0009COR0009COR11

A CRUSADE to Improve A CRUSADE to Improve Quality of Care for ACS PatientsQuality of Care for ACS Patients

A CRUSADE to Improve A CRUSADE to Improve Quality of Care for ACS PatientsQuality of Care for ACS Patients

Eric D. Peterson, MD, MPHAssociate Professor of Medicine

Director of CV Outcomes and QualityDuke Clinical Research Institute (DCRI)

Duke University Medical Center

Eric D. Peterson, MD, MPHAssociate Professor of Medicine

Director of CV Outcomes and QualityDuke Clinical Research Institute (DCRI)

Duke University Medical Center

Annual Admissions for Acute Coronary Syndrome (ACS)

Annual Admissions for Acute Coronary Syndrome (ACS)

1.4 MillionNon-ST-segment

elevation ACSAND GROWING!

600,000ST-segment elevation

MI

~ 2.0 MM patients admittedto CCU or telemetry annually

DiscoveryDiscoveryDiscoveryDiscovery

OutcomesOutcomes

Clinical Clinical TrialsTrials

Clinical Clinical TrialsTrials

GuidelinesGuidelinesGuidelinesGuidelines

PerformanceIndicators

PerformanceIndicators

AssessmentAssessmentAssessmentAssessment

The Cycle of Clinical TherapeuticsThe Cycle of Clinical Therapeutics

Califf R, Peterson, E JACC 2002;40:1895-901Califf R, Peterson, E JACC 2002;40:1895-901

ST-segment Elevation

Time Dependent: Emergency Evaluation of ACS

Time Dependent: Emergency Evaluation of ACS

Chest pain or Short of Breath

Unstable Angina

ST-segment Depression

– + +

Presentation

ECG

Diagnosis

Braunwald E,2002 http://www.acc.org/clinical/guidelines/unstable/unstable

Normal

Markers

Acute MI

–+

Rule-Out

Troponin as a Marker of Increased Risk in ACSTroponin as a Marker of Increased Risk in ACS

30%

12% 11%

34%

22%19% 19%

23%

2%4% 4%

12%

1% 0%

6% 6%

0%

10%

20%

30%

40%

Hamm(1992)

FRISC(1996)

TRIM(1999)

Pettijohn(1997)

Hamm(1997)

Hamm(1997)

Polanczyk(1998)

Galvanni(1997)

Dea

th o

r M

I

Troponin +

Troponin -30%

12% 11%

34%

22%19% 19%

23%

2%4% 4%

12%

1% 0%

6% 6%

0%

10%

20%

30%

40%

Hamm(1992)

FRISC(1996)

TRIM(1999)

Pettijohn(1997)

Hamm(1997)

Hamm(1997)

Polanczyk(1998)

Galvanni(1997)

Dea

th o

r M

I

Troponin +

Troponin -

10 ng/mL troponin standard material, measured by 13 participating cTnI assays, in duplicate samples:

10 ng/mL troponin standard material, measured by 13 participating cTnI assays, in duplicate samples:

Value 1 Value 2 Mean143.7 135.7 139.746.9 47.9 47.419.9 19.9 19.949.2 50.1 49.74.3 4.1 4.2

12.5 12.6 12.67.4 8.9 8.26.0 6.1 6.0

16.5 17.4 17.012.6 13.2 12.912.6 12.4 12.5

Systematic Variation Between cTnI AssaysSystematic Variation Between cTnI Assays

Conclusion: Within assay reproducibility good, but across assay results varied >30-fold different!

