Bridging the gap between acute and community care services for angioplasty treated ST elevation...
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Bridging the gap between acute and community care services for angioplasty treated ST elevation myocardial infarct patients Andrea J. Lavoie MD FRCPC, Debra Lundberg BN, Karen Parker BN, Luana Mychaluk BN, Dean Traboulsi MD FRCPC, Kathryn King RN PhD, David Goodhart MD, FRCPC
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Transcript of Bridging the gap between acute and community care services for angioplasty treated ST elevation...
Bridging the gap between acute and community care services for angioplasty treated ST elevation myocardial infarct
patients
Andrea J. Lavoie MD FRCPC, Debra Lundberg BN,
Karen Parker BN,Luana Mychaluk BN,
Dean Traboulsi MD FRCPC,Kathryn King RN PhD,
David Goodhart MD, FRCPC
Overview
Background Purpose Objectives Methods Analysis Results Conclusions
Background
• Secondary prevention strategies initiated upon diagnosis of coronary artery disease (CAD) –cornerstone to effective CAD management
• Emphasis on CAD risk management post acute care episode is imperative
• Gap in literature and service delivery within early recovery period
Background
• Trend towards early discharge post primary angioplasty Cadillac Risk Score
• Impacts on transition to community Education in hospital Coordinating services
Family Physician Cardiologist Cardiac Rehabilitation
CADILLAC risk score for 30-day and one-year mortality
after primary PCI for STEMI
Risk factor Points
LVEF <40 percent 4
Killip class 2/3 3
Renal insufficiency (estimated creatinine clearance <60 mL/min) 3
TIMI flow grade after PCI of 0 to 2 2
Age >65 years 2
Anemia (hematocrit <39 percent in men and <36 percent in women) 2
Triple-vessel disease 2
Risk score 30-day mortality One-year mortality
Low risk (score 0 to 2) 0.1 to 0.2 percent 0.8 to 0.9 percent
Intermediate risk (score 3 to 5) 1.3 to 1.9 percent 4.0 to 4.5 percent
High Risk >6) 6.6 to 8.1 percent 12.4 to 13.2 percent
Halkin, A, Singh, M, Nikolsky, E, et al, J Am Coll Cardiol 2005; 45:1397.
Background
• Trend towards early discharge post primary angioplasty Cadillac Risk Score
• Impacts on transition to community Education in hospital Coordinating services
Family Physician Cardiologist Cardiac Rehabilitation
Background
STrategic Evaluation and Management of ST Elevation Myocardial Infarctions (STEMI) Program
• Purpose: Improve care in STEMI population in Calgary Health
Region STEMI II Initiative
Address transitional care from hospital to community
Research Question
• What are the barriers and challenges of patients treated with primary percutaneous coronary intervention (PCI) for a STEMI in the early recovery period post hospital discharge?
• Is participation in an early discharge follow-up clinic associated with improved medical therapy, hospital readmission rates, and cardiac rehabilitation participation at 30 days post discharge following a PCI treated STEMI?
1. Improve CAD risk management among PCI treated STEMI patients
2. Facilitate smooth transition between acute and community care setting – identify and address patient needs
3. Provide CAD management education to patients and family
4. Provide a communication bridge with family physician (GP) and cardiologist
5. Minimize preventable emergency room (ER) visits and re-hospitalization
Objectives
STEMI II Clinic Model Identification of all STEMI Patients In Hospital
-identified through STEMI database/nurse clinician/phone referral
Primary CardiologistInterventionalist
Primary Cardiologist Non-Interventionalist
Usual careInitial In-Hospital Visit day 1-3
Contact before leaving hospital
Reviewed in FICS STEMI Clinic day 3-7
Further follow-up if required- may be before/after day 7
visit
Follow-up phone call day 7
STEMI II Clinic Model
Identification of all STEMI Patients In Hospital-identified through STEMI database/nurse clinician/phone referral
Identification of all STEMI Patients In Hospital-identified through STEMI database/nurse clinician/phone referral
Primary CardiologistInterventionalist
