Transcript CPACS-2

Innovate Public Private Partnership to Meet the
Common Goal of the Enterprises, Academics and
Government
—— CPACS Experience
WU Yangfeng
The George Institute for Global Health China
Peking University Clinical Research Institute and School of Public Health
Chinese Society of
Cardiology
Management of ACS in Chinese
CHD is the leading cause of death and premature
death in China. > 700 thousand Chinese die of
acute coronary events each year
Half AMI patients will die before they arrive
hospital. Mortality rate remains 10% for those who
were admitted to hospital
Since 1993, direct expenditure on CVD has
increased by 17％ every year while GDP has
increased by 9％ every year
The Clinical Pathways for Acute Coronary
Syndromes in China –Phase 1(CPACS-1)
Aim : Identify a number of important evidencepractice gaps relating to the diagnosis and treatment
of patients with suspected ACS in China
Method:
– 2004-2006
– Prospective register study
– 51 hospitals from 18 provinces and municipalities, 2973
ACS in-hospital patients registered
– Patient’s data during hospitalization, 6 months and 12
months after discharge were collected
CPACS 1：Prehospital Delay
delay to seek medical help among Chinese ACS patients
•Mean time of onset to arrival of hospital is 9 hours, longer
than GRACE study
•Delay is more obvious among the patients arriving at tertiary
hospitals due to the transfer from other hospitals
Mean time, hour
16
14
12
10
8
6
4
2
0
STEMI
NSTEMI
UAP
Total
CPACS-1：Time to reperfusion
Non-tertiary
hospitals
Door to needle
（minutes）
Tertiary hospitals
N
Median (IQR)
150
55（30－100） 141
Door to balloon 46
（minutes）
51（30-180）
N
188
Median (IQR)
61（26-120）
90（60-175）
CPACS 1：Diagnosis accuracy
20% final ACS diagnosis are inconsistent with ECG/biological markers
Inconsistent ST segment deviation
Biomarker not measured
Inconsistent biomarkers*
No inconsistence
*includes <1% who had both inconsistent biomarkers and ST segment deviation
CPACS-1： Investigation
Exercise test is rarely used in low-risk patients; catheterization, UCG is
less likely to be used in high risk patients
Risk classification（GRACE score）
High risk
Median risk
Low risk
N=157
N=144
N=149
0
1.4
4.0
UCG，％
48.4
59.4
60.4
Cath lab
N=811
N=851
N=861
Exercise test，％
0.4
1.5
4.5
UCG，％
54.9
62.0
61.9
Catheterization，％
34.0
54.1
58.2
No cath lab
Exercise test，％
CPACS-1： Invasive therapy
Low- and median- risk patients were more likely to
receive invasive therapy
GRACE risk score
Gao, et al. Heart 2008;94:554-60
CPACS-1： Medications
Dual antiplatelet usage is relatively low
%
CPACS -1：Reasons for not compliant to
therapy
Aspirin
Level 2
hospitals
No reason，%
Refuse ，%
Intolerance，%
Cost ,%
Other，%
Unknown ,%
55.0
1.8
17.4
16.5
Clopidogrel β-Blockers
ACEI
Statin
38.2
8.9
1.3
23.0
10.6
5.2
34.3
18.1
11.8
21.5
16.6
27.0
6.6
16.6
4.9
15.8
20.2
16.8
5.7
26.7
4.0
14.3
Aspirin Clopidogrel
No reason，%
Level 3 Refuse ，%
Intolerance，%
hospitals Cost ,%
Other，%
Unknown ,%
36.6
3.8
30.1
10.8
30.1
15.0
1.9
27.4
5.7
10.8
β-Blockers
ACEI
Statin
23.7
26.1
15.1
16.7
18.6
23.8
9.1
18.9
10.0
22.0
10.0
27.3
9.1
16.2
9.1
20.3
CPACS-1： In hospital clinical outcome is
suboptimal
Prevalence ,%
Rate of in hospital events was slightly higher than international reports，especially
in level 2 hospitals
Level 2
15
Level 3
10
5
0
Death
MI
Prognosis was poorer among MI patients
Stroke
CHF
Bleeding
Clinical outcomes were different according
to different risk stratification
The Clinical Pathways for Acute Coronary
Syndromes in China –Phase 2(CPACS-2)
Aim: Implement a quality improvement initiative (QCI) to
improve ACS care in China and evaluate the effect of QCI
Method:
– 2007-2011
– Cluster randomized trial, prospective registery study
– 75 hospitals from 17 provinces and municipalities,
more than 15 thousand ACS patients
– Patient’s data were collected during hospitalization
and at every 6 months follow up
CPACS-2：participating hospitals
北京
4/3, 4/2
山西
2/3, 3/2
内蒙古
3/3, 1/2
黑龙江
2/3
辽宁
4/3,
1/2
河北
4/3
新疆
3/3, 1/2
山东
3/3,1/2
江苏
3/3
河南
2/3,2/2
陕西
3/3, 3/2
四川
2/3
上海
3/3, 4/2
湖北
1/3, 4/2
75 hospitals
50 level 3 hospitals
25 level 2 hospitals
湖南
4/3
广东
4/3
浙江
2/3, 2/2
CPACS-2: Intervention
• Clinical pathway is a tool used to optimize
and systematize treatment. The three main
clinical pathways are :
• Risk stratification
• Clinical pathway of UA/NSTEMI
• Clinical pathway of STEMI
• The previous studies have confirmed that
clinical pathway can improve quality of
health care
• But most of the studies are conducted in
high-income counties. No reliable data are
documented in China
CPACS-2: intervention
•
•
•
•
50 consecutive patients were recruited in every 6 months
