STRIVE Teleconference Presentation July20 2005

					CVD Critical Pathways Group
   2005 Teleconferences
                       July 20, 2005




        This activity is supported by an educational grant from
    the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.            TM
                                                                   STRIVE
                                                                                 1
                Faculty

    Gregg C. Fonarow, MD
        Eliot Corday Professor of Medicine
            and Cardiovascular Science
Director, Ahmanson-UCLA Cardiomyopathy Center
            UCLA Division of Cardiology
                UCLA Medical Center
               Los Angeles, California




                                                         TM
                                                STRIVE
                                                              2
              Disclosure Statement

The Network for Continuing Medical Education
requires that CME faculty disclose, during the planning
of an activity, the existence of any personal financial or
other relationships they or their spouses/partners have
with the commercial supporter of the activity or with the
manufacturer of any commercial product or service
discussed in the activity.

                                                             TM
                                                    STRIVE
                                                                  3
     Faculty Disclosure Statement

Gregg C. Fonarow, MD, has served as a consultant
to and has received research support from
GlaxoSmithKline, Pfizer Inc., and Scios Inc. He has
also received honoraria from Merck & Co., Inc.

The team from Aurora Health Care reports
no such relationships.

                                                       TM
                                              STRIVE
                                                            4
          Polling Question #1
What is your institution’s status in terms of
establishing critical pathways for ACS?
 1) ACS pathways are not in place
 2) ACS pathways are in place, but not updated per
    current ACC/AHA UA/NSTEMI and STEMI
    Guidelines
 3) ACS pathways are up-to-date, but not regularly
    implemented
 4) ACS pathways are up-to-date and regularly
    followed
                                                          TM
                                                 STRIVE
                                                               5
  Effective Strategies for Improving
Adherence to the ACC/AHA Guidelines

         Gregg C. Fonarow, MD




                                          TM
                                 STRIVE
                                               6
    CRUSADE ‘Clinician Led QI”
          Objectives


   Determine pattern of non–ST-elevation
    (NSTE) ACS care
   Implement initiatives to improve ACC/AHA
    NSTE ACS guidelines adherence
   Improve outcomes for NSTE ACS patients
    via evidence-based care




                                               7
                           Goals for CRUSADE:
            Improve Adherence to ACC/AHA Guidelines


     Acute Therapies                                  Discharge Therapies
        Aspirin                                         Aspirin
          – Clopidogrel
                                                         Clopidogrel
        Beta-Blocker
                                                         Beta-Blocker
        Heparin (UFH or LMWH)
                                                         ACE Inhibitor
        GP IIb-IIIa Inhibitor
                                                         Statin/Lipid Lowering
          – Cath/PCI
                                                         Smoking Cessation
                                                         Cardiac Rehabilitation

Circulation, JACC 2002 – ACC/AHA Guidelines Update.
                                                                                   8
    Quality Improvement Initiatives

   National/Regional educational meetings
     – ACC/AHA Guidelines recommendations
     – Review program and QI process
   Educational/QI materials
     – ED Risk Stratification Algorithm
     – Sample orders
     – Guidelines posters/pocket cards
     – Discharge MD and patient checklists
     – QI newsletter/stories
   Quarterly Feedback Reports
   1 on 1 visit/calls to sites

                                             9
               CRUSADE Data Submission
                   From 486 Sites     130,735!

130,000
120,000
110,000
100,000
 90,000
 80,000
 70,000
 60,000
 50,000
 40,000
 30,000
 20,000
 10,000
      0
          Sep-03   Dec-03   Mar-04   Jun-04   Sep-04   Dec-04




                                                                10
                 Acute Medications (<24 hrs)
                   Patients Without Contraindications
                 95    98                 96
     100
                                   88                       88
                                                       83
       80                                                                  70

       60
                                                                    44
       40

       20

        0
                 Aspirin        Beta-Blocker          All Heparin   GP IIb-IIIa

                                        Nation        Top 10%
CRUSADE: Quarter 4, 2003–Quarter 3, 2004 (n=40,386)
                                                                                  11
              Invasive Cardiac Procedures

       100
                         88
                  78
        80                                 70
                                                            62
                                     57
        60
                                                       49

