Acute Myocardial Infarction and the Role of Critical Pathways

1
Acute Myocardial Infarctionand the Role of
Critical Pathways

• Christopher P. Cannon, MD Assistant Professor of
  Medicine Harvard Medical SchoolBoston,
  Massachusetts

2
Drug Treatment Peri-MI Meta-AnalysesAcute MI
Guidlines 11/96

• Number RR Death P
• Beta-Blocker During MI 28,970 .87
  (.77-.98) 0.02
• Beta-Blocker Post MI 24,298 .77 (.70-.84) lt0.001
• ACEI During MI 100,963 .94 (.89-.98) 0.006
• ACEI Post-MI if LV Dysfunction 5986 .78
  (.70-.86) lt0.001
• Nitrates During MI 81,908 .94 (.90-.99) 0.03
• Ca2 Blockers 20,342 1.04 (.95-1.14) NS
• Magnesium 61,860 1.02 (.96-1.08) NS
• Lidocaine 9155 1.38 (.98-1.95) NS
• Class I Antiarrhythmics 6300 1.21
  (1.01-1.44) 0.04

Hennekens CH et al. N Engl J Med.
19963351660-1667.
3
NMR-1National Registry of Myocardial Infarction
Medical Therapy In-Hospital
NoThrombolysis
Thrombolysis
Number of Patients
84,477
156,512
Aspirin ()
84
63
Heparin ()
97
56
76
50
IV Nitroglycerin ()
IV Beta-Blockers ()
17
6
Oral Beta-Blockers ()
36
29
Ca-Blockers ()
29
42
Rogers WJ et al. Circulation. 1994902103-2114.
4
NRMI-2Second National Registry of Myocardial
InfarctionDistribution of Door-to-Needle Times
gt90 min
12
0-30 min
61-90 min
34
14
46-60 min
15
31-45 min
25
40
N84,423
Cannon CP. Presented at Annual Scientific Session
of the American College of Cardiology, 2000.
5
NRMI-2Thrombolysis Door-to-Needle Time vs
Mortality
1.4
P0.0001
P0.01
1.2
PNS
1.23
1.11
1
MV Adjusted Odds of Death
1.03
0.8
N28,624 33,867
11,616 10,316
0.6
0-30
31-60
61-90
gt90
Door-to-Needle Time (min)
Cannon CP. Presented at Annual Scientific Session
of the American College of Cardiology, 2000.
6
NRMI-2Primary PCI Distribution of
Door-to-Balloon Times
Door-to-Balloon Time (min)
N27,080
Cannon CP. Presented at Annual Scientific Session
of the American College of Cardiology, 2000.
7
NRMI-2Primary PCI Door-to-Balloon Time vs
Mortality
P0.01
P0.0007
P0.0003
PNS
PNS
2.2
1.8
1.62
1.61
1.41
1.4
MV Adjusted Odds of Death
1.15
1.14
1
0.6
N2,230 5,734 6,616
4,461 2,627 5,412
0.2
0-60
61-90
91-120
121-150
151-180
gt180
Door-to-Balloon Time (min)
Cannon CP et al. JAMA. 20002832941-2947.
8
EUROASPIRE II
Percent of Beta-Blockers
EUROASPIRE IIEuropean Action on Secondary
Prevention through Intervention to Reduce
Events. Wood DA and EUROASPIRE I and II Group.
Lancet. 2001357995-1001.
9
Americas Best Hospitals Ranked by US News and
World Report Aspirin in Ideal Candidates
Patients ()
Chen J et al. N Engl J Med. 1999340286-292.
10
Americas Best Hospitals Ranked by US News and
World Report Beta-Blockers in Ideal Candidates
Patients ()
Chen J et al. N Engl J Med. 1999340286-292.
11
Americas Best Hospitals Ranked by US News and
World Report 30-Day Mortality by Hospital
Category
30
20
30-Day Mortality ()
10
25th, 50th, and 75th percentile for each category
0
US News
Invasive Stars
Noninvasive
Chen J et al. N Engl J Med. 1999340286-292.
12
Americas Best Hospitals Ranked by US News and
World Report Quality Implications

• The lower mortality observed in Americas Best
  Hospitals appears to be explained in part by
  their higher use of aspirin and beta-blockers
• Any hospital can be one of Americas Best by
  increasing their use of aspirin and beta-blockers

Chen J et al. N Engl J Med. 1999340286-292.
13
TIMI III RegistryThrombolysis in Myocardial
Infarction
Pre-Guideline
Post-Guideline
Women
Men
Women
Men
1678 82 63 41
1640 77 50 35
1788 84 66 53
1160 80 60 49
No. Pts On Admission Aspirin Heparin Beta-blockers

Comparing Pre- to Post- P Values
Men Women Aspirin 0.30 0.05 Heparin
0.13 0.001 Beta-Blocker 0.001 0.001
Scirica BM et al. Crit Path Cardiol.
20021151-160.
14
Unadjusted 1-Year Survival
95
81
Percent Surviving
P 0.001
Weeks Post-Discharge
Giugliano RP et al. Arch Intern Med. 2000160.
15

• Standardized protocols
• Goal optimize care
• Emerging Evidence pathways work
• Cardiac Hospitalization Atherosclerosis
  Management Program (CHAMP)
• Guidelines Applied in Practice (GAP)
• American Heart Association Get with the
  Guidelines program

www.critpathcardio.com
16
National Heart Attack Alert Program (NHAAP)
Definitions

