Transcript 1T99 Zocor - University of California, Los Angeles

Closing the CHD
Treatment GAP
Saving Lives Through Better Implementation
of Secondary Prevention Measures
The Impact of Coronary Heart
Disease in the United States

14 million Americans alive today have a history of myocardial
infarction, angina, or both.1
 450,000 recurrent myocardial infarction occur each year, most of
which could have been prevented
 25% of men and 38% of women will die within 5 years of
presenting with a AMI2
 Studies suggest that a large number of CAD patients do not
receive the therapies that can prevent recurrent events and save
lives 3-5
1 AHA Heart and Stroke Facts: 1996 Statistical Supplement
2 Rossouw, et al., N Engl J Med, 323:1112-1119.1990
3 Cohen, et al., Circulation, 83(4):1294-1304, 1991
4 Nieto, et al., Arch Intern Med, 155:677-684, 1995
5 Giles, et al., JAMA, 269 (9):1131-1138, 1993
AHA/ACC Guidelines to Risk Reduction
For Patients With CHD and Other Vascular Disease
Cessation of smoking
 Lipid Management Goals
 Primary Goal: LDL < 100 mg/dl
 Secondary: HDL > 35 mg/dl TG < 200 mg/dl
 Physical activity: 30 minutes 3-4 times per week
 Weight management
 Antiplatelet/anticoagulants:ASA 80 to 325 mg/day
(or warfarin)
 ACE inhibitors (post-MI for LVD)
 Beta blockers for high-risk patients post-MI
 Blood pressure control: goal < 140/90 mm Hg

Adapted from Smith, Circulation 1995;92:3
Comprehensive Medical Therapy For Patients
with CHD or Other Vascular Disease
Risk Reduction




ASA
Beta Blockers
ACE inhibitors
Statins
20-30%
20-35%
22-25%
25-42%
The four medications every atherosclerosis patient should be treated
with, unless contraindications exist and are documented
Adapted from the UCLA CHAMP Guidelines 1994
“Despite compelling scientific evidence and
national treatment guidelines supporting the
use of secondary prevention medical
therapies, these treatments continued to be
underutilized in CVD patients receiving
conventional care”
Adapted from 27th Bethesda Conference Report
JACC 1997;27:958
CAD Treatment Gap - Community
95
100
80
60
40
18
20
0
Physician Awareness
of NCEP Guideline
Patient Treated
to Goal
Provider awareness does not equal successful implementation
Pearson Arch Intern Med 2000;160:459-67
CAD Treatment Gap - Academic Centers
Precent of Patients Treated
Lipid Lowering Medication Treatment Rates
100
80
60
40
27.1
25.1
18
14.9
20
0
The
Brigham
LDS
Hospital
Cleveland
Clinic
PURSUIT
Trial Centers
An academic environment does not equal successful implementation
Brigham and Women’s Hospital: 2003 outpts with CAD
LDS Hospital: 600 CAD patients discharged post cath
Cleveland Clinic: 537 Diabetics with CAD Post PTCA
PURSUIT Trial Centers: 8515 ACS patients
Arch Intern Med 2001:161:53-58
Am J Card 2001;87:256-261
JACC 1999;33:1269-77
JACC 2000;35:411A
Quality Assurance Program (QAP)
At Goal
“On Therapy”
At Goal
7%
“No Therapy”
4%
n = 48,586
No LDL-C
Documented
“No Therapy”
43%
Not at Goal
“On Therapy”
18%
Not at Goal
No LDL-C “No Therapy”
Documented
14%
“On Therapy”
14%
Sueta C, et al. Am J Cardiol. 1999;83:1303-1307.
CAD Treatment Gap - Hospital

ACC Evaluation of Preventive Therapeutics (ACCEPT) Data - Hospital
data (N=50) 1996-97


