Transcript Dr. Tu's PPT AMI National Call

CCORT/CCS 2008 Quality Indicators for
Acute Myocardial Infarction (AMI) Care - Introduction
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
1
CIHR Team Grant in Cardiovascular Outcomes Research
CCORT/CCS AMI Quality Indicator Expert Panel
CIHR Team Grant in Cardiovascular Outcomes Research
Outline
• The Practice Gap
• What are Quality Indicators?
• Canadian AMI Quality Indicators
– 2003 CCORT/CCS AMI Quality Indicators
– Update process
– 2008 CCORT/CCS AMI Quality Indicators – What’s
New?
• Implementation strategies
CIHR Team Grant in Cardiovascular Outcomes Research
The Practice Gap
• Many new life-saving treatments developed for
heart disease over the past three decades
(fibrinolytics, PCI, statins, etc.)
• Uptake of these advances in routine clinical
practice has been slow and varied across
jurisdictions
• Result - A gap between ideal care and actual
practice patterns
CIHR Team Grant in Cardiovascular Outcomes Research
What are Quality Indicators?
• ‘Quality indicators’ or ‘performance measures’
are intended to be a tool for measuring and
improving the quality of care delivered
• Based on:
– Scientific evidence from clinical practice guidelines, clinical
trials or expert panel consensus
• Health system performance indicators have
become very popular in Canada and other
countries recently
Sackett DL, et al. Evidence-Based Medicine:
How to practice and teach EBM, 2nd edition. London: Churchill Livingstone, 2000.
CIHR Team Grant in Cardiovascular Outcomes Research
Publication of AMI Indicators is mandated
in the U.S. and the U.K.
Continuous Quality Improvement
Concept
Clinical
Trials
Guidelines
Performance
Indicators
Outcomes
1 Roe MT, et al. Changing the model of car e for patents
with ACS. Am Heart J 2003; 146: 605-12.
Performance
CIHR Team Grant in Cardiovascular Outcomes Research
Canadian Quality Indicators for AMI
• CCORT (a CIHR-funded outcomes
research team) & the Canadian
Cardiovascular Society (CCS) began
development of the first Canadian
AMI quality indicators in 2001
- Joint CCORT/CCS expert panel
- Multi-disciplinary, national
representation
• 37 AMI Quality Indicators developed
• First published in the CJC 2003
CCORT
• CCORT is a group of over 30 outcomes researchers
from 5 provinces (NS, QC, ON, AB, BC) who are
working together on projects to measure and improve
the quality of cardiac care in Canada
• Funded by a CIHR Team Grant in Cardiovascular
Outcomes Research
• Institute for Clinical Evaluative Sciences (ICES) in
Toronto is the national coordinating centre for CCORT
• www.ccort.ca
2008 CCORT/CCS AMI Quality Indicator
Expert Panel Process
• Work plan May 2007-Oct 2008
• Delphi Process
– Two-staged modified Delphi Panel
Technique
– 3 key features: Anonymity; Iterative &
Controlled feedback; Aggregation of
responses
– 2 rounds of ratings of potential
indicators
– Highest rated indicators included in
final set
• Multi-disciplinary, national panel
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Literature Review
Sept 07 Independent Rating (Round 1)
Analysis of ratings
Oct 07 Expert Panel Meeting (Round 2)
Complete analysis & prepare summary
Dec 07 Follow-up teleconference
Draft paper
Mar 08 Circulate for comments
Finalize paper
Oct 21 08 Publish paper
CIHR Team Grant in Cardiovascular Outcomes Research
ACC/AHA Attributes for Quality Indicators
• Useful in improving
patient outcomes
• Measure Design
1. Evidence-based
2. Interpretable
3. Actionable
• Measure implementation
1. Feasibility
a. Reasonable effort
b. Reasonable cost
c. Reasonable time period
for collection
1. Denominator precisely
defined
2. Numerator precisely
defined
3. Validity
a. Face validity
b. Content validity
c. Construct validity
4. Reliability
Krumholz HM, et al. ACC/AHA clinical performance measures for adults with STEMI
and NSTE MI. J Am Coll Cardiol 2006;47:236-265.
CIHR Team Grant in Cardiovascular Outcomes Research
ACC/AHA Level of Evidence
Antman EM, et al. ACC/AHA guidelines for the management of patients with STEMI-Executive summary: A report of the ACC/AHA Task Force on Practice Guidelines (Writing
Committee to Revise the 1999 Guidelines for the management of patients with AMI). Circulation 2004;110;588-636.
CIHR Team Grant in Cardiovascular Outcomes Research
“Ideal” Subset Methodology
All cases
Cases not eligible
for process of care
Cases “ideal” to receive
process of care
Cases with contraindication to
process of care
CIHR Team Grant in Cardiovascular Outcomes Research
In-hospital process-of-care, outcome and system indicators
New/Revised In-hospital Process-of-Care and System Indicators
PROCESS OF CARE QUALITY INDICATORS
ASA within 24 hours before hospital arrival or within 3 hours after hospital arrival
ACEI or ARB prescribed at hospital discharge
ECG within 10 minutes after hospital arrival
Primary PCI within 90 minutes after hospital arrival (measure separately for transferred / walkin patients)
Reperfusion therapy in eligible patients with ST segment elevation MI
Risk stratification (ie cardiac catheterization, exercise stress testing, etc )
Assessment of left ventricular function
Smoking advice, counselling or therapy during hospital stay
Referral for cardiac rehabilitation
SYSTEM INDICATORS
Fibrinolytic therapy within 60 minutes after call for emergency medical services
Primary PCI within 120 minutes after call for emergency medical services
Pre-hospital 12-lead ECG
Benchmarks
• Expert panel unanimously set benchmark at
90% for all process of care indicators (vs. 7090% in original set of AMI indicators)
• Panel recognized that 90% might be unrealistic
for some centres, and suggested setting an
initial benchmark, to be increased by 10%
increments annually to reach 90%
CIHR Team Grant in Cardiovascular Outcomes Research
Implementation Strategies
• Establish a system to support measurement and
feedback of AMI quality indicators at your local
hospital (e.g. clinical registry, chart audits, etc.)
• Assemble a multidisciplinary team (e.g. EMS, ER docs,
cardiologists, nurses, etc.) to discuss performance and
develop strategies for achieving target benchmarks
• Consider introduction or modification of standardized
admission order sets, care pathways, and discharge
plans for each patient
• Participate in national, regional or local AMI quality
improvement initiatives
CIHR Team Grant in Cardiovascular Outcomes Research
Thank You
For more information please visit
www.ccort.ca
CCORT welcomes feedback on these
indicators. Please send comments or
questions to [email protected]