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CCORT/CCS 2008 Quality Indicators for Acute Myocardial Infarction (AMI) Care-Indicator Definitions

CIHR Team Grant in Cardiovascular Outcomes Research

Jack V. Tu MD PhD FRCPC, Laila Khalid MD, Linda Donovan BScN MBA, Dennis T. Ko MD MSc for the

CCORT/CCS AMI Quality Indicator Panel Christopher E. Buller MD, Virginia F. Flintoft BN MSc, Thao Huynh MD MSc, Cynthia

A. Jackevicius PharmD MSc, Laurie J. Lambert PhD, Michael P. Love MB ChB MD, Michael J. Schull MD MSc, Heather Sherrard BScN MHA, Edward Y.K. Tsoi MD,

Alain Vadeboncoeur MD

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CCORT/CCS 2008 Quality Indicators for AMI Care

Indicator Category #

Indicators from chart review 17

I In-hospital process-of-care indicators - 6 pharmacological & 7 nonpharmacological

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II Outcome indicator 1

III System indicators 3

Indicators from administrative data 21

I Out-of-hospital process-of-care indicators - 9 pharmacological & 4 nonpharmacological

13

II Outcome indicators 8

Total 2008 Indicators 38

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CCORT/CCS 2008 Quality Indicators for AMI Care1 In-hospital Process-of-Care Indicator /Chart Abstracted (Pharmacological)

1.1 ASA within 24 hrs before hospital arrival or within 3 hrs after hospital arrival 1.2 ASA prescribed at hospital discharge

1.3 Beta blocker prescribed at hospital discharge

1.4 ACEI or ARB prescribed at hospital discharge

1.5 Statin prescribed at hospital discharge

1.6 Fibrinolytic therapy within 30 minutes after hospital arrival

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CCORT/CCS 2008 Quality Indicators for AMI Care2 In-hospital Process-of-Care Indicators/Chart Abstracted (Nonpharmacological)

2.1 ECG within 10 minutes after hospital arrival 2.2 Primary percutaneous coronary intervention (PCI) within 90 minutes after hospital

arrival

2.3 Reperfusion therapy in eligible patients with ST-segment elevation MI

2.4 Risk stratification (i.e. cardiac catheterization, exercise stress test, perfusion imaging, stress echocardiography)

2.5 Assessment of left ventricular function

2.6 Smoking cessation advice, counselling or therapy during hospital stay

2.7 Referral to cardiac rehabilitation

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CCORT/CCS 2008 Quality Indicators for AMI Care3 In-hospital Outcome Indicator/Chart Abstracted

3.1 In-hospital mortality 4 In-hospital System Indicators/Chart Abstracted

4.1 Fibrinolytic therapy within 60 minutes after call for emergency medical services

4.2 Primary PCI within 120 minutes after call for emergency medical services

4.3 Pre-hospital 12-lead ECG

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CCORT/CCS 2008 Quality Indicators for AMI Care1 Out-of-Hospital Process-of-Care Indicators/Administrative Data (Pharmacological)

1.1 Prescription for Beta Blocker filled within 30 days after discharge 1.2 Prescription for Beta Blocker filled within 90 days after discharge

1.3 Adherence to Beta Blocker therapy 1 year after discharge

1.4 Prescription for ACEI or ARB filled within 30 days after discharge 1.5 Prescription for ACEI or ARB filled within 90 days after discharge

1.6 Adherence to ACEI or ARB 1 year after discharge

1.7 Prescription for Statin filled within 30 days after discharge 1.8 Prescription for Statin filled within 90 days after discharge

1.9 Adherence to Statin therapy 1 year after discharge

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CCORT/CCS 2008 Quality Indicators for AMI Care2 Out-of-Hospital Process-of-Care Indicators/Administrative Data

(Nonpharmacological)

2.1 Physician visit within 4 weeks after discharge

2.2 Median wait time (in days) for cardiac catheterization after MI

2.3 Median wait time (in days) for percutaneous coronary intervention (PCI) after MI

2.4 Median wait time (in days) for coronary artery bypass graft (CABG) surgery after MI

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CCORT/CCS 2008 Quality Indicators for AMI Care3 Out-of-Hospital Outcome Indicators/ Administrative Data

3.1 30-day mortality

3.2 1-year mortality

3.3 30-day readmission rate because of AMI

3.4 1-year readmission rate because of AMI

3.5 30-day readmission rate because of congestive heart failure

3.6 1-year readmission rate because of congestive heart failure

3.7 30-day readmission rate because of unstable angina

3.8 1-year readmission rate because of unstable angina

1.1 ASA within 24 hours before hospital arrival or within 3 hours after hospital arrivalNumerator Patients with AMI who received ASA within 24 hrs before hospital

arrival or within 3 hours after hospital arrival

Denominator Inclusions: Confirmed AMI

Exclusions:

1. Active Bleeding on arrival

2. Allergy to ASA

3. Documented reason for nonuse of ASA (e.g. high risk of bleeding or patient refusal)

1. In-hospital Process-of-Care Indicators—Pharmacological

1.2 ASA prescribed at hospital dischargeNumerator Patients with AMI who are prescribed ASA at hospital discharge

Denominator Inclusions: Confirmed AMI and alive at discharge

Exclusions:

1. Evidence of i) Active bleeding on arrival or ii) Active bleeding during hospital stay

2. Allergy to ASA

3. Documented reason for nonuse of ASA (e.g. high risk of bleeding or patient refusal)

1. In-hospital Process-of-Care Indicators—Pharmacological

1.3 Beta Blocker prescribed at hospital discharge

Numerator Patients with AMI who are prescribed a Beta Blocker at hospital discharge

Denominator Inclusions: Confirmed AMI and alive at discharge

Exclusions: 1. Bradycardia (heart rate <60 bpm) on day of discharge or day before discharge while not taking beta blocker

2. Conduction disorder defined as a second- or third-degree heart block on ECG on arrival or during hospital stay while not on a pacemaker

3. Allergy or intolerance to beta blocker

4. Documented reason for nonuse of beta blocker (e.g. symptomatic hypotension, systolic blood pressure < 100 mm Hg, severe chronic obstructive pulmonary disease, asthma or patient refusal)

1. In-hospital Process-of-Care Indicators—Pharmacological

1.4 Angiotensin-converting enzyme (ACE) inhibitor or Angiotensin-receptor blocker prescribed at hospital dischargeNumerator Patients with AMI who are prescribed ACEI or ARB at hospital

discharge

Denominator Inclusions: 1. Patients with AMI alive at discharge and 2. Left ventricular ejection fraction <40% and 3. Patients with diabetes, hypertension, heart failure or chronic kidney disease

Exclusions:

1. Severe aortic stenosis

2. Allergy or intolerance to ACEI or ARB

3. Documented reason for nonuse of ACEI or ARB at discharge (e.g. symptomatic hypotension, severe renal dysfunction, hyperkalemia, bilateral renal artery stenosis or patient refusal)

1. In-hospital Process-of-Care Indicators—Pharmacological

1.5 Statin prescribed at hospital discharge

Numerator Patients with AMI who are prescribed a statin at hospital discharge

Denominator Inclusions: Confirmed AMI and alive at discharge

Exclusions: Documented reason for nonuse of statins (e.g. statin intolerance, liver disease or patient refusal)

1. In-hospital Process-of-Care Indicators—Pharmacological

1.6 Fibrinolytic therapy within 30 minutes after hospital arrival

Numerator Patients with AMI who received fibrinolytic therapy within 30 minutes after hospital arrival

Denominator Inclusions: 1. Confirmed AMI and 2. ST-segment elevation or new LBBB on ECG and 3. Fibrinolytic therapy received within 6 hrs after hospital arrival and 4. Fibrinolytic therapy documented as primary reperfusion therapy

Exclusions:

1. Fibrinolytic therapy received in ambulance or in field

2. Documented reason for delay in receiving fibrinolytic therapy (e.g. nondiagnostic ECG or patient refusal)

1. In-hospital Process-of-Care Indicators—Pharmacological

2.1 ECG within 10 minutes after hospital arrival

Numerator Patients with AMI who had an ECG within 10 minutes after hospital arrival (triage time or registration time whichever occurs earlier)

Denominator Inclusions: Confirmed AMI

Exclusions:

Documented reason for delay in ECG (e.g. atypical signs or symptoms, ongoing cardiac arrest or patient refusal)

2. In-hospital Process-of-Care Indicators—Nonpharmacological

2.2 Primary percutaneous coronary intervention (PCI) within 90 minutes after hospital arrivalNumerator Patients with AMI who received primary percutaneous coronary

intervention (PCI) within 90 minutes after first hospital arrival

Denominator Inclusions: 1. Confirmed AMI and 2. ST-segment elevation or new LBBB on ECG, and 3. Primary percutaneous coronary intervention performed within 24 hours after hospital arrival

Exclusions:

1. Patients who received fibrinolytic therapy before PCI

2. Documentation of PCI as non-primary

3. Documented reason for delay in PCI (e.g. patient refusal)

2. In-hospital Process-of-Care Indicators—Nonpharmacological

2.3 Reperfusion therapy in eligible patients with ST-segment elevation MINumerator Patients with AMI who received reperfusion therapy (fibrinolytic

therapy or primary percutaneous coronary intervention [PCI])