Treatment Gap of 80 %
NRMI 3 Data - 1998-1999
 32 % of Post-MI patients discharged on a lipid lowering agent
(N = 138,001)
Treatment gap is not a deficit of knowledge,
rather it is a deficit of implementation
Pearson, T.A. et al., Supplement to Circulation: Oct, 1997;96:8:1733
Fonarow Circulation 2001;103:38-44.
ACCEPT: Most Hospitalized CHD Patients are Not
at Goal 6 Months Post Discharge
Risk Factor Goal
On
Admission
At Discharge
6 mo. Post
Discharge
LDL-C < 100mg/dL
0%
0%
24%
Lipid Lowering Drug
21%
24%
59%
Aspirin
44%
86%
87%
Beta Blocker
34%
58%
63%
Pearson, T.A. et al., Supplement to Circulation: Oct, 1997;96:8:1733.
Utilization of Lipid-Lowering Medications
at Discharge in Patients with AMI
138,001 Patients in the National Registry of Myocardial Infarction-3
68.3%
Independent Predictors
Catheterization
Use of Beta Blocker
Smoking Cessation
CABG
31.7%
No Lipid Lowering
Lipid Lowering
Teaching Hospital
decreased
increased
138,001 patients discharged post AMI from 1470 US hospitals, July 1998 to June 1999
Fonarow Circulation 2001;103:38-44
Utilization of Lipid-Lowering Medications
at Discharge in Patients with AMI
100
Male (N=83,806)
Female (N=54,195)
80
60
P<0.0001
P<0.0001
P<0.0001
40
P=NS
P=NS
20
0
<55
55-64
65-74
75-84
85+
Age (Years)
"Use of Lipid-Lowering Medications at Discharge in Patients With Acute Myocardial Infarction"
Fonarow Circulation 2001;102:38-44
CVD Treatment Gap
OFFICE SETTING
QAP DATA
 30-40% Documented
Treatment Rate
 Treatment Gap of 66%
HOSPITAL SETTING
NRMI / ACCEPT DATA
 20-32% Documented Treatment
Rate
 Treatment Gap of 68-80%
BURDEN OF DISEASE
 23 million CHD patients in
the US
BURDEN OF DISEASE
 2.7 million annual CHD
discharges in the US
National Hospital Discharge Rates
for Secondary Prevention
Percent of Patients
100
80
77
65
60
42
40
37
42
20
0
ASA
Beta blocker
ACEI
Statin
Report from 7/99 to 6/00
NRMI Registry Discharge Medications at 1552 National NRMI III Hospitals (n=167,312)
Includes all patients (no exclusions for contraindications or intolerance)
Smoking
Cessation
Barriers to Implementing Risk Factor Management
in Patients with Documented Coronary Artery Disease
Physician is focused on acute problems
Time constraints and lack of incentives, including reimbursement
Lack of training including inadequate knowledge of benefits and lack of
prescription experience
Lack of resources and facilities
Lack of specialist-generalist communication; passing on responsibility
Guidelines and treatment pathways which delay therapy and call
for multiple steps, laboratory tests, and time points
Adapted from 27th Bethesda Conference Report JACC 1997;27:958
Incentives for Change
 NCQA/HEDIS/JCAHO/GOA reporting measures
– Hospitals
– Managed Care
– Physicians
 Consumer demand for quality care / report cards
Graded on
– ASA after AMI
– Beta blocker after AMI
– ACEI after AMI and CHF
– LDL evaluated/Rxed post cardiac hospitalization
CVD Treatment System Goals

Implement initiatives to put evidence
based guidelines into action

Improve the quality of care for patients
with established cardiovascular disease

Reduce secondary events - and save
lives
Optimal Hospital Discharge Rates
for Secondary Prevention
Indicator
ASA
Beta Blocker
ACE-I
Smoking Cessation
Lipid Lowering
Rate
85%*
72%*
71%*
40%*
32%**
Optimal
100%
100%
100%
100%
100%
*HCFA 1998 and **NRMI 1999
Optimal: UCLA Cardiology Performance Improvement Committee (patients without
contraindications or medical intolerance)
Why a Hospital Based System?

