What Have We Learned From the Mission: Lifeline Registry? Alice K. Jacobs, M.D. Boston University Medical Center Boston, MA CRT2017

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 Hospitals (n) 179 224 334 383 445 STEMI Patients (n) 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 60 59 First door-to-device (min)*+ [transfer] 130 122 119 114 112 Symptom onset to FMC (min)+ 50 52 49 * P<0.0001; +median minutes Granger. AHA Scientific Sessions 2013. 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. Percentage of emergency medical services (EMS)–transported patients meeting guideline goals for first medical contact– to –device time by quarter (Q). Shown are the 5 most-improved regions for patients arriving directly to PCI hospitals by EMS (A) and transferred patients (B). Jollis. Circulation. 2016;134:365-374.

ACTION Registry-GWTG Contracts & Mission: Lifeline Participating Hospitals 2010 – 2016

National Number of STEMI Patients (2012 – 2016*) *Through Q3 2016

EMS First Medical Contact to 1st Device Activation Median Times (2012 – 2016*) *Through Q3 2016

Transfers: Arrival at 1st Facility to Transfer Out (Door-In Door-Out) Median Times (2012 – 2016*) *Through Q3 2016

Transfers: Arrival at 1st Facility to 1st Device Activation Median Times (2012 – 2016*) *Through Q3 2016

STEMI Door-to-Balloon Median Times for Transfer In and Non-Transfer In Patients Time (min) 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 1st Door to Balloon < 90 Minutes 1st 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

Non-PCI Hospital Transfer Non-PCI Hospital No Transfer 30-day mortality PCI Hospital N=10,697 Non-PCI Hospital All N=3174 Non-PCI Hospital Transfer N=2747 Non-PCI Hospital No Transfer N=427 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 Understand 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

AHA Internal Guidelines Roll-Out Call GTO Roadmap & Timeline AHA Internal Guidelines Roll-Out Call Continuous updates of Content (ongoing) Strategic Planning (CR, Science, Quality, Prof Ed, Patients) Final Implementation Plans GL updated on all AHA assets, registries, and out to key audiences AHA Content Development Begins L A U N C H 8-14 months 3 months 1 month DEVELOPMENT & EARLY TRANSLATION (~2yrs/6 mths) TRANSLATION (common core mat. ~6 months) ADOPTION ( Process from 1 yr. to 10+ yrs) 18 month development time (reduced by 6 months, 50%) Guideline to Peer Review Guideline Release online We are working toward simultaneous release of GL with update to AHA assets, registries and dissemination of messaging to key audiences and partner organizations Core activation- key activities from integral business units which include: corporate relations, communications, advocacy, professional education, quality programs, meetings, publishing, patients and communications Guideline Writing Group Kick-off Guideline to Executive Committee GOAL: Standardized process with core activation for all guidelines