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What Have We Learned from the CRUSADE Registry? Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation.

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Presentation on theme: "What Have We Learned from the CRUSADE Registry? Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation."— Presentation transcript:

1 What Have We Learned from the CRUSADE Registry? Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC and AHA Guidelines What Have We Learned from the CRUSADE Registry? Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC and AHA Guidelines Eric D. Peterson, MD, FACC Professor of Medicine Associate Vice Chair for Quality Duke University Medical Center Associate Director and Director of CV Research Duke Clinical Research Institute Durham, NC

2 10 Lessons Learned from CRUSADE: A National Quality Improvement Initiative Eric D. Peterson, MD, MPH Professor of Medicine Vice Chairman of Quality, Dept of Medicine Duke University Medical Center Director of CV Research Duke Clinical Research Institute Eric D. Peterson, MD, MPH Professor of Medicine Vice Chairman of Quality, Dept of Medicine Duke University Medical Center Director of CV Research Duke Clinical Research Institute Disclosures: Research support from Schering Plough, BMS, Sanofi-Aventis, Merck-Schering, PDL Pharma Disclosures: Research support from Schering Plough, BMS, Sanofi-Aventis, Merck-Schering, PDL Pharma

3 CRUSADE National CQI n Academic collaboration between cardiology and emergency medicine initiated in 2001 n Multi-industry sponsor l Millennium-Schering Plough l BMS l Sanofi-Aventis l Merck-Schering l PDL Pharma n Goal: Improve adherence to ACC/AHA ACS guidelines l NSTE ACS and later STEMI

4 Goals for CRUSADE: Improve Adherence to ACC/AHA Guidelines for Acute Coronary Syndrome Goals for CRUSADE: Improve Adherence to ACC/AHA Guidelines for Acute Coronary Syndrome n Aspirin l Clopidogrel n Beta Blocker n Reperfusion Rx (STEMI) l Timely PCI, Lytics n Heparin (NSTEMI) n GP IIb-IIIa (NSTEMI) l Targeted for Trop + n Aspirin n Clopidogrel n Beta Blocker n ACE Inhibitor n Statin/Lipid Lowering n Smoking Cessation n Cardiac Rehabilitation Acute Therapies Discharge Therapies Circulation, JACC 2002 and ACC/AHA Guidelines updates

5 CRUSADE Highlights – n Data collection: 7/ /2006 n > 500 US sites participated in CRUSADE l 25% academic, 68% with PCI/CABG n 201,032 Data Collection Forms received l 190,000 NSTEMI:: 8,800+ STEMI patients l MAINTAIN patients (long-term follow-up) n 50+ CRUSADE publications n Referenced within ACC/AHA guidelines n Successful transition to NCDR ACTION ACS

6 Lesson 1: Complexity of NSTEMI Pts STEMI vs. NSTEMI Characteristics Variable CRUSADE STEMI CRUSADE NSTEMI (n = 8,011) (n = 180,842) Mean age ± SD (yrs) 62 ± ± 14 Female sex (%) Diabetes mellitus (%) Prior MI (%) Prior CHF (%) 6 18 Prior PCI (%) Prior CABG (%) 7 19 CRUSADE through June 30, 2007

7 Lesson 1 ACS Clinical Trials vs Real World Patients VariablePURSUITCURESYNERGYCRUSADE (n = 9461)(n = 12,562)(n = 9975)(n = 180,842) Mean age ± SD (yrs)63 ± 1163 ± 1267 ± 1169 ± 14 Female sex (%) Diabetes mellitus (%) Prior MI (%) Prior CHF (%) Prior PCI (%)1318*2021 Prior CABG (%)1218*1719 NEJM 1998;339: NEJM 2001;345: JAMA 2004:292:45-54 CRUSADE cumulative through June 30, 2006 NEJM 1998;339: NEJM 2001;345: JAMA 2004:292:45-54 CRUSADE cumulative through June 30, 2006

8 CRUSADE NSTE MI vs. ACS Clinical Trials: Early Mortality Rates PURSUIT 1 (n = 9,461) PRISM-PLUS 2 (n = 1,915) SYNERGY 3 (n = 9,975) CRUSADE (n = 180,842) 1.8% 1.9% 1.5% 4.9% 7-day mortality rate In-hospital mortality rate 1.The PURSUIT Trial Investigators. N Engl J Med The PRISM-PLUS Study Investigators. N Engl J Med The Synergy Study JAMA 2004 CRUSADE cumulative data through 6/30/ The PURSUIT Trial Investigators. N Engl J Med The PRISM-PLUS Study Investigators. N Engl J Med The Synergy Study JAMA 2004 CRUSADE cumulative data through 6/30/2006

