Barriers to the routine use of evidence-based care fall into three general categories: knowledge, attitudes, and behavior (9) (Table 28-2). Knowledge barriers include absence of knowledge of new or updated guidelines or, if known, insufficient familiarity with the guidelines to be willing or able to use them. For example, one hospital seeking to extend CAD prevention measure use to patients with peripheral vascular disease engaged vascular surgeons to initiate lipid and angiotensin-converting enzyme (ACE) inhibitor therapies prior to hospital discharge. Resistance to the plan was substantial until a medical consultant offered to select and initiate these therapies in appropriate patients. On further discussion the initial unwillingness to participate centered on unfamiliarity with specific agents and doses. Guidelines and evidence may be known but not adhered to because of a lack of belief in the concept of evidence-based medicine or lack of belief that the benefits seen in clinical trials really occur in the “real world.” These attitudinal barriers may mask knowledge barriers, as illustrated, or may represent concerns about autonomy and control.

The final category, behavioral factors, relates to patients, guidelines, and the organizational environment. Patient preferences may not be consistent with guideline recommendations. Guidelines from multiple organizations may be contradictory, causing confusion. The most common issues relate to the environment, such as organizational constraints in culture, priorities, resources, and systems. Even if physicians know, believe, and intend to use the guidelines every time, this may not result in higher treatment rates. Davis and colleagues have demonstrated that typical didactic presentations may improve knowledge but do not produce increased use of evidence-based therapies (10). In a chart review of primary care practices, selected as practices that were high prescribers of statins, knowledge of the National Cholesterol Education Program (NCEP) guidelines for lipid treatment and the intention of practitioners to use these guidelines were assessed. Although 95% of the physicians could demonstrate complete and accurate knowledge of the guidelines, and 65% stated that they used the guidelines most or all the time, only 18% of their CAD population had low-density lipoprotein (LDL) cholesterol levels of <100 mg/dL, and this was only in their patients who were on treatment (11).

The use of a team approach can help to address patient factors and support patient self-management after discharge. Environmental issues are usually addressed by changes in the underlying culture and systems of care delivery. W. Edwards Demming has said that most problems are 10% about the people and 90% about the systems (12). Systems always produce exactly the result they were designed to produce (Burwick DM, personal communication). It then follows that “trying harder” with the same system will not change practice. This then explains the dichotomy between physicians with knowledge and intention, cited earlier, and yet poor performance of the system to deliver care.

In the hospital setting where the highest-risk patients, those with acute cardiovascular events or stroke, are treated there is a unique opportunity to redesign systems of care. Hospitals
have professionals from a number of disciplines that participate in the care of these patients. System changes, such as the use of preprinted order sets, reduce the reliance on memory that often fails us when there are more urgent, acute treatments to occupy our attention. For this reason preprocedure orders for cardiac catheterization and revascularization procedures are common. Using similar systems for admission orders and a discharge checklist can be helpful in ensuring that key evaluations such as LDL cholesterol measurement, A1C measurement in diabetics, and routine, evidence-based therapies are given for all patients unless there is a specific contraindication. The participation of multidisciplinary teams in the development and implementation of these systems can also lead to the use of all members of the care team to catch the inadvertent omissions that too often characterize secondary prevention.

The American Heart Association’s (AHA) Get With The Guidelines (GWTG) is a program designed to assist hospitals in redesigning these systems of care. GWTG currently offers quality improvement modules for three disease states. The CAD module (GWTG-CAD) was launched nationally in April 2001 and is currently being implemented in almost every state. The stroke module (GWTG-Stroke) and the heart failure module (GWTG-HF) were launched in May 2004 and March 2005, respectively.

Elements of the program include organizational stakeholder and opinion leader meetings, hospital recruitment, collaborative learning sessions, hospital tool kits, local clinical champions, multidisciplinary teams, and hospital recognition (13). Data collection, decision support, and hospital data feedback via multiple on-demand reports of performance on all key measures are done with an Internet-based Patient Management Tool (PMT).

This program uses a collaborative model to bring together teams from many hospitals in a region to work together to address barriers to care (Fig. 28-1). Learning from each other, hospitals can successfully adapt the successful approaches used by others for their own unique environment. This approach significantly speeds up the improvement process and helps to engage hospital leadership, an important ingredient in producing permanent change, by creating a sense of community. Workshops include didactic presentation of clinical trial evidence and the AHA/American College of Cardiology (ACC), American Stroke Association (ASA) guidelines for acute care and secondary prevention for CHD (14,15,16), stroke (17,18,19), or heart failure (20) followed by examples of successful hospital implementation. Observing the successes of other hospitals creates the sense that improvement is achievable. Standardized quality improvement methodology based on the Model for Improvement is presented at each session (21,22).

Hospital teams learn to clearly state their goals for each measure and select a pilot population and location to begin the process. By initially focusing on an area in the hospital where success is most likely, hospital teams can develop positive momentum as they expand to other areas and patient populations. They also learn to use plan-do-study-act (PDSA) cycles to test their ideas for change. These tests are designed to answer two questions. The first is: How will we know that the change is an improvement? This question is designed to provide a framework to quickly evaluate new and creative solutions to defects in their system of care. These change ideas are brought back from GWTG sessions; learned from calls, e-mail lists, and GWTG materials; and developed by the teams themselves (23). Change concepts may be very successful in some environments, but not in others. Even well-developed critical pathways, preprinted orders, and reminders often require adaptation to a specific hospital environment; some may not work at all. Thus after a small test is planned (a few patients on 1 or 2 days using a single physician and care team), done, and the resulting data studied, teams act by adopting or adapting the change and doing further tests on a larger scale or abandoning the idea and moving on to another. The small scale of these initial tests gives teams the ability to try new and innovative ideas not previously considered, sorting through many to find the few highly effective concepts that substantially improve performance. There appears to be relationship to the number of tests run and success in improvement (21,22).