Strive Teleconf Presentation Feb14 2007

ACS Critical Pathways 2007 Teleconferences

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

February 14, 2007

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Faculty

Gregg C. Fonarow, MDEliot Corday Professor of Medicine

and Cardiovascular ScienceDirector, Ahmanson-UCLA Cardiomyopathy Center

UCLA Division of CardiologyUCLA Medical Center

Los Angeles, California

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Disclosure StatementThe 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.

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Faculty Disclosure Statement

Gregg C. Fonarow, MD, has served as a consultant to and has received research support and honoraria from Bristol-Myers Squibb Company, GlaxoSmithKline, Merck & Co., Inc., Pfizer Inc, sanofi-aventis, Schering-Plough Corporation, and Scios, Inc.

Gary S. Ledley, MD, of Albert Einstein Medical Center and Thomas Jefferson University, reports no such relationships.

The NCDR-ACTION Registry:Combining the Power and Resources of

CRUSADE and NRMI

Gregg C. Fonarow, MD

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Polling Question #1

1. Yes

2. No

Does your institution currently participate in an acute coronary syndromes registry?

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NCDR-ACTION RegistryTM

In January 2007, the ACC (in conjunction with the Duke Clinical Research Institute) launched the National Cardiovascular Data Registry—Acute Coronary Treatment and Intervention Outcomes Network (NCDR-ACTIONTM)

Largest, most comprehensive national cardiovascular patient database ever developed

Overall purpose: measure clinically-relevant quality indicators in the treatment of ACS (STEMI and NSTEMI); promote national quality improvement

Combines data collection/quality reporting features of:

– NRMI (National Registry of Myocardial Infarction)

– CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines)

ACC-NCDR 2007. Available at: www.accncdr.com/WebNCDR/Action/default.aspx

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NCDR-ACTION RegistryTM Features Web-based data collection and download tool

Embedded data elements used for JCAHO/CMS reporting can be entered into the ACTION Registry™ and then downloaded for other uses

Quarterly comparative institutional outcomes reports to enable benchmarking with peers and the national experience

Participant training resources (user manuals, workshops, and annual user group meetings)

Tools to advance hospital quality improvement

No cost to participate – sponsored by Genentech, Schering-Plough, and BMS/Sanofi Partnership


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NCDR-ACTION Data CollectionInclusion Criteria

Patients must present for acute ischemic symptoms (typically reflected by primary admission diagnosis of STEMI, NSTEMI)

Patients admitted for other reasons who develop ischemic symptoms and positive cardiac markers during hospitalization are not eligible

Patients who present with ischemic symptoms without positive markers on admission, may be included if they evolve ↑ cardiac markers in the first 24 hours of hospitalization


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NCDR-ACTION Data CollectionPresentation Features to be Collected:

Arrival time at participating hospital Transfer in from an outside hospital? Patient transported by EMS? First 12-lead ECG obtained pre-hospital? ECG findings:

ST-depression (>0.5 mm) Transient ST-elevation (<1.0 mm) for <10 min New LBBB Persistent ST-elevation T-wave inversion


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NCDR-ACTION Data CollectionPresentation Features to be Collected:

Location first evaluated? (refers to first evaluation at your hospital) Emergency department (ED) → Transferred from ED (if patient was first evaluated in

the ED, enter date/time patient was moved out of ED, either to another location within your hospital or to another acute care center)

ICU/CCU/Telemetry/Cardiac Floor Cath Lab Other/noncardiac


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NCDR-ACTION Data CollectionSigns and Symptoms at Presentation:

Onset date and time of ischemic symptoms:______ Signs of Congestive Heart Failure (CHF)?

Mild CHF Severe CHF Cardiogenic Shock

Positive cardiac markers? (check if any present within first 24 hours of admission): Troponin I or T Creatine kinase-myocardial band (CK-MB) Positive bedside troponin assay

Heart rate on admission:_________ Systolic blood pressure on admission:_________


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NCDR-ACTION Data CollectionDemographics:

Age___, Sex___, Wt___, Height___, Race_______

Hispanic origin? (check if patient reports a Cuban, Mexican, Puerto Rican, South or Central American, or any other Spanish culture or origin, regardless of race)

Insurance Status HMO/private? Medicare? Medicaid? Self/none? Military/VAMC?