        40

        20                                                       12   11

          0
                    Cath          Cath <48 hrs          PCI      CABG

                                          Nation      Top 10%
CRUSADE: Quarter 4, 2003–Quarter 3, 2004 (n=40,386)
                                                                           12
        Time-Dependent Variables
80
              in CRUSADE        76
                                                         69

60
                  Nation           Top 10%

40
                       25              23
                            22               20
20      15 13


0
     1st ECG (mins)   Cath (hrs)       PCI (hrs)   CABG (hrs)

       Median Times to ECG and Invasive Procedures (hrs)


                                                                13
                       Discharge Medications
                   Patients Without Contraindications

     100       93 98                              96
                                   87        89                            87
      80                                                        75    76
                              69
                                                           63
      60

      40

      20

        0
               Aspirin     Clopidogrel       Beta-        ACE-I or     Lipid
                                            Blocker        ARB       Lowering

                                        Nation        Top 10%
CRUSADE: Quarter 4, 2003–Quarter 3, 2004 (n=40,386)
                                                                                14
  Lifestyle Modification Interventions
100         90                88
       79               78
80                                               72

60                                         56


40

20

 0
       Smoking      Dietary Counseling   Cardiac Rehab
      Counseling

                   Nation     Top 10%
                                                         15
             Quality Improvement Interventions:
                         Site Predictors of Success

                     Administrative support
                     Strong clinician “champions”
                     Shared targets for improvement
                     High-quality data feedback




Bradley EH, et al. JAMA. 2001;285(20):2604-2611.
                                                       16
What Works to Improve ACS Care?
       Lessons from CRUSADE Sites

   Devoted leaders and team
     – Administrative support + inspiring clinician
   Sharing data among providers
     – EM, cardiology, IM, FM, cardiac surgery
   Preprinted Orders and Algorithms
     – Develop consensus + use consistently!
   Implement discharge document checklist
     – Improve documentation, patient adherence


                                                      17
      Novel QI Strategies by Sites
   Confidential provider-specific feedback
     – Depends upon practice environment
     – Anecdotal reports of success
   “Real time” data collection linked to QI
     – Data collected prospectively before discharge
     – Discharge care checked by QI personnel
   Standard orders stimulate optimal care
     – Default is to give all guidelines therapies
     – MDs can “opt out” by documenting
       contraindications on order sheets

                                                       18
               Trends in Acute Therapy Adherence
                         (Among Patients Without Contraindications)

  100%             95%   96%
             90%                           91%
                                                             88%
                                     83%               85%
                                                 82%
                               76%
    75%

                                                                                                 55%
                                                                                           51%
    50%                                                                        46%
                                                                         40%
                                                                                     37%
                                                                   33%

    25%


     0%
              Antiplatelet     Beta-Blocker        Heparin          GP IIb-IIIa      Clopidogrel
                          Q1-02       Q1-04       Q2-04       Q3-04       Q4-04

Quarter 1, 2002 through Quarter 4, 2004.
                                                                                                       19
                     Trends in Discharge Therapy
                      (Among Patients Without Contraindications)
 100%                     94%
           90%91%                                            91%
                                                                                               88%
                                                       87%
                                                 81%                                     83%
                                                                                      78%
  75%                                      72%
                                                                                69%
                                   62%                                   64%
                                                                   58%
                             50%
  50%


  25%


    0%
                Aspirin         Clopidogrel      Beta-Blocker ACE Inhibitor Lipid-lowering
                                                                or ARB          Agent

                        Q1-02        Q1-04        Q2-04       Q3-04            Q4-04

Quarter 1, 2002 through Quarter 4, 2004.
                                                                                                     20
            Overall Adherence Trends Over Time
                         Quarter 1, 2002 – Quarter 3, 2004
                                                                                          80.7%
80%                                                                               79.3%
                                                                    77.9% 78.0%

                                                           75.2%
                                                   73.6%
                                           73.0%
                                 72.3%
                        71.0%
                69.6%
70%
       68.1%




60%
       Q1 '02                    Q4 '02                    Q3 '03                         Q3 '04


Quarter 1, 2002 through Quarter 4, 2004.
                                                                                                   21
What Are GAP’s Key Elements?
       Partnerships
       Tools
       Learning Sessions
       Patient Care Triangle
       ACC/AHA Guidelines



