What Have We Learned From the Mission Lifeline

What Have We Learned From the Mission: Lifeline Registry? Alice K. Jacobs, M. D. Boston University Medical Center Boston, MA CRT 2017

Disclosures • I have no relevant relationships to disclose

Developing Systems of Care for STEMI

Trained AHA 350 field staff in Mission: Lifeline implementation in July 2008 (local adaptation of national recommendations)

Trends in Treatment and Process for STEMI Patients 2008 -2012 Year Variable 2008 2009 2010 2011 2012 179 224 334 383 445 18, 583 21, 670 29, 886 35, 683 41, 644 Eligible, No reperfusion (%)* 6. 2 4. 4 3. 3 Pre-hospital ECG (%) [direct]* 45 58 61 66 71 FMC-to-device (min) [direct]*+ 93 89 88 85 84 Door-to-device (min) [direct]*+ 68 63 61 60 59 First door-to-device (min)*+ 130 122 119 114 112 50 50 50 52 49 Hospitals (n) STEMI Patients (n) [transfer] Symptom onset to FMC (min)+ * P<0. 0001; +median minutes Granger. AHA Scientific Sessions 2013.

In-hospital Mortality for STEMI Patients 2008 -2012 Granger. AHA Scientific Sessions 2013.

Emergency Medical Services (EMS)–transported patients meeting guideline goals for FMC– to –device time for direct admission (A) and transferred (B) patients in ACCELERATOR 1. Jollis. Circulation. 2016; 134: 365 -374.

1200 ACTION Registry-GWTG Contracts & Mission: Lifeline Participating Hospitals 2010 – 2016 1079 1036 1000 988 951 890 Number of Contracts/Hospitals 878 792 800 656 640 600 534 400 200 708 680 345 196 0 2011 # ARG Contracts 2012 2013 2014 2015 # Hospitals Participating in Mission: Lifeline 2016

National Number of STEMI Patients (2012 – 2016*) 90 000 80 000 77 076 71 381 70 000 66 057 Number of STEMI Patients 62 642 60 000 56 884 52 274 52 052 50 000 45 008 47 914 36 343 30 000 20 000 15 709 20 192 19 107 18 143 17 634 10 000 0 2012 *Through Q 3 2016 2013 Transfer In 2014 Direct Presentation 2015 Total Number of STEMIs 2016

EMS First Medical Contact to 1 st Device Activation Median Times (2012 – 2016*) 84 83 82 82 81 Minutes (median) 81 81 80 80 79 79 78 77 76 75 2012 (n = 32, 709) *Through Q 3 2016 2013 (n = 40, 507) 2014 (n = 43, 123) 2015 (n=46, 524) Median EMS FMC to 1 st Device Activation Times 2016 (n = 50, 627)

Transfers: Arrival at 1 st Facility to Transfer Out (Door-In Door-Out) Median Times (2012 – 2016*) 80 70 Minutes (median) 60 50 45 45 45 2012 (n = 11, 468) 2013 (n =13, 226) 2014 (n = 13, 607) 2015 (n=13, 948) 2016 (n = 15, 144) 40 30 20 10 0 *Through Q 3 2016 Median Door-In Door-Out Times

108 106 Transfers: Arrival at 1 st Facility to 1 st Device Activation Median Times (2012 – 2016*) 106 105 104 104 2015 (n=13, 948) 2016 (n = 15, 144) Minutes (median) 102 100 98 96 94 92 90 2012 (n = 11, 468) *Through Q 3 2016 2013 (n =13, 226) 2014 (n = 13, 607) Median Transfer Times

Time (min) STEMI Door-to-Balloon Median Times for Transfer In and Non-Transfer In Patients Transfer in DTB Times Non-Transfer in DTB Times ACTION Registry-GWTG DATA: January 01, 2014 - December 31, 2014

STEMI Primary PCI Results DTB Benchmarks for Transfer-In Patients 1 st Door to Balloon < 90 Minutes 1 st Door to Balloon < 120 Minutes ACTION Registry-GWTG DATA: January 01, 2014 - December 31, 2014

STEMI Patients Presenting to Non-PCI Capable Hospitals in New York State (2011 -12) Treatment Received N=10, 697 PCI CABG Angiography Only No PCI, CABG, Angiography

30 -day mortality PCI Hospital N=10, 697 Non-PCI Hospital All No Transfer N=3174 N=427 N=2747 Elderly and African Americans and pts with heart rate ≥ 100 bpm, heart failure, depression, fluid and electrolyte disorders and metastatic cancer were less likely to be transferred.

AHA Guideline Transformation Optimization (GTO) The GTO VISION • By 2020, transform and optimize guideline translation, adoption and use Increase Awareness and Understan d Guidelines by HCPs Amplify Use of Guidelines in Care Coordination & Population Health Management Enhance Quality of Life of Patients Via Guideline Insight Baseline, Repeatable Tracking Study & Data from Programs to Set Goals and Measure Progress

GTO ROADMAP & TIMELINE Strategic Planning (CR, Science, Quality, Prof Ed, AHA Content Patients) Development Begins AHA Internal Guidelines Roll-Out Call GL updated on all AHA assets, Final Implementation registries, and out to key Plans audiences L A 1 month 3 months 8 -14 months U DEVELOPMENT ADOPTION TRANSLATIO N & EARLY ( Process from 1 yr. C N (common core TRANSLATION yrs) mat. ~6 months) H (~2 yrs/6 mths) 18 month development time (reduced by 6 months, 50%) Guideline Writing Group Kickoff Guideline to Peer Review Guideline to Executive Committee Guideline Release online GOAL: Standardized process with core activation for all guidelines Continuous updates of Content (ongoing ) to 10+