1. 1 CCORT/CCS 2008 Quality Indicators for Acute Myocardial Infarction (AMI) Care - Introduction CIHR Team Grant in Cardiovascular Outcomes Research 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

2. CCORT/CCS AMI Quality Indicator Expert Panel

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 Sackett DL, et al. Evidence-Based Medicine: How to practice and teach EBM, 2 nd edition. London: Churchill Livingstone, 2000.

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

7. Continuous Quality Improvement Concept Guidelines Performance Indicators Performance Outcomes Clinical Trials 1 Roe MT, et al. Changing the model of car e for patents with ACS. Am Heart J 2003; 146: 605-12. CIHR Team Grant for 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 CIHR Team Grant for Cardiovascular Outcomes Research

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 www.ccort.ca

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 21 08 Publish paper CIHR Team Grant for Cardiovascular Outcomes Research

11. ACC/AHA Attributes for Quality Indicators Useful in improving patient outcomes 1.Evidence-based 2.Interpretable 3.Actionable Measure implementation 1.Feasibility a.Reasonable effort b.Reasonable cost c.Reasonable time period for collection Measure Design 1.Denominator precisely defined 2.Numerator precisely defined 3.Validity a.Face validity b.Content validity c.Construct validity 4.Reliability Krumholz HM, et al. ACC/AHA clinical performance measures for adults with STEMI and NSTE MI. J Am Coll Cardiol 2006;47:236-265.

12. 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;588-636. ACC/AHA Level of Evidence

13. CIHR Team Grant for 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 process of care CIHR Team Grant for 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

18. Benchmarks Expert panel unanimously set benchmark at 90% for all process of care indicators (vs. 70- 90% 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% CIHR Team Grant for 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 CIHR Team Grant for Cardiovascular Outcomes Research

20. Thank You For more information please visit www.ccort.ca CCORT welcomes feedback on these indicators. Please send comments or questions to Tara.ONeill@ices.on.ca