Primary Cardiologist Non-Interventionalist
Usual careInitial In-Hospital Visit day 1-3
Contact before leaving hospital
Reviewed in FICS STEMI Clinic day 3-7
Further follow-up if required- may be before/after day 7 visit
Follow-up phone call day 7
Inclusion Criteria:Primary PCI for treatment of STEMITreated in the Foothills Medical Centre,Calgary AB between Jan 15 – June 23/07Interventional cardiologist – primary cardiologist
Exclusion:Cadillac Risk Score >2** Received thrombolytics or coronary artery bypass graft as adjunct therapy for STEMI hospitalizationDiagnosis of NSTEMI/UA
STEMI II Clinic Model
Identification of all STEMI Patients In Hospital-identified through STEMI database/nurse clinician/phone referral
Primary CardiologistInterventionalist
Primary Cardiologist Non-Interventionalist
Usual careInitial In-Hospital Visit day 1-3
Contact before leaving hospital
Reviewed in FICS STEMI Clinic day 3-7
Further follow-up if required- may be before/after day 7 visit
Follow-up phone call day 7
Primary CardiologistInterventionalist
Primary Cardiologist Non-Interventionalist
STEMI II Clinic Model
Identification of all STEMI Patients In Hospital-identified through STEMI database/nurse clinician/phone referral
Primary CardiologistInterventionalist
Primary Cardiologist Non-Interventionalist
Usual careInitial In-Hospital Visit day 1-3
Contact before leaving hospital
Reviewed in FICS STEMI Clinic day 3-7
Further follow-up if required- may be before/after day 7 visit
Follow-up phone call day 7
Initial In-Hospital Visit day 1-3
Contact before leaving hospital
Reviewed in FICS STEMI Clinic day 3-7
Further follow-up if required
- may be before/after day 7 visit
Follow-up phone call day 7
Methods
Data Collection – Prospective 30 day phone follow-up
ER visit Readmission Cardiac Rehab participation Medication
Clinic charts recorded patients needs STEMI II telephone-help line logs
– Retrospective Survey with phone follow-up at 4-8 months post clinic
participation Chart review (missing data)
STEMI Patient Flow
STEMI patients treated with 1º PCI
Jan 15th – June 23rd 2007 (n=200)
Clinic participants (n=36) Non-participants (n=150)
In-hospital death (n= 14)
Allocated but did not participate (n=1)Lost to follow-up (n=1)
Final (n=34)Clinic visit (n=25) Telephone visit (n=9)
Lost to follow-up (n=39)Outcome evaluation (n=111)
STEMI Population (n=74)
Clinic Participant (n=25)
Control (clinic non-participants)(n=49)
Age (years) 53.2 C.I.( 49.3-57.0) 56.2 C.I.(53.4-59.1)
Sex (male) 92.0% (23) 71.4% (35)
Length of stay (days)* 3.7 C.I. (3.0- 4.4) 5.0 C.I. (3.8-6.2)
Cadillac Risk Score* 0.3 C.I. (0.01- 0.6) 0.7 C.I.( 0.4-0.9)
Diabetic 12% (3) 12.2% (6)
Hypertension 32.0% (8) 38.7% (19)
Smoker 44.0% (11) 46.9% (23)
Family History 60% (15) 34.7% (17)
Previous Myocardial Infarction
12% (3) 10.2% (5)
Low Risk (Cadillac Risk Score 0-2)
*P=0.03
*P=0.03
Moderate-High Risk (Cadillac Risk Score >2-18)
STEMI Population (n=71)
Clinic Participant (n=9)
Control (clinic non-participants)(n=62)
Age (years) 53.2 C.I.( 49.3-57.0) 61.7 C.I.(59.0-64.4)
Sex (male) 66.7% (6) 71.0% (44)
Length of stay (days)* 6.6 C.I. (3.4- 9.9) 8.0 C.I. (6.7-9.3)
Cadillac Risk Score* 5.0 C.I. (3.8-6.2) 5.5 C.I.(5.1-6.1)
Diabetic 11% (1) 26.3% (16)
Hypertension 33.0% (3) 60.0% (37)
Smoker 66.7% (6) 38.7% (24)
Family History 33.0% (3) 32.5% (20)
Previous Myocardial Infarction
11.0% (1) 11.3% (7)
N/S
N/S
N/S
Medication TherapyBaseline
0
10
20
30
40
50
60
70
80
90
100
%
ASA Plavix B-B ACE-I Statin
Control (n=111)Clinic (n=34)
Medication Therapyat 30 days
0
10
20
30
40
50
60
70
80
90
100
%
ASA B-B Statin
Control (n=111)Clinic (n=34)
Clopidogrel ACE
Emergency Room Visits and Hospital Readmissions at 30 days
02468
10121416
LowRisk
Mod-HighRisk
LowRisk
Mod-HighRisk
Control (n=111)Clinic (n=34)
ER Visits Hospital Readmission
%
Cardiac Rehabilitation Participation at 30 days
0
10
20
30
40
50
60
70
Low Risk Mod-High Risk
Control (n=108)Clinic (n=31)
%
Clinic Visit Documentation & Telephone Help Line Log
Themes: 1. Access to health care provider (family physician)
(n=4) 11.7% needed assistance in securing a family physician at clinic visit.