                                22
                     GAP Key Elements
       ACC                                                    Patient
                               Tool Kit
                     •   Standing Orders
    Patients         •   Critical Pathways                       Key
   Providers         •   Patient Information                    Care
   Hospitals                                                  Priorities
                     •   Patient Discharge Contract
         Health      •   Hospital Data
MPRO                                                  Nurse            Doctor
        Coalitions




                                                                                23
                      Wanting to Improve Works Less
                       Well than Creating a System
          100
                                                                      100
                           93                          98
                                                  92             93                   90
           80         87                                    88
                 84                                                              85                  86
                                             81
                                        77
                                73 73                                       72
Percent




           60
                                                                                                          Control
                                                                                                          GAP Remeas
                                                                                                50        GAP Tools
           40
                                                                                           40


           20


            0
                ASA/24 hrs      BB/24 hrs    D/C ASA        D/C BB           ACE-I          Smoking
                                                                                           Counseling



Mehta RH, et al. JAMA. 2002;287(10):1269-1276.
                                                                                                                       24
                    Wanting to Improve Works Less
                     Well than Creating a System
                                          A. SEMHPP*                    B. GAP                A vs B          When GAP
                                           Hospitals                  Participating                           tools used
Quality indicators                         (Controls)                  Hospitals
                                          20 hospitals                10 hospitals
                                      Baseline     Follow up      Baseline     Follow up      P value1     Rates      P value2

Early Aspirin (%)                       82.8           84.2         76.5           87.1         0.284        93         0.010
Early -blockers (%)                    59.5           72.9         62.5           73.3         0.934        77         0.487
Discharge Aspirin (%)                   77.5           81.3         82.0           91.7         0.000        98         0.000
Discharge -blockers (%)                65.8           87.5         87.3           92.9         0.207       100         0.000
Discharge ACE Inhibitors (%)            79.9           71.5         80.0           84.7         0.010        90         0.002
Smoking Cessation (%)                   38.2           40.3         27.2           50.4         0.119        86         0.000

P value1 = For comparison between SEMHPP hospitals (controls) and GAP participating hospitals.
P value2 = For comparison between SEMHPP hospitals (controls) and GAP participating hospitals in patients in whom tools were
used.
*SEMHPP = Southeast Michigan Hospital Profiling Project.




Mehta RH, et al. JAMA. 2002;287(10):1269-1276.
                                                                                                                                 25
                             Use of Tools Drives
                          Improvement on Indicators
     100
                                                                              93***
                                                               94***
                      91***                                                 92***                                                        91***    Pre
                                                            90***                                                           87***
          80        87*
                                                                                                85**           86***                              Post
                                                 81*** 82
               85                76*
                                                                       84                  81                                                     Post with tools
                                            73                                        77                                78*
                            73                                                                                                       74***
Percent




                          71           72                                                                    68***
          60                                                                                                           73
                                                                                                                                    68


                                                                                                        51
          40


          20


           0
                    ASA       BB       LDL Chol         ASA             BB            ACE               Smoking        Chol      Dietary
                                                                                                       Counseling       Rx      Counseling
                                                    * P0.05            ** P0.01 ***P0.01

Eagle KA, et al. The guidelines applied in practice (GAP) initiative to improve MI care in Michigan –
lessons learned from 3 projects in 33 hospitals. J Am Coll Cardiol. 2003;41.
                                                                                                                                                               26
                                   GAP Works Best Where
                                    You Need it the Most
                                     Early Aspirin                    Early -blocker
                             90
                             80
                             70           88               87*
                                     86
                             60
                                                                                           76*
                  Percent


                             50                       76               73
                                                                 71                                        Pre
                             40                                                       55
                                                                                                           Post
                             30
                             20
                             10
                              0
                                     Male            Female      Male             Female

                                    Non-Medicare                                 Medicare
                             100
                              90
                              80     88                                     87
                              70   91           76         76
                              60                                                      73
                   Percent




                                                                       77                             67
                              50           70         72
                                                                                 63              58
                              40
                              30
                              20
                              10
                               0
                                   ASA         BB     LDL              ASA        BB             LDL
                                                     CHOL                                        Chol

