1. Innovate Public Private Partnership to Meet the Common Goal of the Enterprises, Academics and Government —— CPACS Experience WU Yangfeng The George Institute for Global Health China Peking University Clinical Research Institute and School of Public Health Chinese Society of Cardiology

2. Management of ACS in Chinese CHD is the leading cause of death and premature death in China. > 700 thousand Chinese die of acute coronary events each year Half AMI patients will die before they arrive hospital. Mortality rate remains 10% for those who were admitted to hospital Since 1993, direct expenditure on CVD has increased by 17 ％ every year while GDP has increased by 9 ％ every year

4. The Clinical Pathways for Acute Coronary Syndromes in China –Phase 1(CPACS-1) Aim : Identify a number of important evidence- practice gaps relating to the diagnosis and treatment of patients with suspected ACS in China Method: –2004-2006 –Prospective register study –51 hospitals from 18 provinces and municipalities, 2973 ACS in-hospital patients registered –Patient’s data during hospitalization, 6 months and 12 months after discharge were collected

5. CPACS 1 ： Prehospital Delay delay to seek medical help among Chinese ACS patients Mean time of onset to arrival of hospital is 9 hours, longer than GRACE study Delay is more obvious among the patients arriving at tertiary hospitals due to the transfer from other hospitals 0 2 4 6 8 10 12 14 16 STEMINSTEMIUAP Total Mean time, hour

6. Non-tertiary hospitals Tertiary hospitals NMedian (IQR)N Door to needle （ minutes ） 150 55 （ 30 － 100 ） 141 61 （ 26-120 ） Door to balloon （ minutes ） 46 51 （ 30-180 ） 188 90 （ 60-175 ） CPACS-1 ： Time to reperfusion

7. CPACS 1 ： Diagnosis accuracy No inconsistence *includes <1% who had both inconsistent biomarkers and ST segment deviation Inconsistent ST segment deviation Inconsistent biomarkers* Biomarker not measured 20% final ACS diagnosis are inconsistent with ECG/biological markers

8. Risk classification （ GRACE score ） High riskMedian riskLow risk No cath labN=157N=144N=149 Exercise test ，％ 01.44.0 UCG ，％ 48.459.460.4 Cath labN=811N=851N=861 Exercise test ，％ 0.41.54.5 UCG ，％ 54.962.061.9 Catheterization ，％ 34.054.158.2 CPACS-1 ： Investigation Exercise test is rarely used in low-risk patients; catheterization, UCG is less likely to be used in high risk patients

9. CPACS-1 ： Invasive therapy Low- and median- risk patients were more likely to receive invasive therapy GRACE risk score Gao, et al. Heart 2008;94:554-60

10. CPACS-1 ： Medications Dual antiplatelet usage is relatively low %

11. AspirinClopidogrelβ-BlockersACEIStatin No reason ， % 38.234.321.520.2 Refuse ， % 55.08.918.116.616.8 Intolerance ， % 1.81.311.827.05.7 Cost,%23.026.7 Other ， % 17.410.66.64.94.0 Unknown,%16.55.216.615.814.3 AspirinClopidogrelβ-BlockersACEIStatin No reason ， % 30.123.716.710.0 Refuse ， % 36.615.026.118.627.3 Intolerance ， % 3.81.915.123.89.1 Cost,%27.416.2 Other ， % 30.15.79.110.09.1 Unknown,%10.8 18.922.020.3 Level 2 hospitals Level 3 hospitals CPACS -1 ： Reasons for not compliant to therapy

12. CPACS-1 ： In hospital clinical outcome is suboptimal Prevalence,% 0 5 10 15 Level 2 Level 3 Death MI Stroke CHF Bleeding Rate of in hospital events was slightly higher than international reports ， especially in level 2 hospitals Prognosis was poorer among MI patients Clinical outcomes were different according to different risk stratification

13. The Clinical Pathways for Acute Coronary Syndromes in China –Phase 2(CPACS-2) Aim: Implement a quality improvement initiative (QCI) to improve ACS care in China and evaluate the effect of QCI Method: –2007-2011 –Cluster randomized trial, prospective registery study –75 hospitals from 17 provinces and municipalities, more than 15 thousand ACS patients –Patient’s data were collected during hospitalization and at every 6 months follow up

