1 CCORT/CCS 2008 Quality Indicators for Acute Myocardial Infarction (AMI) Care-Indicator Definitions CIHR Team Grant in Cardiovascular Outcomes Research Jack V. Tu MD PhD FRCPC, Laila Khalid MD, Linda Donovan BScN MBA, Dennis T. Ko MD MSc for the CCORT/CCS AMI Quality Indicator Panel Christopher E. Buller MD, Virginia F. Flintoft BN MSc, Thao Huynh MD MSc, Cynthia A. Jackevicius PharmD MSc, Laurie J. Lambert PhD, Michael P. Love MB ChB MD, Michael J. Schull MD MSc, Heather Sherrard BScN MHA, Edward Y.K. Tsoi MD, Alain Vadeboncoeur MD

2 CCORT/CCS 2008 Quality Indicators for AMI Care Indicator Category # Indicators from chart review 17 IIn-hospital process-of-care indicators - 6 pharmacological & 7 nonpharmacological 13 IIOutcome indicator 1 IIISystem indicators 3 Indicators from administrative data 21 IOut-of-hospital process-of-care indicators - 9 pharmacological & 4 nonpharmacological 13 IIOutcome indicators 8 Total 2008 Indicators 38

3 CCORT/CCS 2008 Quality Indicators for AMI Care 1 In-hospital Process-of-Care Indicator /Chart Abstracted (Pharmacological) 1.1 ASA within 24 hrs before hospital arrival or within 3 hrs after hospital arrival 1.2ASA prescribed at hospital discharge 1.3Beta blocker prescribed at hospital discharge 1.4ACEI or ARB prescribed at hospital discharge 1.5Statin prescribed at hospital discharge 1.6Fibrinolytic therapy within 30 minutes after hospital arrival

4 CCORT/CCS 2008 Quality Indicators for AMI Care 2 In-hospital Process-of-Care Indicators/Chart Abstracted (Nonpharmacological) 2.1 ECG within 10 minutes after hospital arrival 2.2 Primary percutaneous coronary intervention (PCI) within 90 minutes after hospital arrival 2.3 Reperfusion therapy in eligible patients with ST-segment elevation MI 2.4 Risk stratification (i.e. cardiac catheterization, exercise stress test, perfusion imaging, stress echocardiography) 2.5 Assessment of left ventricular function 2.6 Smoking cessation advice, counselling or therapy during hospital stay 2.7 Referral to cardiac rehabilitation

5 CCORT/CCS 2008 Quality Indicators for AMI Care 3In-hospital Outcome Indicator/Chart Abstracted 3.1 In-hospital mortality 4In-hospital System Indicators/Chart Abstracted 4.1Fibrinolytic therapy within 60 minutes after call for emergency medical services 4.2Primary PCI within 120 minutes after call for emergency medical services 4.3Pre-hospital 12-lead ECG

6 CCORT/CCS 2008 Quality Indicators for AMI Care 1Out-of-Hospital Process-of-Care Indicators/Administrative Data (Pharmacological) 1.1 Prescription for Beta Blocker filled within 30 days after discharge 1.2Prescription for Beta Blocker filled within 90 days after discharge 1.3Adherence to Beta Blocker therapy 1 year after discharge 1.4 Prescription for ACEI or ARB filled within 30 days after discharge 1.5Prescription for ACEI or ARB filled within 90 days after discharge 1.6Adherence to ACEI or ARB 1 year after discharge 1.7 Prescription for Statin filled within 30 days after discharge 1.8Prescription for Statin filled within 90 days after discharge 1.9Adherence to Statin therapy 1 year after discharge

7 CCORT/CCS 2008 Quality Indicators for AMI Care 2Out-of-Hospital Process-of-Care Indicators/Administrative Data (Nonpharmacological) 2.1Physician visit within 4 weeks after discharge 2.2Median wait time (in days) for cardiac catheterization after MI 2.3Median wait time (in days) for percutaneous coronary intervention (PCI) after MI 2.4Median wait time (in days) for coronary artery bypass graft (CABG) surgery after MI

8 CCORT/CCS 2008 Quality Indicators for AMI Care 3Out-of-Hospital Outcome Indicators/ Administrative Data day mortality 3.21-year mortality day readmission rate because of AMI 3.41-year readmission rate because of AMI day readmission rate because of congestive heart failure 3.61-year readmission rate because of congestive heart failure day readmission rate because of unstable angina 3.81-year readmission rate because of unstable angina

