Advancing Research, Applying Knowledge, Improving Healthcare Quality

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Perception often lacks reality, and for many cardiologists and other physicians, the image and understanding of the nationÔÇÖs premier private organization dedicated to the prevention and treatment of heart disease and stroke is woefully out of date. For many physicians, the mission of the American Heart Association (AHA) is simply research, education, and advocacy, but it is much more than that. Since its founding in 1924 by a group of six cardiologists, the AHA has evolved into a multidimensional organization that emphasizes a three-pronged strategy to advance the prevention and treatment of heart disease and stroke.This strategy is much like the proverbial three-legged stool - advancing research, applying knowledge, and improving healthcare quality. If any of the legs gets short-changed, the stool or strategy will become ineffectual. Heart disease, stroke, and other cardiovascular diseases remain the leading killers in the US, causing almost 950,000 deaths annually. About 63 million Americans suffer from some form of these diseases. In 2002, cardiovascular diseases cost the nation an estimated US$350 billion in medical expenses and lost productivity.

Research Fuels the Mission

Medical research into preventing and treating heart disease and stroke fuels the AHAÔÇÖs mission to reduce disability and death from these diseases. Research is also the core of its public and professional educational programs. Consequently, funding research remains a top priority. The AHA is second only to the National Institutes of Health (NIH) in non-industry spending for heart and stroke research. In fiscal year 2003, the organization invested US$135.3 million to fund meritorious research projects - more than 25% of its annual expenses.

To maintain the flow of research advances, the AHA provides a continuum of support to help talented researchers build their careers. Pre-doctoral research fellowships help students conduct research before receiving their PhD or MD; post-doctoral fellowships provide research training and mentorship.The Fellow-to- Faculty Transition Award gives physician-scientists vital research time and resources to obtain research training and to establish investigative careers that will ensure continued medical advances.

The Scientist Development grant helps new scientists develop into independent, productive researchers. The Established Investigator Award recognizes past accomplishment and helps an investigator to achieve the promise of future discoveries. Beginning Grants-in-Aid and Grants-in-Aid round out the AHAÔÇÖs research offerings.

The fruits of research, however, have little impact unless physicians and others know about the findings. The organization also supports research by disseminating late-breaking knowledge through its respected scientific journals, councils, interdisciplinary working groups, and scientific sessions. More than 27,000 attended the AHAÔÇÖs 76th Scientific Sessions in Orlando, and more than 3,500 abstracts were presented in basic, clinical, and population science. Scientific Sessions 2004 will focus on advancing research, applying knowledge, and improving healthcare.

Core Strategy - Improving Patient Outcomes

The AHAÔÇÖs support for medical research is well known. Less visible, perhaps, is the organizationÔÇÖs commitment to improving patient outcomes. The AHAÔÇÖs 2010 Strategic Plan commits the AHA to

ÔÇ£mobilize relationships that maximize the discovery, process and transfer of knowledge applied to improving quality cardiovascular health outcomes for patientsÔÇØ.

The organization is in a unique position to develop, process, and translate the best available science into practical applications for healthcare systems and providers, and then steer the use of those practical applications into the healthcare marketplace where they ultimately affect patient care. Because of its reputation and impartiality, the AHA makes a special contribution in this arena. In this process, the organization seeks to continually raise the bar on quality of patient care - through advocacy and creating systems, programs, and partnerships that ensure that AHA guidelines become the standard for patient care.

The primary underpinnings of quality for the association are discovery, translation, and implementation, and all are linked.

  • Discovery - the quality process begins with the discovery and cultivation of science associated with cardiovascular disease and stroke through support for research.
  • Translation - as an extension of discovery, the science that results from research is further translated into guidelines for specific disease states and/or procedures, performance measures, clinical data standards, and a health policy that influences the healthcare system.
  • Implementation - with the development of clinical guidelines and performance standards, programs and activities are developed to facilitate the implementation and adoption of the guidelines and measures in actual healthcare settings.

Studies show that improving the quality of care that heart disease and stroke patients receive could save thousands of lives each year. Consequently, the AHA has developed and begun to implement several initiatives aimed at improving the quality of patient care.

Get With The GuidelinesSM (GWTG) is a hospital-based program designed to ensure that patients are consistently treated and discharged according to evidence-based guidelines for coronary artery disease (CAD) and stroke. The quality improvement program empowers healthcare teams to save lives and reduce healthcare costs by providing training and staffing recommendations so that hospitals can create an infrastructure and multidisciplinary teams, providing implementation tools, such as a Web-based, realtime patient management tool that complies with reporting requirements, facilitating best practices discussion among participating hospitals, and providing customized patient education materials.The program has two modules - GWTG-Coronary Artery Disease (GWTG-CAD) and GWTG-Stroke.

Since its launch in 2001, more than 400 hospitals are participating in GWTG-CAD and more than 100,000 patient records have been entered into the GWTG-CAD patient management tool database. This program alone has the potential to save 80,000 lives annually if fully implemented nationwide. GWTG-CAD focuses on interventions, such as smoking cessation, lipid-lowering therapy, angiotensin-converting enzyme (ACE) inhibitor use, blood pressure treatment, beta-blocker use, weight and exercise management, and diabetes management. Studies show that GWTG-CAD implementation significantly improves compliance in key indicators.