Clin Chem 2001;47:431-437Clin Chem 2001;47:431-437

US PURSUIT Results: Treatment Effect of Eptifibatide in High Risk Subgroups

Death or MI

US PURSUIT Results: Treatment Effect of Eptifibatide in High Risk Subgroups

Death or MI

MenMen

Old age tertileOld age tertile

No diabetes mellitusNo diabetes mellitus

Low age tertileLow age tertile

Middle age tertileMiddle age tertile

WomenWomen

Diabetes mellitusDiabetes mellitus

USING THE TIMI RISK SCORE TO PREDICT BENEFIT OF GP IIb-IIIa THERAPYUSING THE TIMI RISK SCORE TO PREDICT BENEFIT OF GP IIb-IIIa THERAPY

7.7 9.9

23.327.3

37.3

6.3

15 17.322.8 21.3

0

10

20

30

40

50

1//2 3 4 5 6//7

14 d

ay e

nd

po

int

(%) placebo

GP IIb/IIIa

7.7 9.9

23.327.3

37.3

6.3

15 17.322.8 21.3

0

10

20

30

40

50

1//2 3 4 5 6//7

14 d

ay e

nd

po

int

(%) placebo

GP IIb/IIIa

Morow DA,Eur HeartJ 2002;23:223-229

Number of risk factors

NNT 72 NA 17 22 6.2

Benefits of GP IIb-IIIa by Troponin Status in Clinical Trials

Benefits of GP IIb-IIIa by Troponin Status in Clinical Trials

TnT-negativeTnT-negativeTnT-positiveTnT-positive

PARAGONPARAGON BB

PRISMPRISM

CAPTURECAPTURE

COMBINEDCOMBINED

0.1250.125 1111 22 22

Newby, Circulation 2001Newby, Circulation 2001

0.1250.1250.50.50.50.5

In-hospital Mortality By Early GP IIb-IIIa Inhibitor Use (within 24 hrs) †

Cumulative Q1 2003 Data

In-hospital Mortality By Early GP IIb-IIIa Inhibitor Use (within 24 hrs) †

Cumulative Q1 2003 Data

∆ 42%P < 0.0001∆ 42%

P < 0.0001

*Includes patients who received late GP IIb-IIIa inhibitor (> 24 hrs) therapy.† Unadjusted for risk.

2.71%

4.68%

0%

2%

4%

6%

8%

% In-hospital Mortality

No Early GP IIb-IIIa Inhibitor (n = 26,596)

Early GP IIb-IIIaInhibitor (n = 14,296)

Mortality Benefits of Early GP IIb-IIIa Inhibitor: Results from Clinical Trials, NRMI and CRUSADE

Mortality Benefits of Early GP IIb-IIIa Inhibitor: Results from Clinical Trials, NRMI and CRUSADE

NRMI NSTEMINRMI NSTEMI##

(N=60,770)(N=60,770)

95% CI Odds Ratio

1.0 2.00.5 No Early GP IIb-IIIa Inhibitor Better

Early GP IIb-IIIa Inhibitor Better

0.91 (0.81, 1.03)

CRUSADE ACSCRUSADE ACS††

(n=31,257)(n=31,257)

0.88 (0.79, 0.97)

0.90 (0.78, 1.04)

6 RCTs ACS6 RCTs ACS** (n=31,402)(n=31,402)

Boersma Lancet 2002;359:189-98 # Peterson JACC 2003;42:45-53††Adjusted for risk, treatment, hospital factorsAdjusted for risk, treatment, hospital factors

Boersma Lancet 2002;359:189-98 # Peterson JACC 2003;42:45-53††Adjusted for risk, treatment, hospital factorsAdjusted for risk, treatment, hospital factors

Adjusted Mortality by Early GP IIb-IIIa Inhibitor Results by Troponin Status

Adjusted Mortality by Early GP IIb-IIIa Inhibitor Results by Troponin Status

95% CI Odds Ratio

1.0 2.00.5 No Early GP IIb-IIIa Inhibitor Better

Early GP IIb-IIIa Inhibitor Better

CRUSADE OverallCRUSADE Overall(n=31,257)(n=31,257)

0.90 (0.78, 1.04)

0.84 (0.71, 0.99) CRUSADE Trop PosCRUSADE Trop Pos (n=25,848)(n=25,848) CRUSADE Trop PosCRUSADE Trop Pos (n=25,848)(n=25,848)