Mehta RH, et al. J Am Coll Cardiol. 2002;39(suppl 2):A453.
                                                                                                                  27
                   GAP Doesn’t Always Work!
                                     Discharge Indicators
                                                                       CABG           No CABG
           100     P=0.39       P=0.89
                                              P=0.008          P<0.001
                                                                          P=0.19        P=0.77
                        90     92    92
           80      87                            84             84
                                                                          75                 75
                                                                               74      71
 Percent




           60                               61

                                                          55
           40

           20

            0
                 (103) (716)   (38) (247)   (48) (283)    (56) (454)     (63) (369)   (188) (1174)
                   ASA          BB          ACE-I         Lipid         Smoking   Dietary
                                                         Lowering      Cessation Counseling


Mehta RH, et al. J Am Coll Cardiol. 2004;43(5 suppl 2):419A.
                                                                                                     28
                          Pay for Quality Seems to Work:
                                  Discharge Rates
                                                                                       * P0.05       ** P0.01 ***P0.01
     100
                        94***           93***
                                                                                                               91***
                    90***            92***
                                                          85**                                87***                    Pre
          80                                                              86***                                        Post
               82               84
                                                     81                                 78*                            Post with tools
                                                                                                           74***
                                                77
                                                                                  73
Percent




          60                                                           68***                          68


                                                                  51
          40


          20


           0
               ASA *             BB *                ACE          Smoking          Chol                Dietary
                                                                 Counseling         Rx                Counseling
*Indicators with differential payments in Michigan.

 Eagle KA, et al. The guidelines applied in practice (GAP) initiative to improve MI care in Michigan –
 lessons learned from 3 projects in 33 hospitals. J Am Coll Cardiol. 2003;41.                                                       29
                    Uptake was Extremely Variable
             100
                                                                                    Standing Orders

              90
                                                                                    Discharge Tool

              80

              70
   Percent




              60

              50

              40

              30

              20

              10

               0

                   Rate of Standing Order and Discharge Tool Use by Hospital

Riba AL, et al. American College of Cardiology (ACC) acute myocardial infarction guidelines
applied in practice. Southern Michigan Expansion Project: a model of collaborative quality.
Eur Heart J. 2003;24:584.
                                                                                                       30
      Factors for Success!
   Support of senior leaders
   Highly engaged physician champions
   Active involvement of ED
   Minimum physician and nurse resistance
   Management expectation to use tools
   Planned and monitored project phases
   Use of Unit Champions
   Ability to identify and overcome barriers



                                                31
        Factors for Failure
   Without administrative support
   Physician champion not actively engaged
   ED not involved in the project
   Inability to identify barriers and develop
    strategies to overcome them




                                                 32
                                 The Holy Grail
                        Reducing Poor Outcomes
              Independent Influence of GAP and Discharge Tool
                     Use on 30-Day and 1-Year Mortality

                                  Odds Ratio for                       Odds Ratio for
                                 30-Day Mortality                      1-Year Mortality
GAP Effect Only           OR          95% CI        P value     OR         95% CI         P value
  GAP                     0.74       0.59-0.94       0.012      0.78      0.64-0.95       0.013
  C - Statistic               c=0.757 (13 variables)              c=0.767 (12 variables)


GAP and Tool              OR          95% CI        P value     OR         95% CI         P value
  GAP                     0.84       0.59-1.20       0.339      0.95      0.75-1.21       0.687
  Discharge tool          0.52       0.27-0.98       0.042      0.53      0.36-0.76       0.0006
  C - Statistic               c=0.800 (10 variables)              c=0.774 (10 variables)


 Eagle KA, et al. J Am Coll Cardiol. 2004;43(5 suppl 2):A405.
                                                                                                    33
Featured Institution
  Aurora Health Care
 Milwaukee, Wisconsin




                                 TM
                        STRIVE
                                      34
Background St. Luke’s Medical Center
Aurora Health Care

System
 14 hospitals in system
 80 clinics
 130 pharmacies
SLMC – Tertiary Access Center
 Licensed for 938 beds
 Submit data to: Premier, CMS, GWTG-CAD,
  Crusade, and ACC-NCDR
 Many physicians are private practice