2. Lack of education and support for spouses. 3. 25 calls to help-line, 18 unique callers4. Medication questions- 32% (n=8)5. Symptom checks – 24% (n=6)6. Coordinating community care services 28% (n=7)7. Clarification of discharge instructions by
pharmacists and family doctors 8% (n=2)
Clinic Survey Results
0%10%20%30%40%50%60%70%80%90%
100%
Access to GP Education forSpouses
Access toSTEMI help-
line
Early accessto CR
Participationin STEMI
Clinic
STEMI Clinic Recommendations Survey
Extremely Important Somewhat Important Not Very Important Unimportant Not Sure
N=32/34
Strengths
• Descriptive Addresses a gap in the literature Identify patient needs in early discharge period
• Inform practice Develop interventions Evaluate or design in-hospital education programming,
discharge planning, clinic programming, home support Stimulate future research questions
Limitations
• Design Protocol changes to limit patients to low risk STEMI after
2 months due to staff and resource constraints
• Measurement Bias Survey not validated Recall bias of survey
• Selection Bias Selected only interventional cardiologist patients Convenience sampling – Calgary Health Region Loss to follow-up (control group)
Conclusions• Gaps in acute to community care transition period
Access to family physician Education and support for spouses Access to cardiac rehabilitation Medication use questions (patients/GP/pharmacists)
• Help-line and clinic were important to patients in their transition to the community
• Apparent improvement in CAD management with evidence-based medication use in clinic patients
Clopidogrel + B-blockers + Statins
• Trend to reduced 30 day ER visits among clinic patients
• CR access continues to be a challenge within early recovery period
References
Argulian, E., Patel, A. D., Abramson, J. L., Kulkarni, A., Champney, K., Palmer, S. et al. (2006). Gender Differences in Short-Term Cardiovascular Outcomes After Percutaneous Coronary Interventions. The American Journal of Cardiology, 98, 48-53.
Assmann, G., Benecke, H., Neiss, A., Cullen, P., Schulte, H., & Bestehorn, K. (2006). Gap between guidelines and practice: attainment of treatment targets in patients with primary hypercholesterolemia starting statin therapy. Results of the 4E-Registry (Efficacy Calculation and Measurement of Cardiovascular and Cerebrovascular Events including Physicians' Experience and Evaluation). European Journal of Cardiovascular Prevention & Rehabilitation, 13, 776-783.
Cortas, O. R. & Arthur, H. M. R. (2006). Determinants of referral to cardiac rehabilitation programs in patients with coronary arterydisease: A systematic review. American Heart Journal, 151, 249-256.
Gaziano, M. (2005). Global Burden of Cardiovascular Disease. In D.Zipes, P. Libby, R. Bonow, & E. Braunwald (Eds.), Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine (7 ed., pp. 1-19). Philadelphia, PA.: Elsevier Saunders.
Giannuzzi, P., Temporelli, P. L., Maggioni, A. P., Ceci, V., Chieffo, C., Gattone, M. et al. (2005). GlObal Secondary Prevention strategiEs to Limit event recurrence after myocardial infarction: the GOSPEL study. A trial from the Italian Cardiac Rehabilitation Network: rationale and design. European Journal of Cardiovascular Prevention & Rehabilitation, 12,
Heidrich, J., Behrens, T., Raspe, F., & Keil, U. (2005). Knowledge and perception of guidelines and secondary prevention of coronary heart disease among general practitioners and internists. Results from a physician survey in Germany. European Journal of Cardiovascular Prevention & Rehabilitation, 12, 521-529.
Refernces
Heidrich, J., Behrens, T., Raspe, F., & Keil, U. (2005). Knowledge and perception of guidelines and secondary prevention of coronary heart disease among general practitioners and internists. Results from a physician survey in Germany. European Journal of Cardiovascular Prevention & Rehabilitation, 12, 521-529.
Jackson, L., Leclerc, J., Erskine, Y., & Linden, W. (2005). Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors. Heart, 91, 10-14.
Johnson, N. A. & Heller, R. F. (1998). Prediction of patient nonadherence with home-based exercise for cardiac rehabilitation: the role of perceived barriers and perceived benefits. Preventive Medicine, 27, 56-64.
