1. STRIVE TM What Is the Evidence That Critical Pathways Work? UCLA Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) ACC Guidelines Applied in Practice (GAP) initiative AHA “Get With The Guidelines” program CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines)

2. STRIVE TM CHAMP Study: UCLA Designed to determine whether physician/patient compliance with preventive therapies can be improved through a hospital- initiated program Tracked initiation of aspirin, β-blocker, ACE inhibitor, statins Used preprinted orders, guidelines, lectures, discharge forms Population: patients with symptomatic atherosclerosis treated at university-associated teaching hospital Methods: no specific algorithms used before CHAMP (1992-1993) National guidelines (ACC/AHA, NCEP ATP I and ATP II) used in CHAMP (1994-1995) Evaluation: treatment rates and clinical outcomes pre-CHAMP and CHAMP in patients hospitalized for acute MI Fonarow GC, Gawlinski A. Am J Cardiol. 2000;85(3A):10A-17A. Cardiac Hospitalization Atherosclerosis Management Program

3. STRIVE TM Discharge Medications at UCLA Compared With 1437 NRMI Hospitals 0 20 40 60 80 100 Aspirin β-blockers ACEIStatins 68 92 91 94 96 12 68 72 78 85 52 64 70 75 88 89 90 91 98/99 Post-CHAMP (UCLA) 00/01 Post-CHAMP (UCLA) 92/93 Pre-CHAMP (UCLA) 94/95 Post-CHAMP (UCLA) 96/97 Post-CHAMP (UCLA) Fonarow GC, et al. Am J Cardiol. 2001;87:819-822. [NRMI Hospitals 00/01 (n=154,602)] Nat’l Benchmark Utilization Rate (%) CHAMP Over an 8-Year Period: Rapid and Sustained Improvement, Superior to National Benchmarks 37 42 65 77

4. STRIVE TM Adapted from Mehta RH, et al. JAMA. 2002;287:1269-1276. 0 20 40 60 80 100 At AdmissionAt Discharge Pre-GAP Post-GAP Aspirin Usage (%) 81 87 84 92 P=.02 P=.002 ACC’s Guidelines Applied in Practice (GAP) Initiative: Impact on Aspirin Usage at Admission and Discharge

5. STRIVE TM Adapted with permission from Mehta RH, et al. JAMA. 2002;287:1269-1276. Quality Adherence (%) Preintervention No Tool Use Tool Use Postintervention 0 20 40 60 80 100 Aspirin β-Blocker LDL-C No. of Ideal Patients 81 86 93 65 73 77 64 82 343308962131747113116587 P=.004P=.001 Early Quality Indicators and Standard Admission Orders GAP Initiative: Adherence Improves With Tool Use

6. STRIVE TM GAP Initiative: Changes in Mortality Before and After GAP Project Eagle KA, et al. J Am Coll Cardiol. 2005;46:1242-1248. 0 5 10 15 20 25 30 35 40 45 In-hospital Mortality 30-d Mortality 1-yr Mortality % Baseline Post-GAP P=.017 P=.001 P=.004

7. STRIVE TM AHA “Get With The Guidelines” Program Components Training materials for hospital staff Patient education materials Assistance in creating multidisciplinary team Secondary prevention guidelines CME workshops Sample materials (care maps, discharge protocols, discharge forms) American Heart Association Web site. Get With The Guidelines. Available at: http://www.americanheart.org/presenter.jhtml?identifier=1165.

8. STRIVE TM Clinical/Lab: 8 clicks Clinical/Lab: 8 clicks Interactively checks patient’s data with the AHA Guidelines Discharge meds and interventions: 7 clicks Discharge meds and interventions: 7 clicks Demographics: 6 clicks AHA Tool: Simple One-Page, Online Form American Heart Association Web site. Get With The Guidelines. Available at: http://www.americanheart.org/presenter.jhtml?identifier=1165.