• Standardized protocols for care
• Strict definition
• Full list of all tasks, tracks variances
• Broader definition
• Includes clinical protocols (NHAAP 4Ds)
• Diagnostic pathways - chest pain centers
• Treatment pathways - thrombolysis

NHAAPNational Heart Attack Alert Program.
17
Goals of Critical Pathways

• Increase use of recommended medical therapies
  (eg, aspirin)
• Decrease use of unnecessary tests
• Decrease hospital length of stay
• Increase participation in clinical research
• Improve patient care and decrease costs

18
Need and Rationale for Critical Pathways

• Underutilization of recommended medications (eg,
  aspirin)
• Overutilization of procedures
• Length of stay, number of ICU days
• Quality of care measures(door-to-drug,
  door-to-balloon times)

19
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

20
Methods of Implementation of Pathways

• Specific case manager for each patient
• -High compliance, high cost
• Standardized order sheets, pocket guides
• Championing - grand rounds
• Recent study similar improvements in care with
  either formal or simpler pathways1
• 1. Holmboe ES et al. Am J Med. 1999107324-133.
  

21
AMI Time-to-Treatment
Goal lt 30 min
Clock Time

Onset of AMIsymptoms
Time 0 Onset

Arrival at ED
ED Time 1 Door
Time Interval I (ED Time 2minus ED Time I)
minutes

ED Time 2 Data
ECG obtained
Time Interval II (ED Time 3minus ED Time 2)
minutes
Drug ordered(decision to treatwith
thrombolyticagent)

ED Time 3 Decision
Time Interval III (ED Time 4minus ED Time 3)
minutes

ED Time 4 Drug
Thrombolyticdrug infusionstarted
Total Door-to-Drug Time (ED Time 4 minus ED Time
1Intervals I, II, III)
minutes
Total Time From Onset of Symptomsto Thrombolytic
Drug Administration (ED Time 4 minus Time 0)
minutes
NHAAP. Ann Emerg Med. 199423311-29.
22
NRMI 1 2 Trends Door-to-Drug (tPA) Interval


All Hospitals, tPA-Treated Patients N241,757
65
60
55
Minutes (median)
50
45
40
35
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
Year
NRMINational Registry of Myocardial Infarction
tPATissue plasminogem activator.Rogers W.
Personal communication.
23
Brigham and Womens HospitalThrombolysis
Critical PathwayInitial Experience
120
Women
100
Men
80
P0.013
60
Door-to-Needle Time (before min)
40
20
0
Jun-Nov 20, 93
Nov 21, 93 - June 94
July 94 -Dec 94
Jan 95 -June 95
Cannon CP et al. Clin Cardiol. 19992217-22.
24
Effect of Continuous Quality Improvement on
Primary Percutaneous Coronary Intervention Outcome
P
2/94 - 1/95
2/95 - 7/95
Number of Patients
27
35
Door-Balloon
205/- 130
97 /- 57
0.02
Time (min)
Adverse
41
17
0.04
Outcome
Death
26
0
0.004
Caputo RP et al. Am J Cardiol. 1997791159-1164.
25
GAP Guidelines Applied in Practice

• Launched by American College of Cardiology 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. 20022871269-1276.
26
GAP Guidelines Applied in Practice Results
Early Indicators


Time (min)
100
87
81
74
150
70
64
80
65
130
111
60
100
40
40
38
50
20
0
0
(343) (404) (213) (245)
(131) (252)
(40) (24)
(32) (45)
ASA
BB
LDL Chol
Lysis
PTCA
Plt 0.05 Plt 0.01
Pre Post
ASAAspirin BBbeta-blocker LDL Chollow
density lipoprotien cholesterol
PTCApercutaneous coronary angioplastyMehta R et
al. JAMA. 20022871269-1276.
27
GAP Guidelines Applied in Practice Adherence
Improves with Tool Use
P 0.004
P 0.001
Preintervention
100
Postintervention
No Tool Use
80
Tool Use
60
Quality Adherence ()
40
20
0
343
308
96
213
174
71
131
165
87
No of Ideal Patients
Beta-Blocker
Aspirin
LDL Cholesterol
Mehta R et al. JAMA. 20022871269-1276.
28
Demographics 6 clicks
Clinical/Lab 8 clicks
Interactively checks patients data with the AHA
guidelines
Discharge meds and interventions 7 clicks
29
Importance of Data-Collection Registries

• Track adherence to guidelines
• Support local quality-improvement programs
• Compare practice patterns/outcomeswith
  benchmarks
• Comply with regulatory requirements
• Provide research data
• Major Data-Collection Registries
• National Registry of Myocardial Infarction (NRMI)
• American Heart Association Get With the
  Guidelines
• American College of Cardiology National
  Cardiovascular Data Registry (NCDR)
• The Global Registry of Acute Coronary Events
  (GRACE)
• Can Rapid Risk Stratification of Unstable Angina
  Patients Suppress Adverse Outcomes with Early
  Implementation of the ACC/AHA Guidelines
  (CRUSADE)
• Veterans Administration transformation

30
Veterans Administration 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. 20033482218-2227.
31
Veterans Administration Transformation Results
Jha AK et al. N Engl J Med. 20033482218-2227.
32
Conclusions

• Critical pathways hold great promiseto improve
• Quality of care
• Clinical outcomes
• Cost-effectiveness
• Initial studies show better quality of care and
  suggest improved outcomes