CRUSADE Trop NegCRUSADE Trop Neg (n=5,964)(n=5,964) CRUSADE Trop NegCRUSADE Trop Neg (n=5,964)(n=5,964)

0.95 (0.46, 1.35)

Excludes pts transferred out, GP IIb-IIIa contraindications Excludes pts transferred out, GP IIb-IIIa contraindications

4.15%

5.02%

1.65%1.32%

0%

1%

2%

3%

4%

5%

6%

Death Death/MI

"In-lab Only" GP IIb-IIIa (n =3,642)

"Upfront" GP IIb-IIIa (n = 2,191)

In-hospital Events by “Upfront” vs. “In-lab Only” GP IIb-IIIa Inhibitor Use

(Patients receiving PCI < 48 hrs + GP IIb-IIIa; n= 5,833)

In-hospital Events by “Upfront” vs. “In-lab Only” GP IIb-IIIa Inhibitor Use

(Patients receiving PCI < 48 hrs + GP IIb-IIIa; n= 5,833)

Adjusted OR 0.95; (95% CI 0.60-1.15)Adjusted OR 0.95; (95% CI 0.60-1.15)

Adjusted OR 0.83; (95% CI 0.63-1.09)Adjusted OR 0.83; (95% CI 0.63-1.09)

Peterson ACC 2003Peterson ACC 2003

14.5

24.2

16.914.3

0

5

10

15

20

25

30

TnT - TnT +

14.5

24.2

16.914.3

0

5

10

15

20

25

30

TnT - TnT +

6 m

o D

eath

/ MI/

Reh

osp

(%

)

CONS INV

TACTICS-TIMI 18Early Intervention vs Conservative

By Troponin Status

TreatmentTreatmentInteractionInteraction

P<0.001P<0.001

N=414N=414 N=396N=396 N=463N=463 N=495N=495

11.8

20.3

12.816.1

19.5

30.6

0

5

10

15

20

25

30

35

Low 0-2 Intermed. 3-4 High 5-7

11.8

20.3

12.816.1

19.5

30.6

0

5

10

15

20

25

30

35

Low 0-2 Intermed. 3-4 High 5-7

6 m

o D

eath

/ M

I/ R

eho

sp (

%) CONS INV

TACTICS-TIMI 18Early Intervention vs Conservative

By TIMI Risk Score

CRUSADE: Benefits of Early Catheterization within 48 hrs by Risk GroupCRUSADE: Benefits of Early Catheterization within 48 hrs by Risk Group

0

2

4

6

8

10

12

Low Risk Moderate Risk High Risk

% I

n-H

os

pit

al

Mo

rta

lity

Early Cath No Early Cath

0

2

4

6

8

10

12

Low Risk Moderate Risk High Risk

% I

n-H

os

pit

al

Mo

rta

lity

Early Cath No Early Cath

- Bhatt AHA 2002- Bhatt AHA 2002

Does Current Practice Mirror Guidelines Recommendations?

Does Current Practice Mirror Guidelines Recommendations?

AK(0)

WA(11)

OR(5)

CA(43)

ID(1)

NV(1)

MT(0)

WY(0)

CO(4)

NM(2)

ND(1)

SD(2)

NE (3)

KS(7)

OK(5)

TX(19)

MN(6)

IA(4)

MO(12)

AR(5)

LA(5)

WI(5) MI

(23)

MI

UT(1)

AZ(14)

HI (3)

IL(14)

IN(9)

KY(13)

TN (14)

MS(8)

AL(9)

GA(12)

FL(49)

SC(7)

NC(13)

VA(17)

OH(34)

WV(4)

PA(48)

NY(40)

MD (13)

ME(1)

VT (1)

NH (2)

NJ (14)

MA (14)

CT (9)

DE (3)

RI (0)

DC (4)

Active sites = 43056,400 Patients

CRUSADE Site Distribution

Hospital PresentationCharacteristics in CRUSADEHospital PresentationCharacteristics in CRUSADE

