ACTION Registry-GWTG Mission Lifeline STEMI Summit Sioux Falls, SD November 4, 2010 How Will We Measure Our Success If You Don't Measure It, You Can't Improve It!

Susan Rogers RN, BSN, MSN Associate Director ACTION Registry-GWTG Nothing to Disclose

Objectives 1.Verbalize the history of the ACTION Registry-GWTG 2.Describe the tools available in the ACTION Registry-GWTG 3.Describe the ACTION Registry-GWTG recognition process

Purpose of ACTION Registry-GWTG National surveillance system for high-risk AMI patients admitted with STEMI/NSTEMI: –Assess characteristics, treatments, and outcomes of this patient population –Optimize outcomes and management of AMI patients through implementation of ACC/AHA evidence-based guideline recommendations in clinical practice –Facilitate efforts to improve quality and safety of ACS patient care; and investigate QI methods

The History Behind the ACTION Registry-GWTG ACTION Registry transitioned from CRUSADE and NRMI Registries January 2007 ACTION was established May 2008 ACTION merged with AHA GWTG CAD to become ACTION Registry-GWTG Dec. 31, 2009 GWTG CAD sunset Current membership of 640 Hospitals Over 205,719 records submitted

Inclusion Population Acute Myocardial Infarctions-STEMI & NSTEMI only Patient must present to 1 st Facility with symptoms of ACS, within 24 hours of arrival Patient must have positive ECG- ST elevation, new LBBB, or documented Posterior MI OR Positive Biomarkers- Troponin or CK-MB Transfer In patients- STEMI must arrive within 72 hours, NSTEMI within 24 hours If presents with any other symptoms, or procedures, the patient is excluded

Acute/In-hospital Measures Aspirin Arrival STEMI - Any reperfusion (PCI or Lytic) STEMI - Lytic -Door to Needle (Median Time and % <30min) STEMI - PCI – D2B (Median Time and % <90min STEMI - D2B Transfer in (Median Time) LVSD Evaluation Discharge Measures Aspirin B-blocker ACE or ARB (EF <40%) Statin for LDL ≥100mg/dL Smoking cessation (among smokers) Cardiac rehabilitation Performance Measures

Quality Metrics ACTION Metrics Door to EKG (within 10 min) STEMI- Acute ADP Receptor Inhibitor Therapy within 24 hours of arrival_ Revascularized Patients Discharged on ADP Receptor Inhibitors ADP Receptor Inhibitors Prescribed at Discharge for Medically Treated Patients LDL assessment (in-hospital) NSTEMI - Excessive Initial UFH Dosing (>70 U/kg bolus, >15 U/kg/min infusion Excessive Initial Enoxaparin Dosing (SQ >1.05 mg/kg) Excessive Initial GP IIb/IIIa Dosing (Full dose Tirofiban if CrCl<30& Full dose Eptifibatide CrCl <50, or dialysis with either) STEMI - Anticoagulant- UFH, enoxaparin, bivalarudin or fondaparinux (first 24 hours) Aldosterone Blocking Agents at Discharge (EF<40%, with DM, or HF)

Premier vs. Limited Detailed

ACTION Registry-GWTG Premier Full ACTION Registry-GWTG data set Complete quarterly Outcome Report for benchmarking Report on 17 Core Performance Measures Report on 12 Quality Metrics Sites will be eligible for Higher level of Recognition Program

ACTION Registry-GWTG Limited 50% of full ACTION Registry-GWTG data set Limited quarterly Outcome Report for benchmarking Report on 17 Core Performance Measures Report on 7 Quality Metrics Lower level of Recognition

Limited and Premier Forms 140 fields in Limited vs. 280 fields in Premier –Simple/Average patient fields vs in Premier –Complicated patient fields vs in Premier –Non PCI centers 60 fields vs. 100 in Premier Either form is available to all ACTION Registry- GWTG participants Strongly encourage participants to use Premier data set, especially PPCI capable centers

Limited Form: Pros and Cons Pros Fewer Data Elements Less time required for data abstraction and entry Accommodating for Non PCI Centers Great form for new sites to start Cons No Excessive dosing Reports for Anticoagulants Lower Level of Recognition Limited Quarterly Outcomes Report Data not available to allow Physicians to participate in PACE project

Premier Form: Pros and Cons Pros Detailed Quarterly Excessive Dosing Reports for Anticoagulants Higher level of Recognition Robust Data Set Full Quarterly Outcomes Report Required if Physician participating in PACE PI-CME project Cons More time required for data abstraction and entry Answering fields that are less likely to pertain to Non-PCI Centers

Acute/In-hospital Measures Aspirin Arrival STEMI - Any reperfusion (PCI or Lytic) STEMI - Lytic -Door to Needle (Median Time and % <30min) STEMI - PCI – D2B (Median Time and % <90min STEMI - D2B Transfer in (Median Time) LVSD Evaluation Discharge Measures Aspirin B-blocker ACE or ARB (EF <40%) Statin for LDL ≥100mg/dL Smoking cessation (among smokers) Cardiac rehabilitation Performance Measures

