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Overview of critical pathways in the management of the MI patient

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									Acute Myocardial Infarction and
 the Role of Critical Pathways

       Christopher Cannon, M.D.
     Brigham and Women’s Hospital
               Boston


                                    1
            ACUTE MI GUIDELINES 11/96

             Drug Rx Peri MI: Meta-Analyses
                            Number       RR Death        p value
Beta blocker during MI      28,970      .87 (.77-.98)     0.02
Beta blocker post MI        24,298      .77 (.70-.84)    <0.001
ACEI during MI              100,963     .94 (.89-.98)    0.006
ACEI post MI if LV dysfxn    5,986      .78 (.70-.86)    <0.001
Nitrates during MI          81,908      .94 (.90-.99)     0.03
Ca++ blockers               20,342    1.04 (.95-1.14)      NS
Magnesium                   61,860    1.02 (.96-1.08)      NS
Lidocaine                    9,155    1.38 (.98-1.95)      NS
Class I Antiarrhythmics      6,300    1.21 (1.01-1.44)    0.04
                                              NEJM 335:1662, 1996
    NRMI-2: Distribution of Door-to-Needle
                    Times
      N=84,423




                     40%
Cannon CP ACC 2000
             NRMI-2: Thrombolysis
         Door-to-Needle Time vs. Mortality
                                             P=0.0001
                                 P=0.01
                       P=NS                       1.23
                                     1.11
                          1.03




            N=28,624    33,867      11,616         10,316



Cannon CP ACC 2000
          NRMI-2: Primary PCI
  Distribution of Door-to-Balloon times

            N=27,080




                        Door-to-Balloon Time (minutes)
Cannon CP, et al JAMA 2000;283:2941-2947.
      NRMI-2: Primary PCI
Door-to-Balloon Time vs. Mortality
            P=NS      P=NS           P=0.01 P=0.0007 P=0.0003



                                                        1.62      1.61
                                             1.41

                   1.14           1.15




 N=2,230   5,734          6,616          4,461      2,627      5,412




                          Cannon CP, et al JAMA 2000;283:2941-2947.
           EUROASPIRE II



 European Action on Secondary and Primary
      Prevention through Intervention
             to Reduce Events

       Euro Heart Survey Programme
    European Society of Cardiology-ESC

Wood et al. Lancet 2001; 357: 995-1001
                                          European Society of Cardiology ESC
               % beta-blockers at interview
                              by center
EUROASPIRE




    Wood et al. Lancet 2001; 357: 995-1001
                                              European Society of Cardiology ESC
US News and World Report
Aspirin in ideal candidates




Chen J, et al N Engl J Med. 1999;340:286-292.   10
US News and World Report
Beta-blockers in ideal candidates




Chen J, et al N Engl J Med. 1999;340:286-292.   11
US News and World Report
30-day mortality by hospital category*




Chen J, et al N Engl J Med. 1999;340:286-292.
                   * 25th, 50th and 75th percentile for each category
Quality implications

    – The lower mortality observed in “America’s
      Best Hospitals” appear to be explained in
      part by their higher use of aspirin and beta-
      blockers
    – Any hospital can be one of “America’s Best”
      by increasing their use of aspirin and beta-
      blockers




Chen J, et al N Engl J Med. 1999;340:286-292.         13
  TIMI III Registry                     GUARANTEE
                    Pre Guideline              Post Guideline
                  Men       Women          Men         Women

   No. Pts         1678        1640        1788         1160
 On Admission
   ASA              82           77         84            80
 Heparin            63           50         66            60
B-blockers          41           35         53            49

    Comparing Pre- to Post-:           Men              Women
    P values :   ASA                   0.30             0.05
                 Heparin               0.13             0.001
                 B-blocker             0.001            0.001
Scirica BM, Cannon CP, et al. Crit Path Cardiol. 2002;1:151-160.
       Unadjusted One Year Survival
                                                     95%
Percent surviving




                                         P = .0001   81%




                      Weeks post discharge
Giugliano RP,et al. Arch Intern Med 2000;160.
                •   Standardized protocols

                •   Goal: optimize care

                •   Emerging Evidence –
                    Pathways work:
                    – CHAMP
                    – Guidelines Applied in
                      Practice (GAP)
                    – AHA “Get with the
                      Guidelines” program



www.critpathcardio.com
    National Heart Attack
    Alert Program (NHAAP)


    CRITICAL PATHWAYS
  FOR THE TREATMENT OF
       PATIENTS WITH
ACUTE CORONARY SYNDROMES
        Critical Pathways - Definitions

• Standardized protocols for care
• Strict definition
   – Full list of all tasks, tracks variances
• Broader definition
   – Includes clinical protocols (NHAAP
     4D’s)
• Diagnostic pathways - Chest Pain Centers
• Treatment pathways - Thrombolysis
                                                18
          Goals of Critical Pathways

• Increase use of recommended medical therapies
  (e.g., aspirin)

• Decrease use of unnecessary tests.


