Eric D. Peterson, MD, MPH Professor of Medicine, Vice by fhy50518

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									CRUSADE/ACTION
    Update

     Eric D. Peterson, MD, MPH
Professor of Medicine, Vice Chair for Quality
      Duke University Medical Center
Associate Director & Director of CV Research
      Duke Clinical Research Institute
                Durham, NC
CRUSADE National CQI


   Academic collaboration between cardiology and
    emergency medicine initiated in 2001
   Multi-industry sponsor
       Millennium-Schering Plough
       BMS
       Sanofi-Aventis
       Merck-Schering
       PDL Pharma
   Goal: Improve adherence to ACC/AHA ACS guidelines
     NSTE ACS and later STEMI
CRUSADE Highlights –

   Data collection: 7/2001- 12/2006
   > 500 US sites participated in CRUSADE
       25% academic, 68% with PCI/CABG
   201,032 ACS patients received
       190,000 NSTEMI:: 8,800+ STEMI patients
       1000+ MAINTAIN patients (long-term follow-up)
   50+ CRUSADE publications
   Referenced within ACC/AHA guidelines
   Successful transition to NCDR ACTION ACS
  ACS Clinical Trials vs Real World Patients


Variable                   PURSUIT               CURE         SYNERGY      CRUSADE
                           (n = 9461)          (n = 12,562)   (n = 9975)   (n = 180,842)
Mean age ± SD (yrs)          63 ± 11            63 ± 12        67 ± 11       69 ± 14
Female sex (%)                  36                 39            34             40
Diabetes mellitus (%)           23                 23            29             33
Prior MI (%)                    32                 25            28             30
Prior CHF (%)                   11                  8             9             18
Prior PCI (%)                   13                 18*           20             21
Prior CABG (%)                  12                 18*           17             19


    NEJM 1998;339:436-43
    NEJM 2001;345:494-502
    JAMA 2004:292:45-54
    CRUSADE cumulative through June 30, 2006
CRUSADE NSTE MI vs. ACS Clinical Trials:
        Early Mortality Rates
                                                                        In-hospital
  6                                                                    mortality rate
                                                                          4.9%
  5

  4

  3                             7-day mortality rate

                  1.8%                    1.9%
  2                                                       1.5%

  1

  0
              PURSUIT1                PRISM-PLUS2        SYNERGY3        CRUSADE
              (n = 9,461)              (n = 1,915)       (n = 9,975)    (n = 180,842)

  1.The PURSUIT Trial Investigators. N Engl J Med 1998
  2.The PRISM-PLUS Study Investigators.
  N Engl J Med 1998
  3. The Synergy Study JAMA 2004
  CRUSADE cumulative data through 6/30/2006
                          Variations Among Hospitals
                                         430 CRUSADE hospitals


                       Acute                                                                 Discharge
100%   95%                                   Leading Centers 100%    94%
                                   91%                                           89%
             86%    86%                                                    82%
                                             Lagging Centers                                              81%
80%                                                            80%
                                         71%                                           69%    68%
                          65%                                                                                   64%
                                                                                                                       60%
60%                                                            60%
                                                 50%                                                49%

                                                               40%                                                           36%
40%
                                                        21%
20%                                                            20%


 0%                                                            0%

        Aspirin    Beta Blockers   Heparin       GP IIb-IIIa          ASA        B Blocker     ACE*       Statin*     Clopidogrel


                                                                           Peterson et al, JAMA 2006;295:1863-1912
                           Lesson 3: Hospital Link Between Overall
                           Guidelines Adherence and Mortality

                      7          6.31
                          5.95
                      6
% In-Hosp Mortality




                                             5.16 5.06         4.97
                      5                                               4.63
                                                                                      4.16 4.15
                      4
                      3
                      2
                                       Every 10%  in guidelines adherence 
                      1             10%  in mortality (OR=0.90, 95% CI: 0.84-0.97)

                      0
                           <=25%              25 - 50%          50 - 75%               >=75%
                                        Hospital Composite Quality Quartiles

                                               Adjusted     Unadjusted
                                                    Peterson et al, JAMA 2006;295:1863-1912
                 Timely Care:
       Reperfusion among STEMI Patients
                                                   Median Times
100%                                               • Thrombolytics – 33 min
                                                   • Primary PCI – 98 min
80%      77%



60%
                                                       47%
                       40%
40%

                                      21%
20%


 0%
       Primary PCI   Primary PCI   Thrombolytics   Thrombolytics
                     <90 minutes                    <30 minutes