Patients

Hospital Structure
– Patient Capture Point
– Have patients/family attention: “teachable moment’
– Predictor of care in community
– Standardized processes/protocols/orders/teams
– JCAHO
• Process Improvement Examples
– HCFA--Peer Review Organizations
• Six Scope of Work
In-Hospital Initiation of Risk Factor
Modification and Cardioprotective Therapies
Initiation of interventions for smoking cessation while patients are
hospitalized with AMI has been shown to result in higher cessation
rates then similar interventions initiated in the outpatient setting
(1 year cessation rate of 71% vs 45%, P<0.01)
The UCLA Comprehensive Heart Failure Management Program
demonstrated a 96% utilization rate of ACEI at 6 months when
treatment was initiated at the time of hospitalization, a rate which
was significantly higher as compared to conventionally managed
outpatients
Taylor Annals Intern Med 1990;113:118-123
Fonarow JACC 1997;30:725-732
CHD Patient Flow in the Hospital
Advocate/Champion
Inpatient Care
Group
Practice
Outpatient Care
Lab
Cath
6 Million
Acute
Coronary
Event
Quality
Control
ICU/CCU
ER
Cardiology
Discharge
Nurse
Cardiologist
2.7
Million
Family Practice
Medicine
Discharged
Telemetry
Pharmacy
LOST
Inpatient
Rehab
10%
Protocol development process
Implementation
Outpatient
Rehab
Challenges to In-Hospital Initiation
of Lipid Lowering Treatment

BARRIERS
1. Communication gaps - cardiologists vs
PCPs
2. Lack of ownership - acute vs chronic
disease dilemma
3. Poor lab standardization and reporting
4. Lack of financial incentives
5. Lack of tools/resources
6. Lack of proof of concept

SOLUTIONS
1. Education and mobilizing case management teams
2. Hospital is the capture point for patients with acute
disease
3. Routine lipid testing for CHD patients by protocol
4. Joint Commission, NCQA, PROs will be measuring
and reporting
5. HCFA - 6 scope of work, Joint Commission, ORYX
are standardizing measurement tools
6. UCLA CHAMP demonstrates improved treatment
rates and outcomes
Challenges to a Hospital Based System
this will not work in a community hospital
we can not get a consensus
the cardiologists will not agree to this
the primary care physicians will not agree to this
the managed care organization will not pay for it
patients do not want to be on a lot of medications
there is not enough time
the lipid panel in not accurate when drawn in the hospital
it may not be safe to start lipid lowering medications in hospitalized patients
it will cost too much
this will benefit the competition
the hospital administration will not pay for it
what about the liability
there are exceptions x, y, and z
it will take too much time
it is too hard to get things through the hospital committee
the patients should all be followed in my lipid clinic
the physicians at my hospital do not like cookbook medicine
we do not have anyone to collect this data
Design of the UCLA Cardiovascular Hospitalization
Atherosclerosis Management Program :CHAMP

Based on hypothesis that physician use of and patient compliance with
secondary prevention therapies could be improved with a hospital
based treatment initiation program

Focused on initiation of aspirin, beta blocker, ACE inhibitor, and statin
dosed to achieve LDL < 100 mg/dl in all cardiovascular disease patients
prior to hospital discharge

Use of preprinted orders, simple guidelines, educational lectures,
discharge forms, and prospective monitoring of treatment use.