Qualifying CriteriaQualifying CriteriaST-segment depressionST-segment depression 39% 39%Transient ST-segment elevationTransient ST-segment elevation 11% 11%Positive cardiac markersPositive cardiac markers 88% 88%

Baseline cardiac markersBaseline cardiac markers DrawnDrawnPositivePositive

CK-MBCK-MB 85%85%35%35%TnT/TnITnT/TnI 97%97%84%84%

Bedside assaysBedside assays CK-MBCK-MB 9%9%TroponinTroponin 11%11%

Qualifying CriteriaQualifying CriteriaST-segment depressionST-segment depression 39% 39%Transient ST-segment elevationTransient ST-segment elevation 11% 11%Positive cardiac markersPositive cardiac markers 88% 88%

Baseline cardiac markersBaseline cardiac markers DrawnDrawnPositivePositive

CK-MBCK-MB 85%85%35%35%TnT/TnITnT/TnI 97%97%84%84%

Bedside assaysBedside assays CK-MBCK-MB 9%9%TroponinTroponin 11%11%

Baseline Characteristics:CRUSADE vs. ACS Clinical TrialsBaseline Characteristics:CRUSADE vs. ACS Clinical Trials

Variable PURSUITPURSUIT PRISM-PLUSPRISM-PLUS GUSTO-IV ACSGUSTO-IV ACS CRUSADECRUSADE(n = 9461) (n = 1915) (n = 7800) (n =

41,267)

Mean age ± SD (yrs) 63 ± 11 63 ± 12 65 ± 11 68 ± 13

Female sex (%) 36 32 38 40

Diabetes mellitus (%) 23 23 22 33

Prior MI (%) 32 43 31 31

Prior CHF (%) 11 10 8 17

Prior PCI (%) 13 10 10 21

Prior CABG (%) 12 15 8 20

ST depression (%) 50 58 80 39

Variable PURSUITPURSUIT PRISM-PLUSPRISM-PLUS GUSTO-IV ACSGUSTO-IV ACS CRUSADECRUSADE(n = 9461) (n = 1915) (n = 7800) (n =

41,267)

Mean age ± SD (yrs) 63 ± 11 63 ± 12 65 ± 11 68 ± 13

Female sex (%) 36 32 38 40

Diabetes mellitus (%) 23 23 22 33

Prior MI (%) 32 43 31 31

Prior CHF (%) 11 10 8 17

Prior PCI (%) 13 10 10 21

Prior CABG (%) 12 15 8 20

ST depression (%) 50 58 80 39

NEJM, 1998 NEJM, 1998 Lancet, 2001Lancet, 2001NEJM, 1998 NEJM, 1998 Lancet, 2001Lancet, 2001

CRUSADE vs. ACS Clinical Trials:Early Mortality RatesCRUSADE vs. ACS Clinical Trials:Early Mortality Rates

0

1

2

3

4

5

6

0

1

2

3

4

5

6

PURSUIT PURSUIT (n = 9,461)(n = 9,461)

PRISM-PLUSPRISM-PLUS(n = 1,915)(n = 1,915)

GUSTO IV-GUSTO IV-ACSACS

(n = 7,800)(n = 7,800)

CRUSADE CRUSADE (n = 41,267)(n = 41,267)

1.8%1.8% 1.9%1.9% 1.8%1.8%

4.7%4.7%

7-day mortality rate7-day mortality rate

In-hospital mortality rate

In-hospital mortality rate

NEJM, 1998 NEJM, 1998 Lancet, 2001Lancet, 2001NEJM, 1998 NEJM, 1998 Lancet, 2001Lancet, 2001

Goal for CRUSADE: Improve Adherence to ACC/AHA Guidelines

Goal for CRUSADE: Improve Adherence to ACC/AHA Guidelines

Aspirin Clopidogrel

Beta Blocker

Heparin (UFH or LMWH)

GP IIb-IIIa Inhibitor All receiving PCI

Aspirin Clopidogrel

Beta Blocker

Heparin (UFH or LMWH)