GWTG-Stroke, launched in early 2004, provides tools and hospital protocols consistent with guidelines for treating stroke. Modeled after its successful counterpart GWTG-CAD, GWTG-Stroke had more than 200 hospitals participating and more than 47,000 patients entered into the GWTG-Stroke patient management tool. Preliminary results from the aggregate data show improvement across all performance measures. In acute stroke treatment, the program measures time of symptom onset, time from emergency medical services (EMS) receiving a call to EMS arrival, time patient arrived at emergency department, time of computed tomography (CT)/magnetic resonance imaging (MRI) scan, and time of thrombolytic therapy. For secondary stroke prevention, the program measures smoking cessation counseling, lipid-lowering therapy, weight and exercise management, diabetes management, atrial fibrillation (AF) management, and alcohol management.

An excellent precursor for GWTG-Stroke, the Acute Stroke Treatment Program provides a step-by-step tool kit that helps hospitals and healthcare professionals apply the Brain Attack CoalitionÔÇÖs recommendations for establishing primary stroke centers. The Brain Attack Coalition consists of key stroke organizations representatives across the US, including the American Stroke Association (ASA), a division of the AHA.

To complement the Acute Stroke Treatment Program and GWTG-Stroke, the ASA collaborated with the Joint Commission on Accreditation of Healthcare Organizations to develop a Primary Stroke Center Certification Program.The program recognizes sites that demonstrate compliance with clinical practice guidelines to manage and optimize care, and document performance measurement and improvement activities.The Heart and Stroke Recognition Program, the AHA/ASAÔÇÖs collaborative effort with the National Committee for Quality Assurance, recognizes physicians or physician groups who demonstrate high levels of performance in cardiovascular and stroke care. This program identifies physicians who consistently provide important screenings and work effectively with patients to control such key risk factors as high blood pressure and high cholesterol levels.

The associationÔÇÖs Emergency Cardiovascular Care Programs educate healthcare providers, care-givers, and the general public about how to respond to cardiovascular emergencies, including cardiac arrest, heart attack, and stroke. Annually, these programs train more than eight million people in topics ranging from basic cardiopulmonary resuscitation (CPR), the use of automated external defibrillators (AEDs) and first aid to advanced cardiac life support and pediatric advanced life support. The association develops Emergency Cardiovascular Care (ECC) Guidelines that serve as the standard for both ECC programs and US training organizations, and are used in more than 66 countries. Heart Profilers™ is the AHAÔÇÖs free online tool to help patients understand their treatment options for high blood pressure, heart failure, CAD, cholesterol disorders, and AF. Based on the latest scientific research, Heart Profilers™ provides an authoritative, confidential source for relevant research studies. It also provides important considerations for patients to discuss with their doctor. Healthcare professionals benefit from using its search mechanism to find the latest information on relevant studies and research specific to a virtual case model.

Getting Disease Management Right

In recent years, private and government public policy-makers and health insurance plans have embraced 'disease-managementÔÇÖ programs as a strategy to control costs and improve the quality of care. The term typically refers to multi-disciplinary efforts to improve the quality and cost-effectiveness of care for selected patients with chronic illnesses, such as cardiovascular disease and stroke.

The growth of the trend has compelled the AHA to assess the clinical and public policy implications of this phenomenon from the perspectives of the patientsÔÇÖ best interests and quality of care. The association assembled a multi-disciplinary advisory working group on disease management in 2002 to offer on-going guidance in this evolving area. The expert panel developed a working definition of disease management and established core principles for the application of disease management to cardiovascular disease and stroke. The advisory groupÔÇÖs recommendations were accepted by the AHA Board of Directors in October 2002.

The advisory group is concerned that disease management has, in some cases, become a thinly-veiled device to cut costs and that the quality of patient care sometimes becomes secondary. Ultimately, the goal of disease management, the advisory group said, should be to both maximize the functionality and quality of patient care systems and reduce the public health burden. The expert panel recommended nine guiding principles for the development, implementation, and evaluation of disease management initiatives:

  • the main goal of disease management should be to improve the quality of care and patient outcomes;
  • scientifically-derived peer reviewed guidelines should be the basis of all disease management programs. These guidelines should be evidence-based and consensus driven;
  • the disease management program should help increase adherence to treatment plans based on the best available evidence;
  • disease management programs should include consensus-driven performance measures;
  • all disease management efforts must include ongoing and scientifically-based evaluations, including clinical outcomes;
  • disease management programs should exist within an integrated and comprehensive system of care in which the patient-provider relationship is central;
  • to ensure optimal patient outcomes, disease management programs should address the complexities of medical co-morbidities;
  • disease management programs should be developed for all populations and particularly address members of the under-served or vulnerable populations; and
  • organizations involved in disease management should scrupulously address potential conflicts of interest.

On this final point, the expert panel emphasized that the primary goal of disease management organizations should be to improve patient outcomes.

ÔÇ£Efforts to achieve secondary goals, such as product marketing or product sales, should not adversely affect the primary goal of improving patient outcomes. To the extent any conflict of interest arises that may compromise the primary goal of improving patient outcomes, it should not be pursued.ÔÇØ

Verdict Still Out on Payment for Quality

Another issue closely related to disease management is what is referred to as 'payment for qualityÔÇÖ. Both the private and public sectors are trying to determine how to align incentives - both financial and non-financial - to improve quality of care. On this, too, the AHA is exploring payment-for-quality incentives as a potential strategy for improving healthcare. Much more information about the effectiveness of using financial incentives for improving care and performance is still needed.

As the healthcare delivery system becomes increasingly complex and stressed by competing interests, and financial, and demographic pressures, the role of private, non-profit healthcare advocacy organizations such as the AHA is more critical than ever. The AHA, for one, will maintain its position as an unbiased advocate for healthcare policies and practices that are based on the best available scientific evidence, and provide the best hope for positive patient outcomes.