Denominator Inclusions: 1. Patients with ST-segment elevation MI or new LBBB on ECG who are eligible for fibrinolytic therapy or primary PCI and

2. Patients who present within 12 hours after symptom onset

Exclusions:

Documented reason for not receiving reperfusion therapy (e.g. patient refusal)

2. In-hospital Process-of-Care Indicators—Nonpharmacological

2.4 Risk stratification (i.e. cardiac catheterization, exercise stress testing, perfusion imaging or stress echocardiography)Numerator Patients with AMI who underwent risk stratification (i.e. cardiac

catheterization, exercise stress testing, perfusion imaging or stress echocardiography) during hospital stay or were referred for risk stratification (e.g. outpatient or transfer to another hospital) after discharge

Denominator Inclusions: Confirmed AMI

Exclusions:

1. Primary or rescue percutaneous coronary intervention (PCI)

2. Documented reason for no cardiac catherterization or noninvasive stress test (e.g. physical limitations, do-not-resuscitate status or patient refusal)

2. In-hospital Process-of-Care Indicators—Nonpharmacological

2.5 Left Ventricular Function Assessment

Numerator Patients with AMI who had assessment of left ventricular function (e.g. via echocardiography, radionuclide angiography or left ventriculography) during their hospital stay or were referred for assessment after hospital discharge

Denominator Inclusions: Confirmed AMI

Exclusions:

1. Primary or rescue percutaneous coronary intervention (PCI )

2. Documented reason for no assessment of left ventricular function (e.g. recent assessment of left ventricular function or patient refusal)

2. In-hospital Process-of-Care Indicators—Nonpharmacological

2.6 Smoking cessation advice, counselling or therapy during hospital stayNumerator Patients with AMI who are smokers and who received

smoking cessation advice, counselling or therapy during hospital stay

Denominator Inclusions: 1. Confirmed AMI and 2. Active smoker or history of smoking in the past year

Exclusions:

Documented reason for no smoking cessation advice, counselling or therapy (e.g. patient refusal)

2. In-hospital Process-of-Care Indicators—Nonpharmacological

2.7 Referral to cardiac rehabilitation

Numerator Patients with AMI who are referred to cardiac rehabilitation during hospital stay or at discharge

Denominator Inclusions: Confirmed AMI

Exclusions:

Documented reason for no referral to cardiac rehabilitation (e.g. patient-associated factors [e.g. patient refusal], provider-associated factors [e.g. patient with a high-risk condition or a contraindication to exercise], health care system-associated factors [e.g. financial obstacles or absence of a cardiac rehabilitation program near patient’s home])

2. In-hospital Process-of-Care Indicators—Nonpharmacological

3.1 In-hospital mortality

Numerator Patients with AMI who died in hospital during this encounter/stay

Denominator Inclusions: Confirmed AMI

Exclusions:

None

3. Outcome Indicator

4.1 Fibrinolytic therapy within 60 minutes after call for emergency medical servicesNumerator Patients with AMI who were eligible for fibrinolytic therapy and

received it within 60 minutes after call for emergency medical services

Denominator Inclusions: 1. Confirmed AMI and 2. ST-segment elevation or new LBBB on ECG and 3. Fibrinolytic therapy within 6 hours after hospital arrival and 4. Fibrinolytic therapy is primary reperfusion therapy 5. Call made to emergency medical services (EMS)

Exclusions:

1. In-field fibrinolysis

2. Walk-in patients

3. Documented reason for delay in receiving finbrinolytic therapy (e.g. patient refusal)

4. System Indicators

4.2 Primary percutaneous coronary intervention (PCI) within 120 minutes after call for emergency medical servicesNumerator Patients with AMI who were eligible for PCI and received primary PCI

within 120 minutes after call for emergency medical services

Denominator Inclusions: 1. Confirmed AMI and 2. ST-segment elevation or new LBBB on ECG and 3. PCI performed within 24 hours after hospital arrival 4. Call made to emergency medical services (EMS)

Exclusions:

1. Patients who received fibrinolytic therapy before PCI

2. Documentation of PCI as non-primary

3. Documented reason for delay in PCI (e.g. patient refusal)

4. System Indicators

4.3 Pre-hospital 12-lead ECG

Numerator Patients with AMI who had a prehospital 12-lead ECG done by emergency medical services personnel

Denominator Inclusions: 1. Confirmed AMI and 2. Ambulance transportation

Exclusions:

1. Walk-in patients

2. Documented reason for no prehospital ECG (e.g. patient refusal)

4. System Indicators

CCORT welcomes feedback on these indicators. Please send comments or questions to Tara.ONeill@ices.on.ca