GP IIb-IIIa Inhibitor All receiving PCI

Aspirin

Clopidogrel

Beta Blocker

ACE Inhibitor

Statin/Lipid Lowering

Smoking Cessation

Cardiac Rehabilitation

Aspirin

Clopidogrel

Beta Blocker

ACE Inhibitor

Statin/Lipid Lowering

Smoking Cessation

Cardiac Rehabilitation

Acute TherapiesAcute TherapiesAcute TherapiesAcute Therapies Discharge TherapiesDischarge TherapiesDischarge TherapiesDischarge Therapies

Circulation, JACC 2002 - ACC/AHA Guidelines updateCirculation, JACC 2002 - ACC/AHA Guidelines updateCirculation, JACC 2002 - ACC/AHA Guidelines updateCirculation, JACC 2002 - ACC/AHA Guidelines update

Acute Medication Use(within 1st 24 hours)

Acute Medication Use(within 1st 24 hours)

94%94%94%94%

79%79%79%79%

84%84%84%84%

36%36%36%36%

0%0%

20%20%

40%40%

60%60%

80%80%

100%100%

ASAASAASAASA BetaBetaBlockersBlockers

BetaBetaBlockersBlockers

HeparinHeparin(LMW + UFH)(LMW + UFH)

HeparinHeparin(LMW + UFH)(LMW + UFH)

GP IIb-IIIaGP IIb-IIIaInhibitorsInhibitorsGP IIb-IIIaGP IIb-IIIaInhibitorsInhibitors

95%86% 91%

50%

86%

65% 71%

21%

0%

20%

40%

60%

80%

100%

Aspirin < 24 hrs Beta Blocker < 24 Hrs

Heparin GP IIb-IIIaInhibitor

95%86% 91%

50%

86%

65% 71%

21%

0%

20%

40%

60%

80%

100%

Aspirin < 24 hrs Beta Blocker < 24 Hrs

Heparin GP IIb-IIIaInhibitor

Gap between Leading and Lagging Gap between Leading and Lagging Hospital Quartiles: Hospital Quartiles:

Acute CareAcute Care

Gap between Leading and Lagging Gap between Leading and Lagging Hospital Quartiles: Hospital Quartiles:

Acute CareAcute Care

Leading CentersLeading Centers Lagging CentersLagging Centers

Invasive Cardiac ProceduresInvasive Cardiac Procedures

62%62%62%62%

43%43%43%43%37%37%37%37%

23%23%23%23%

0%0%

15%15%

30%30%

45%45%

60%60%

75%75%

CathCathCathCath Cath < 48 hrCath < 48 hrCath < 48 hrCath < 48 hr PCIPCIPCIPCI CABGCABGCABGCABG

12%12%12%12%

PCI < 48 hrPCI < 48 hrPCI < 48 hrPCI < 48 hr

Median TimesMedian Times

• Cath - 28 hrsCath - 28 hrs

• PCI - 26 hrsPCI - 26 hrs

• CABG - 71 hrsCABG - 71 hrs

Acute Therapies (< 24 hrs)Acute Therapies (< 24 hrs)by Peak Troponin Levelby Peak Troponin LevelAcute Therapies (< 24 hrs)Acute Therapies (< 24 hrs)by Peak Troponin Levelby Peak Troponin Level

00

1010

2020

3030

4040

5050

6060

7070

8080

9090

100100 Tn 0-1 xULNTn 0-1 xULN

Tn 1-2 xULNTn 1-2 xULN

Aspirin Aspirin BB-Blockers-Blockers Heparin GP IIb/IIIa Clopidogrel Heparin GP IIb/IIIa Clopidogrel(UFH + LMWH)(UFH + LMWH)

Aspirin Aspirin BB-Blockers-Blockers Heparin GP IIb/IIIa Clopidogrel Heparin GP IIb/IIIa Clopidogrel(UFH + LMWH)(UFH + LMWH)

