1. for the CCORT/CCS AMI Quality Indicator Panel
CCORT/CCS 2008 Quality Indicators for Acute Myocardial Infarction (AMI) Care - Introduction
Jack V. Tu MD PhD FRCPC, Laila Khalid MD, Linda Donovan BScN MBA, Dennis T. Ko, MD MSc
for the CCORT/CCS AMI Quality Indicator Panel
Christopher E. Buller MD, Virginia F. Flintoft BN MSc, Thao Huynh MD MSc, Cynthia A. Jackevicius PharmD MSc, Laurie J. Lambert PhD, Michael P. Love MB ChB MD, Michael J. Schull MD MSc, Heather Sherrard BScN MHA, Edward Y.K. Tsoi MD,
Alain Vadeboncoeur MD
CIHR Team Grant in Cardiovascular Outcomes Research

2. CCORT/CCS AMI Quality Indicator Expert Panel
CIHR Team Grant in Cardiovascular Outcomes Research

3. Outline The Practice Gap What are Quality Indicators?
Canadian AMI Quality Indicators
2003 CCORT/CCS AMI Quality Indicators
Update process
2008 CCORT/CCS AMI Quality Indicators – What’s New?
Implementation strategies
CIHR Team Grant in Cardiovascular Outcomes Research

4. The Practice Gap
Many new life-saving treatments developed for heart disease over the past three decades (fibrinolytics, PCI, statins, etc.)
Uptake of these advances in routine clinical practice has been slow and varied across jurisdictions
Result - A gap between ideal care and actual practice patterns
CIHR Team Grant in Cardiovascular Outcomes Research

5. What are Quality Indicators?
‘Quality indicators’ or ‘performance measures’ are intended to be a tool for measuring and improving the quality of care delivered
Based on:
Scientific evidence from clinical practice guidelines, clinical trials or expert panel consensus
Health system performance indicators have become very popular in Canada and other countries recently
Expert group consensus care
Sackett DL, et al. Evidence-Based Medicine:
How to practice and teach EBM, 2nd edition. London: Churchill Livingstone, 2000.
CIHR Team Grant in Cardiovascular Outcomes Research

6. Publication of AMI Indicators is mandated in the U.S. and the U.K.

7. Continuous Quality Improvement
Concept
1 Roe MT, et al. Changing the model of car e for patents with ACS. Am Heart J 2003; 146:
CIHR Team Grant in Cardiovascular Outcomes Research

8. Canadian Quality Indicators for AMI
CCORT (a CIHR-funded outcomes research team) & the Canadian Cardiovascular Society (CCS) began development of the first Canadian AMI quality indicators in 2001
Joint CCORT/CCS expert panel
Multi-disciplinary, national representation
37 AMI Quality Indicators developed
First published in the CJC 2003

9. CCORT
CCORT is a group of over 30 outcomes researchers from 5 provinces (NS, QC, ON, AB, BC) who are working together on projects to measure and improve the quality of cardiac care in Canada
Funded by a CIHR Team Grant in Cardiovascular Outcomes Research
Institute for Clinical Evaluative Sciences (ICES) in Toronto is the national coordinating centre for CCORT

10. 2008 CCORT/CCS AMI Quality Indicator Expert Panel Process
Delphi Process
Two-staged modified Delphi Panel Technique
3 key features: Anonymity; Iterative & Controlled feedback; Aggregation of responses
2 rounds of ratings of potential indicators
Highest rated indicators included in final set
Multi-disciplinary, national panel
Work plan May 2007-Oct 2008
Literature Review
Sept 07 Independent Rating (Round 1)
Analysis of ratings
Oct 07 Expert Panel Meeting (Round 2)
Complete analysis & prepare summary
Dec 07 Follow-up teleconference
Draft paper
Mar 08 Circulate for comments
Finalize paper
Oct Publish paper
CIHR Team Grant in Cardiovascular Outcomes Research

11. ACC/AHA Attributes for Quality Indicators
Useful in improving patient outcomes
Evidence-based
Interpretable
Actionable
Measure implementation
Feasibility
Reasonable effort
Reasonable cost
Reasonable time period for collection
Measure Design
Denominator precisely defined
Numerator precisely defined
Validity
Face validity
Content validity
Construct validity
Reliability
Krumholz HM, et al. ACC/AHA clinical performance measures for adults with STEMI and NSTE MI. J Am Coll Cardiol 2006;47:
CIHR Team Grant in Cardiovascular Outcomes Research

12. ACC/AHA Level of Evidence
Antman EM, et al. ACC/AHA guidelines for the management of patients with STEMI-Executive summary: A report of the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the management of patients with AMI). Circulation 2004;110;

13. CIHR Team Grant in Cardiovascular Outcomes Research

14. “Ideal” Subset Methodology
All cases
Cases not eligible
for process of care
Cases with contra-
indication to
process of care
Cases “ideal” to receive
CIHR Team Grant in Cardiovascular Outcomes Research

15. In-hospital process-of-care, outcome and system indicators

16. New/Revised In-hospital Process-of-Care and System Indicators
PROCESS OF CARE QUALITY INDICATORS
ASA within 24 hours before hospital arrival or within 3 hours after hospital arrival
ACEI or ARB prescribed at hospital discharge
ECG within 10 minutes after hospital arrival
Primary PCI within 90 minutes after hospital arrival (measure separately for transferred / walk-in patients)
Reperfusion therapy in eligible patients with ST segment elevation MI
Risk stratification (ie cardiac catheterization, exercise stress testing, etc )
Assessment of left ventricular function
Smoking advice, counselling or therapy during hospital stay
Referral for cardiac rehabilitation
SYSTEM INDICATORS
Fibrinolytic therapy within 60 minutes after call for emergency medical services
Primary PCI within 120 minutes after call for emergency medical services
Pre-hospital 12-lead ECG
Now what we have also established are benchmarks for care that reflect the minimum proportion of AMI patients that are ideal candidates and who should receive a particular intervention
Target levels may not be …

18. Benchmarks
Expert panel unanimously set benchmark at 90% for all process of care indicators (vs % in original set of AMI indicators)
Panel recognized that 90% might be unrealistic for some centres, and suggested setting an initial benchmark, to be increased by 10% increments annually to reach 90%
Now what we have also established are benchmarks for care that reflect the minimum proportion of AMI patients that are ideal candidates and who should receive a particular intervention
Target levels may not be …
CIHR Team Grant in Cardiovascular Outcomes Research

19. Implementation Strategies
Establish a system to support measurement and feedback of AMI quality indicators at your local hospital (e.g. clinical registry, chart audits, etc.)
Assemble a multidisciplinary team (e.g. EMS, ER docs, cardiologists, nurses, etc.) to discuss performance and develop strategies for achieving target benchmarks
Consider introduction or modification of standardized admission order sets, care pathways, and discharge plans for each patient
Participate in national, regional or local AMI quality improvement initiatives
Now what we have also established are benchmarks for care that reflect the minimum proportion of AMI patients that are ideal candidates and who should receive a particular intervention
Target levels may not be …
CIHR Team Grant in Cardiovascular Outcomes Research

20. For more information please visit
Thank You
For more information please visit
CCORT welcomes feedback on these indicators. Please send comments or questions to
Now what we have also established are benchmarks for care that reflect the minimum proportion of AMI patients that are ideal candidates and who should receive a particular intervention
Target levels may not be …