9. STRIVE TM Rehab/ Exercise Baseline4-6 Months9-12 MonthsBenchmark* Intervention 0 20 40 60 80 100 Smoking Counsel LDL-CBP Control Proportion of Patients *Benchmarks established by CMS AND NRMI. Reprinted with permission from the American Heart Association Web site. Get With The Guidelines. Available at: http://www.americanheart.org/presenter.jhtml?identifier=1165. Get With The Guidelines 12-Month Pilot Results: 85 New England Hospitals N=1709

10. STRIVE TM CRUSADE Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines Nationwide quality improvement (QI) initiative –Up to 600 participating hospitals Collaborative effort between emergency medicine, cardiology, hospital QI, academia, and industry Focused on improving the care of NSTEMI ACS patients Adapted from CRUSADE Overview 2004. Available at: http://www.crusadeqi.com. © 2005 Duke Clinical Research Institute. Used with permission.

11. STRIVE TM CRUSADE: Inclusion Criteria Ischemic symptoms lasting >10 minutes within previous 24 hours and at least one of the following: –Positive cardiac markers CK-MB or Tnl/TnT above ULN Positive bedside troponin assay –ST-segment ECG changes ST-segment depression >0.5 mm Transient ST-segment elevation 0.6–1 mm (lasting <10 mins) Transfer patients (with any of the above) must arrive at CRUSADE hospital within 24 hours of symptoms © 2005 Duke Clinical Research Institute. Used with permission. Available at http://www.crusadeqi.com.

12. STRIVE TM Goals for CRUSADE Aspirin –Clopidogrel  -Blocker Heparin (UFH or LMWH) GP IIb/IIIa Inhibitor –Cath/PCI Aspirin Clopidogrel  -Blocker ACE Inhibitor Statin/Lipid Lowering Smoking Cessation Cardiac Rehabilitation Acute Therapy Discharge Therapy 2002 ACC/AHA Guidelines Update. Adapted from 2005 CRUSADE 2nd Quarter Results. Available at: http://www.crusadeqi.com. © 2005 Duke Clinical Research Institute. Used with permission. Improve Adherence to ACC/AHA Guidelines Improve Patient Outcomes

13. STRIVE TM Hospital Presentation Characteristics in CRUSADE: July 1, 2005–June 30, 2006 (n=31,665) Qualifying criteria ST-segment depression 28% Transient ST-segment elevation 5% Positive cardiac markers 93% Baseline cardiac markersDrawnPositive CK-MB82%75% TnT/TnI99%91% Presenting characteristics Tachycardia23% Hypotension 4% Signs of CHF23% Adapted from 2006 CRUSADE Results. Available at: http://www.crusadeqi.com. © 2006 Duke Clinical Research Institute. Used with permission.

14. STRIVE TM Baseline Characteristics: CRUSADE vs ACS Clinical Trials VariablePURSUITCURESYNERGYCRUSADE (n = 9461)(n = 12,562)(n = 9975)(n = 180,842) Mean age ± SD (yrs)63 ± 1163 ± 1267 ± 1167 ± 14 Female sex (%)36393440 Diabetes mellitus (%)23232933 Prior MI (%)32252830 Prior CHF (%)118918 Prior PCI (%)1318*2021 Prior CABG (%)1218*1719 ST depression (%)50425534 N Engl J Med. 1998;339:436-43. N Engl J Med. 2001;345:494-502. JAMA. 2004:292:45-54. CRUSADE cumulative through June 30, 2006. N Engl J Med. 1998;339:436-43. N Engl J Med. 2001;345:494-502. JAMA. 2004:292:45-54. CRUSADE cumulative through June 30, 2006.

15. STRIVE TM CRUSADE: Trends in Acute Therapy Adherence Adapted from 2006 CRUSADE Results. Available at: http://www.crusadeqi.com. © 2006 Duke Clinical Research Institute. Used with permission. 96% 90% 84% 46% 97% 93% 88% 50% 0% 25% 50% 75% 100% Antiplateletβ-BlockerHeparinGP IIb/IIIa Inhibitor Quarter 3-05Quarter 4-05Quarter 1-06Quarter 2-06 Quarter 3, 2005, through Quarter 2, 2006.