Started in 1994 and continues to be the standard of care at UCLA
Fonarow Circulation 1997;96(8):I-67
CHAMP Algorithm for Patients with Clinically
Evident Atherosclerosis
Coronary
Carotid
Peripheral
Atherosclerosis
Clinical
Ultrasound
Stress Test
Angiographic
Admission Lipid Panel, LFTs
Hospital
Phase of care
Aspirin, Beta Blocker, ACEI
HMG Co A Reductase Inhibitor
Exercise and Dietary Counseling
6 weeks
Fasting Lipid Panel, LFTs
LDL > 100 mg/dl
Outpatient
Phase of care
Adv ance dose and/or
add niacin, resin
Recheck 6 weeks
CHAMP
Fonarow Am J Cardiol 2000; 85:10A-17A
LDL < 100 mg/dl
Continue Treatment
Recheck in 3-6 months
Implementation of CHAMP
Focused Treatment
Guidelines and Algorithm
Discharge Forms
and Outpt F/U
Process
Preprinted Admit
Order Sheets
Patient Education
M aterials
Focused Lectures
by Opinion Leader
M easurement and
Utilization Reports
Fonarow Circulation 1997;96(8):I-67
Standardized Admission Order Sheets
UCLA Chest Pain/Unstable Angina Orders
Patient ID #
Admit patient to the CCU / COU
Attending ________ Resident ________ Intern _______
Vital Signs:
Diet:
2 gm Na Step II AHA
4 gm Na Step II AHA
Laboratories:
CK and CK-MB q 8 x 3,
Troponin I now and 6 hours
Lipid panel (nonfasting) TC, LDL, HDL, TG
ECG now and q AM x ___
Medications:
Aspirin 325 mg PO qd or ________________
Beta Blocker: Metroprolol ________ mg PO bid or __________
ACE Inhibitor: _________ ___ mg PO ___
HMG CoA RI: _________ ___ mg PO ___
Smoking cessation program
Cardiac rehabilitation referral
UCLA Division of Cardiology
Implementation of CHAMP
Impact of CHAMP on Treatment Rates
Improved Treatment Utilization Across All Patient Categories
120
Statin Utilization Rate (%)
Admit
Discharge
100
92
86
82
80
76
74
68
60
40
22
20
16
15
14
8
8
0
UA
Acute MI
Chest pain
PTCA
1779 patients hospitalized for coronary heart disease 1994-1995
Fonarow Am J. Card. 2000; 85:10A-17A
CABG
CHF
Proof of Concept
The UCLA-CHAMP Experience
CAD Patient Treatment Rates
Hospital discharge:
Aspirin
Beta-Blocker
ACEI
Statin
12-month follow-up:
Statin
LDL < 100 mg/dL
‘92-’93
‘94-’95
(n=256)
(n=302)
78%
12%
4%
6%
92%
61%
56%
86%
10%
6%
91%
58%
*Fonarow, G. et al. “Improved Treatment of Cardiovascular Disease by Implementation of a Cardiac Hospitalization Atherosclerosis
Management Program: CHAMP,” Abstract #364 from the 70th Scientific Sessions, American Heart Association, November, 1997.
Results: Adherence to NCEP Treatment Goals
in Patients One Year Post Myocardial Infarction
LDL
Pre-CHAM P 92/93
Post-CHAM P 94/95
< 100 mg/dl
6%
58%
100-130 mg/dl
15%
16%
130-160 mg/dl
18%
4%
> 160 mg/dl
14%
0%
Not Documented
48%
22%
Fonarow Am J Cardiol 2001;87:819-822
Pre and Post CHAMP Clinical Event Rates
Pre-CHAMP 92/93
(n=256)
Post-CHAMP 94/95
(n=302)
Recurrent MI
20 (7.8%)
10 (3.1%)
CHF
12 (4.7%)
8 (2.6%)
Hospitalization
38 (14.8%)
23 (7.6%)
Sudden Death
3 (1.2%)
2 (0.6%)
Cardiac Mortality
13 (5.1%)
6 (2.0%)
Noncardiac Mortality
2 (0.8%)
2 (0.6%)
Total Mortality
18 (7.0%)
10 (3.3%)
Event
Follow-up for one year after discharge after acute myocardial infarction
Fonarow Am J Cardiol 2001;87:819-822
*
*
*
*
* P < 0.05
CHAMP ~ Impact on Clinical Outcomes in
the First Year Post Hospital Discharge
RR 0.43
p<0.01
256 AMI pts discharged in 92/93 pre-CHAMP compared to 302 pts in 94/95 post-CHAMP
ASA 78% vs 92%; Beta Blocker 12% vs 61%; ACEI 4% vs 56%; Statin 6% vs 86%
Fonarow Am J Cardiol 2001;87;819-822
CHAMP ~ Sustained Impact Over a 6
Year Period
UCLA
77
59
41
28
Comparison to
National Rx Rates
NRMI
98/99
NRMI Registry Discharge Medications at UCLA compared to 1437 NRMI Hospitals
Implementation of a Cardiovascular Hospitalization
Atherosclerosis Management Program: CHAMP
The CHAMP Protocol was associated with a significant increase in
treatment utilization at the time of hospital discharge of medications
previously demonstrated to improve survival in patients with CAD.
Initiation of cholesterol lowering medications prior to hospital
discharge is safe, results in a high rate of utilization during longer
term follow-up, and results in a significant increase in patients
reaching LDL < 100 mg/dl.
CAD risk factor modification and treatment can be systematically
integrated into the treatment received during cardiac hospitalizations
without additional resources or medical personnel and is
considerably more effective than conventional guidelines and care.
"Improv ed Treatment of Cardiov ascular Disease by Implementation of a Cardiac Hospitalization
Atherosclerosis Management Program: CHAMP" Fonarow Circulation 1997;96(8):I-67
Early Statin Treatment
and Survival in AMI
25% Risk
Reduction
RR 0.75 (0.63-0.89)
P=0.001
19,599 men and women < 80 yo discharged post AMI, 58 Swedish Hospitals, 1995-1998
5528 (28%) statin rx vs 14071 (72%) no statin rx, highest hospital rates of use 48%; lowest 12%
Stenestrand JAMA 2001;285;430-436
In-Hospital Lipid Lowering Therapy
is Associated with Markedly Lower Mortality
10 Month Compliance Rate
P<0.0001
10.0%
42% Risk
Reduction
90.0%
No Lipid Rx
10,288 patients with ACS OPUS-TIMI 16
3883 (38% ) statin rx in hospital vs 6405 (62% ) no statin rx
Cannon JACC 2001;35:334A
Lipid Rx
Clinical Implications
CardiovascularHospitalizationAtherosclerosisManagement Program
At present, a large number of patients with coronary artery and
other atherosclerotic vascular disease are not receiving
treatments that have been demonstrated to reduce recurrent
cardiovascular events and mortality.
Widespread application of hospital based treatment programs such
as GWTG could dramatically effect CVD treatment rates with proven
cost-effective therapies and thus substantially reduce the risk of
future coronary events and prolong life in the large number of
patients hospitalized each year with CVD.
"Improv ed Treatment of Cardiov ascular Disease by Implementation of a Cardiac Hospitalization
Atherosclerosis Management Program: CHAMP" Fonarow Circulation 1997;96(8):I-67
Problem: Large CVD treatment gap
and poor patient compliance with
conventional management
Solution: In-hospital initiation of
therapy with excellent treatment rates
and long term patient compliance
Simple, Rapid, and Most Importantly Effective
“The CHAMP study shows that the key to keeping heart
disease patients alive is providing them with immediate and
thorough treatment before they walk out of the hospital”
“This study provides the scientific foundation for programs
similar to CHAMP such as the AHA’s new hospital-based
quality improvement program called Get With The Guidelines”
Sidney Smith MD
AHA Chief Science Officer
What’s Involved in Starting a Hospital
Based Treatment Program