Jolliffe, J. A., Rees, K., Taylor, R. S., Thompson, D., Oldridge, N., & Ebrahim, S. (2006). Exercise-based rehabilitation for coronary heart disease [Systematic Review]. Cochrane Database of Systematic Reviews.
Jolly, K., Bradley, F., Sharp, S., Smith, H., & Mant, D. (1998). Follow-up care in general practice of patients with myocardial infarction or angina pectoris: initial results of the SHIP trial. Southampton Heart Integrated Care Project. Family practice, 15, 548-555.
Kaul, P., Newby, L. K., Fu, Y., Mark, D. B., Califf, R. M., Topol, E. J. et al. (2004). International differences in evolution of early discharge after acute myocardial infarction. Lancet, 363, 511-517.
Khot, U. N. M., Khot, M. B. M., Bajzer, C. T. M., Sapp, S. K. M., Ohman, E. M. M., Brener, S. J. M. et al. (2003). Prevalence of Conventional Risk Factors in Patients With Coronary Heart Disease. JAMA, 290, 898-904.
References
Khot, U. N. M., Khot, M. B. M., Bajzer, C. T. M., Sapp, S. K. M., Ohman, E. M. M., Brener, S. J. M. et al. (2003). Prevalence of Conventional Risk Factors in Patients With Coronary Heart Disease. JAMA, 290, 898-904.
King, K. M. & Teo, K. K. (1998). Cardiac rehabilitation referral and attendance: not one and the same. Rehabilitation Nursing, 23, 246-251.
Lindgren, P., Borgstrom, F., Stalhammar, J., Alemao, E., Yin, D. D., & Jonsson, L. (2005). Association between achieving treatment goals for lipid-lowering and cardiovascular events in real clinical practice. European Journal of Cardiovascular Prevention & Rehabilitation, 12, 530-534.
Maron, D. M., Grundy, S. M., Ridker, P. M., & Pearson, T. P. (2004). Dyslipidemia, Other Risk Factors, and the Prevention of Coronary Heart Disease. Hurst's The Heart [On-line]. Retrieved Aug 22, 2007
Oldridge, N., Gottlieb, M., Guyatt, G., Jones, N., Streiner, D., & Feeny, D. (1998). Predictors of health-related quality of life with cardiac rehabilitation after acute myocardial infarction. Journal of Cardiopulmonary Rehabilitation, 18, 95-103.
Rasalingam, R. & Pearson, T. (2002). An integrated approach to risk-factor modification. In E.Topol (Ed.), Textbook of Cardiovascular Medicine (2 ed., Books@Ovid.
Reid, R. D., Morrin, L. I., Pipe, A. L., Dafoe, W. A., Higginson, L. A. J., Wielgosz, A. T. et al. (2006). Determinants of physical activity after hospitalization for coronary artery disease: the Tracking Exercise After Cardiac Hospitalization (TEACH) Study. European Journal of Cardiovascular Prevention & Rehabilitation, 13, 529-537.
References
Smith, K. M., Harkness, K., & Arthur, H. M. (2006). Predicting cardiac rehabilitation enrollment: the role of automatic physician referral. European Journal of Cardiovascular Prevention & Rehabilitation, 13, 60-66.
Smith, S. C., Jr., Allen, J., Blair, S. N., Bonow, R. O., Brass, L. M., Fonarow, G. C. et al. (2006). AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update: Endorsed by the National Heart, Lung, and Blood Institute. Circulation, 113, 2363-2372.
The Heart and Stroke Foundation of Canada (2003). The Growing Burden of Heart Disease and Stroke in Canada 2003. Heart and Stroke Foundation of Canada website [On-line]. Retrieved from http://www.cvdinfobase.ca/cvdbook/CVD_En03.pdf.
Thompson, D. R. & Oldridge, N. B. (2004). Secondary prevention and cardiac rehabilitation: have we got the terms right? European Journal of Cardiovascular Prevention & Rehabilitation, 11, 183-184.
van, d., V, Pedersen, S. S., Boersma, E., Erdman, R. A. M., Leenders, C. M., Pop, G. A. M. et al. (2001). Early discharge of patients with acute myocardial infarction has no adverse psychological consequences. Coronary Health Care, 5, 73-79.Thom, T., Haase, N., Rosamond, W., Howard, V. J., Rumsfeld, J., Manolio, T. et al. (2006). Heart Disease and Stroke Statistics--2006 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 113, e85-151.
Yusuf, S., Hawken, S., Ôunpuu, S., Dans, T., Avezum, A., Lanas, F. et al. (2004). Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet, 364, 937-952.