16. STRIVE TM CRUSADE Data: July 1, 2005-June 30, 2006 (n=31,665) CRUSADE: Invasive Cardiac Procedures July 1, 2005 – June 30, 2006 (n=31,665) (Among Patients Without Contraindications to Cath) Adapted from 2006 CRUSADE Results. Available at: http://www.crusadeqi.com. © 2006 Duke Clinical Research Institute. Used with permission. 83% 67% 53% 38% 12% 0% 20% 40% 60% 80% 100% Cath <48 hr PCIPCI <48 hrCABG

17. STRIVE TM CRUSADE: Trends in Discharge Therapy Adherence Quarter 3, 2005, through Quarter 2, 2006 Adapted from 2006 CRUSADE Results. Available at: http://www.crusadeqi.com. © 2006 Duke Clinical Research Institute. Used with permission. 94% 72% 91% 64% 89% 74% 94% 66% 88% 95% 0% 25% 50% 75% 100% AspirinClopidogrelβ-BlockerACE InhibitorLipid- Lowering Agent Quarter 3-05Quarter 4-05Quarter 1-06

18. STRIVE TM CRUSADE: Trends in Discharge Recommendations Adherence 84% 81% 62% 84% 62% 92% 0% 25% 50% 75% 100% Smoking Cessation Counseling Dietary ModificationCardiac Rehabilitation Referral Quarter 3-06Quarter 4-06Quarter 1-06Quarter 2-06 Quarter 3, 2005, through Quarter 2, 2006. Adapted from 2006 CRUSADE Results. Available at: http://www.crusadeqi.com. © 2006 Duke Clinical Research Institute. Used with permission.

19. STRIVE TM CRUSADE: Overall Guideline Adherence Trends Over Time Available at www.crusadeqi.com © 2006 Duke Clinical Research Institute. Used with permission. Quarter 1 2002 Quarter 1 2003 Quarter 1 2004 Quarter 1 2005 Quarter 2 2006 68.1% 73.0% 78.0% 80.8% 83.2% 0% 25% 50% 75% 100%

20. STRIVE TM Performance Matters! Association Between Hospital Guideline Adherence and In-hospital Mortality in CRUSADE Adapted with permission from Peterson ED, et al. JAMA.2006;295:1912-1920. NSTE ACS = non-ST-segment elevation ACS; NSTEMI = non-ST-segment elevation MI. 8 7 6 5 4 3 2 1 0 1234 In-Hospital Mortality, % Hospital Composite Guideline Adherence Quartiles NSTE ACS 8 7 6 5 4 3 2 1 0 1234 In-Hospital Mortality, % Hospital Composite Guideline Adherence Quartiles NSTEMI CRUSADE = Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines.

21. STRIVE TM NRMI. Available at: http://www.nrmi.org/index.html. Get With The Guidelines. Available at: http://www.americanheart.org. ACC National Cardiovascular Data Registry. Available at: http://www.acc.org/ncdr/index.htm. GRACE. Available at: http://www.umassmed.edu/outcomes/grace. CRUSADE. Available at: http://www.crusadeqi.com. REACH. Available at: http://www.REACHregistry.org Importance of Data-Collection Registries Track adherence to guidelines Support local quality-improvement programs Compare practice patterns/outcomes with national benchmarks Comply with regulatory requirements Provide research data Major data-collection registries –NRMI –AHA “Get With The Guidelines” Patient Management Tool –ACC National Cardiovascular Data Registry –GRACE –CRUSADE –REACH

22. STRIVE TM CRUSADE: Latest Results in NSTEMI ACS in US: Conclusions Care for NSTEMI ACS is improving: –Continued progress in adherence to ACC/AHA Guidelines for both acute and discharge treatments –More early cath, leading to earlier discharge Yet opportunities for improvement persist –Largest gaps: acute GP IIb/IIIa, D/C ACE, clopidogrel –“Right dosing” to reduce adverse events And can lead to even better patient outcomes! Available at www.crusadeqi.com. © 2005 Duke Clinical Research Institute. Used with permission.

23. STRIVE TM Conclusions Gap between knowledge of guidelines and practice Several studies show: –Critical pathways interventions improve care and improve patient outcomes Need local champions, implementation plan, and action!