Current State of Use of Evidence- Based Therapies for Acute Coronary Syndromes Strategies to Improve Implementation of Guidelines-Based Care Strategies to Improve Implementation of Guidelines-Based Care

AHA/ACC Guideline Recommendations n Aspirin l Clopidogrel n Beta-Blocker n ACE-Inhibitor n Heparin (UFH or LMWH) n GP IIbIIIa Inhibitor l High-risk patients l All receiving PCI n Aspirin l Clopidogrel n Beta-Blocker n ACE-Inhibitor n Heparin (UFH or LMWH) n GP IIbIIIa Inhibitor l High-risk patients l All receiving PCI n Aspirin l Clopidogrel n Beta-Blocker n ACE-Inhibitor n Statin n Smoking Cessation n Cardiac Rehab Acute Therapy Discharge Therapy JACC 2000;36: ACC/AHA 2002 Update JACC 2000;36: ACC/AHA 2002 Update

NRMI-4 NSTE MI Acute Care : 3rd Quarter 2001

NRMI-4 NSTE MI Discharge Care : 3rd Quarter % 75% 56% 71% 21% 0% 20% 40% 60% 80% 100% ASABeta BlockerACE Inhibitor * Statins #Cardiac Rehab * LVEF < 40% # Known hyperlipidemia * LVEF < 40% # Known hyperlipidemia

Performance Quality IndicatorBottom 10% Top 10% ASA use < 24 h54%99%  -blocker use < 24 h33%98% Heparin use <24 h50%92% GP IIb-IIIa < 24 h0%51% D/C ASA use 54%99% D/C  -blocker use44%96% D/C ACE-I use21%83% D/C lipid lowering33%99% Performance Quality IndicatorBottom 10% Top 10% ASA use < 24 h54%99%  -blocker use < 24 h33%98% Heparin use <24 h50%92% GP IIb-IIIa < 24 h0%51% D/C ASA use 54%99% D/C  -blocker use44%96% D/C ACE-I use21%83% D/C lipid lowering33%99% Gap between ‘Leading and Lagging’ US Hospitals

Evidence-Based Medicine: What’s the Problem? “There is an unsettling truth about the practice of medicine. …study after study shows that few physicians systematically apply to everyday treatment the scientific evidence about what works best.” Millenson, ML. Demanding Medical Excellence: Doctors and Accountability in the Information Age, 1997 Millenson, ML. Demanding Medical Excellence: Doctors and Accountability in the Information Age, 1997

Physician Barriers to Guidelines Adherence n Lack of awareness or agreement with guidelines n Lack of outcome expectancy l Uncertainty regarding impact of guidelines adherence on patient outcomes n Overcoming established practice patterns n External barriers to improved care l Time constraints, lack of resources, no reminders n Lack of awareness or agreement with guidelines n Lack of outcome expectancy l Uncertainty regarding impact of guidelines adherence on patient outcomes n Overcoming established practice patterns n External barriers to improved care l Time constraints, lack of resources, no reminders Cabana M, JAMA 1999

Does it Matter? Correlating Process of Care with Outcomes

Additional Lives Additional Lives Current Use Saved per 1,000 Therapy(ideal pts)(ideal use) Aspirin86%9 Beta-Blockers59%11 ACE-Inhibitors52%23 Ca 2+ Blockers * 27%*13 Total56 Additional Lives Additional Lives Current Use Saved per 1,000 Therapy(ideal pts)(ideal use) Aspirin86%9 Beta-Blockers59%11 ACE-Inhibitors52%23 Ca 2+ Blockers * 27%*13 Total56 Alexander K, JACC, 1998 * Contraindicated use in low EF pts Ideal benefits from 0% use Ideal benefits from 0% use * Contraindicated use in low EF pts Ideal benefits from 0% use Ideal benefits from 0% use Benefits of Using Evidence-Based Therapies (Non-ST  ACS Patients from GUSTO IIb)

US News and World Reports’ “Top Ranked Hospitals” Chen J, NEJM, 1999 p < 0.01

Adherence to ACC/AHA Guidelines and Mortality: Results from NRMI-4 (n= 57,806 Acute MI patients, 1185 hospitals) %50-60%60-70%>70% % In-hospital Mortality Rate of Hospital Composite Adherence (13 Indicators) Rate of Hospital Composite Adherence (13 Indicators) Peterson E, ACC 2002

Local Quality Improvement Initiative Francis M. Fesmire, MD Erlanger Medical Center Chattanooga, TN Francis M. Fesmire, MD Erlanger Medical Center Chattanooga, TN

