1

Acute Myocardial Infarction and Acute Myocardial Infarction and the Role of Critical Pathwaysthe Role of Critical Pathways

Christopher Cannon, M.D.

Brigham and Women’s Hospital

Boston

ACUTE MI GUIDELINES 11/96

Drug Rx Peri MI: Meta-Analyses

Beta blocker during MI

Beta blocker post MI

ACEI during MI

ACEI post MI if LV dysfxn

Nitrates during MI

Ca++ blockers

Magnesium

Lidocaine

Class I Antiarrhythmics

Number RR Death p value

28,970

24,298

100,963

5,986

81,908

20,342

61,860

9,155

6,300

.87 (.77-.98)

.77 (.70-.84)

.94 (.89-.98)

.78 (.70-.86)

.94 (.90-.99)

1.04 (.95-1.14)

1.02 (.96-1.08)

1.38 (.98-1.95)

1.21 (1.01-1.44)

0.02

<0.001

0.006

<0.001

0.03

NS

NS

NS

0.04

NEJM 335:1662, 1996

NRMI-1: Medical Therapy In-hospitalNRMI-1: Medical Therapy 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.

0-30 mins34%

31-45 mins25%

46-60 mins15%

61-90 mins14%

>90 mins12%

0-30 mins34%

31-45 mins25%

46-60 mins15%

61-90 mins14%

>90 mins12%

N=84,423N=84,423

NRMI-2: Distribution of Door-to-Needle Times

40%40%Cannon CP ACC 2000

0.6

0.8

1

1.2

1.4

0-30 31-60 61-90 >90

Door-to-Needle Time (minutes)

MV

Ad

just

ed

Od

ds

of

De

ath

Cannon CP ACC 2000

NRMI-2: Thrombolysis Door-to-Needle Time vs. Mortality

N=28,624 33,867 11,616 10,316

P=0.01P=0.0001

P=NS

1.03

1.11

1.23

8.2

21.224.4

16.5

9.7

20.0

0

5

10

15

20

25

30

0-60 61-90 91-120 121-150 151-180 >180

% o

f Pat

ient

s

8.2

21.224.4

16.5

9.7

20.0

0

5

10

15

20

25

30

0-60 61-90 91-120 121-150 151-180 >180

% o

f Pat

ient

s

N=27,080N=27,080

NRMI-2: Primary PCI Distribution of Door-to-Balloon times

Door-to-Balloon Time (minutes) Cannon CP, et al JAMA 2000;283:2941-2947.

0.2

0.6

1

1.4

1.8

2.2

0-60 61-90 91-120 121-150 151-180 >180

Door-to-Balloon Time (minutes)

MV

Ad

just

ed

Od

ds

of

De

ath

P=0.01 P=0.0007 P=0.0003P=NSP=NS

1.14 1.15

1.41

1.62 1.61

N=2,230 5,734 6,616 4,461 2,627 5,412

NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality

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

European Society of Cardiology ESC

Wood et al. Wood et al. Lancet Lancet 2001; 357: 995-10012001; 357: 995-1001

% beta-blockers at interviewby center

EUROASPIRE

7774

8860

6855

84

4761

4862

6647

6444

63

0 20 40 60 80 100

BEL/GHE

CZE/PP

FIN/KUO

FRA/LLRT

GER/MUNS

GRE/ATCI

HUN/BUD

IRE/DUB

ITA/TV

NET/ROT

POL/CRA

SLO/LJU

SPA/BAR

SWE/MAL

UK/HL

ALL

European Society of Cardiology ESC

Wood et al. Wood et al. Lancet Lancet 2001; 357: 995-10012001; 357: 995-1001

10

US News and World Report US News and World Report Aspirin in ideal candidatesAspirin in ideal candidates

0%

20%

40%

60%

80%

100%

Top-ranked Invasive Non-invasive

Chen J, et al N Engl J Med. 1999;340:286-292.

11

US News and World Report US News and World Report Beta-blockers in ideal candidatesBeta-blockers in ideal candidates

0%

20%

40%

60%

80%

100%

Top-ranked Invasive Non-invasive

Chen J, et al N Engl J Med. 1999;340:286-292.

US News and World ReportUS News and World Report30-day mortality by hospital category*30-day mortality by hospital category*

0%

5%

10%

15%

20%

25%

30%

US News Invasive Non-invasive

Stars

* 25th, 50th and 75th percentile for each categoryChen J, et al N Engl J Med. 1999;340:286-292.

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Quality implicationsQuality implications

– The lower mortality observed in “America’s Best Hospitals” appear to be explained in part by their higher use of aspirin and beta-blockers

– Any hospital can be one of “America’s Best” by increasing their use of aspirin and beta-blockers

Chen J, et al N Engl J Med. 1999;340:286-292.