  Q2 2006 CRUSADE STEMI data
    Are We Performing Interventional Procedures in the
                     Right Patients
                                   Low Risk
                                   Mod Risk    75.5
     80                            High Risk
     75
     70     64.1
     65                                         63.2
     60     53.5
     55
     50
     45
     40
     35
                                               32.2
     30     26.6
     25
     20
    20 1

    20 2

    20 3

    20 4

    20 1

    20 2

    20 3

    20 4

    20 1

    20 2

    20 3

          4
         Q

         Q

         Q

         Q

         Q

         Q

         Q

         Q

         Q

         Q

         Q

         Q
       02

       02

       02

       02

       03

       03

       03

       03

       04

       04

       04

       04
    20




Tricoci et al, AHA 2005 Abstract
                             What Must Go Up…..
                        Tech Trends: DES in CRUSADE

        100
                                                        80      82
        80                              71      74
                                68
                        61
        60     55.3
% Use




        40

        20

         0
              Q2 2003 Q3 2003 Q4 2003 Q1 2004 Q2 2004 Q3 2004 Q4 2004
                               Must Come Down: DES Use
                                  July 2006- March 2007

                        100     92     90.5    89.5
                         90                            81.6
% DES among Stent Pts




                         80
                                                               66.7
                        70                                              63.3
                        60
                        50
                        40
                        30
                        20
                        10
                         0
                              Q1 2006 Q2 2006 Q3 2006 Q4 2006 Q1 2007 Q2 2007


                                                        Data on File DCRI: CRUSADE/ACTION
                                   Safe Care?
                         Excessive Antithrombotic Dosing
                   70                                                             64.5
                   60
% Excessive Dose




                   50

                   40                               37 38.5
                                                                           33.1
                                             28.7
                   30

                   20               16.5
                        12.5 12.5
                                                                     8.5
                   10

                   0
                         LMW Heparin             UF Heparin             GP IIb/IIIa
                                      < 65 yrs    65-75 yrs    >75 yrs

                                                          Alexander KA, et al. JAMA 2005;294:3108-3116
             Lesson 9 Hospital Safety, Quality, and Outcomes
                                   N=318 Hospitals; 56,245 Patients


                          6
% In-hospital Mortality




                          5
                          4
                          3
                          2
                          1
                          0
                              Both Poor    Safe-Low     Unsafe-High   Both Superior
                                           Adherence     Adherence

                                                                  - Peterson ACC 2006
 Lesson 10: Improving Care:

    Concept                            Clinical
                                        Trials

                                                    Guidelines

                                      CRUSADE
                Outcomes
                                        CQI

                                                    Performance
                  Intervention                       Indicators
                     Action

                                      Measurement

Adapted from Califf RM, Peterson ED
et al. JACC 2002;40:1895-901
     Efforts to Improve Care Delivery:
        CRUSADE QI Interventions
   Ongoing quarterly site feedback
     Benchmarking care versus peers

   National, regional, and local meetings
      Share treatment results and successful quality
       improvement strategies
   Clearinghouse for successful site QI solutions
   QI Materials: Algorithms, order sets, etc
   Publications: Updates, Focus on QI
   “Care Consults” by CRUSADE leadership
      Site results teleconferences
                                     Improvements in Guidelines Adherence And
                                        Rates of Drug Overdosing Over Time

                            80%                                                    79.3%                           35
                                                                          77.9%78.0%
Composite Adherence Rates




                                                                                                                   30    27.5




                                                                                           Rate of Excess Dosing
                                                                75.2%                                                            24.9
                                                            73.6%                                                  25                    22.1
                                                       73.0%
                                                  72.3%
                                             71.0%                                                                 20
                                         69.6%
                            70%
                                  68.1%                                                                            15

                                                                                                                   10

                                                                                                                    5

                            60%                                                                                     0
                                   Q1             Q4                Q3              Q2                                  Q4 2005 Q1 2006 Q2 2006
                                   '02            '02               '03             '04
                                   Mehta RH, et al AHJ 2007
          Quality Improvement Initiatives
• Institutional Feedback Reports
• Ready data availability
   for rapid cycle measurement