Tn 2-5 xULNTn 2-5 xULN

Tn > 5 xULNTn > 5 xULN

P < 0.001P < 0.001P < 0.001P < 0.001 P < 0.001P < 0.001P < 0.001P < 0.001 P < 0.001P < 0.001P < 0.001P < 0.001 P < 0.001P < 0.001P < 0.001P < 0.001 P < 0.001P < 0.001P < 0.001P < 0.001

Roe, ACC 2003Roe, ACC 2003

Use of Invasive Procedures by Peak Use of Invasive Procedures by Peak Troponin LevelTroponin LevelUse of Invasive Procedures by Peak Use of Invasive Procedures by Peak Troponin LevelTroponin Level

CathCath

PCIPCI

0

10

20

30

40

50

60

70

80

0-1 xULN 1-2 xULN 2-5 xULN > 5 xULN

Peak Troponin Ratio

%%%%

CABGCABGRoe, ACC 2003Roe, ACC 2003

Peak Tn Ratio

1-2 X ULN

2-5 X ULN

> 5 X ULN

Peak Tn Ratio

1-2 X ULN

2-5 X ULN

> 5 X ULN

NormalNormal

11 1.51.5 2.02.0 2.52.5

Adjusted Risk of In-Hospital Mortality by Peak Troponin Level

Adjusted Risk of In-Hospital Mortality by Peak Troponin Level

P = 0.03

P = 0.02

P < 0.001

P = 0.03

P = 0.02

P < 0.001

Roe, ACC 2003Roe, ACC 2003

Discharge Medication UseDischarge Medication Use

LVEF < 40%, CHF, DM, HTNLVEF < 40%, CHF, DM, HTN

# Known hyperlipidemia, # Known hyperlipidemia, TC, TC, LDLLDL

90%90% 83%83%

0%0%

20%20%

40%40%

60%60%

80%80%

100%100%

ASAASA Beta Beta BlockersBlockers

ACE-ACE-Inhibitors*Inhibitors*

61%61%

Lipid-Lipid-LoweringLowering

AgentAgent##

79%79%

56%56%

ClopidogrelClopidogrel

Discharge InterventionsDischarge Interventions

59%59%59%59%

72%72%72%72%

42%42%42%42%

66%66%66%66%

0%0%

20%20%

40%40%

60%60%

80%80%

100%100%

Lipid Panel Lipid Panel DrawnDrawn

Lipid Panel Lipid Panel DrawnDrawn

DietaryDietaryCounselingCounseling

DietaryDietaryCounselingCounseling

Cardiac RehabCardiac RehabReferralReferral

Cardiac RehabCardiac RehabReferralReferral

Smoking Smoking Cessation Cessation CounselingCounseling

Smoking Smoking Cessation Cessation CounselingCounseling

Gap between Leading and Lagging Gap between Leading and Lagging Hospital Quartiles: Hospital Quartiles:

Discharge CareDischarge Care

Gap between Leading and Lagging Gap between Leading and Lagging Hospital Quartiles: Hospital Quartiles:

Discharge CareDischarge Care 94% 89%

68%

81%

60%

82%

69%

49%

64%

36%

0%

20%

40%

60%

80%

100%

Aspirin Beta-blocker Ace Inhibitor*

Statin Clopidogrel

94% 89%

68%

81%

60%

82%

69%

49%

64%

36%

0%

20%

40%

60%

80%

100%

Aspirin Beta-blocker Ace Inhibitor*

Statin Clopidogrel

* LVEF < 40%* LVEF < 40%# Known hyperlipidemia# Known hyperlipidemia* LVEF < 40%* LVEF < 40%# Known hyperlipidemia# Known hyperlipidemia

##

Leading CentersLeading Centers Lagging CentersLagging Centers

0009COR0009COR3232

Paradoxical Care:Failing to Treat High Risk ACS

Paradoxical Care:Failing to Treat High Risk ACS

Risk of ACS in Elderly*Risk of ACS in Elderly*

2.8

67.4

8.5

13.3

16.1

02468

1012141618

Death Death/MI CHF

<75 Years >75 Years

* Kulkarni S et al ACC 2003 CRUSADE Presentation

Medical Therapy in the Elderly Medical Therapy in the Elderly

<75 yrs ≥75 yrs Adj. OR (95%CI)**

AcuteAspirin 92 88* 0.91 (0.83, 1.00)

