1. 1 Acute Myocardial Infarction and the Role of Critical Pathways Christopher Cannon, M.D. Brigham and Women’s Hospital Boston

2. ACUTE MI GUIDELINES 11/96 Drug Rx Peri MI: Meta-Analyses Beta blocker during MI Beta blocker post MI ACEI during MI ACEI post MI if LV dysfxn Nitrates during MI Ca ++ blockers Magnesium Lidocaine Class I Antiarrhythmics NumberRR Deathp value 28,970 24,298 100,963 5,986 81,908 20,342 61,860 9,155 6,300.87 (.77-.98).77 (.70-.84).94 (.89-.98).78 (.70-.86).94 (.90-.99) 1.04 (.95-1.14) 1.02 (.96-1.08) 1.38 (.98-1.95) 1.21 (1.01-1.44) 0.02 <0.001 0.006 <0.001 0.03 NS 0.04 NEJM 335:1662, 1996

4. N=84,423 NRMI-2: Distribution of Door-to-Needle Times 40% Cannon CP ACC 2000

5. NRMI-2: Thrombolysis Door-to-Needle Time vs. Mortality N=28,624 33,867 11,616 10,316 P=0.01 P=0.0001 P=NS 1.03 1.11 1.23

6. N=27,080 NRMI-2: Primary PCI Distribution of Door-to-Balloon times Door-to-Balloon Time (minutes) Cannon CP, et al JAMA 2000;283:2941-2947.

7. P=0.01P=0.0007P=0.0003P=NS 1.14 1.15 1.41 1.62 1.61 N=2,230 5,734 6,616 4,461 2,6275,412 NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality Cannon CP, et al JAMA 2000;283:2941-2947.

8. EUROASPIRE II European Action on Secondary and Primary Prevention through Intervention to Reduce Events Euro Heart Survey Programme European Society of Cardiology-ESC  European Society of Cardiology ESC Wood et al. Lancet 2001; 357: 995-1001

9. % beta-blockers at interview by center EUROASPIRE  European Society of Cardiology ESC Wood et al. Lancet 2001; 357: 995-1001

10. 10 US News and World Report Aspirin in ideal candidates Chen J, et al N Engl J Med. 1999;340:286-292.

11. 11 US News and World Report Beta-blockers in ideal candidates Chen J, et al N Engl J Med. 1999;340:286-292.

12. US News and World Report 30-day mortality by hospital category* * 25th, 50th and 75th percentile for each category Chen J, et al N Engl J Med. 1999;340:286-292.

13. 13 Quality implications –The lower mortality observed in “America’s Best Hospitals” appear to be explained in part by their higher use of aspirin and beta- blockers –Any hospital can be one of “America’s Best” by increasing their use of aspirin and beta- blockers Chen J, et al N Engl J Med. 1999;340:286-292.

14. No. Pts On Admission On AdmissionASAHeparinB-blockers 1678826341Men1640775035Women1788846653 Men Men1160806049 Women Pre Guideline TIMI III Registry Scirica BM, Cannon CP, et al. Crit Path Cardiol. 2002;1:151-160. Post Guideline ARANTEE GU Comparing Pre- to Post-:Men Women P values :ASA0.300.05 Heparin0.130.001 B-blocker0.0010.001

15. Unadjusted One Year Survival Weeks post discharge Percent surviving 95% 81% P =.0001 Giugliano RP,et al. Arch Intern Med 2000;160.

16. Standardized protocols Goal: optimize care Emerging Evidence – Pathways work: –CHAMP –Guidelines Applied in Practice (GAP) –AHA “Get with the Guidelines” program www.critpathcardio.com

17. National Heart Attack Alert Program (NHAAP) CRITICAL PATHWAYS FOR THE TREATMENT OF PATIENTS WITH ACUTE CORONARY SYNDROMES

18. 18 Critical Pathways - Definitions Standardized protocols for care Strict definition –Full list of all tasks, tracks variances Broader definition –Includes clinical protocols (NHAAP 4D’s) Diagnostic pathways - Chest Pain Centers Treatment pathways - Thrombolysis

19. 19 Goals of Critical Pathways Increase use of recommended medical therapies (e.g., aspirin) Decrease use of unnecessary tests. Decrease hospital length of stay Increase participation in clinical research Improve patient care and decrease costs.

20. 20 Need and Rationale for Critical Pathways Underutilization of recommended medications (e.g. Aspirin) Overutilization of procedures Length of stay, # ICU days Quality of care measures (door-to-drug, door-to-balloon times)

21. 21 Development And Implementation Of Critical Pathways Identify problems ( practice variation) Identify working committee/task force to develop path Distribute draft Critical Pathway to all personnel and departments involved. Revise based on approach. Implement pathway Collect and monitor data on pathway performance. Modify the pathway as needed to further improve performance.

22. 22 Methods of Implementation of Pathways Specific case manager for each Pt –High compliance, high cost Standardized order sheets, Pocket guides “Championing” - Grand rounds Recent study -> similar improvements in care with either formal or simpler pathways (Holmboe, ES et al. Am J Med 1999;107:324-31.)

23. 23 Goal: < 30 Minutes NHAAP Ann Emerg Med 1994;23:311-29.

24. W. Rogers, personal communication

25. 25 BWH Thrombolysis Critical Pathway: Initial Experience *P=0.013 Cannon CP, et al. Clin Cardiol 1999;22:17-22 BEFORE

26. 26

27. 27 Guidelines Applied in Practice (GAP) Launched by ACC in February 2000 to: –Bridge gap between ideal therapy and treatment practice –Create/implement guideline tools/processes Initial project: –Michigan hospitals –Implemented 1999 ACC/AHA AMI Guideline –Determine whether quality of care can be improved via guideline tools –Status: pilot completed, expansion now in progress Mehta R, et al. JAMA. 2002;287:1269-1276.

28. 28 (343) (404) (213) (245) (131) (252) ASA BBLDL CHOL ** * p < 0.05 ** p < 0.01 Time in Minutes (40) (24) (32) (45) LYSIS PTCA PRE POST GAP Results: Early Indicators Mehta R, et al. JAMA. 2002;287:1269-1276.

29. 29 GAP: Adherence Improves With Tool Use Mehta R, et al. JAMA. 2002;287:1269-1276. Quality Adherence, % Pre-intervention No Tool Use Tool Use Post-intervention 0 20 40 60 80 100 Aspirin  -Blocker LDL Cholesterol No. of Ideal Patients 81 86 93 65 73 77 64 82 343308962131747113116587 P =.004P =.001

30. Demographics 6 clicks Clinical/Lab 8 clicks Discharge meds and interventions 7 clicks Interactively checks patient’s data with the AHA guidelines

31. 31 Importance of Data-Collection Registries Track adherence to guidelines Support local quality-improvement programs Compare practice patterns/outcomes with benchmarks Comply with regulatory requirements Provide research data Major Data-Collection Registries –NRMI –AHA Get With the Guidelines –ACC NCDR –GRACE –CRUSADE –VA transformation

32. 32 VA Transformation - Methods 1995, VA launched a major reengineering of its health care system with aims that included: –Better use of information technology, –measurement and reporting of performance, –and integration of services –and realigned payment policies. Jha AK, et al. N Engl J Med 2003;348:2218-27.

33. VA Transformation - Results

34. 34 Conclusions Critical pathways hold great promise to improve –Quality of care, –Clinical outcomes –Cost-effectiveness Initial studies show better quality of care and suggest improved outcomes