Transitional Care for Patients with Acute MI Jason

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Transitional Care for Patients with Acute MI Jason H. Wasfy, MD MPhil Director, Cardiology

Transitional Care for Patients with Acute MI Jason H. Wasfy, MD MPhil Director, Cardiology Outcomes Research Harvard Medical School and Massachusetts General Hospital Medical Director, Massachusetts General Physicians Organization

Jason H. Wasfy, MD MPhil Grants American Heart Association National Institutes of Health/Harvard Catalyst

Jason H. Wasfy, MD MPhil Grants American Heart Association National Institutes of Health/Harvard Catalyst (KL 2) National Institutes of Health (to spouse) National Football League Players Association (to spouse) American College of Cardiology National Cardiovascular Data Registry Consulting/Advisory Board/Board Member Pfizer Biotronik Institute for Clinical and Economic Review Unpaid Committees NHLBI Working Group on Valvular Heart Disease American College of Cardiology Learning and Action Network Cardiac Episode Payment

Recurrent events after AMI • One quarter readmitted in 30 days • 1 of

Recurrent events after AMI • One quarter readmitted in 30 days • 1 of 20 with recurrent AMI in 1 year • How can we risk reduce through care delivery systems? Roe MT et al JACC 2010 Smolina K Circ CQO 2012 Armstrong et al Circulation 1998

Cardiac Rehabilitation • CR a/w lower risk of CV death (RR 0. 74) •

Cardiac Rehabilitation • CR a/w lower risk of CV death (RR 0. 74) • Lower risk of readmission (RR 0. 82) • Randomized data! Anderson L JACC 2016

Cardiac Rehabilitation • Fewer than 2/3 of patients referred (Aragam et al JACC 2015)

Cardiac Rehabilitation • Fewer than 2/3 of patients referred (Aragam et al JACC 2015) • Electronic referrals can double referrals (Pirruccello et al CAD 2017)

Readmission Reduction After PCI • Risk prediction/patient education • Two pillars (1) Mandatory outpatient

Readmission Reduction After PCI • Risk prediction/patient education • Two pillars (1) Mandatory outpatient follow up (2) NP based electronic notifications when patients are in the ED 6

Claims data include patients with T 2 MI

Claims data include patients with T 2 MI

Review of AMI Readmissions Of 197 AMI readmissions, 111 received no revascularization. 28. 4%

Review of AMI Readmissions Of 197 AMI readmissions, 111 received no revascularization. 28. 4% too high risk 11. 7% type 2 MI 6. 6% patient declined interventions Martin et al. JAHA 2018 So we developed CMS-aligned standards for AMI patients and included them in the protocols.

40% drop in index readmission rate

40% drop in index readmission rate

Evaluation of clinical intervention • Pre-post comparison not adequate (case mix, concurrent interventions, statistical

Evaluation of clinical intervention • Pre-post comparison not adequate (case mix, concurrent interventions, statistical noise) • Index readmission rate not adequate • Linked data from patients in risk contracts

Statistical Process Control Charts Isixsigma. org • Problems with SPC – does not account

Statistical Process Control Charts Isixsigma. org • Problems with SPC – does not account for (1) case mix, (2) secular trend, (3) autocorrelation BMJ Qual Safety 2015

Interrupted time series French et al. Stat Med 2008

Interrupted time series French et al. Stat Med 2008

Results • Outpatient follow up and routine ED based consultation with cardiology resulted in:

Results • Outpatient follow up and routine ED based consultation with cardiology resulted in: Level reduction in 30 day readmission (-9. 8%, p = 0. 002) and 30 day mortality (-2. 6%, p = 0. 041) Trends unchanged

Thank you! jwasfy@mgh. harvard. edu @jasonwasfy

Thank you! jwasfy@mgh. harvard. edu @jasonwasfy

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