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NCDR-ACTION Data CollectionMedical History:

Hypertension? Diabetes mellitus? Peripheral arterial disease?

Claudication, either with exertion or at rest Amputation for arterial vascular insufficiency Vascular reconstruction, bypass surgery, or percutaneous intervention

to the extremities Documented aortic aneurysm Positive noninvasive (eg, ABI <0.8)

Current/recent smoker? Dyslipidemia? Prior MI, PCI, or CABG? Prior CHF? Prior stroke? Current dialysis?


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NCDR-ACTION Data CollectionMedications (Check all that apply):

Home medications (check if the patient has been taking the medicine routinely at home prior to this hospitalization)

Medications in first 24 hours of treatment (enter date/time of initial dose and amount of dose) Aspirin _____________ Clopidogrel __________ Beta blocker ____________ ACE inhibitor ______________ Angiotensin Receptor Blocker (ARB) ________ Statin _____________ Other lipid-lowering agent (nonstatin) _______

Documented evidence of acute contraindication


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NCDR-ACTION Data CollectionGP IIb-IIIa Inhibitor Type of Medication: Check if GP IIb-IIIa was administered during

the hospital stay. If yes, check the type of GP IIb-IIIa used: Eptifibatide (Integrilin); dose:_____________ Tirofiban (Aggrastat); dose: ______________ Abciximab (ReoPro); dose: ______________

Date and Time of Therapy Start (enter date/time of either the first bolus or beginning of infusion; if

patient was transferred to your hospital with therapy ongoing and initiation date/time unavailable, leave blank, but complete therapy stop time)

Stop (enter date/time infusion was permanently discontinued; do not record stop date/time if patient was transferred from your hospital with therapy ongoing)

Documented Evidence of Contraindication


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NCDR-ACTION Data CollectionAnti-Thrombin Agent Type of Medication: Check if anti-thrombin was administered during

the hospital stay. If yes, check the type of anti-thrombin used: IV UFH (dose:__________) LMWH (dose: _____________) Bivalirudin (dose: ___________) Fondaparinux (dose: ____________)

Date and Time of Therapy IV UFH (enter date/time of 1st IV administration; do not record SC UFH) LMWH (Record date/time of 1st SC administration; Do not record IV

LMWH) Bivalirudin (Record date/time of 1st admin) Fondaparinux (Record date/time of 1st admin)

Documented Evidence of a Contraindication


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NCDR-ACTION Data CollectionIn-Hospital Procedures Reperfusion Tx? (<12h from symptom onset?) If yes:

Thrombolytic therapy? (date/time of first bolus or beginning of infusion; indicate type of lytic first administered and the dose strength)

Primary PCI? (time patient arrived to cath lab where PCI performed; time first device activated): Time of first balloon inflation; if no balloon inflated, then time first stent

deployed, or Time of first treatment of lesion (eximer time, time rotablader used, time

angiojet, or other device) Stent placed? Indicate type and reason for PCI

If no reperfusion therapy administered, document evidence of contraindication


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NCDR-ACTION Data CollectionIn-Hospital Procedures Noninvasive stress testing (refers to exercise or pharmacologic stress

testing with or without echo or radionuclide imaging) Date of procedure: _________

Diagnostic Cath: Enter date/time vascular access obtained or 1st time documented on cath report. Select all vessels with >50% stenosis, including native stenosis in vessels perfused by a graft. If stenosis located in a marginal branch, record location of stenosis as parent vessel: LM: Left main artery LAD: Left anterior descending artery LCX/CX: Left circumflex artery RCA: Right coronary artery Graft: Saphenous vein or artery, or internal mammary artery graft

If no cath, document evidence of contraindication


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NCDR-ACTION Data CollectionIn-Hospital Procedures LVEF? If yes, enter result from cath or noninvasive imaging. If value reported as range

