Implementing the Guidelines: Critical Pathways

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Implementing the Guidelines Critical Pathways
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Awareness Is Not Enough!
95
100
80
60
Sample ()
38
40
20
0
Physician Awareness of
Patient Treated to Goal
NCEP Guideline
NCEP, National Cholesterol Education
Program. Pearson TA, et al. Arch Intern Med.
2000160459-467.
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Smooth Transition From Acute to Long-term
Management
Primary Care Secondary Prevention
Cardiology Acute Care
GUIDELINES
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Why Develop Critical Pathways?

• A treatment gap between therapy that is dictated
  by evidence-based medicine and therapy that
  occurs in practice is not a deficit of knowledge
  rather, it is a deficit of implementation.
• Sidney Smith, MD
• Chief Scientific Officer, American Heart
  Association

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• Standardized protocols
• Goal optimize care
• Emerging Evidence Pathways work
• CHAMP
• Guidelines Applied in Practice (GAP)
• AHA Get with the Guidelines program

www.critpathcardio.com
CHAMP, Cardiac Hospitalization Atherosclerotic
Management Program.
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UCLA CHAMP Study
Cardiac Hospitalization Atherosclerosis
Management Program

• Designed to determine whether physician/patient
  compliance with preventive therapies can be
  improved through a hospital-initiated program
• Tracked initiation of ASA, ?-blocker, ACE
  inhibitor, and statins
• Used preprinted orders, guidelines, lectures,
  discharge forms
• Population Patients with symptomatic
  atherosclerosis treated at university-associated
  teaching hospital

ASA, acetylsalicyclic acid ACE,
angiotensin-converting enzyme. Fonarow GC, et al.
Am J Cardiol. 20008510A-17A.
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CHAMP Study Treatment Rates at Discharge and
1-Year Follow-up
CHAMP, Cardiac Hospitalization Atherosclerotic
Management Program. Plt.01 pre- vs post-CHAMP at
discharge and at 1 year. Fonarow GC, et al. Am
J Cardiol. 200187819-822.
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CHAMP Study Clinical Events for the First Year
After Discharge for Acute MI
CHAMP, Cardiac Hospitalization Atherosclerotic
Management Program.Fonarow GC, et al. Am J
Cardiol. 200187819-822.
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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

ACC, American College of Cardiology AHA,
American Heart Association AMI, acute myocardial
infarction.
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GAP Adherence Improves With Tool Use
P .004
P .001
Pre-intervention
100
Post-intervention
80
No Tool Use
Tool Use
60
Quality Adherence ()
40
20
Ideal Patients (n)
0
343
308
96
213
174
71
131
165
87
Aspirin
b-Blocker
LDL-C
LDL-C, low-density lipoprotein cholesterol.
Mehta RH, et al. JAMA. 2871269-1276. (with
permission)
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Demographics 6 clicks
Clinical/Lab 8 clicks
Interactively checks patients data with the AHA
guidelines
Discharge meds and interventions 7 clicks
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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

NRMI, National Registry of Myocardial Infarction
AHA, American Heart Association ACC NCDR,
American College of Cardiology National
Cardiovascular Data Registry GRACE, Global
Registry of Acute Coronary Events CRUSADE, Can
Rapid Risk Stratification of Unstable Angina
Patients Suppress Adverse Outcomes with Early
Implementation of the ACC/AHA Guidelines.
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Current Use of ACS Rx in US(Jan-July 2002)
Can Rapid Risk Stratification of Unstable Angina
Patients Suppress ADverse Outcomes with Early
Implementation of the ACC/AHA Guidelines
300 Hospitals 19,000 Patients
ACS, acute coronary syndrome ACC, American
College of Cardiology AHA, American Heart
Association. Roe, et al. ESC 2002.
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Discharge Medication Use
100
35 had PCI
88
80
77
80
59
60
49
Discharge Rx Use ()
40
20
0
ASA
?-Blockers
Lipid- Lowering Agent
Clopidogrel
ACEInhibitors
PCI, percutaneous coronary intervention ASA,
acetylsalicylic acid ACE, angiotensin-converting
enzyme LVEF, left ventricular ejection
fraction CHF, coronary heart disease DM,
diabetes mellitus HTN, hypertension TC, total
cholesterol LDL, low-density lipoprotein. LVEF
lt40, CHF, DM, HTN Known hyperlipidemia, ? TC,
? LDL Roe, et al. ESC. 2002.
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Conclusions

• Gap between knowledge of guidelines and current
  practice
• Several studies show
• Critical pathway interventions improve care
• Suggestion of improved outcomes
• CQI important Monitor performance
• Need local champions, implementation plan, and
  action!
• Need tools/strategies to ensure smooth transition
  from acute care to long-term management

CQI, continuous quality improvement.