Transcript Treatment of Osteoarthritis

Acute Myocardial Infarction and
the Role of Critical Pathways
Christopher Cannon, M.D.
Brigham and Women’s Hospital
Boston
1
ACUTE MI GUIDELINES 11/96
Drug Rx Peri MI: Meta-Analyses
Number
RR Death
p value
Beta blocker during MI
28,970
.87 (.77-.98)
0.02
Beta blocker post MI
24,298
.77 (.70-.84)
<0.001
ACEI during MI
100,963
.94 (.89-.98)
0.006
ACEI post MI if LV dysfxn
5,986
.78 (.70-.86)
<0.001
Nitrates during MI
81,908
.94 (.90-.99)
0.03
Ca++ blockers
20,342
1.04 (.95-1.14)
NS
Magnesium
61,860
1.02 (.96-1.08)
NS
Lidocaine
9,155
1.38 (.98-1.95)
NS
Class I Antiarrhythmics
6,300
1.21 (1.01-1.44)
0.04
NEJM 335:1662, 1996
NRMI-1:
NRMI-1:
Medical
Medical Therapy
Therapy In-hospital
In-hospital
Thrombolysis
No Thrombolysis
No. Pts
84477
156512
ASA (%)
84
63
Heparin (%)
97
56
IV nitro (%)
76
50
IV B-Blockers (%)
17
6
Oral B-Blockers (%)
36
29
Ca-Blockers (%)
29
42
Rogers WJ, et al. Circulation 1994;90:2103-2114.
NRMI-2: Distribution of Door-to-Needle
Times
N=84,423
>90 mins
12%
0-30 mins
34%
61-90 mins
14%
46-60 mins
15%
31-45 mins
25%
Cannon CP ACC 2000
40%
MV Adjusted Odds of Death
NRMI-2: Thrombolysis
Door-to-Needle Time vs. Mortality
P=0.0001
1.4
P=0.01
P=NS
1.2
1.23
1.11
1.03
1
0.8
N=28,624
33,867
11,616
10,316
0.6
0-30
Cannon CP ACC 2000
31-60
61-90
Door-to-Needle Tim e (m inutes)
>90
NRMI-2: Primary PCI
Distribution of Door-to-Balloon times
N=27,080
30
24.4
% of Patients
25
21.2
20.0
20
16.5
15
10
9.7
8.2
5
0
0-60
61-90
91-120
121-150
151-180
Door-to-Balloon Time (minutes)
Cannon CP, et al JAMA 2000;283:2941-2947.
>180
MV Adjusted Odds of Death
NRMI-2: Primary PCI
Door-to-Balloon Time vs. Mortality
P=NS
2.2
P=NS
P=0.01 P=0.0007 P=0.0003
1.8
1.62
1.4
1.61
1.41
1.15
1.14
1
0.6
0.2
N=2,230
5,734
6,616
0-60
61-90
91-120
4,461
2,627
121-150 151-180
5,412
>180
Door-to-Balloon Tim e (m inutes)
Cannon CP, et al JAMA 2000;283:2941-2947.
EUROASPIRE II
European Action on Secondary and Primary
Prevention through Intervention
to Reduce Events
Euro Heart Survey Programme
European Society of Cardiology-ESC
Wood et al. Lancet 2001; 357: 995-1001
 European Society of Cardiology ESC
% beta-blockers at interview
by center
EUROASPIRE
77
BEL/GHE
74
CZE/PP
88
FIN/KUO
60
FRA/LLRT
68
GER/MUNS
55
GRE/ATCI
84
HUN/BUD
47
IRE/DUB
61
ITA/TV
48
NET/ROT
62
POL/CRA
66
SLO/LJU
47
SPA/BAR
64
SWE/MAL
44
UK/HL
63
ALL
0
20
40
60
80
100
Wood et al. Lancet 2001; 357: 995-1001
 European Society of Cardiology ESC
US News and World Report
Aspirin in ideal candidates
100%
80%
60%
40%
20%
0%
Top-ranked
Invasive
Chen J, et al N Engl J Med. 1999;340:286-292.
Non-invasive
10
US News and World Report
Beta-blockers in ideal candidates
100%
80%
60%
40%
20%
0%
Top-ranked
Invasive
Chen J, et al N Engl J Med. 1999;340:286-292.
Non-invasive
11
US News and World Report
30-day mortality by hospital category*
30%
25%
20%
15%
10%
5%
0%
US News
Invasive
Non-invasive
Stars
Chen J, et al N Engl J Med. 1999;340:286-292.
* 25th, 50th and 75th percentile for each category
Quality implications
– The lower mortality observed in “America’s
Best Hospitals” appear to be explained in
part by their higher use of aspirin and betablockers
– Any hospital can be one of “America’s Best”
by increasing their use of aspirin and betablockers
Chen J, et al N Engl J Med. 1999;340:286-292.
13
GUARANTEE
TIMI III Registry
Pre Guideline
Men
No. Pts
Women
Post Guideline
Men
Women
1678
1640
1788
1160
82
63
41
77
50
35
84
66
53
80
60
49
On Admission
ASA
Heparin
B-blockers
Comparing Pre- to Post-:
P values :
ASA
Heparin
B-blocker
Men
0.30
0.13
0.001
Women
0.05
0.001
0.001
Scirica BM, Cannon CP, et al. Crit Path Cardiol. 2002;1:151-160.
Unadjusted One Year Survival
95%
Percent surviving
100
80
P = .0001
81%
60
40
Guideline ( n = 189 )
20
Not guideline ( n = 86 )
0
0
8
16
24
32
Weeks post discharge
Giugliano RP,et al. Arch Intern Med 2000;160.