Beta-Blocker 79 75* 0.91 (0.84, 0.99)Clopidogrel 41 32* 0.82 (0.76, 0.88)

Gp 2b3a 41 22* 0.64 (0.59, 0.69)

Cath (<48 hrs) 46 16* 0.51 (0.42-0.59)

PCI (≤ 48hrs) 32 14* 0.60 (0.55, 0.66)

* Unadjusted p<0.05 ** Comparison of age ≥75 with <75 yrs. Adjusted for gender, race, comorbidity, cardiac markers, insurance status, hospital features, and clustering effects (#elderly treated, similar outcomes).

<75 yrs ≥75 yrs Adj. OR (95%CI)**

AcuteAspirin 92 88* 0.91 (0.83, 1.00)

Beta-Blocker 79 75* 0.91 (0.84, 0.99)Clopidogrel 41 32* 0.82 (0.76, 0.88)

Gp 2b3a 41 22* 0.64 (0.59, 0.69)

Cath (<48 hrs) 46 16* 0.51 (0.42-0.59)

PCI (≤ 48hrs) 32 14* 0.60 (0.55, 0.66)

* Unadjusted p<0.05 ** Comparison of age ≥75 with <75 yrs. Adjusted for gender, race, comorbidity, cardiac markers, insurance status, hospital features, and clustering effects (#elderly treated, similar outcomes).

Acute Risks and Treatment of ACS in Women

Acute Risks and Treatment of ACS in Women

49

323837

20

29

0

10

20

30

40

50

60

Cath<48 PCI <48 GP IIbIIIa<24

Men Women

2003 4th Quarter CRUSADE

4.3

7.1

8.8

5.6

8.6

12.1

0

2

4

6

8

10

12

14

Death Death/MI CHF

Men Women

Risks Treatment

Acute Risks and Treatment of ACS in Diabetes*Acute Risks and Treatment of ACS in Diabetes*

4.3

7.28.5

5.7

8.6

13.8

0

2

4

6

8

10

12

14

16

Death Death/MI CHF

Non-DM DM

* CRUSADE 4th Quarter

49

30

49

39

20

39

0

10

20

30

40

50

60

Cath<48 PCI <48 GP IIbIIIa<24

No DM DM

TreatmentRisks

Acute Treatment of CHFAcute Treatment of CHF

52

30

48

25

11

32

0

10

20

30

40

50

60

Cath<48 PCI <48 GP IIbIIIa<24

No CHF CHF2003 4th Quarter CRUSADE

3.1

5.7

10.6

14.7

0

2

4

6

8

10

12

14

16

Death Death/MI

No CHF CHF

TreatmentRisks

If the guidelines are implemented, Do outcomes improved?

If the guidelines are implemented, Do outcomes improved?

0

1

2

3

4

5

6

7

<65% 65-75% 75-80% >80%

Hospital Composite Adherence Quartiles

In-h

osp

ital

Mo

rtal

ity

(%)

Performance Matters!Relationship between Process and Outcome

Performance Matters!Relationship between Process and Outcome

5.95.9

5.05.04.64.6

3.63.6

Peterson ED 2002 AHA

Peterson ED 2002 AHA

0009COR0009COR4040

Can We Improve Care?Can We Improve Care?