(eg, 40-45%), record lowest value (eg, 40%). If no numeric value given, record “normal, mild, or severe”

PCI (if not primary PCI for STEMI): Refers to balloon angioplasty, stenting, atherectomy, or laser intervention not used as a reperfusion strategy. Check “yes” if a guidewire was placed and device activated/inflated, even if final PCI result unsuccessful. If unable to place guidewire or activate a device, check “no.” If yes, indicate time of first balloon inflation. If no balloon inflated, indicate time first

stent deployed; or Time of first treatment of lesion (excimer time, time rotablader used, time angiojet,

or other thrombectomy device used) If stent was placed, check “yes” and indicate type of stent and primary reason PCI

was performed or attempted. CABG? If yes, enter date/time the patient entered O.R. or

first time documented on O.R. report


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NCDR-ACTION Data CollectionIn-Hospital Clinical Events

For each clinical event, check “no” or “yes.” If yes, enter date of first occurrence, and answer all subquestions.

Death (Enter date/time of death; check “died” in discharge section.) Postadmission infarction (clinical signs/symptoms of new infarction or repeat infarction

distinct from presenting event and meeting at least one of the definitions below): In patients presenting without an MI:

CK-MB or troponin values above the ULN New, significant Q waves in at least 2 contiguous ECG leads

In patients presenting with an MI: Prior to revascularization

New, significant Q waves in >2 contiguous ECG leads An increase in CK-MB or troponin above the ULN (if most cardiac markers prior to

the event were normal) An increase in CK-MB or troponin by >50% above the recent value (if most recent

cardiac markers prior to the event were above the ULN)


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In patients presenting with an MI (continued): Within 24 hours of PCI

↑ in CK-MB >50% over level preceding the procedure (if most recent cardiac markers prior to procedure were above the ULN)

↑ in CK-MB to a value at least 3x the ULN (if most recent cardiac markers prior to procedure were normal)

New, significant Q waves in >2 contiguous ECG leads Within 24 hours of CABG

Increase in CK-MB to a value at least 5x the ULN New, significant Q waves in >2 contiguous ECG leads


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Cardiogenic shock? Congestive heart failure? Stroke?

Hemorrhagic? Witnessed bleeding event?

Event resulted in hemodynamic instability? Any RBC/whole blood transfusion?

Related to CABG?


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NCDR-ACTION Data CollectionLaboratory Results Cardiac Markers

Total CPK value CK-MB: If CPK was ever abnormal, record CK-MB results:

Initial Sample (check “not done” or fill in date, value, ULN) Peak Sample (check “not done” or fill in date, value, ULN)

Troponin: Initial Sample (check “not done” or fill in date, value, ULN) Peak Sample (check “not done” or fill in date, value, ULN)


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NCDR-ACTION Data CollectionLaboratory Results Initial Creatinine Hematocrit Values

Initial Lowest Recorded Sample

Hemoglobin A1C INR on Admission Lipids (ie, total cholesterol, HDL, LDL, TG) performed either

during this admission or within 6 months prior to hospitalization)

BNP Value


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NCDR-ACTION Data CollectionDischarge Recommendations for Discharge: Check “yes” if documentation exists in the

medical chart that refers to discussion about smoking cessation, dietary modification, cardiac rehab referral, exercise counseling, or provision to patient of educational materials regarding these interventions Cardiac rehab referral Primary inpatient service during hospitalization (check specialty of

attending physician who primarily cared for patient according to most frequent and consistent notations in medical record)

Patient: Discharged (check “to home, rehab center, or extended care facility”;

enter date) Died Transferred to another acute-care center


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NCDR-ACTION RegistryTM

Enrollment and data collection has started

First NCDR-ACTION Registry report will include first quarter 2007 (January to March 2007) data and is tentatively scheduled to be distributed in August 2007 and quarterly from that time forward

Current CRUSADE and NRMI participants will receive FAQs unique to their participation

For more information, contact the NCDR-ACTION Registry by e-mail or phone:

– [email protected]