No. PtsNo. Pts On AdmissionOn Admission

ASAASA

HeparinHeparin

B-blockersB-blockers

16781678

8282

6363

4141

MenMen

1640 1640

7777

5050

3535

WomenWomen

17881788

8484

6666

5353

MenMen

1160 1160

8080

6060

4949

WomenWomen

Pre GuidelinePre Guideline

TIMI III RegistryTIMI III Registry

Scirica BM, Cannon CP, et al. Crit Path Cardiol. 2002;1:151-160.

Post GuidelinePost Guideline

ARANTEEARANTEEGUGU

Comparing Pre- to Post-:Comparing Pre- to Post-: Men Men WomenWomenP values :P values : ASAASA 0.300.30 0.050.05

HeparinHeparin 0.130.13 0.0010.001B-blockerB-blocker 0.0010.001 0.0010.001

Unadjusted One Year SurvivalUnadjusted One Year SurvivalUnadjusted One Year SurvivalUnadjusted One Year Survival

0

20

40

60

80

100

0 8 16 24 32 40 48

Guideline ( n = 189 )

Not guideline ( n = 86 )

0

20

40

60

80

100

0 8 16 24 32 40 48

Guideline ( n = 189 )

Not guideline ( n = 86 )

Weeks post discharge

Per

cen

t su

rviv

ing

95%

81%P = .0001

Giugliano RP,et al. Arch Intern Med 2000;160.

• 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

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Critical Pathways - DefinitionsCritical 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

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Goals of Critical PathwaysGoals 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.

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Need and Rationale for Critical Need and Rationale for Critical PathwaysPathways

• 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)

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Development And Implementation Of Development And Implementation Of Critical PathwaysCritical 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.

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Methods of Implementation of Methods of Implementation of PathwaysPathways

• 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.)

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Goal: < 30 MinutesNHAAP Ann Emerg Med 1994;23:311-29.

24

35

40

45

50

55

60

65

Minutes (median)

NRMI 1 & 2 Trends:NRMI 1 & 2 Trends: Door to Drug (t-PA) IntervalDoor to Drug (t-PA) Interval

All Hospitals, t-PA-treated Patients (N = 241,757)

W. Rogers, personal communication

25

BWH Thrombolysis Critical Pathway: Initial BWH Thrombolysis Critical Pathway: Initial ExperienceExperience

0

20

40

60

80

100

120

Jun-Nov 20, 93 Nov 21, 93-June 94

July 94- Dec 94 Jan 95- June 95

Doo

r-to

-Nee

dle

Tim

e (M

ins) Women

Men

*P=0.013

Cannon CP, et al. Clin Cardiol 1999;22:17-22

BEFORE

26

2/94 - 1/95 2/95 - 7/95 P value

No Pts. 27 35

Door-Balloon Time

205+/- 130 97 +/- 57 0.02

Adverse Outcome

41% 17% 0.04

Death 26% 0% 0.004

Effect of CQI on Primary PCI Outcome

Caputo RP, Am J Cardiol 1997;79:1159-1164.

27

Guidelines Applied in Practice Guidelines Applied in Practice (GAP)(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.

28

64%65%81%

70%87% 74%

0%

20%

40%

60%

80%

100%

(343) (404) (213) (245) (131) (252)

ASA BB LDL CHOL

* *

* p < 0.05

** p < 0.01

111130

38 40

0

50

100

150

Time in Minutes

(40) (24) (32) (45)

LYSIS PTCA

PRE POST

GAP Results: Early IndicatorsGAP Results: Early Indicators

Mehta R, et al. JAMA. 2002;287:1269-1276.

29

GAP: Adherence Improves With Tool GAP: Adherence Improves With Tool UseUse

Mehta R, et al. JAMA. 2002;287:1269-1276.

Qu

alit

y

Ad

he

ren

ce

, %

Pre-intervention

No Tool UseTool Use

Post-intervention

0

20

40

60

80

100

Aspirin -Blocker LDL Cholesterol

No. of Ideal Patients

8186

93

6573

77

64 64

82

343 308 96 213174 71 131165 87

P = .004P = .001

Demographics 6 clicks

Clinical/Lab 8 clicks

Dischargemeds and interventions 7 clicks

Interactivelychecks patient’sdata with theAHA guidelines

31

Importance of Importance of Data-Collection RegistriesData-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

32

VA Transformation - MethodsVA 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.

Jha AK, et al. N Engl J Med 2003;348:2218-27.

VA Transformation - ResultsVA Transformation - Results

34

ConclusionsConclusions

• 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