                                                   TM
                                            STRIVE35
                                                        35
Background St. Luke’s Medical Center
Aurora Health Care
System AMI Care Management Initiative 1997
 Multidisciplinary team developed guidelines, tools,
  and education plan
Metro Region 2001 (4 hospitals)
 Revised evidenced-based tools: physician orders,
  care plans, teaching records, and educational
  materials
 Collected outcome data and provided feedback to
  physicians and patient care units on compliance to
  defined measures
 Meet quarterly in region to update tools and identify
  barriers and action plans for improvement
                                                          TM
                                                   STRIVE36
                                                               36
GAP Analysis


Identified several gaps over time
 Documentation: where to document and lack of
   documentation
 Lack of staff education and ongoing education
 Clarification of quality measures
 Physician adherence to measures
 Physician orders not used



                                                         TM
                                                  STRIVE37
                                                              37
Additional Barriers


   Early diagnosis of chest pain patients (ie,
    identification of NSTEMI patients)
   Lack of documentation of contraindications
   Lack of documentation of EF and treatment plan
   Changing definitions (ie, time of arrival)
   Disease-specific discharge note underutilized



                                                     TM
                                              STRIVE38
                                                          38
Improvements


   Site-based teams initiated: multidisciplinary,
    representation from all units who see ACS patient
   PDSA improvement plans developed based on unit
    data
   Physician order sets improved: added abbreviated
    order set focused just on quality measures
   Implemented bedside cardiac markers in ED,
    implemented “Chest Pain” physician orders to be
    initiated in ED and followed through inpatient
    admission
                                                         TM
                                                  STRIVE39
                                                              39
Other Improvements


     Disease-specific discharge note for ACS
      improved with more education
     Standardized where to document measures
     Physician memos addressing goals for CMS
      and that staff will approach physicians with
      compliance to these measures
     Strong administrative leadership support
     Active role of physician champion


                                                            TM
                                                     STRIVE40
                                                                 40
Summary


   Staff education is an ongoing process
   Standardize acceptable documentation
   Active participation of bedside nurses and
    pharmacists at site-based team meetings extremely
    valuable
   Timely data driven improvements to accomplish goal




                                                         TM
                                                  STRIVE41
                                                              41
            Polling Question #2
If you participated in a previous teleconference,
how much progress have you made since then?

  (Please refer to the checklists on the next 3 slides.)

 1)   We are currently on the same item
 2)   We have since moved to the next checkbox on
      the checklist
 3)   We have progressed by more than one item on
      the checklist
 4)   ACS pathways are up-to-date and regularly
      followed
                                                               TM
                                                      STRIVE
                                                                    42
            Progress Checklist:
             Immediate Goals
   Assemble team and set up meeting of working
    group
   Develop draft pathways

   Circulate pathways to all cardiology, ED, and CV
    nursing staff for comments
   Circulate discharge plan and other tools to all
    cardiology, ED, and CV nursing staff for
    comments


                                                           TM
                                                  STRIVE
                                                                43
         Progress Checklist:
      Short-term Goals/Activities
   Finalize critical pathways

   Launch critical pathways

   Circulate memo

   Grand rounds/conference: Cardiology/IM

   Grand rounds/conference: Emergency Dept.

   Grand rounds/conference: Nursing


                                                        TM
                                               STRIVE
                                                             44
         Progress Checklist:
      Long-term Goals/Activities
   Monitor data: which registry?
     NRMI
     AHA Get With The Guidelines
     ACC National Cardiovascular Data Registry
     CRUSADE
     GRACE
     REACH
     Other


                                                       TM
                                              STRIVE
                                                            45
Question-and-Answer Session




                                  TM
                         STRIVE
                                       46
  Concluding Remarks
     Gregg C. Fonarow, MD

Next program: Wednesday, August 10, 2005
at 12:00 Noon Eastern Time (9:00 AM Pacific)

Topic: Cost-effectiveness of CVD Therapies:
  Which Therapies Provide Good Value?

    Faculty: Christopher P. Cannon, MD


                                                        TM
                                               STRIVE
                                                             47

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:8
posted:7/10/2011
language:English
pages:47