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What Have We Learned from the CRUSADE Registry

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Presentation on theme: "What Have We Learned from the CRUSADE Registry"— Presentation transcript:

1 What Have We Learned from the CRUSADE Registry
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 Disclosures: Research support from Schering Plough, BMS, Sanofi-Aventis, Merck-Schering, PDL Pharma

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

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

5 CRUSADE Highlights – Data collection: 7/2001- 12/2006
> 500 US sites participated in CRUSADE 25% academic, 68% with PCI/CABG 201,032 Data Collection Forms received 190,000 NSTEMI:: 8,800+ STEMI patients 1000+ MAINTAIN patients (long-term follow-up) 50+ CRUSADE publications Referenced within ACC/AHA guidelines 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) ± ± 14 Female sex (%) Diabetes mellitus (%) Prior MI (%) Prior CHF (%) Prior PCI (%) Prior CABG (%) Update to end of 4th quarter CRUSADE data. CRUSADE through June 30, 2007

7 Lesson 1 ACS Clinical Trials vs Real World Patients
Variable PURSUIT CURE SYNERGY CRUSADE (n = 9461) (n = 12,562) (n = 9975) (n = 180,842) Mean age ± SD (yrs) 63 ± ± ± ± 14 Female sex (%) Diabetes mellitus (%) Prior MI (%) Prior CHF (%) Prior PCI (%) 13 18* 20 21 Prior CABG (%) 12 18* 17 19 Update to end of 4th quarter CRUSADE data. NEJM 1998;339:436-43 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
In-hospital mortality rate 4.9% 7-day mortality rate 1.9% 1.8% 1.5% PURSUIT1 (n = 9,461) PRISM-PLUS2 (n = 1,915) SYNERGY3 (n = 9,975) CRUSADE (n = 180,842) 1.The PURSUIT Trial Investigators. N Engl J Med 1998 2.The PRISM-PLUS Study Investigators. N Engl J Med 1998 3. 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
Every 10%  in guidelines adherence  10%  in mortality (OR=0.90, 95% CI: ) 350 sites; 64, 775 patients Peterson et al, JAMA 2006;295:

12 Lesson 4 Timely Care: Reperfusion among STEMI Patients
Median Times Thrombolytics – 33 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
75.5 64.1 63.2 53.5 32.2 26.6 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

16 Recent Decline in DES Use: CRUSADE July 2006- March 2007

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

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

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

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

21 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 Lesson 9: Adjusted Risk By Transfusion Status*
Death Death or Re-MI Finally, inorder to assess the independent prognostic value of peak C-MB we included it in a multivariable model with other predictors of 30-day mortality. We found a strong, linear positive association between peak CK-MB and mortality. After adjustment, the increased risk of 30-day death associated with CK-MB elevations 1 to 2 times the upper limit of normal was no longer statistically significant. 1 2.0 * Non-CABG patients only Yang X, JACC 2005;46: 17

24 Adjusted* Odds of Major Bleeding
Lesson 9: Likelihood of Major Bleeding with Excess Anti-thrombotic Dose Excess v. Recommended 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) UF Heparin LMWH GP IIb/IIIa inhibitor One Excessive Agent Both Excessive 1 2 Adjusted* Odds of Major Bleeding Adjusted for age, sex, SBP, CHF, renal insufficiency Alexander KA, JAMA 2005

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

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

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

Need for Growth Many US hospitals not in CRUSADE Need for Alignment Several similar US registries (AHA GWTG, ACC PCI registry, NRMI) Hospitals wanted single source answer Need for National Policy Change: Live under the direction of professional societies 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 Regional Group Meetings NCDR™ participants in many cases have organized themselves into regional training and networking groups. ACTION Registry™ staff will support these groups and also seek and organize additional groups as needed. Educational meetings and/or teleconferences may include presentations regarding recent findings from ACTION Registry ™ analyses, strategies for ensuring successful collaboration between various specialties and departments within the institution in support of the quality improvement process, and other topics of interest. They may also include questions and answers, or case studies. Members of the ACTION Registry™ Steering Committee and staff will conduct these sessions. Institutional Feedback Reports ACTION Registry™ participants receive access to comprehensive, timely information about measuring quality of care for their ACS patients in the form of quarterly and annual comparative benchmark reports. These reports comprise data on evidence-based elements corresponding to the ACTION Registry™ data elements and definitions. These reports are institution-specific and provide participants the opportunity to compare their institution’s practice patterns to ACTION Registry™ averages and volume-based peer comparison groups. Participants use this information for improving patient care, supporting local quality-improvement programs, and communicating with regulatory and contracting organizations. D2B: An Alliance for Quality The D2B Alliance is a network of hospitals, physician champions, and strategic partners who have come together as a nationwide community of committed organizations and individuals to address the challenge of lowering door to balloon (D2B) times. This program is designed to provide hospitals with the key evidence-based strategies and supporting tools that they need to begin reducing their door to balloon times. A web-based networking component will create a learning community hospitals can use to share their findings and experiences with others. The ACTION Registry™ encourages its participants to join this nationwide effort and supports them by providing detailed feedback reports and graphical depictions of critical measures related to reducing door to balloon/needle time. TAKE ACTION™ The TAKE ACTION™ campaign will be a three-year, multi-phased project during which NCDR™ will design, develop, and implement the nationwide TAKE ACTION™ campaign—focused on improving the quality of care.  During the first phase of the project the campaign develop tools for physicians and clinicians to improve implementation of the ACC/AHA Guideline recommendations—including conducting educational workshops, developing standardized order sets, pocket cards and other tools.  Included in the initial phase will be participation in the D2B campaign, which aims to reduce door to balloon times for primary PCI.  Additional outreach programs will look at extending the reach of guideline-recommended care to the outpatient setting and improving the continuity of care post initial hospitalization.  Finally, in later phase, the campaign will broaden to include the patient/consumer populations and focus on "What can patients do to TAKE ACTION."  It is envisioned that these phases will be overlapping over the course of the project.

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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