Summary feedback information is then made available to each hospital
Based on feedback information, hospital modify the clinical pathway
The modified clinical pathways are used in the next cycle
Pathway implement
baseline
基线
HOSPITAL
hospital
医院
X
6 months
个月
12 months
个月
collection
of data collection
of data 记录50个病人
collection of data
记录50个病人
记录50个病人
for
50 patients for
50 patients
for
50 patients
的临床资料
的临床资料
的临床资料
18 months
个月
24 months
个月 + +
collection
of data 记录50个病人
记录50个病人
collection of data
for
50 patients
的临床资料*
for
50 patients
的临床资料*
Alive patients Alive patients Alive patients Alive patients Alive patients
Follow up every 6 months
CPACS-2: Study design
5 pilot
centers
75 hospitals
32 early
intervention
hospitals
（group A）
Group A
intervention
24 months
12 month
randomize
38 late
interventio
n hospitals
(group B）
Group A
intervention
12 months
Group A intervention
12 months Vs Group
B baseline
Baseline vs
24 months
Baseline vs
18 months
Baseline vs
12 months
75
hospitals
Baseline
3750
patients
6 months
3750
patients
12 months
3750
patients
18 months
1850
patients
24 months
1850
patients
Summary data from
15000 patients
available for evaluation
of trend over time
CPACS 2－ key performance indicators
Expected results: improve the accuracy of clinical diagnosis, significantly
shorten the time receive treatment, improve hospital management of
ACS, improve compliance to the guidelines.
Proportion of STEMI patients receive thrombolysis or primary PCI
Door-to-needle time and Door-to-balloon time
Proportion of patients with final diagnosis consistent with
ECG/biomarker findings
Proportion of high-risk patients undergoing coronary angiography
Proportion of low-risk patients undergoing functional testing
Proportion of patients discharged on appropriate medical therapy
Hospital length-of-stay
Effective clinical pathway intervention reduce evidence-practice gap
CPACS-2: Preliminary results
• Significantly improved KPIs:
– Proportion of patients discharged on appropriate
medical therapy
– Proportion of high-risk patients undergoing
coronary angiography
– Length of hospital stay
• Not improved KPIs:
– Proportion of low-risk patients undergoing
function testing
The Clinical Pathways for Acute Coronary
Syndromes in China –Phase 3 (CPACS-3)
Aim: Develop and evaluate the effects of quality care initiative
(QCI) system to reduce acute events and death of patients with
ACS in level 2 hospitals with limited resources.
Method:
– 2011-2014
– Registry-based cluster randomized step-weddged controlled trial
– 96 hospitals from 15 provinces and municipalities, more than 25
thousand ACS patients
– Patient’s data will be collected during hospitalization and at 6 months
and 12 months follow up
Outcomes ：
– Major adverse cardiovascular events（MACE）
Academic achievements
Heart 2008;94:554-60.
Am Heart J 2009;157:509-516
Changes in organization and management in
different stages of CPACS
Phase
CPACS-1
Initiator
Organizer
The George
GI, China
Institute for
CSC
Global Health (GI),
Austraila
SC
Financial Support
Experts from
both sides and
officials from
MOH
Sanofi - Aventis
(China), the Royal
Australian Institute of
Physicians, National
Heart Foundation of
Australia, the United
States Guidant Corp.
Chinese Society of
Cardiology (CSC)
CPACS-2
GI, Australia
CSC
GI, China;
CSC;
With support from
Division of Medical
Administration, MOH
Experts from
both sides and
officials from
MOH
Sanofi - Aventis (China)
CPACS-3
GI, China
CSC
Division of Medical
Administration, MOH
Experts from
China, USA,
Australia, UK,
and officials
from MOH
Sanofi - Aventis (China)
Changes in organization and management in
different stages of CPACS
CPACS-1
Academic
achievements
Government
Involvement/policy
impact
Corporate social
responsibility
/business
development
CPACS-2
CPACS-3
Increased
increased
increased
The common interests of enterprise, academia
and government
Common interest
Specific
interest
Enterprise
Whether the product is effective Profit
/helpful?
Academia
Which measures are effective
/helpful?
Government Which measures are effective
/helpful?
Innovation
Political
achievements
For CPACS, how to transfer the scientific evidence into
practice to improve the outcomes of ACS patients?
CPACS is still going forward，please keep
your eyes on our progress!
Acknowledgment
• CPACS-1 administration committee：
– Anushka Patel，高润霖
– 高炜、胡大一、黄德嘉、孔灵芝、戚文航、武阳丰、杨跃进、
Phillip Harris
• CPACS-2 administration committee ：
– Anushka Patel，高润霖
– 高炜、胡大一、黄德嘉、孔灵芝、沈卫峰、吕树铮、韩雅玲、林
曙光、武阳丰、葛均波、杨跃进、马爱群
• CPACS-3 administration committee ：
– 高润霖、武阳丰
– 胡大一、霍勇、孔灵芝、焦亚辉、 Anushka Patel、Eric Peterson、
Kalipso Chalkidou、Mark Woodward、Fiona Turnbull