1
Acute Myocardial Infarction and Acute Myocardial Infarction and the Role of Critical Pathwaysthe Role of Critical Pathways
Christopher Cannon, M.D.
Brigham and Women’s Hospital
Boston
ACUTE MI GUIDELINES 11/96
Drug Rx Peri MI: Meta-Analyses
Beta blocker during MI
Beta blocker post MI
ACEI during MI
ACEI post MI if LV dysfxn
Nitrates during MI
Ca++ blockers
Magnesium
Lidocaine
Class I Antiarrhythmics
Number RR Death p value
28,970
24,298
100,963
5,986
81,908
20,342
61,860
9,155
6,300
.87 (.77-.98)
.77 (.70-.84)
.94 (.89-.98)
.78 (.70-.86)
.94 (.90-.99)
1.04 (.95-1.14)
1.02 (.96-1.08)
1.38 (.98-1.95)
1.21 (1.01-1.44)
0.02
<0.001
0.006
<0.001
0.03
NS
NS
NS
0.04
NEJM 335:1662, 1996
NRMI-1: Medical Therapy In-hospitalNRMI-1: Medical Therapy In-hospital
Thrombolysis No Thrombolysis
No. Pts 84477 156512
ASA (%) 84 63
Heparin (%) 97 56
IV nitro (%) 76 50
IV B-Blockers (%) 17 6
Oral B-Blockers (%) 36 29
Ca-Blockers (%) 29 42
Rogers WJ, et al. Circulation 1994;90:2103-2114.
0-30 mins34%
31-45 mins25%
46-60 mins15%
61-90 mins14%
>90 mins12%
0-30 mins34%
31-45 mins25%
46-60 mins15%
61-90 mins14%
>90 mins12%
N=84,423N=84,423
NRMI-2: Distribution of Door-to-Needle Times
40%40%Cannon CP ACC 2000
0.6
0.8
1
1.2
1.4
0-30 31-60 61-90 >90
Door-to-Needle Time (minutes)
MV
Ad
just
ed
Od
ds
of
De
ath
Cannon CP ACC 2000
NRMI-2: Thrombolysis Door-to-Needle Time vs. Mortality
N=28,624 33,867 11,616 10,316
P=0.01P=0.0001
P=NS
1.03
1.11
1.23
8.2
21.224.4
16.5
9.7
20.0
0
5
10
15
20
25
30
0-60 61-90 91-120 121-150 151-180 >180
% o
f Pat
ient
s
8.2
21.224.4
16.5
9.7
20.0
0
5
10
15
20
25
30
0-60 61-90 91-120 121-150 151-180 >180
% o
f Pat
ient
s
N=27,080N=27,080
NRMI-2: Primary PCI Distribution of Door-to-Balloon times
Door-to-Balloon Time (minutes) Cannon CP, et al JAMA 2000;283:2941-2947.
0.2
0.6
1
1.4
1.8
2.2
0-60 61-90 91-120 121-150 151-180 >180
Door-to-Balloon Time (minutes)
MV
Ad
just
ed
Od
ds
of
De
ath
P=0.01 P=0.0007 P=0.0003P=NSP=NS
1.14 1.15
1.41
1.62 1.61
N=2,230 5,734 6,616 4,461 2,627 5,412
NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality
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
European Society of Cardiology ESC
Wood et al. Wood et al. Lancet Lancet 2001; 357: 995-10012001; 357: 995-1001
% beta-blockers at interviewby center
EUROASPIRE
7774
8860
6855
84
4761
4862
6647
6444
63
0 20 40 60 80 100
BEL/GHE
CZE/PP
FIN/KUO
FRA/LLRT
GER/MUNS
GRE/ATCI
HUN/BUD
IRE/DUB
ITA/TV
NET/ROT
POL/CRA
SLO/LJU
SPA/BAR
SWE/MAL
UK/HL
ALL
European Society of Cardiology ESC
Wood et al. Wood et al. Lancet Lancet 2001; 357: 995-10012001; 357: 995-1001
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US News and World Report US News and World Report Aspirin in ideal candidatesAspirin in ideal candidates
0%
20%
40%
60%
80%
100%
Top-ranked Invasive Non-invasive
Chen J, et al N Engl J Med. 1999;340:286-292.
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US News and World Report US News and World Report Beta-blockers in ideal candidatesBeta-blockers in ideal candidates
0%
20%
40%
60%
80%
100%
Top-ranked Invasive Non-invasive
Chen J, et al N Engl J Med. 1999;340:286-292.
US News and World ReportUS News and World Report30-day mortality by hospital category*30-day mortality by hospital category*
0%
5%
10%
15%
20%
25%
30%
US News Invasive Non-invasive
Stars
* 25th, 50th and 75th percentile for each categoryChen J, et al N Engl J Med. 1999;340:286-292.
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Quality implicationsQuality implications
– The lower mortality observed in “America’s Best Hospitals” appear to be explained in part by their higher use of aspirin and beta-blockers
– Any hospital can be one of “America’s Best” by increasing their use of aspirin and beta-blockers
Chen J, et al N Engl J Med. 1999;340:286-292.
