1. Eric D. Peterson, MD, MPH Professor of Medicine, Vice Chair for Quality Duke University Medical Center Associate Director & Director of CV Research Duke Clinical Research Institute Durham, NC CRUSADE/ACTION Update

2. 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

3. CRUSADE Highlights – n Data collection: 7/2001- 12/2006 n > 500 US sites participated in CRUSADE l 25% academic, 68% with PCI/CABG n 201,032 ACS patients received l 190,000 NSTEMI:: 8,800+ STEMI patients l 1000+ MAINTAIN patients (long-term follow-up) n 50+ CRUSADE publications n Referenced within ACC/AHA guidelines n Successful transition to NCDR ACTION ACS

4. 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 (%)36393440 Diabetes mellitus (%)23232933 Prior MI (%)32252830 Prior CHF (%)118918 Prior PCI (%)1318*2021 Prior CABG (%)1218*1719 NEJM 1998;339:436-43 NEJM 2001;345:494-502 JAMA 2004:292:45-54 CRUSADE cumulative through June 30, 2006 NEJM 1998;339:436-43 NEJM 2001;345:494-502 JAMA 2004:292:45-54 CRUSADE cumulative through June 30, 2006

5. 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 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 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

6. Variations Among Hospitals 430 CRUSADE hospitals Acute Discharge Peterson et al, JAMA 2006;295:1863-1912

7. Lesson 3: Hospital Link Between Overall Guidelines Adherence and Mortality Peterson et al, JAMA 2006;295:1863-1912 Every 10%  in guidelines adherence  10%  in mortality (OR=0.90, 95% CI: 0.84-0.97)

8. Timely Care: Reperfusion among STEMI Patients Median Times Thrombolytics – 33 min Thrombolytics – 33 min Primary PCI – 98 min Primary PCI – 98 min Q2 2006 CRUSADE STEMI data

9. Are We Performing Interventional Procedures in the Right Patients 26.6 32.2 53.5 63.2 64.1 75.5 Tricoci et al, AHA 2005 Abstract

10. What Must Go Up….. Tech Trends: DES in CRUSADE

11. Must Come Down: DES Use July 2006- March 2007 Data on File DCRI: CRUSADE/ACTION

12. Safe Care? Excessive Antithrombotic Dosing Alexander KA, et al. JAMA 2005;294:3108-3116

13. Lesson 9 Hospital Safety, Quality, and Outcomes N=318 Hospitals; 56,245 Patients - Peterson ACC 2006

14. 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;40:1895-901 Intervention Action

15. 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

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

17. 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

18. Current ACTION Site Distribution Last updated: 1/4/07 AK (1) WA (12) OR (6) CA (15) ID (1) NV (0) MT (1) WY (0) CO (7) NM (0) ND (1) SD (1) NE (4) KS (5) OK (2) TX (11) MN (5) IA (7) MO (8) AR (1) LA (2) WI (6) MI (14) MI UT (0) AZ (3) HI (0) IL (18) IN (12) KY (2) TN (8) MS (5) AL (3) GA (8) FL (9) SC (3) NC (17) VA (11) OH (22) WV (1) PA (26) NY (10) MD (11) ME (1) VT (0) NH (1) NJ (6) MA (1) CT (2) DE (0) RI (0) DC (0) Active Sites = 290

19. ACTION 2007 Cumulative Data Submission Number of records

20. Complexity of ACS Patients STEMI vs. NSTEMI ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007

21. In-Hospital Outcomes STEMI vs. NSTEMI *Transfusion among non-CABG patients ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007 *Transfusion among non-CABG patients ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007

22. DTB = 1 st Door to Balloon DTN = 1 st Door to Needle for Lytics ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007 (n=11,854) STEMI – Timing of Reperfusion

23. Acute Medications STEMI vs NSTEMI ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007 STEMI (n=11,854) NSTEMI (n=26,956)

24. Discharge Medications STEMI vs NSTEMI * Ideal Patients ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007 STEMI (n=11,854) NSTEMI (n=26,956)

25. 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