Transcript Duke Clinical Research Institute

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
6/04
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.
6/04
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.
6/04
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
Clopidogrel
Beta blocker
ACE inhibitor
Lipid-lowering agent
Cardiac rehabilitation
Smoking cessation
Dietary modification
6/04
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
6/04
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) must arrive
at CRUSADE hospital within 24 hrs of symptoms
6/04
Data Collection

Web-based Data Collection Form (DCF)



Data collected includes:




Retrospective data collection
Sites enter data via secure Internet website
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
6/04
Quality Improvement Initiative:
Measuring Change

Effectiveness of QI initiatives measured by changes
in adherence to ACC/AHA treatment Guidelines
 Early / discharge antiplatelet use (ASA, clopidogrel)
 Early / discharge beta blocker use
 Early heparin 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
Dietary modification
6/04
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
6/04
Sample Quarterly Report:
Trend Graphs
6/04
Sample Quarterly Report:
Descriptive Tables
6/04
Benefits of Participation

Quality improvement performance feedback
 Reports documenting utilization of evidencebased 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
6/04
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
6/04
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
 Whether improved early adherence to
treatment guidelines leads to better acute
outcomes
6/04
CRUSADE Implementation

Training of staff and physicians should be
conducted by CRUSADE co-advocates and
DCRI team prior to the start of CRUSADE

Participating hospitals must complete, sign, and
return a CRUSADE Participation Agreement and
Data Use Agreement

Data collection personnel must obtain log-in
access and training for the data entry website

Quarterly, the site will receive a Feedback
Report detailing use of Guidelinesrecommended therapies
6/04