– 1-800-257-4737


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NCDR-ACTION Registry Sample Report: Guidelines Adherence

Sample Report:GuidelinesAdherence

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NCDR-ACTION Registry Sample Report: Discharge Therapies

Sample Report:Discharge Therapies

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CRUSADE Update Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early

Implementation of the ACC/AHA Guidelines

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Hospital Presentation Characteristics in CRUSADE:

October 1, 2005 – September 30, 2006 (n=31,613) Qualifying criteriaST-segment depression 28%Transient ST-segment elevation 5%Positive cardiac markers 93%

Baseline cardiac markers DrawnPositive

CK-MB 81%75%TnT/TnI 99%92%

Presenting characteristics Tachycardia 22%Hypotension 3%Signs of CHF 23%

Available at: http://www.crusadeqi.com.© 2007 Duke Clinical Research Institute. Adapted with permission.

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CRUSADE: Trends in Acute Therapy Adherence


98%92%

89%

48%

98%91% 87%

50%

0%

25%

50%

75%

100%

Antiplatelet β-Blocker Heparin GP IIb/IIIaInhibitor

Quarter 4-05 Quarter 1-06 Quarter 2-06 Quarter 3-06

Quarter 4, 2005, through Quarter 3, 2006.

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CRUSADE Data: October 1, 2005-September 30, 2006 (n=31,613)

CRUSADE: Invasive Cardiac Procedures October 1, 2005 – September 30, 2006 (n=31,613)

(Among Patients Without Contraindications to Cath)


84%

67%

53%

39%

12%

0%

20%

40%

60%

80%

100%

Cath Cath<48 hr

PCI PCI <48 hr CABG

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CRUSADE: Trends in Discharge Therapy Adherence

Quarter 4, 2005, through Quarter 3, 2006


93%

77%

93%

68%

90%

76%

93%

65%

90%96%

0%

25%

50%

75%

100%

Aspirin Clopidogrel β-Blocker ACE Inhibitor Lipid- Lowering

Agent


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CRUSADE: Trends in Discharge Recommendations Adherence

89%

80%

60%

85%

64%

88%

0%

25%

50%

75%

100%

Smoking CessationCounseling

Dietary Modification Cardiac RehabilitationReferral


Quarter 4, 2005, through Quarter 3, 2006. Available at: http://www.crusadeqi.com.© 2007 Duke Clinical Research Institute. Adapted with permission.

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CRUSADE: Overall Guideline Adherence Trends Over Time

Available at www.crusadeqi.com © 2007 Duke Clinical Research Institute. Adapted with permission.

Quarter 1 2002

Quarter 12003

Quarter 22004

Quarter 32005

Quarter 32006

68.1%73.0%

78.3%80.1% 83.3%

0%

25%

50%

75%

100%

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Performance Matters! Association Between Hospital Guideline

Adherence and In-Hospital Mortality in CRUSADE

Adapted with permission from Peterson ED, et al. JAMA. 2006;295:1912-1920.

NSTE ACS = non–ST-segment elevation ACS; NSTEMI = non–ST-segment elevation MI.

8

7

6

5

4

3

2

1

01 2 3 4

In-H

osp

ital

Mo

rtal

ity

, %

Hospital Composite GuidelineAdherence Quartiles

NSTE ACS 8

7

6

5

4

3

2

1

01 2 3 4

In-H

osp

ital

Mo

rtal

ity

, %

Hospital Composite GuidelineAdherence Quartiles

NSTEMI

CRUSADE = Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines.

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Featured Institution

Albert Einstein Medical CenterPhiladelphia, Pennsylvania

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Polling Question #2

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

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.)

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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

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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

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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

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Question-and-Answer Session

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Concluding RemarksGregg C. Fonarow, MD

Next ProgramGregg C. Fonarow, MD

Wednesday, March 14, 20073:00 PM Eastern Time

(12:00 Noon Pacific Time)AHA Get With The Guidelines:

New Guidelines, New Challenges

Strive Teleconf Presentation Feb14 2007

Health & Medicine

Transcript of Strive Teleconf Presentation Feb14 2007