STRIVETM

What Is the EvidenceThat Critical Pathways Work?

UCLA Cardiac Hospitalization Atherosclerosis Management Program (CHAMP)

ACC Guidelines Applied in Practice (GAP) initiative

AHA “Get With The Guidelines” program

CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines)

STRIVETM

CHAMP Study: UCLA

Designed to determine whether physician/patient compliance with preventive therapies can be improved through a hospital-initiated program

Tracked initiation of aspirin, β-blocker, ACE inhibitor, statins Used preprinted orders, guidelines, lectures, discharge forms Population: patients with symptomatic atherosclerosis treated at

university-associated teaching hospital Methods: no specific algorithms used before CHAMP (1992-1993) National guidelines (ACC/AHA, NCEP ATP I and ATP II) used in

CHAMP (1994-1995) Evaluation: treatment rates and clinical outcomes pre-CHAMP

and CHAMP in patients hospitalized for acute MI

Fonarow GC, Gawlinski A. Am J Cardiol. 2000;85(3A):10A-17A.

Cardiac Hospitalization Atherosclerosis Management Program

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Discharge Medications at UCLA Compared With 1437 NRMI Hospitals

0

20

40

60

80

100

Aspirin β-blockers ACEI Statins

68

92 9194 96

12

6872

78

85

52

6470

75

88 8990 91

98/99 Post-CHAMP (UCLA)00/01 Post-CHAMP (UCLA)

92/93 Pre-CHAMP (UCLA)94/95 Post-CHAMP (UCLA)96/97 Post-CHAMP (UCLA)

Fonarow GC, et al. Am J Cardiol. 2001;87:819-822.

[NRMI Hospitals 00/01 (n=154,602)]Nat’l Benchmark

Uti

lizat

ion

Rat

e (%

)CHAMP Over an 8-Year Period: Rapid and Sustained

Improvement, Superior to National Benchmarks

3742

65

77

STRIVETMAdapted from Mehta RH, et al. JAMA. 2002;287:1269-1276.

0

20

40

60

80

100

At Admission At Discharge

Pre-GAPPost-GAP

Asp

irin

Usa

ge

(%)

81 87 8492

P=.02 P=.002

ACC’s Guidelines Applied in Practice (GAP) Initiative: Impact on Aspirin Usage

at Admission and Discharge

STRIVETMAdapted with permission from Mehta RH, et al. JAMA. 2002;287:1269-1276.

Qu

alit

y

Ad

he

ren

ce

(%

)

Preintervention

No Tool Use

Tool Use

Postintervention

0

20

40

60

80

100

Aspirin β-Blocker LDL-CNo. of Ideal

Patients

81 8693

6573 77

64 64

82

343 308 96 213 174 71 131 165 87

P=.004P=.001

Early Quality Indicators and Standard Admission Orders

GAP Initiative: Adherence Improves With Tool Use

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GAP Initiative: Changes in Mortality Before and After GAP Project

Eagle KA, et al. J Am Coll Cardiol. 2005;46:1242-1248.

0

5

10

15

20

25

30

35

40

45

In-hospitalMortality

30-dMortality

1-yrMortality

% Baseline

Post-GAP P=.017

P=.001

P=.004

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AHA “Get With The Guidelines” Program

Components Training materials for hospital staff Patient education materials Assistance in creating multidisciplinary team Secondary prevention guidelines CME workshops Sample materials (care maps, discharge

protocols, discharge forms)

American Heart Association Web site. Get With The Guidelines. Available at: http://www.americanheart.org/presenter.jhtml?identifier=1165.

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Clinical/Lab: 8 clicks

Clinical/Lab: 8 clicks

Interactively checks patient’s data with the AHA Guidelines

Interactively checks patient’s data with the AHA Guidelines

Discharge meds and interventions: 7 clicks

Discharge meds and interventions: 7 clicks

Demographics: 6 clicks

Demographics: 6 clicks

AHA Tool: Simple One-Page, Online Form

American Heart Association Web site. Get With The Guidelines. Available at: http://www.americanheart.org/presenter.jhtml?identifier=1165.