Collect baseline data or use existing data source
– i.e. NRMI IV or collect data with discharge nurse, medical student, etc.
Appoint team to develop treatment algorithm,
preprinted orders, discharge forms
Present at lectures and staff in-services
– present results
– review successes and failures
– lead discussion regarding recommendations on protocol improvement
Revise Protocol to close Gaps
Communicate Revisions to Key departments
Repeat cycle every quarter = CQI
Continuous Quality Improvement
(CQI) Process
Assess CHD Treatment
Rates
Implement Refined
Protocol
Evaluate
Assessment
Refine Protocol
Hospital Based
Continuous Quality Improvement (CQI) Process
Mobilize GWTG Initiative
•Establish “Buy In”
•Identify “Champions”
•Build Team
Plan & Prep Program
Monitor & Support
•Attend CME Program
•Develop Hospital Plan
•Assign Roles & Responsibilities
•Collect & Report f/u Data
•Review & Improve Process
Implement Program
•Establish D/C Protocol
•Collect Baseline Data
•Obtain consensus
What is the AHA“Get With
the Guidelines” Program ?
Implemented by AHA Affiliates/Volunteers who will mobilize advocacy networks
at the Affiliate level to:
 Implement CME-driven educational programs
 Provide workshops for dissemination of guidelines
 Develop care maps
 Formalize a national discharge protocol
 Implement discharge protocols in hospital setting
 Identify best practices for AHA recognition awards
 Develop and disseminate reports and publications
 Measure changes and report outcomes data
 Drive impact into communities
GWTG Tools and Resources







AHA/ACC Guidelines
AHA National Discharge Protocol/Discharge Form Template
Care maps - ED, cath lab, etc.
CME programs
AHA National teleconferences
Public Service Announcements
National and regional advocates
www.med.ucla.edu/champ
www.americanheart.org
Secondary Prevention:
Making it a Reality

A major CHD treatment gap still exists

The hospital is the ideal capture point, provides a teachable
moment, and predicts care in the community

Programs like CHAMP improve treatment rates and saves lives,
making it essential that each hospital implement a prospective
process to help improve CHD patient care immediately

Measure and report treatment rates to ensure CHD patient care
is optimal