present as well. • AHA presented on their efforts. Cabinet for Health and Family Services

25. What Happened After? • Dr. Remmel made impression on board. • Change was sought at licensure level for hospitals who claim to be Stroke Centers to be JCAHO Stroke Center Certified. • Not successful in licensure change. • Dr. Remmel invited to speak to legislature by AHA. • Resolution adopted by senate to “Urge the development of stroke systems of care.” Cabinet for Health and Family Services

26. GWTG Module Data - Hospitals Data Current as of August 31, 2006 Cabinet for Health and Family Services

27. GWTG Module Data - Patients Enrolled Data Current as of August 31, 2006 Cabinet for Health and Family Services

28. RECOGNITION PROGRAM Cabinet for Health and Family Services

29. CONTACT INFORMATION Brian Boisseau, Program Manager Heart Disease and Stroke Prevention Program Kentucky Department for Public Health 275 E Main St, HS2W-E Frankfort, KY 40621 Tel: 502-564-7996 ext. 3823 Fax: 502-564-4667 Email: Brian.Boisseau@ky.gov Cabinet for Health and Family Services