Quality Improvement Interventions:Quality Improvement Interventions:Site Predictors of SuccessSite Predictors of Success

Quality Improvement Interventions:Quality Improvement Interventions:Site Predictors of SuccessSite Predictors of Success

Strong clinician “champions” Strong clinician “champions”

Administrative support for CQIAdministrative support for CQI

Shared targets for improvementShared targets for improvement

High-quality data feedbackHigh-quality data feedback

Strong clinician “champions” Strong clinician “champions”

Administrative support for CQIAdministrative support for CQI

Shared targets for improvementShared targets for improvement

High-quality data feedbackHigh-quality data feedback

Bradley E, JAMA 2001 - Use of Beta-Blockers Post-MIBradley E, JAMA 2001 - Use of Beta-Blockers Post-MIBradley E, JAMA 2001 - Use of Beta-Blockers Post-MIBradley E, JAMA 2001 - Use of Beta-Blockers Post-MI

Practical Steps to Improve the Use of Evidence-Practical Steps to Improve the Use of Evidence-Based Therapies for Non-ST Based Therapies for Non-ST ACS ACS

Practical Steps to Improve the Use of Evidence-Practical Steps to Improve the Use of Evidence-Based Therapies for Non-ST Based Therapies for Non-ST ACS ACS

Identify local Cardiology and ED physician championsIdentify local Cardiology and ED physician champions

Secure institutional commitment to improved pt careSecure institutional commitment to improved pt care

Develop educational materials to improve Develop educational materials to improve allall physicians’ physicians’ knowledge of the ACC/AHA guidelinesknowledge of the ACC/AHA guidelines

Track adherence to ACC/AHA recommendationsTrack adherence to ACC/AHA recommendations Identify areas for QI Identify areas for QI

Provide standard QI toolsProvide standard QI tools

Give ongoing quarterly feedbackGive ongoing quarterly feedback

Identify local Cardiology and ED physician championsIdentify local Cardiology and ED physician champions

Secure institutional commitment to improved pt careSecure institutional commitment to improved pt care

Develop educational materials to improve Develop educational materials to improve allall physicians’ physicians’ knowledge of the ACC/AHA guidelinesknowledge of the ACC/AHA guidelines

Track adherence to ACC/AHA recommendationsTrack adherence to ACC/AHA recommendations Identify areas for QI Identify areas for QI

Provide standard QI toolsProvide standard QI tools

Give ongoing quarterly feedbackGive ongoing quarterly feedback

Trends in Acute Therapy AdherenceTrends in Acute Therapy Adherence

0%

25%

50%

75%

100%

Antiplatelet Beta Blocker Heparin GP IIb- IIIaInhibitor

Q1 Q2 Q3 Q4

0%

25%

50%

75%

100%

Antiplatelet Beta Blocker Heparin GP IIb- IIIaInhibitor

Q1 Q2 Q3 Q4

Trends in Discharge Therapy AdherenceTrends in Discharge Therapy Adherence

0%

25%

50%

75%

100%

Aspirin Clopidogrel Beta blocker ACE Inhibitor Lipid-loweringAgent

Q1 Q2 Q3 Q4

0%

25%

50%

75%

100%

Aspirin Clopidogrel Beta blocker ACE Inhibitor Lipid-loweringAgent

Q1 Q2 Q3 Q4

Trends in Discharge Recommendations Trends in Discharge Recommendations AdherenceAdherence

25%

50%

75%

100%

Smoking CessationCounseling

Dietary Modification Cardiac RehabilitationReferral

Q1 Q2 Q3 Q4

Conclusions: Quality ACS CareConclusions: Quality ACS Care

Clinicians need to rapidly assess pt risk Risk factors + markers

Pts at highest risk tend to benefit from most aggressive interventions

However, current ACS care demonstrates: Wide variability between leading and lagging centers Paradoxical care

Given tight links between care and outcome We need to work together develop successful ACS

quality improvement efforts

Clinicians need to rapidly assess pt risk Risk factors + markers

Pts at highest risk tend to benefit from most aggressive interventions

However, current ACS care demonstrates: Wide variability between leading and lagging centers Paradoxical care

Given tight links between care and outcome We need to work together develop successful ACS

quality improvement efforts

How to Take This Home…How to Take This Home…

Look critically at your data Identify targets

Look at your system

Learn from your neighbors

Make practical, actionable plans

Follow-up

Never be satisfied

Look critically at your data Identify targets

Look at your system

Learn from your neighbors

Make practical, actionable plans

Follow-up

Never be satisfied