Acute Myocardial Infarction and the Role of Critical

Acute Myocardial Infarction and the Role of Critical Pathways Christopher Cannon, M. D. Brigham and Women’s Hospital Boston 1

ACUTE MI GUIDELINES 11/96 Drug Rx Peri MI: Meta-Analyses Number RR Death p value Beta blocker during MI 28, 970 . 87 (. 77 -. 98) 0. 02 Beta blocker post MI 24, 298 . 77 (. 70 -. 84) <0. 001 ACEI during MI 100, 963 . 94 (. 89 -. 98) 0. 006 ACEI post MI if LV dysfxn 5, 986 . 78 (. 70 -. 86) <0. 001 Nitrates during MI 81, 908 . 94 (. 90 -. 99) 0. 03 Ca++ blockers 20, 342 1. 04 (. 95 -1. 14) NS Magnesium 61, 860 1. 02 (. 96 -1. 08) NS Lidocaine 9, 155 1. 38 (. 98 -1. 95) NS Class I Antiarrhythmics 6, 300 1. 21 (1. 01 -1. 44) 0. 04 NEJM 335: 1662, 1996

NRMI-2: Distribution of Door-to-Needle Times N=84, 423 Cannon CP ACC 2000 40%

NRMI-2: Thrombolysis Door-to-Needle Time vs. Mortality P=0. 0001 P=0. 01 P=NS 1. 23 1. 11 1. 03 N=28, 624 Cannon CP ACC 2000 33, 867 11, 616 10, 316

NRMI-2: Primary PCI Distribution of Door-to-Balloon times N=27, 080 Door-to-Balloon Time (minutes) Cannon CP, et al JAMA 2000; 283: 2941 -2947.

NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality P=NS P=0. 01 P=0. 0007 P=0. 0003 1. 62 1. 61 1. 41 1. 15 1. 14 N=2, 230 5, 734 6, 616 4, 461 2, 627 5, 412 Cannon CP, et al JAMA 2000; 283: 2941 -2947.

EUROASPIRE II European Action on Secondary and Primary Prevention through Intervention to Reduce Events Euro Heart Survey Programme European Society of Cardiology-ESC Wood et al. Lancet 2001; 357: 995 -1001 8 European Society of Cardiology ESC

% beta-blockers at interview EUROASPIRE by center Wood et al. Lancet 2001; 357: 995 -1001 9 European Society of Cardiology ESC

US News and World Report Aspirin in ideal candidates Chen J, et al N Engl J Med. 1999; 340: 286 -292. 10

US News and World Report Beta-blockers in ideal candidates Chen J, et al N Engl J Med. 1999; 340: 286 -292. 11

US News and World Report 30 -day mortality by hospital category* Chen J, et al N Engl J Med. 1999; 340: 286 -292. * 25 th, 50 th and 75 th percentile for each category 12

Quality implications – The lower mortality observed in “America’s Best Hospitals” appear to be explained in part by their higher use of aspirin and betablockers – Any hospital can be one of “America’s Best” by increasing their use of aspirin and betablockers Chen J, et al N Engl J Med. 1999; 340: 286 -292. 13

GUARANTEE TIMI III Registry Pre Guideline Men No. Pts Women Post Guideline Men Women 1678 1640 1788 1160 82 63 41 77 50 35 84 66 53 80 60 49 On Admission ASA Heparin B-blockers Comparing Pre- to Post-: P values : ASA Heparin B-blocker Men 0. 30 0. 13 0. 001 Women 0. 05 0. 001 Scirica BM, Cannon CP, et al. Crit Path Cardiol. 2002; 1: 151 -160.

