1. 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!

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. Premier vs. Limited Detailed

10. 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

11. 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

12. Limited and Premier Forms 140 fields in Limited vs. 280 fields in Premier –Simple/Average patient 60-80 fields vs. 100-150 in Premier –Complicated patient 80-100 fields vs. 150- 200 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

13. 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

14. 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

15. 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

16. 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

17. National Data Slide Sets Produced every 6 months

18. ACTION Door-to-Balloon Times – Median Times for Transfer In and Non-Transfer In Patients Transfer in DTB TimesNon-Transfer in DTB Times 123 169 236 62 79 103 Q1 07 120 158 223 60 78 102 Q2 07 116 151 215 57 75 Q3 07 113 156 212 57 74 95 Q4 07 Time (min) 50 220 210 60 70 80 90 110 100 120 130 140 150 160 170 200 180 190 240 230 96 40 30 20 250 10 0

19. STEMI Door-to-Balloon Times – Median Times for Transfer In and Non-Transfer In Patients Transfer in DTB TimesNon-Transfer in DTB Times 102 130 182 53 70 88 Q1 08 97 123 165 52 67 84 Q2 08 96 120 157 51 66 Q3 08 94 117 150 50 64 79 Q4 08 Time (min) 50 220 210 60 70 80 90 110 100 120 130 140 150 160 170 200 180 190 240 230 82 40 30 20 250 10 0

20. STEMI Door-to-Balloon Times – Median Times for Transfer In and Non-Transfer In Patients Transfer in DTB TimesNon-Transfer in DTB Times 96 123 159 49 63 79 Q1 09 96 117 147 48 61 77 Q2 09 92 112 142 48 62 Q3 09 91 113 143 48 62 76 Q4 09 Time (min) 50 220 210 60 70 80 90 110 100 120 130 140 150 160 170 200 180 190 240 230 77 40 30 20 250 10 0

21. 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

22. 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

23. 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

24. Performance Graph

25. Summary Table

26. On Demand Patient Detail Page

27. 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

28. 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.

29. 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

30. 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

31. 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

32. 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

33. How to join ACTION Registry-GWTG Go to www.ncdr.comwww.ncdr.com 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

34. Thank You ACTION Registry-GWTG Phone 800-257-4737 Email ncdr@acc.orgncdr@acc.org