Transcript crusade - Clinical Trial Results

CRUSADE:
A National Quality Improvement Initiative
Can Rapid Risk Stratification of Unstable Angina
Patients Suppress ADverse Outcomes
with Early Implementation of the
ACC/AHA Guidelines
CRUSADE Description

CRUSADE is a Quality Improvement Initiative
designed to improve the care of high-risk
patients with NSTE ACS

by collecting data regarding patient
management practice patterns in the U.S.
and

using those data to target educational
interventions designed to promote
adherence to the revised ACC/AHA NSTE
ACS guidelines recommendations.
CRUSADE Objectives

Determine the current state of awareness of and
adherence to the ACC/AHA Non-ST-segment Elevation
Acute Coronary Syndromes (NSTE ACS) Guidelines.

Implement quality improvement initiatives to promote
ACC/AHA NSTE ACS Guidelines recommendations.

Improve clinical outcomes for NSTE ACS patients via
early risk stratification and implementation
of evidence-based care, both in-hospital and
post-discharge.
ACC/AHA Treatment Recommendations
Acute Therapy





Aspirin

Clopidogrel/ticlopidine,
if contraindicated
Beta blocker

Ca2+ blocker ,
if contraindicated
ACE inhibitor (HTN, CHF)
Heparin (UFH or LMWH)
GP IIb-IIIa inhibitor

All high-risk patients

All receiving PCI

Those with recurring ischemia
Discharge Therapy

Aspirin

Beta blocker

Lipid-lowering
agent/statin

ACE inhibitor

Cardiac rehabilitation

Smoking cessation
CRUSADE Design

Nationwide Quality Improvement (QI) initiative

Up to 600 participating hospitals

Collaborative effort between Emergency
Medicine, Cardiology, Hospital QI, Academia,
and Industry

Focused on improving the care of NSTE ACS
patients
Inclusion Criteria: High-Risk NSTE ACS

Ischemic symptoms lasting  10 minutes
within previous 24 hours and at least one
of the following:

Positive cardiac markers
• CK-MB or TnI / TnT above ULN
• Positive bedside troponin assay

ST-segment ECG changes:
• ST-segment depression  0.5 mm
• Transient ST-segment elevation 0.6 - 1 mm
(lasting < 10 mins)

Transfer patients (with any of the above) who
arrive at CRUSADE hospital within 24 hrs of
symptoms
Data Collection

Concise, 3-page Data Collection Form (DCF)

Retrospective data collection

Data collected includes:

Patient risk factors/presenting symptoms

Use of medications/ use of invasive
procedures/in-hospital clinical outcomes

Institutional Review Boards:

May be viewed by hospital as QI

May not require IRB review and/or approval

May not require informed consent

Local hospital decision
Quality Improvement Initiative:
Measuring Change

Effectiveness of QI initiatives measured by
changes in adherence to ACC/AHA treatment
Guidelines

Early / discharge aspirin use

Early / discharge beta blocker use

Discharge ACE inhibitor and statin use

GP IIb-IIIa inhibitors: early use and use
during PCI

Appropriate secondary prevention measures
• Smoking cessation
• Cardiac rehabilitation
Quality Improvement Initiatives:
Data Reporting to Sites

Quarterly feedback reports to sites regarding
their adherence to ACC/AHA Guidelines



Focused on the ACC/AHA Guidelines treatment &
management recommendations
Site confidentiality maintained—data supplied
back to sites in a blinded fashion
Provides sites with benchmark performance data
Sample Quarterly Report:
GP IIb-IIIa Inhibitor Use
GP IIb-IIIa Inhibitor Use in First 24 Hours
100%
75%
Q2 2000
YTD 2000
60.3% 59.2%
50%
25%
10.1% 10.9%
14.0%
5.4%
15.3%
4.9%
0%
Your
Hospital
Like
Hospitals
National
Best
Practice
Sample Quarterly Report:
Discharge Beta Blocker Use
Beta Blocker Use
100%
75%
Q2 2000
YTD 2000
88.3% 89.5%
74.0%
64.1%
60.2%
70.3%
54.4% 56.9%
50%
25%
0%
Your
Hospital
Like
Hospitals
National
Best
Practice
Benefits of Participation

Quality improvement performance feedback




Reports documenting utilization of evidence-based
management strategies and therapies.
Performance ranking among “like”, national, and
“best practice” hospitals.
Insight into hospital care and areas for improvement.
May be applied to hospital QI monitoring
efforts/requirements.
Benefits of Participation

Quality improvement tools to help improve
outcomes for high-risk NSTE ACS patients.

Initiatives to help increase understanding
of the ACC/AHA Guidelines.


Initiatives to improve risk stratification
and diagnosis of NSTE ACS patients.
Newsletters and website for continuing
education.
Promoting a New Paradigm of
Evidence-Based Cardiovascular Care

The CRUSADE national quality improvement
initiative will teach us much about:




Why current ACC/AHA Guidelines for ACS
are not followed.
What initiatives can improve adherence.
How to promote Emergency Medicine Cardiology collaboration.
Will improved early adherence to treatment
guidelines lead to better acute outcomes.
CRUSADE Implementation

Training of staff and physicians should be conducted by
CRUSADE co-advocates prior to the start of CRUSADE.

Participating hospitals must complete, sign, and return a
CRUSADE Participation Agreement.

Data collection can then commence.

Quarterly, the site will receive a Feedback Report detailing
use of Guidelines-recommended therapies.