Site Specific Quarterly Reports Composites (12 months) –Percent of compliance –Benchmark National Line graphs (12 months) –Breakdown Quarterly performance Tables (Quarterly, 12 months) –Benchmark Like Hospitals, National, Top 10% –All AMI details, and side by side STEMI and NSTEMI –Overall AMI Subgroups- Compares composites by race, gender, age, transfer and non-transfer, DM and non-DM, CrCl patients

National Data Slide Sets Produced every 6 months

ACTION Door-to-Balloon Times – Median Times for Transfer In and Non-Transfer In Patients Transfer in DTB TimesNon-Transfer in DTB Times Q Q Q Q4 07 Time (min)

STEMI Door-to-Balloon Times – Median Times for Transfer In and Non-Transfer In Patients Transfer in DTB TimesNon-Transfer in DTB Times Q Q Q Q4 08 Time (min)

STEMI Door-to-Balloon Times – Median Times for Transfer In and Non-Transfer In Patients Transfer in DTB TimesNon-Transfer in DTB Times Q Q Q Q4 09 Time (min)

NSTEMI Acute Medication Overdosing Trends * Infusion (> 15 units/kg/hr) or bolus (> 70 units/kg) # Initial dose (> 1.05 mg/kg) or total 24 hr dose (> 10 mg over recommended) ACTION Registry-GWTG DATA: January 1, 2009 – December 31, 2009

On-Demand Reports Reports that are created “On-Demand” A summary of Patient Level Data From data submitted through the DQR Must have Yellow or Green light The Reports are automatically created

What Reports are available ACE Inhibitor/ ARB at Discharge among STEMI & NSTEMI Patients Adult Smoking Cessation Advice Counseling among STEMI & NSTEMI ASA at Arrival among STEMI & NSTEMI Patients ASA at Discharge among STEMI & NSTEMI Patients Beta Blocker at Discharge among STEMI & NSTEMI Patients Statin at Discharge among STEMI & NSTEMI Patients Cardiac Rehabilitation Patient Referral among STEMI & NSTEMI Patients Evaluation of LV Systolic Function among STEMI & NSTEMI Patients Door In Door Out Transfer in Patients Door to Balloon Door to Balloon Transfer in Patients Door to Needle Reperfusion Therapy among STEMI Patients

Performance Graph

Summary Table

On Demand Patient Detail Page

Export Functionality The export function of the ACTION Registry ® -GWTG ™ will allow sites to download and export raw data into an Excel, Tab Separated, and Coma Separated formats 4 Pre-set reports will be available »JCAHO Measures »Pre Hospital Care EMS and 1 st Hospital »Acute Care Measures »Discharge Care Measures Availability to export by: Each section of the data collection form separately The entire form Individual data elements

Recognition Criteria Patient Volume –10 NSTEMI within each quarter; and/or –10 STEMI within past quarter Previous GWTG-CAD recognition status will be factored into recognition level if appropriate Data Evaluated will follow calendar year Must maintain uninterrupted data submission for the measurement period.

ACTION Registry-GWTG Performance Recognition Criteria For Data Entered in 2011 Award LevelsMust meet compliance on composite measures Participate in Platinum90% compliance for > = 8 consecutive quarters Premier Gold90% compliance for >= 8 consecutive quarters Premier or Limited Silver90% compliance for >= 4 consecutive quarters Premier or Limited

Recognition Thresholds Recognition Threshold –Silver Performance-90% performance on composite measures achieved for 4 consecutive quarters using the Premier or Limited DCF –Gold Performance-90% performance on composite measures achieved for 8 consecutive quarters using the Premier or Limited DCF –Platinum Performance- 90% performance on composite measures achieved for 8 consecutive quarters using the Premier DCF

Application Process Data is reviewed over a calendar year Recognition data for Q1-Q4 is aggregated Sites are then identified as eligible Press release sent to all sites accepting recognition Marketing establishes designation of professional publications

Why Participation Makes Sense Now Unique opportunity for a comprehensive, nationwide assessment of ACS care Guide for future quality improvement efforts Facilitate equitable and comprehensive delivery of care for ACS patients Measure your risk-adjusted performance against national benchmarks

How to join ACTION Registry-GWTG Go to ACTION Registry-GWTG “How to Join” Download the appropriate participation documents If you do not currently participate in an NCDR registry (CARE Registry ®, CathPCI Registry ®, ICD Registry TM ), sign the NCDR Master Agreement and the ACTION Registry-GWTG Addendum If you currently participate in an NCDR registry, sign the ACTION Registry-GWTG Addendum

Thank You ACTION Registry-GWTG Phone