• Decrease hospital length of stay


• Increase participation in clinical research


• Improve patient care and decrease costs.
                                                19
       Need and Rationale for Critical
       Pathways

• Underutilization of recommended
  medications (e.g. Aspirin)
• Overutilization of procedures
• Length of stay, # ICU days
• Quality of care measures (door-to-drug,
  door-to-balloon times)



                                            20
        Development And Implementation Of
        Critical Pathways


• Identify problems ( practice variation)
• Identify working committee/task force to develop
  path
• Distribute draft Critical Pathway to all personnel
  and departments involved. Revise based on
  approach.
• Implement pathway
• Collect and monitor data on pathway
  performance.
• Modify the pathway as needed to further improve
  performance.                                  21
        Methods of Implementation of
        Pathways


• Specific case manager for each Pt
   – High compliance, high cost
• Standardized order sheets, Pocket guides
• “Championing” - Grand rounds
• Recent study -> similar improvements in
  care with either formal or simpler pathways
  (Holmboe, ES et al. Am J Med
  1999;107:324-31.)
                                          22
                  Goal: < 30 Minutes
NHAAP
Ann Emerg Med
1994;23:311-29.              23
W. Rogers, personal communication
BWH Thrombolysis Critical Pathway: Initial
Experience

        BEFORE




                                           *P=0.013




                         Cannon CP, et al. Clin Cardiol 1999;22:17-22
                                                           25
26
     Guidelines Applied in Practice
     (GAP)
 •   Launched by ACC in February 2000 to:
       –   Bridge gap between ideal therapy and treatment practice
       –   Create/implement guideline tools/processes
 •   Initial project:
       –   Michigan hospitals
       –   Implemented 1999 ACC/AHA AMI Guideline
       –   Determine whether quality of care can be improved via
           guideline tools
       –   Status: pilot completed, expansion
           now in progress


Mehta R, et al. JAMA. 2002;287:1269-1276.                          27
GAP Results: Early Indicators

            *            *                                    Time in Minutes




      (343) (404)   (213) (245)       (131) (252)                    (40) (24)   (32) (45)

      ASA           BB            LDL CHOL                           LYSIS       PTCA



                                       PRE          POST


  *   p < 0.05

 **   p < 0.01
                         Mehta R, et al. JAMA. 2002;287:1269-1276.
                                                                                     28
  GAP: Adherence Improves With Tool
  Use

                              P = .001                       P = .004
                                                                          Pre-intervention
                                      93
                      100        86
                            81                                      82   Post-intervention
                                                      77                  No Tool Use
                                                 73
                      80
       Adherence, %




                                            65             64 64          Tool Use
         Quality




                      60

                      40

                      20

                       0
      No. of Ideal          343 308 96     213 174 71      131 165 87
       Patients
                             Aspirin        b-Blocker        LDL
                                                           Cholesterol
Mehta R, et al. JAMA. 2002;287:1269-1276.                                            29
Demographics
  6 clicks


 Clinical/Lab
  8 clicks

                Interactively
Discharge       checks
meds and        patient’s
interventions   data with the
                AHA guidelines
 7 clicks
Importance of
Data-Collection Registries

•   Track adherence to guidelines
•   Support local quality-improvement programs
•   Compare practice patterns/outcomes with benchmarks
•   Comply with regulatory requirements
•   Provide research data
Major Data-Collection Registries
    – NRMI
    – AHA Get With the Guidelines
    – ACC NCDR
    – GRACE
    – CRUSADE
    – VA transformation
                                                         31
 VA Transformation - Methods
 •   1995, VA launched a major reengineering of its
     health care system with aims that included:
     – Better use of information technology,
     – measurement and reporting of performance,
     – and integration of services
     – and realigned payment policies.




Jha AK, et al. N Engl J Med 2003;348:2218-27.         32
 VA Transformation - Results




Jha AK, et al. N Engl J Med 2003;348:2218-27.
Conclusions
•   Critical pathways hold great promise to improve
    – Quality of care,
    – Clinical outcomes
    – Cost-effectiveness
•   Initial studies show better quality of care and
    suggest improved outcomes




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