No. PtsNo. Pts On AdmissionOn Admission
ASAASA
HeparinHeparin
B-blockersB-blockers
16781678
8282
6363
4141
MenMen
1640 1640
7777
5050
3535
WomenWomen
17881788
8484
6666
5353
MenMen
1160 1160
8080
6060
4949
WomenWomen
Pre GuidelinePre Guideline
TIMI III RegistryTIMI III Registry
Scirica BM, Cannon CP, et al. Crit Path Cardiol. 2002;1:151-160.
Post GuidelinePost Guideline
ARANTEEARANTEEGUGU
Comparing Pre- to Post-:Comparing Pre- to Post-: Men Men WomenWomenP values :P values : ASAASA 0.300.30 0.050.05
HeparinHeparin 0.130.13 0.0010.001B-blockerB-blocker 0.0010.001 0.0010.001
Unadjusted One Year SurvivalUnadjusted One Year SurvivalUnadjusted One Year SurvivalUnadjusted One Year Survival
0
20
40
60
80
100
0 8 16 24 32 40 48
Guideline ( n = 189 )
Not guideline ( n = 86 )
0
20
40
60
80
100
0 8 16 24 32 40 48
Guideline ( n = 189 )
Not guideline ( n = 86 )
Weeks post discharge
Per
cen
t su
rviv
ing
95%
81%P = .0001
Giugliano RP,et al. Arch Intern Med 2000;160.
• Standardized protocols
• Goal: optimize care
• Emerging Evidence – Pathways work:
– CHAMP
– Guidelines Applied in Practice (GAP)
– AHA “Get with the Guidelines” program
www.critpathcardio.com
National Heart Attack
Alert Program (NHAAP)
CRITICAL PATHWAYS FOR THE TREATMENT OF
PATIENTS WITH ACUTE CORONARY SYNDROMES
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Critical Pathways - DefinitionsCritical Pathways - Definitions
• Standardized protocols for care
• Strict definition
– Full list of all tasks, tracks variances
• Broader definition
– Includes clinical protocols (NHAAP 4D’s)
• Diagnostic pathways - Chest Pain Centers
• Treatment pathways - Thrombolysis
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Goals of Critical PathwaysGoals 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.
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Need and Rationale for Critical Need and Rationale for Critical PathwaysPathways
• 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)
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Development And Implementation Of Development And Implementation Of Critical PathwaysCritical 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.
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Methods of Implementation of Methods of Implementation of PathwaysPathways
• 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.)
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Goal: < 30 MinutesNHAAP Ann Emerg Med 1994;23:311-29.
24
35
40
45
50
55
60
65
Minutes (median)
NRMI 1 & 2 Trends:NRMI 1 & 2 Trends: Door to Drug (t-PA) IntervalDoor to Drug (t-PA) Interval
All Hospitals, t-PA-treated Patients (N = 241,757)
W. Rogers, personal communication
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BWH Thrombolysis Critical Pathway: Initial BWH Thrombolysis Critical Pathway: Initial ExperienceExperience
0
20
40
60
80
100
120
Jun-Nov 20, 93 Nov 21, 93-June 94
July 94- Dec 94 Jan 95- June 95
Doo
r-to
-Nee
dle
Tim
e (M
ins) Women
Men
*P=0.013
Cannon CP, et al. Clin Cardiol 1999;22:17-22
BEFORE
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2/94 - 1/95 2/95 - 7/95 P value
No Pts. 27 35
Door-Balloon Time
205+/- 130 97 +/- 57 0.02
Adverse Outcome
41% 17% 0.04
Death 26% 0% 0.004
Effect of CQI on Primary PCI Outcome
Caputo RP, Am J Cardiol 1997;79:1159-1164.
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Guidelines Applied in Practice Guidelines Applied in Practice (GAP)(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.
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64%65%81%
70%87% 74%
0%
20%
40%
60%
80%
100%
(343) (404) (213) (245) (131) (252)
ASA BB LDL CHOL
* *
* p < 0.05
** p < 0.01
111130
38 40
0
50
100
150
Time in Minutes
(40) (24) (32) (45)
LYSIS PTCA
PRE POST
GAP Results: Early IndicatorsGAP Results: Early Indicators
Mehta R, et al. JAMA. 2002;287:1269-1276.
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GAP: Adherence Improves With Tool GAP: Adherence Improves With Tool UseUse
Mehta R, et al. JAMA. 2002;287:1269-1276.
Qu
alit
y
Ad
he
ren
ce
, %
Pre-intervention
No Tool UseTool Use
Post-intervention
0
20
40
60
80
100
Aspirin -Blocker LDL Cholesterol
No. of Ideal Patients
8186
93
6573
77
64 64
82
343 308 96 213174 71 131165 87
P = .004P = .001
Demographics 6 clicks
Clinical/Lab 8 clicks
Dischargemeds and interventions 7 clicks
Interactivelychecks patient’sdata with theAHA guidelines
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Importance of Importance of Data-Collection RegistriesData-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
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VA Transformation - MethodsVA 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.
Jha AK, et al. N Engl J Med 2003;348:2218-27.
VA Transformation - ResultsVA Transformation - Results
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ConclusionsConclusions
• 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