9 Lesson 2: Acute Medications NSTEMI vs STEMI Use CRUSADE DATA: July 1, 2005 – June 30, 2006 (n=31,665)

10 Lesson 2 Variations Among Hospitals 430 CRUSADE hospitals Acute Discharge Peterson et al, JAMA 2006;295:

11 Lesson 3: Hospital Link Between Overall Guidelines Adherence and Mortality Peterson et al, JAMA 2006;295: Every 10%  in guidelines adherence  10%  in mortality (OR=0.90, 95% CI: )

12 Lesson 4 Timely Care: Reperfusion among STEMI Patients Median Times Thrombolytics – 33 min Thrombolytics – 33 min Primary PCI – 98 min Primary PCI – 98 min Q CRUSADE STEMI data

13 Lesson 5: Invasive Cardiac Procedures (Excluding Patients with Contraindications to Cath) CRUSADE DATA: July 1, 2005 – June 30, 2006 (n=31,665)

14 Lesson 6: Interventional Care Trends in Early Cath Use by Risk Status Tricoci et al, AHA 2005 Abstract

15 Trends in Type of Revascularization Strategy for 3-Vessel CAD in CRUSADE Gogo P, ACC Scientific Sessions, 2006 Gogo P, ACC Scientific Sessions, 2006

16 Recent Decline in DES Use: CRUSADE July March 2007

17 *LVEF < 40%, CHF, DM, HTN # Known hyperlipidemia,  TC,  LDL Lesson 7: Discharge Care Gaps % Use CRUSADE DATA: July 1, 2005 – June 30, 2006 (n=31,665)

18 Proportion of Patients Receiving 100% of All Guidelines-Recommended Therapies * *In patients without contraindications Mehta et al, AHA 2005

19 Challenges To Healthcare Delivery Medical Errors n Errors of omission l Failure to use therapies proven to be beneficial n Errors of commission l Inappropriate or incorrect use of treatment strategies, dose, procedures

20 Lesson 8 Safe Care Hospital Variation in RBC Transfusion Rates Percentage of Patients Receiving Blood Transfusions (%) Percentage of Hospitals (%) Yang X, J Am Coll Cardiol 2005;46:

21 Safety Concerns in ACS Care: Need for Blood Transfusions Safety Concerns in ACS Care: Need for Blood Transfusions Yang X, JACC 2005;46:

22 Excessive Antithrombotic Dosing by Age Alexander KA, et al. JAMA 2005;294:

23 Death Death or Re-MI Death Death or Re-MI Lesson 9: Adjusted Risk By Transfusion Status* * Non-CABG patients only Yang X, JACC 2005;46:

24 Lesson 9: Likelihood of Major Bleeding with Excess Anti-thrombotic Dose 1.40 (1.12, 1.75) 1.09 (0.99, 1.26) 1.38 (1.12, 1.70) 2.02 (1.51, 2.69) 1.42 (1.16, 1.73) Both Excessive LMWH UF Heparin GP IIb/IIIa inhibitor One Excessive Agent Adjusted* Odds of Major Bleeding Excess v. Recommended Adjusted for age, sex, SBP, CHF, renal insufficiency Alexander KA, JAMA 2005

25 Concept Outcomes Clinical Trials Guidelines Performance Indicators Performance Indicators MeasurementMeasurement Lesson 10: Improving Care: CRUSADECQICRUSADECQI Adapted from Califf RM, Peterson ED et al. JACC 2002;40: Intervention Action

26 Lesson 10 Efforts to Improve Care Delivery: CRUSADE QI Interventions n Ongoing quarterly site feedback l Benchmarking care versus peers n National, regional, and local meetings l Share treatment results and successful quality improvement strategies n Clearinghouse for successful site QI solutions n QI Materials: Algorithms, order sets, etc n Publications: Updates, Focus on QI n “Care Consults” by CRUSADE leadership l Site results teleconferences

27 Improvements in Guidelines Adherence And Rates of Drug Overdosing Over Time Mehta RH, et al AHJ 2007 Rate of Excess Dosing Composite Adherence Rates

28 CRUSADE to NCDR ACTION™ n Need for Growth l Many US hospitals not in CRUSADE n Need for Alignment l Several similar US registries (AHA GWTG, ACC PCI registry, NRMI) l Hospitals wanted single source answer n Need for National Policy Change: l Live under the direction of professional societies l Be single source answer for ACS for providers, payers and policy makers

29 Quality Improvement Initiatives Institutional Feedback Reports Ready data availability for rapid cycle measurement TAKE ACTION™ Campaign D2B: An Alliance for Quality Monthly Webcasts National/Regional Group Meetings

30 Taking These Lessons to ACTION!  Broaden Quality Mission  No hospital or patient left behind  Personalized site feedback  National QI new initiatives  Bridging the transitions in care  Continue research mission  Support science and guidelines  Broaden policy mission  Become nation’s leading ACS surveillance system


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