14. CPACS-2 ： participating hospitals 75 hospitals 50 level 3 hospitals 25 level 2 hospitals 黑龙江 2/3 辽宁 4/3, 1/2 河北 4/3 山东 3/3,1/2 江苏 3/3 上海 3/3, 4/2 河南 2/3,2/2 广东 4/3 湖北 1/3, 4/2 四川 2/3 陕西 3/3, 3/2 内蒙古 3/3, 1/2 北京 4/3, 4/2 浙江 2/3, 2/2 湖南 4/3 新疆 3/3, 1/2 山西 2/3, 3/2

15. Clinical pathway is a tool used to optimize and systematize treatment. The three main clinical pathways are : Risk stratification Clinical pathway of UA/NSTEMI Clinical pathway of STEMI The previous studies have confirmed that clinical pathway can improve quality of health care But most of the studies are conducted in high-income counties. No reliable data are documented in China CPACS-2: Intervention

16. 50 consecutive patients were recruited in every 6 months Summary feedback information is then made available to each hospital Based on feedback information, hospital modify the clinical pathway The modified clinical pathways are used in the next cycle CPACS-2: intervention Alive patients

17. CPACS-2: Study design

18. CPACS 2 － key performance indicators Expected results: improve the accuracy of clinical diagnosis, significantly shorten the time receive treatment, improve hospital management of ACS, improve compliance to the guidelines. Proportion of STEMI patients receive thrombolysis or primary PCI Door-to-needle time and Door-to-balloon time Proportion of patients with final diagnosis consistent with ECG/biomarker findings Proportion of high-risk patients undergoing coronary angiography Proportion of low-risk patients undergoing functional testing Proportion of patients discharged on appropriate medical therapy Hospital length-of-stay Effective clinical pathway intervention reduce evidence-practice gap

19. CPACS-2: Preliminary results Significantly improved KPIs: –Proportion of patients discharged on appropriate medical therapy –Proportion of high-risk patients undergoing coronary angiography –Length of hospital stay Not improved KPIs: –Proportion of low-risk patients undergoing function testing

20. The Clinical Pathways for Acute Coronary Syndromes in China –Phase 3 (CPACS-3) Aim: Develop and evaluate the effects of quality care initiative (QCI) system to reduce acute events and death of patients with ACS in level 2 hospitals with limited resources. Method: –2011-2014 –Registry-based cluster randomized step-weddged controlled trial –96 hospitals from 15 provinces and municipalities, more than 25 thousand ACS patients –Patient’s data will be collected during hospitalization and at 6 months and 12 months follow up Outcomes ： –Major adverse cardiovascular events （ MACE ）

21. Academic achievements Am Heart J 2009;157:509-516 Heart 2008;94:554-60.

22. Changes in organization and management in different stages of CPACS PhaseInitiatorOrganizerSCFinancial Support CPACS-1The George Institute for Global Health (GI), Austraila Chinese Society of Cardiology (CSC) GI, China CSC Experts from both sides and officials from MOH Sanofi - Aventis (China), the Royal Australian Institute of Physicians, National Heart Foundation of Australia, the United States Guidant Corp. CPACS-2GI, Australia CSC GI, China; CSC; With support from Division of Medical Administration, MOH Experts from both sides and officials from MOH Sanofi - Aventis (China) CPACS-3GI, China CSC Division of Medical Administration, MOH Experts from China, USA, Australia, UK, and officials from MOH Sanofi - Aventis (China)

23. Changes in organization and management in different stages of CPACS CPACS-1CPACS-2CPACS-3 Academic achievements Increased Government Involvement/policy impact increased Corporate social responsibility /business development increased

24. The common interests of enterprise, academia and government Common interestSpecific interest EnterpriseWhether the product is effective /helpful? Profit AcademiaWhich measures are effective /helpful? Innovation GovernmentWhich measures are effective /helpful? Political achievements For CPACS, how to transfer the scientific evidence into practice to improve the outcomes of ACS patients?

25. CPACS is still going forward ， please keep your eyes on our progress!

26. Acknowledgment CPACS-1 administration committee ： –Anushka Patel ，高润霖 – 高炜、胡大一、黄德嘉、孔灵芝、戚文航、武阳丰、杨跃进、 Phillip Harris CPACS-2 administration committee ： –Anushka Patel ，高润霖 – 高炜、胡大一、黄德嘉、孔灵芝、沈卫峰、吕树铮、韩雅玲、林 曙光、武阳丰、葛均波、杨跃进、马爱群 CPACS-3 administration committee ： – 高润霖、武阳丰 – 胡大一、霍勇、孔灵芝、焦亚辉、 Anushka Patel 、 Eric Peterson 、 Kalipso Chalkidou 、 Mark Woodward 、 Fiona Turnbull