•   TAKE ACTION™ Campaign
•   D2B: An Alliance for Quality
•   Monthly Webcasts
•   National/Regional Group Meetings
Current ACTION Site Distribution
                                                  Active Sites = 290
            WA                                                                                                                                          ME
            (12)                                                                                                                              VT (0)
                                                                                                                                                        (1)
                                  MT                     ND
                                                         (1)                                      MI                                                            NH (1)
                                  (1)
                                                                            MN
      OR                                                                    (5)                                                               NY                  MA (1)
      (6)                                                SD                                 WI                                               (10)
                     ID                                                                     (6)           MI                                                     RI (0)
                                                         (1)
                     (1)            WY                                                                   (14)
                                                                                                                                    PA                        CT (2)
                                    (0)                                       IA                                                   (26)                 NJ (6)
                                                          NE                  (7)                                 OH                                   DE (0)
               NV                                         (4)                                  IL        IN       (22)
               (0)                                                                            (18)                         WV                             MD (11)
                                                                                                        (12)                            VA
                            UT                                                                                             (1)
                                          CO                                                                                           (11)
                            (0)                                 KS                  MO                          KY                                       DC (0)
    CA                                    (7)
                                                                (5)                 (8)                         (2)
   (15)                                                                                                                                NC
                                                                                                          TN                           (17)
                                                                                                          (8)
                                                                      OK                                                         SC
                                                                      (2)            AR                                          (3)
                      AZ                NM                                           (1)
                      (3)               (0)                                                               AL             GA
                                                                                                  MS      (3)            (8)
                                                                                                  (5)
                                                                                      LA
                                                                TX                    (2)
                                                               (11)
                                                                                                                                       FL
      AK                                                                                                                               (9)
      (1)

                                                HI (0)




                                                                                                                      Last updated: 1/4/07
                    ACTION 2007 Cumulative Data Submission
                                                                          24319
                     25000

                                                                 20355
                     20000
Number of records




                                                        16201

                     15000
                                               11960

                     10000
                                      7956


                      5000   4169



                         0
                             Jan-07   Feb-07   Mar-07   Apr-07   May-07   Jun-07
        Complexity of ACS Patients
               STEMI vs. NSTEMI

                        STEMI             NSTEMI
Variable              (n=11,854)         (n=26,956)
Mean age + SD (yrs)     62 + 12            69 + 14
Female sex               30%                39%
Diabetes mellitus        23%                33%
Prior MI                 18%                28%
Prior CHF                 5%                16%
Prior PCI                18%                23%
Prior CABG                7%                18%


                      ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007
               In-Hospital Outcomes
                    STEMI vs. NSTEMI

                         STEMI                    NSTEMI
Variable               (n=11,854)                (n=26,956)
Death                     6.0%                      3.9%
Re-infarction             1.2%                      1.4%
CHF                       6.6%                      7.1%
Cardiogenic Shock         7.1%                      2.5%
Stroke                    0.8%                      0.7%
RBC Transfusion           6.2%                      8.8%




                            *Transfusion among non-CABG patients
                            ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007
         STEMI – Timing of Reperfusion
80%


           60%
60%


                                                           40%
40%



20%

                                    5%
0%
      DTB <= 90 min -        DTB <= 90 min -      DTN <= 30 min - All
      Non-Transfer In          Transfer In

                             ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007 (n=11,854)


          DTB = 1st Door to Balloon
          DTN = 1st Door to Needle for Lytics
                          Acute Medications
                          STEMI vs NSTEMI
         98%   97%    96%
100%                        93%      93%
                                           90%
                                                                        84%
80%                                                   75%


                                                                                59%
60%                                                          52%


40%


20%


 0%
           ASA       Beta Blockers     Heparin        GP llb-llla       Clopidogrel
                                     (LMW+UFH)        Inhibitors
                                       ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007
       STEMI     NSTEMI                STEMI (n=11,854) NSTEMI (n=26,956)
                          Discharge Medications
                            STEMI vs NSTEMI
         99%   97%   97%
100%                        95%
                                     89%              91%                90%
                                                              86%

80%                                         76%                                  74%



60%



40%



20%



 0%
           ASA       Beta Blockers   ACE-I or ARB*        Statins         Clopidogrel

                                                * Ideal Patients
       STEMI     NSTEMI                         ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007
                                                STEMI (n=11,854) NSTEMI (n=26,956)
    Taking These Lessons to ACTION!



   Broaden Quality Mission
      No hospital or patient left behind

      Personalized site feedback

      National QI new initiatives
       Bridging the transitions in care
   Continue research mission
      Support science and guidelines

   Broaden policy mission
      Become nation’s leading ACS surveillance system

								
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