Erlanger QI Project - Objectives n Determine early utilization of GP IIb-IIIa inhibitors use in ED in high-risk NSTE ACS patients n Implement stepped QI program n Re-measure effectiveness of QI program n Determine early utilization of GP IIb-IIIa inhibitors use in ED in high-risk NSTE ACS patients n Implement stepped QI program n Re-measure effectiveness of QI program

n Prospective Observational Study n 2,074 patients presenting with chest pain n Patients not undergoing urgent cardiac cath underwent standard Chest Pain Evaluation Protocol at Erlanger n Prospective Observational Study n 2,074 patients presenting with chest pain n Patients not undergoing urgent cardiac cath underwent standard Chest Pain Evaluation Protocol at Erlanger Erlanger QI Project - Methods

n Control (months 1-4): No intervention n Phase I (months 5-8): Posted eligibility criteria for GP IIb/IIIa inhibitors in ED n Phase II (months 9-12): Mandated QI form for completion by the evaluating ED physician with weekly review and feedback n Control (months 1-4): No intervention n Phase I (months 5-8): Posted eligibility criteria for GP IIb/IIIa inhibitors in ED n Phase II (months 9-12): Mandated QI form for completion by the evaluating ED physician with weekly review and feedback Erlanger QI Project - Interventions

n % of patients who received GP IIb/IIIa inhibitors: l Control Phase: 6% l Phase I QI Intervention: 16% l Phase II QI Intervention: 45% n % of patients who received GP IIb/IIIa inhibitors: l Control Phase: 6% l Phase I QI Intervention: 16% l Phase II QI Intervention: 45% Erlanger QI Project - Results (1)

n Reasons for not treatment in Phase II l 63% - ED Physician Never Realized Eligibility l 24% - Treatment was perceived to delay transfer to the cardiac cath lab l 10% - Admitting Physician did not want GP IIb/IIIa inhibitors to be administered l 3% - Contraindication n Reasons for not treatment in Phase II l 63% - ED Physician Never Realized Eligibility l 24% - Treatment was perceived to delay transfer to the cardiac cath lab l 10% - Admitting Physician did not want GP IIb/IIIa inhibitors to be administered l 3% - Contraindication Erlanger QI Project - Results (2)

UCLA Cardiovascular Hospitalization Atherosclerosis Management Program (CHAMP) Gregg C. Fonarow, MD; Anna Gawlinski, DNSc Am J Cardiol 2000;85:10A-17A Am J Cardiol 2001;87:

CHAMP - Program Overview (1) n CHAMP focused on the in-hospital initiation of: l Aspirin l Cholesterol-lowering therapy (statins) l Beta-blockers l ACE-Inhibitors n Medical interventions were done together with diet, exercise, and smoking cessation counseling before discharge in patients with acute MI n CHAMP focused on the in-hospital initiation of: l Aspirin l Cholesterol-lowering therapy (statins) l Beta-blockers l ACE-Inhibitors n Medical interventions were done together with diet, exercise, and smoking cessation counseling before discharge in patients with acute MI Am J Cardiol 2000;85:10A-17A

CHAMP - Program Overview (2) n Implementation of CHAMP involved the use of: l Focused treatment guidelines l Standardized admission orders l Educational lectures by local thought leaders l Tracking and reporting of medication treatment rates n Treatment rates and clinical outcomes were compared in patients with acute MI discharged in the 2-year periods before and after CHAMP was implemented n Implementation of CHAMP involved the use of: l Focused treatment guidelines l Standardized admission orders l Educational lectures by local thought leaders l Tracking and reporting of medication treatment rates n Treatment rates and clinical outcomes were compared in patients with acute MI discharged in the 2-year periods before and after CHAMP was implemented Am J Cardiol 2000;85:10A-17A

Medication Utilization Rates at Discharge Pre-CHAMPPost-CHAMP ( )( ) Discharge Therapy (n=256) (n=302)p-value Aspirin 78 92<0.001 Beta-Blockers 12 61<0.001 Nitrates 62 34<0.01 Calcium Antagonists 68 12<0.001 ACE-Inhibitors 4 56<0.001 Statins 6 86< Am J Cardiol 2000;85:10A-17A

77 NRMI Data from UCLA compared to 1437 other NRMI Hospitals UCLA CHAMP - Sustained Impact Over 6 Years

Regional Quality Improvement Initiative: The Guidelines Applied in Practice (“GAP”) Initiative in Southeast Michigan Kim A. Eagle, M.D. University of Michigan

Partnership   GAP Committee   AMI Committee GDAHC   Michigan Peer Review Organization   QI Network   Measurement   Greater Detroit Area Health Council   Employers, Insurers Providers MPRO ACC