1.1 ASA within 24 hours before hospital arrival or within 3 hours after hospital arrival NumeratorPatients with AMI who received ASA within 24 hrs before hospital arrival or within 3 hours after hospital arrival DenominatorInclusions: Confirmed AMI Exclusions: 1. Active Bleeding on arrival 2. Allergy to ASA 3. Documented reason for nonuse of ASA (e.g. high risk of bleeding or patient refusal) 1. In-hospital Process-of-Care Indicators — Pharmacological

1.2 ASA prescribed at hospital discharge NumeratorPatients with AMI who are prescribed ASA at hospital discharge DenominatorInclusions: Confirmed AMI and alive at discharge Exclusions: 1. Evidence of i) Active bleeding on arrival or ii) Active bleeding during hospital stay 2. Allergy to ASA 3. Documented reason for nonuse of ASA (e.g. high risk of bleeding or patient refusal) 1. In-hospital Process-of-Care Indicators — Pharmacological

1.3 Beta Blocker prescribed at hospital discharge NumeratorPatients with AMI who are prescribed a Beta Blocker at hospital discharge DenominatorInclusions: Confirmed AMI and alive at discharge Exclusions: 1. Bradycardia (heart rate <60 bpm) on day of discharge or day before discharge while not taking beta blocker 2. Conduction disorder defined as a second- or third-degree heart block on ECG on arrival or during hospital stay while not on a pacemaker 3. Allergy or intolerance to beta blocker 4. Documented reason for nonuse of beta blocker (e.g. symptomatic hypotension, systolic blood pressure < 100 mm Hg, severe chronic obstructive pulmonary disease, asthma or patient refusal) 1. In-hospital Process-of-Care Indicators — Pharmacological

1.4 Angiotensin-converting enzyme (ACE) inhibitor or Angiotensin-receptor blocker prescribed at hospital discharge NumeratorPatients with AMI who are prescribed ACEI or ARB at hospital discharge DenominatorInclusions: 1. Patients with AMI alive at discharge and 2. Left ventricular ejection fraction <40% and 3. Patients with diabetes, hypertension, heart failure or chronic kidney disease Exclusions: 1. Severe aortic stenosis 2. Allergy or intolerance to ACEI or ARB 3. Documented reason for nonuse of ACEI or ARB at discharge (e.g. symptomatic hypotension, severe renal dysfunction, hyperkalemia, bilateral renal artery stenosis or patient refusal) 1. In-hospital Process-of-Care Indicators — Pharmacological

1.5 Statin prescribed at hospital discharge NumeratorPatients with AMI who are prescribed a statin at hospital discharge DenominatorInclusions: Confirmed AMI and alive at discharge Exclusions: Documented reason for nonuse of statins (e.g. statin intolerance, liver disease or patient refusal) 1. In-hospital Process-of-Care Indicators — Pharmacological

1.6 Fibrinolytic therapy within 30 minutes after hospital arrival NumeratorPatients with AMI who received fibrinolytic therapy within 30 minutes after hospital arrival DenominatorInclusions: 1. Confirmed AMI and 2. ST-segment elevation or new LBBB on ECG and 3. Fibrinolytic therapy received within 6 hrs after hospital arrival and 4. Fibrinolytic therapy documented as primary reperfusion therapy Exclusions: 1. Fibrinolytic therapy received in ambulance or in field 2. Documented reason for delay in receiving fibrinolytic therapy (e.g. nondiagnostic ECG or patient refusal) 1. In-hospital Process-of-Care Indicators — Pharmacological

2.1 ECG within 10 minutes after hospital arrival NumeratorPatients with AMI who had an ECG within 10 minutes after hospital arrival (triage time or registration time whichever occurs earlier) DenominatorInclusions: Confirmed AMI Exclusions: Documented reason for delay in ECG (e.g. atypical signs or symptoms, ongoing cardiac arrest or patient refusal) 2. In-hospital Process-of-Care Indicators — Nonpharmacological

2.2 Primary percutaneous coronary intervention (PCI) within 90 minutes after hospital arrival NumeratorPatients with AMI who received primary percutaneous coronary intervention (PCI) within 90 minutes after first hospital arrival DenominatorInclusions: 1. Confirmed AMI and 2. ST-segment elevation or new LBBB on ECG, and 3. Primary percutaneous coronary intervention performed within 24 hours after hospital arrival Exclusions: 1. Patients who received fibrinolytic therapy before PCI 2. Documentation of PCI as non-primary 3. Documented reason for delay in PCI (e.g. patient refusal) 2. In-hospital Process-of-Care Indicators — Nonpharmacological