40
48
•
Standardized protocols
•
Goal: optimize care
•
Emerging Evidence –
Pathways work:
– CHAMP
– Guidelines Applied in
Practice (GAP)
– AHA “Get with the
Guidelines” program
www.critpathcardio.com
National Heart Attack
Alert Program (NHAAP)
CRITICAL PATHWAYS
FOR THE TREATMENT OF
PATIENTS WITH
ACUTE CORONARY SYNDROMES
Critical Pathways - Definitions
• Standardized protocols for care
• Strict definition
– Full list of all tasks, tracks variances
• Broader definition
– Includes clinical protocols (NHAAP
4D’s)
• Diagnostic pathways - Chest Pain Centers
• Treatment pathways - Thrombolysis
18
Goals of Critical Pathways
• Increase use of recommended medical therapies
(e.g., aspirin)
• Decrease use of unnecessary tests.
• Decrease hospital length of stay
• Increase participation in clinical research
• Improve patient care and decrease costs.
19
Need and Rationale for Critical
Pathways
• Underutilization of recommended
medications (e.g. Aspirin)
• Overutilization of procedures
• Length of stay, # ICU days
• Quality of care measures (door-to-drug,
door-to-balloon times)
20
Development And Implementation Of
Critical Pathways
• Identify problems ( practice variation)
• Identify working committee/task force to develop
path
• Distribute draft Critical Pathway to all personnel
and departments involved. Revise based on
approach.
• Implement pathway
• Collect and monitor data on pathway
performance.
• Modify the pathway as needed to further improve
performance.
21
Methods of Implementation of
Pathways
• Specific case manager for each Pt
– High compliance, high cost
• Standardized order sheets, Pocket guides
• “Championing” - Grand rounds
• Recent study -> similar improvements in
care with either formal or simpler pathways
(Holmboe, ES et al. Am J Med
1999;107:324-31.)
22
Goal: < 30 Minutes
NHAAP
Ann Emerg Med
1994;23:311-29.
23
N
R
M
I1
&
2
T
r
e
n
d
s
:D
o
o
r
t
o
D
r
u
g
(
t
P
A
)
I
n
t
e
r
v
a
l
A
l
lH
o
s
p
i
t
a
l
s
,t
P
A
t
r
e
a
t
e
d
P
a
t
i
e
n
t
s
(
N
=
2
4
1
,
7
5
7
)
Minut es
(median)
65
60
55
50
45
40
90-b
91-a
91-b
92-a
92-b
93-a
93-b
94-a
94-b
95-a
95-b
96-a
96-b
97-a
97-b
98-a
35
W. Rogers, personal communication
Door-to-Needle Time (Mins)
BWH Thrombolysis Critical Pathway: Initial
Experience
120
BEFORE
Women
Men
100
80
*P=0.013
60
40
20
0
Jun-Nov 20, 93
Nov 21, 93June 94
July 94- Dec 94 Jan 95- June 95
Cannon CP, et al. Clin Cardiol 1999;22:17-22
25
26
Guidelines Applied in Practice
(GAP)
•
•
Launched by ACC in February 2000 to:
–
Bridge gap between ideal therapy and treatment practice
–
Create/implement guideline tools/processes
Initial project:
–
Michigan hospitals
–
Implemented 1999 ACC/AHA AMI Guideline
–
Determine whether quality of care can be improved via
guideline tools
–
Status: pilot completed, expansion
now in progress
Mehta R, et al. JAMA. 2002;287:1269-1276.
27
GAP Results: Early Indicators
100%
81%
* 87%
80%
65%
*
74%
Time in Minutes
64% 70%
60%
150
130 111
100
40%
50
20%
0%
(343) (404)
(213) (245)
ASA
BB
LDL CHOL
PRE
*
p < 0.05
**
p < 0.01
0
(131) (252)
38 40
(40) (24)
LYSIS
(32) (45)
PTCA
POST
Mehta R, et al. JAMA. 2002;287:1269-1276.
28
GAP: Adherence Improves With Tool
Use
P = .001
100
Quality
Adherence, %
81
86
P = .004
Pre-intervention
93
73
80
82
77
65
64 64
Post-intervention
No Tool Use
Tool Use
60
40
20
0
No. of Ideal
Patients
343 308 96
213 174 71
131 165 87
Aspirin
b-Blocker
LDL
Cholesterol
Mehta R, et al. JAMA. 2002;287:1269-1276.
29
Demographics
6 clicks
Clinical/Lab
8 clicks
Discharge
meds and
interventions
7 clicks
Interactively
checks
patient’s
data with the
AHA guidelines
Importance of
Data-Collection Registries
•
Track adherence to guidelines
•
Support local quality-improvement programs
•
Compare practice patterns/outcomes with benchmarks
•
Comply with regulatory requirements
•
Provide research data
Major Data-Collection Registries
– NRMI
– AHA Get With the Guidelines
– ACC NCDR
– GRACE
– CRUSADE
– VA transformation
31
VA Transformation - Methods
•
1995, VA launched a major reengineering of its
health care system with aims that included:
– Better use of information technology,
– measurement and reporting of performance,
– and integration of services
– and realigned payment policies.
Jha AK, et al. N Engl J Med 2003;348:2218-27.
32
VA Transformation - Results
Jha AK, et al. N Engl J Med 2003;348:2218-27.
Conclusions
•
Critical pathways hold great promise to improve
– Quality of care,
– Clinical outcomes
– Cost-effectiveness
•
Initial studies show better quality of care and
suggest improved outcomes
34