Nonteaching GWTG hospitals close quality gap over time

In a study of care provided to 270,902 patients with coronary artery disease (CAD) at 361 hospitals participating in the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) program, researchers found that teaching hospitals provided more guideline-concordant care but that nonteaching hospitals closed that gap over time. The results were published online Dec. 11 in Circulation: Cardiovascular Quality and Outcomes.

Lori M. Tam, MD, of Johns Hopkins Hospital in Baltimore, and colleagues reviewed admission records of patients from hospitals participating in the GWTG-CAD program that were known to be either teaching hospitals or nonteaching hospitals. Patient records were included in the analysis if they were admitted with CAD or CAD equivalents (acute ST-segment and non-ST-segment MI, heart failure with CAD, peripheral artery disease, and/or unstable angina). The study population consisted of 155,414 patients admitted to teaching hospitals and 115,488 patients admitted to nonteaching hospitals between 2000 and 2009.

The primary outcome was 100 percent adherence to the six GWTG-CAD quality measures: for CAD patients, aspirin and beta blockers at discharge; for patients with acute coronary syndrome, aspirin within 24 hours of admission; for patients with low-density lipoprotein levels greater than 100 mg/dL, lipid lowering medication; angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers at discharge for patients with left ventricular systolic dysfunction and smoking cessation counseling for current smokers.

The researchers also analyzed and compared the number of inpatient invasive procedures, inpatient mortality rate, length of stay, and several additional quality measures:

  • ACE inhibitors for patients with acute MI;
  • Beta blockers within 24 hours for patients with acute MI;
  • Blood pressure 140/90 mm Hg or less at discharge;
  • Lipid-lowering medication at discharge; and
  • Cardiac rehabilitation or exercise counseling.

According to their unadjusted analysis, teaching hospitals reached significantly higher achievement of quality measures of care than did nonteaching hospitals, with the exception of aspirin administration with the first 24 hours. Teaching hospitals reached the primary endpoint of 100 percent concordance with guidelines with 78.4 percent of their patients whose records were examined, compared with 73.3 percent for nonteaching hospitals.

Both types of hospital improved over time. Between 2000 and 2009, guideline-concordant care in teaching hospitals increased from 65.3 percent to 88.3 percent and in nonteaching hospitals from 61 percent to 93.9 percent. After participating in the GWTG-CAD program for five years, nonteaching hospitals exceeded, by a statistically nonsignificant margin, the performance of teaching hospitals in providing guideline-concordant care.

“At baseline, the opportunities for medical education and dis­semination of practice guidelines may be greater at THs [teaching hospitals], but the implementation of this quality improvement program mini­mizes these differences and allows NTH [nonteaching hospitals] to achieve a level of guideline compliance that is comparable with the care at TH,” Tam and colleagues wrote.

The authors noted that care is significantly more expensive at teaching hospitals, but after experience with the GWTG-CAD program any disparity in quality between teaching and nonteaching hospitals is minimal. They also pointed out that their research identified an opportunity for improved quality of care, as both teaching and nonteaching hospitals failed to reach 100 percent guideline concordance with over 20 percent of their CAD patients.