2.3 Reperfusion therapy in eligible patients with ST-segment elevation MI NumeratorPatients with AMI who received reperfusion therapy (fibrinolytic therapy or primary percutaneous coronary intervention [PCI]) DenominatorInclusions: 1. Patients with ST-segment elevation MI or new LBBB on ECG who are eligible for fibrinolytic therapy or primary PCI and 2. Patients who present within 12 hours after symptom onset Exclusions: Documented reason for not receiving reperfusion therapy (e.g. patient refusal) 2. In-hospital Process-of-Care Indicators — Nonpharmacological

2.4 Risk stratification (i.e. cardiac catheterization, exercise stress testing, perfusion imaging or stress echocardiography) NumeratorPatients with AMI who underwent risk stratification (i.e. cardiac catheterization, exercise stress testing, perfusion imaging or stress echocardiography) during hospital stay or were referred for risk stratification (e.g. outpatient or transfer to another hospital) after discharge DenominatorInclusions: Confirmed AMI Exclusions: 1. Primary or rescue percutaneous coronary intervention (PCI) 2. Documented reason for no cardiac catherterization or noninvasive stress test (e.g. physical limitations, do-not-resuscitate status or patient refusal) 2. In-hospital Process-of-Care Indicators — Nonpharmacological

2.5 Left Ventricular Function Assessment NumeratorPatients with AMI who had assessment of left ventricular function (e.g. via echocardiography, radionuclide angiography or left ventriculography) during their hospital stay or were referred for assessment after hospital discharge DenominatorInclusions: Confirmed AMI Exclusions: 1. Primary or rescue percutaneous coronary intervention (PCI ) 2. Documented reason for no assessment of left ventricular function (e.g. recent assessment of left ventricular function or patient refusal) 2. In-hospital Process-of-Care Indicators — Nonpharmacological

2.6 Smoking cessation advice, counselling or therapy during hospital stay NumeratorPatients with AMI who are smokers and who received smoking cessation advice, counselling or therapy during hospital stay DenominatorInclusions: 1. Confirmed AMI and 2. Active smoker or history of smoking in the past year Exclusions: Documented reason for no smoking cessation advice, counselling or therapy (e.g. patient refusal) 2. In-hospital Process-of-Care Indicators — Nonpharmacological

2.7 Referral to cardiac rehabilitation NumeratorPatients with AMI who are referred to cardiac rehabilitation during hospital stay or at discharge DenominatorInclusions: Confirmed AMI Exclusions: Documented reason for no referral to cardiac rehabilitation (e.g. patient-associated factors [e.g. patient refusal], provider-associated factors [e.g. patient with a high-risk condition or a contraindication to exercise], health care system-associated factors [e.g. financial obstacles or absence of a cardiac rehabilitation program near patient’s home]) 2. In-hospital Process-of-Care Indicators — Nonpharmacological

3.1 In-hospital mortality NumeratorPatients with AMI who died in hospital during this encounter/stay DenominatorInclusions: Confirmed AMI Exclusions: None 3. Outcome Indicator

4.1 Fibrinolytic therapy within 60 minutes after call for emergency medical services NumeratorPatients with AMI who were eligible for fibrinolytic therapy and received it within 60 minutes after call for emergency medical services DenominatorInclusions: 1. Confirmed AMI and 2. ST-segment elevation or new LBBB on ECG and 3. Fibrinolytic therapy within 6 hours after hospital arrival and 4. Fibrinolytic therapy is primary reperfusion therapy 5. Call made to emergency medical services (EMS) Exclusions: 1. In-field fibrinolysis 2. Walk-in patients 3. Documented reason for delay in receiving finbrinolytic therapy (e.g. patient refusal) 4. System Indicators

4.2 Primary percutaneous coronary intervention (PCI) within 120 minutes after call for emergency medical services NumeratorPatients with AMI who were eligible for PCI and received primary PCI within 120 minutes after call for emergency medical services DenominatorInclusions: 1. Confirmed AMI and 2. ST-segment elevation or new LBBB on ECG and 3. PCI performed within 24 hours after hospital arrival 4. Call made to emergency medical services (EMS) Exclusions: 1. Patients who received fibrinolytic therapy before PCI 2. Documentation of PCI as non-primary 3. Documented reason for delay in PCI (e.g. patient refusal) 4. System Indicators

4.3 Pre-hospital 12-lead ECG NumeratorPatients with AMI who had a prehospital 12-lead ECG done by emergency medical services personnel DenominatorInclusions: 1. Confirmed AMI and 2. Ambulance transportation Exclusions: 1. Walk-in patients 2. Documented reason for no prehospital ECG (e.g. patient refusal) 4. System Indicators

CCORT welcomes feedback on these indicators. Please send comments or questions to