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Rehab/Exercise

Baseline 4-6 Months 9-12 Months Benchmark*

Intervention

0

20

40

60

80

100

SmokingCounsel

LDL-C BPControl

Pro

po

rtio

n o

f P

ati

ents

*Benchmarks established by CMS AND NRMI.Reprinted with permission from the American Heart Association Web site. Get With The Guidelines. Available at: http://www.americanheart.org/presenter.jhtml?identifier=1165.

Get With The Guidelines 12-Month Pilot Results: 85 New England Hospitals

N=1709

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CRUSADE Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early

Implementation of the ACC/AHA Guidelines

Nationwide quality improvement (QI) initiative– Up to 600 participating hospitals

Collaborative effort between emergency medicine, cardiology, hospital QI, academia, and industry

Focused on improving the care of NSTEMI ACS patients

Adapted from CRUSADE Overview 2004. Available at: http://www.crusadeqi.com.© 2005 Duke Clinical Research Institute. Used with permission.

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CRUSADE: Inclusion Criteria Ischemic symptoms lasting >10 minutes within previous 24

hours and at least one of the following:

– Positive cardiac markers CK-MB or Tnl/TnT above ULN Positive bedside troponin assay

– ST-segment ECG changes ST-segment depression >0.5 mm Transient ST-segment elevation 0.6–1 mm (lasting

<10 mins)

Transfer patients (with any of the above) must arrive at CRUSADE hospital within 24 hours of symptoms

© 2005 Duke Clinical Research Institute. Used with permission. Available at http://www.crusadeqi.com.

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Goals for CRUSADE

Aspirin– Clopidogrel

-Blocker Heparin (UFH or LMWH) GP IIb/IIIa Inhibitor

– Cath/PCI

Aspirin Clopidogrel -Blocker ACE Inhibitor Statin/Lipid Lowering Smoking Cessation Cardiac Rehabilitation

Acute Therapy Discharge Therapy

2002 ACC/AHA Guidelines Update. Adapted from 2005 CRUSADE 2nd Quarter Results. Available at: http://www.crusadeqi.com.© 2005 Duke Clinical Research Institute. Used with permission.

Improve Adherence to ACC/AHA Guidelines Improve Patient Outcomes

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Hospital Presentation Characteristics in CRUSADE:

July 1, 2005–June 30, 2006 (n=31,665) Qualifying criteriaST-segment depression 28%Transient ST-segment elevation 5%Positive cardiac markers 93%

Baseline cardiac markers DrawnPositive

CK-MB 82%75%TnT/TnI 99%91%

Presenting characteristics Tachycardia 23%Hypotension 4%Signs of CHF 23%Adapted from 2006 CRUSADE Results.

Available at: http://www.crusadeqi.com.© 2006 Duke Clinical Research Institute. Used with permission.

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Baseline Characteristics:CRUSADE vs ACS Clinical Trials

Variable PURSUIT CURE SYNERGY CRUSADE(n = 9461) (n = 12,562) (n = 9975) (n = 180,842)

Mean age ± SD (yrs)63 ± 11 63 ± 12 67 ± 11 67 ± 14

Female sex (%) 36 39 34 40

Diabetes mellitus (%) 23 23 29 33

Prior MI (%) 32 25 28 30

Prior CHF (%) 11 8 9 18

Prior PCI (%) 13 18* 20 21

Prior CABG (%) 12 18* 17 19

ST depression (%) 50 42 55 34

N Engl J Med. 1998;339:436-43.N Engl J Med. 2001;345:494-502.JAMA. 2004:292:45-54.CRUSADE cumulative through June 30, 2006.

N Engl J Med. 1998;339:436-43.N Engl J Med. 2001;345:494-502.JAMA. 2004:292:45-54.CRUSADE cumulative through June 30, 2006.

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CRUSADE: Trends in Acute Therapy Adherence

Adapted from 2006 CRUSADE Results. Available at: http://www.crusadeqi.com.© 2006 Duke Clinical Research Institute. Used with permission.

96%90%

84%

46%

97%93% 88%

50%

0%

25%

50%

75%

100%

Antiplatelet β-Blocker Heparin GP IIb/IIIaInhibitor

Quarter 3-05 Quarter 4-05 Quarter 1-06 Quarter 2-06

Quarter 3, 2005, through Quarter 2, 2006.

