STEMI Systems of Care – Update on Mission: Lifeline: We are Better – Are the Patients as Well? Alice K. Jacobs, M.D. Boston University Medical Center Boston, MA

Disclosure Information FINANCIAL DISCLOSURE: Research Support: Abbott Vascular UNLABELED/UNAPPROVED USES DISCLOSURE: None

May 30, 2007 Conference Proceedings published in Circulation and Mission: Lifeline Launched

Developing Systems of Care for STEMI

Trained AHA field staff in Mission: Lifeline implementation in July 2008 (over 350 staff from all over the United States)

Mission: Lifeline Staff 6

Establishing Local Initiatives Task force members: Patients and care givers Physicians, nurses and other providers Payers EMS PCI capable and non-PCI capable hospitals Department of Health Rural health association Quality improvement organizations State and local policymakers OPTIONAL SLIDE: slide could be used with volunteers and external partners

AHA Model Legislation: HEart Attack Response and Treatment Act (HEART Act) Section 3. A Statewide System for Heart Attack Response and Treatment Must be consistent with ACC/AHA guidelines Must have a community perspective Components Hospital Classification EMS Equipment and training Transport and transfer Continuous quality improvement Data collection and analysis ACTION Registry – Get With The Guidelines

State Legislative and Regulatory Actions Missouri In 2008, first state law that specifically addresses creation of STEMI system of care Time Critical Diagnosis STEMI and Stroke Hospital designation Assess capacity of EMS Establish protocols Establish regions for coordination of care Promote development of regional plans 9

State Legislative and Regulatory Actions In 2010, Maryland enacted regulations that formally identify STEMI receiving facilities.  The criteria used in Maryland are consistent with Mission: Lifeline STEMI receiving facility criteria. Maryland’s regulations also require that these facilities use Action Registry-Get With The Guidelines as the required data collection/quality improvement tool In 2010, Washington State enacted broad systems of care legislation to improve the continuum of care for STEMI, sudden cardiac arrest and stroke patients 10

Mission: Lifeline Involvement Accreditation Recognition Examples ML Hospital Registration ML System Registration Participation Memorandum of Understanding Quality Improvement/ Data Analysis Participation, Recognition, & Certification criteria available: www.americanheart/missionlifeline

Mission: Lifeline Social Networking Community http://mlcommunity.heart.org Registration: Every individual user will need to set up a log in and password. This is located in the middle of the welcome page. After log- in, the user will receive a welcome email that states the purpose of the site. Each new user will receive 2 welcome emails, please be sure to check the spam 12 12

Use of Reperfusion Therapy for STEMI ACTION Registry-GWTG DATA: July 1, 2010 – June 30, 2011 No Reperfusion – No Contraindication Listed N = 2,303 (7%) Not Eligible for Reperfusion Therapy Contraindication Listed N= 4,460 (13%) Primary PCI – 84%* Fibrinolytics – 7%* Both PCI + Lytics – 1%* 92% of eligible patients reperfused ©2010, American Heart Association 18 * Among patients receiving reperfusion

STEMI – D2B and D2N Times: ACTION-GWTG Registry % of Patients

Trend in Percentage of Patients with Door-to-Balloon Time <90 Minutes Trend in percentage of patients with door-to-balloon (D2B) time <90 minutes over 6 years. Krumholz. Circulation 2011;124:1038-1045.

Trend in Percentage of Patients with Door-to-Balloon Time <75 Minutes Trend in percentage of patients with door-to-balloon (D2B) time <90 minutes over 6 years. Krumholz. Circulation 2011;124:1038-1045.

Distribution of Median Door-in to Door-out (DIDO) Times for 1034 Hospitals in 2009 Herrin. Arch Intern Med 2011;171:1879-1886.

Outcomes in RACE PCI Hospitals First Door-to-Device < 90 Minutes Mortality P=0.002 Percent P=0.01 P=0.38 N=164 N=232 N=127 N=102 N=579 N=585 Jollis. JAMA 2007;298:2371-2380.

Improvement in Door-to-Balloon Time and In-hospital Mortality 2005-2007 AHA GWTG 101 Hospitals N=43,678 Mean DTB decreased from 101 to 87 minutes, P<0.001 Wang. Arch Intern Med 2009;169:1411-1419.

Median door-to-balloon (DTB) time and In-hospital Mortality in Patients with STEMI Undergoing Primary PCI from 2003 to 2008 N=8771 Flynn Arch Intern Med 2010;170:1842-1849.

ACTION Registry® – GWTG ™ and Mission: Lifeline Hospital Participation Add title and tell what astericks and angle data labels Please note that * denotes change in data reported and new ARG fee ©2010, American Heart Association 27

Systems of Care for STEMI Door-in-Door-out