Unadjusted One Year Survival Percent surviving 95% P =. 0001 Weeks post discharge Giugliano RP, et al. Arch Intern Med 2000; 160. 81%

• Standardized protocols • Goal: optimize care • Emerging Evidence – Pathways work: – CHAMP – Guidelines Applied in Practice (GAP) – AHA “Get with the Guidelines” program www. critpathcardio. com 16

National Heart Attack Alert Program (NHAAP) CRITICAL PATHWAYS FOR THE TREATMENT OF PATIENTS WITH ACUTE CORONARY SYNDROMES

Critical Pathways - Definitions • Standardized protocols for care • Strict definition – Full list of all tasks, tracks variances • Broader definition – Includes clinical protocols (NHAAP 4 D’s) • Diagnostic pathways - Chest Pain Centers • Treatment pathways - Thrombolysis 18

Goals of Critical Pathways • Increase use of recommended medical therapies (e. g. , aspirin) • Decrease use of unnecessary tests. • Decrease hospital length of stay • Increase participation in clinical research • Improve patient care and decrease costs. 19

Need and Rationale for Critical Pathways • Underutilization of recommended medications (e. g. Aspirin) • Overutilization of procedures • Length of stay, # ICU days • Quality of care measures (door-to-drug, door-to-balloon times) 20

Development And Implementation Of Critical Pathways • Identify problems ( practice variation) • Identify working committee/task force to develop path • Distribute draft Critical Pathway to all personnel and departments involved. Revise based on approach. • Implement pathway • Collect and monitor data on pathway performance. • Modify the pathway as needed to further improve performance. 21

Methods of Implementation of Pathways • Specific case manager for each Pt – High compliance, high cost • Standardized order sheets, Pocket guides • “Championing” - Grand rounds • Recent study -> similar improvements in care with either formal or simpler pathways (Holmboe, ES et al. Am J Med 1999; 107: 324 -31. ) 22

Goal: < 30 Minutes NHAAP Ann Emerg Med 1994; 23: 311 -29. 23

W. Rogers, personal communication 24

BWH Thrombolysis Critical Pathway: Initial Experience BEFORE *P=0. 013 Cannon CP, et al. Clin Cardiol 1999; 22: 17 -22 25

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Guidelines Applied in Practice (GAP) • Launched by ACC in February 2000 to: – Bridge gap between ideal therapy and treatment practice – Create/implement guideline tools/processes • Initial project: – Michigan hospitals – Implemented 1999 ACC/AHA AMI Guideline – Determine whether quality of care can be improved via guideline tools – Status: pilot completed, expansion now in progress Mehta R, et al. JAMA. 2002; 287: 1269 -1276. 27

GAP Results: Early Indicators * * (343) (404) (213) (245) ASA BB Time in Minutes LDL CHOL PRE * p < 0. 05 ** p < 0. 01 (40) (24) (131) (252) LYSIS (32) (45) PTCA POST Mehta R, et al. JAMA. 2002; 287: 1269 -1276. 28

GAP: Adherence Improves With Tool Use P =. 001 Quality Adherence, % 100 81 86 P =. 004 Pre-intervention 93 80 65 73 82 77 64 64 Post-intervention No Tool Use 60 40 20 0 No. of Ideal Patients 343 308 96 213 174 71 131 165 87 Aspirin b-Blocker LDL Cholesterol Mehta R, et al. JAMA. 2002; 287: 1269 -1276. 29

Demographics 6 clicks Clinical/Lab 8 clicks Discharge meds and interventions 7 clicks Interactively checks patient’s data with the AHA guidelines 30

Importance of Data-Collection Registries • Track adherence to guidelines • Support local quality-improvement programs • Compare practice patterns/outcomes with benchmarks • Comply with regulatory requirements • Provide research data Major Data-Collection Registries – NRMI – AHA Get With the Guidelines – ACC NCDR – GRACE – CRUSADE – VA transformation 31

VA Transformation - Methods • 1995, VA launched a major reengineering of its health care system with aims that included: – Better use of information technology, – measurement and reporting of performance, – and integration of services – and realigned payment policies. Jha AK, et al. N Engl J Med 2003; 348: 2218 -27. 32

VA Transformation - Results Jha AK, et al. N Engl J Med 2003; 348: 2218 -27. 33

Conclusions • Critical pathways hold great promise to improve – Quality of care, – Clinical outcomes – Cost-effectiveness • Initial studies show better quality of care and suggest improved outcomes 34