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CRUSADE Data: July 1, 2005-June 30, 2006 (n=31,665)

CRUSADE: Invasive Cardiac Procedures July 1, 2005 – June 30, 2006 (n=31,665)

(Among Patients Without Contraindications to Cath)

Adapted from 2006 CRUSADE Results. Available at: http://www.crusadeqi.com.© 2006 Duke Clinical Research Institute. Used with permission.

83%

67%

53%

38%

12%

0%

20%

40%

60%

80%

100%

Cath Cath<48 hr

PCI PCI <48 hr CABG

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CRUSADE: Trends in Discharge Therapy Adherence

Quarter 3, 2005, through Quarter 2, 2006

Adapted from 2006 CRUSADE Results. Available at: http://www.crusadeqi.com.© 2006 Duke Clinical Research Institute. Used with permission.

94%

72%

91%

64%

89%

74%

94%

66%

88%95%

0%

25%

50%

75%

100%

Aspirin Clopidogrel β-Blocker ACE Inhibitor Lipid- Lowering

Agent

Quarter 3-05 Quarter 4-05 Quarter 1-06 Quarter 1-06

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CRUSADE: Trends in Discharge Recommendations Adherence

84%81%

62%

84%

62%

92%

0%

25%

50%

75%

100%

Smoking CessationCounseling

Dietary Modification Cardiac RehabilitationReferral

Quarter 3-06 Quarter 4-06 Quarter 1-06 Quarter 2-06

Quarter 3, 2005, through Quarter 2, 2006. Adapted from 2006 CRUSADE Results. Available at: http://www.crusadeqi.com.© 2006 Duke Clinical Research Institute. Used with permission.

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CRUSADE: Overall Guideline Adherence Trends Over Time

Available at www.crusadeqi.com © 2006 Duke Clinical Research Institute. Used with permission.

Quarter 1 2002

Quarter 12003

Quarter 12004

Quarter 12005

Quarter 22006

68.1%73.0%

78.0%80.8% 83.2%

0%

25%

50%

75%

100%

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Performance Matters! Association Between Hospital Guideline

Adherence and In-hospital Mortality in CRUSADE

Adapted with permission from Peterson ED, et al. JAMA.2006;295:1912-1920.

NSTE ACS = non-ST-segment elevation ACS; NSTEMI = non-ST-segment elevation MI.

8

7

6

5

4

3

2

1

01 2 3 4

In-H

osp

ital

Mo

rtal

ity

, %

Hospital Composite GuidelineAdherence Quartiles

NSTE ACS 8

7

6

5

4

3

2

1

01 2 3 4

In-H

osp

ital

Mo

rtal

ity

, %

Hospital Composite GuidelineAdherence Quartiles

NSTEMI

CRUSADE = Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines.

STRIVETM

NRMI. Available at: http://www.nrmi.org/index.html. Get With The Guidelines. Available at: http://www.americanheart.org. ACC National Cardiovascular Data Registry. Available at: http://www.acc.org/ncdr/index.htm. GRACE. Available at: http://www.umassmed.edu/outcomes/grace. CRUSADE. Available at: http://www.crusadeqi.com.REACH. Available at: http://www.REACHregistry.org

Importance of Data-Collection Registries Track adherence to guidelines Support local quality-improvement programs Compare practice patterns/outcomes with national benchmarks Comply with regulatory requirements Provide research data Major data-collection registries

– NRMI– AHA “Get With The Guidelines” Patient Management Tool– ACC National Cardiovascular Data Registry– GRACE– CRUSADE– REACH

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CRUSADE: Latest Results in NSTEMI ACS in US: Conclusions

Care for NSTEMI ACS is improving:– Continued progress in adherence to ACC/AHA Guidelines for

both acute and discharge treatments

– More early cath, leading to earlier discharge

Yet opportunities for improvement persist– Largest gaps: acute GP IIb/IIIa, D/C ACE, clopidogrel

– “Right dosing” to reduce adverse events

And can lead to even better patient outcomes!

Available at www.crusadeqi.com.© 2005 Duke Clinical Research Institute. Used with permission.

STRIVETM

Conclusions Gap between knowledge of guidelines

and practice

Several studies show:– Critical pathways interventions improve

care and improve patient outcomes

Need local champions, implementation plan, and action!