GAP Toolkit for AMI Care n Standard Orders n Pocket Guidelines Cards n Clinical Pathways n Patient Information Forms n Patient Discharge Forms (Flight plan) n Hospital Performance Charts n Chart Stickers n Standard Orders n Pocket Guidelines Cards n Clinical Pathways n Patient Information Forms n Patient Discharge Forms (Flight plan) n Hospital Performance Charts n Chart Stickers

Hospital Selection Project Kick-off Presentation Individual Hospital Kick-off Project Implementation Hospital Remeasurement Data Analysis Major Results Presentation March 2001 January – February 2001 September – December 2000 March – September 2000 March 2000 February 2000 April- June 2000 GAP Rapid Cycle Change

64% 65% 81% 70% 87% 74% 0% 20% 40% 60% 80% 100% (343) (404) (213) (245) (131) (252) (343) (404) (213) (245) (131) (252) ASA BB LDL CHOL * * Time in Minutes (40) (24) (32) (45) LYSIS PTCA PTCA PRE POST GAP Results: Early Indicators (Aggregate) * p < 0.05 ** p < 0.01

68% 53% 80% 84% 89% 75% 65% 86% 92% 93% 0% 20% 40% 60% 80% 100% GAP Results: Late Indicators (Aggregate) (267) (406) (106) (146) (139) (173) (159) (226) (112) (209) ASA BB ACE SMOKING CHOL RX ASA BB ACE SMOKING CHOL RX * ** PRE POST * p < 0.05 ** p < 0.01

GAP Conclusions n Performance regarding early quality indicators is enhanced when AMI-specific standard order sets are used n Adherence to late quality indicators is enhanced by use of an AMI-specific standard discharge tool n Further studies are underway to compare the performance levels achieved in GAP hospitals to non-GAP hospitals in the region n Performance regarding early quality indicators is enhanced when AMI-specific standard order sets are used n Adherence to late quality indicators is enhanced by use of an AMI-specific standard discharge tool n Further studies are underway to compare the performance levels achieved in GAP hospitals to non-GAP hospitals in the region

Challenges to Improved Patient Care Poor knowledge of best treatments Lack of use of best treatments Lack of systems to collect and understand clinical information Lack of knowledge of how to influence practice

Concept Outcomes Clinical Trials Guidelines Performance Indicators Performance Indicators PerformancePerformance The Cycle of Clinical Therapeutics

Mobilization Identify Physician Champions Establish Local Consensus Planning Local Education Develop Hospital Plan Build Local QI Team Implementation Collect Baseline Data Care Pathways Feedback  Intervention Review local treatment data Determine need for improvement Develop targeted interventions Process of Continuous Quality Improvement (CQI)

Strategies to Improve Patient Care n Physician Continuing Medical Education n Local Opinion Leaders/Champions n Regular Feedback on Performance n Reminders, Care Pathways, Algorithms n Patient-Oriented Interventions n Total Quality Management - Multifaceted Interventions n Physician Continuing Medical Education n Local Opinion Leaders/Champions n Regular Feedback on Performance n Reminders, Care Pathways, Algorithms n Patient-Oriented Interventions n Total Quality Management - Multifaceted Interventions Grol R, JAMA 2001

Quality Improvement Interventions: Predictors of Success n Shared goals among health care providers regarding use of evidence-based therapies n Administrative support for CQI projects n Strong leadership by physician “champions” for improved patient care n High-quality data feedback mechanisms n Shared goals among health care providers regarding use of evidence-based therapies n Administrative support for CQI projects n Strong leadership by physician “champions” for improved patient care n High-quality data feedback mechanisms Bradley E, JAMA Use of Beta-Blockers Post-MI

Practical Steps to Improve the Use of Evidence-Based Therapies for Non-ST  ACS n Improve physicians’ knowledge of the ACC/AHA practice guidelines n Encourage cooperation between Emergency Medicine physicians and Cardiologists n Accurately track adherence to treatment recommendations from the guidelines n Secure institutional commitment to improved patient care with guidelines implementation n Improve physicians’ knowledge of the ACC/AHA practice guidelines n Encourage cooperation between Emergency Medicine physicians and Cardiologists n Accurately track adherence to treatment recommendations from the guidelines n Secure institutional commitment to improved patient care with guidelines implementation

Steps for Improved ACS Care n Utilize simple data collection tools n Encourage multi-disciplinary collaboration n Study entire spectrum of ACS n Continuously update clinical practice guidelines n Mandate quality monitoring for all hospitals n Tie financial reimbursement to quality of care n Utilize simple data collection tools n Encourage multi-disciplinary collaboration n Study entire spectrum of ACS n Continuously update clinical practice guidelines n Mandate quality monitoring for all hospitals n Tie financial reimbursement to quality of care