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CRUSADE/ACTION Update

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. CRUSADE National CQI .

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CRUSADE/ACTION Update

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

  2. 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

  3. CRUSADE Highlights – • Data collection: 7/2001- 12/2006 • > 500 US sites participated in CRUSADE • 25% academic, 68% with PCI/CABG • 201,032 ACS patients 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

  4. 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 ± 11 63 ± 12 67 ± 11 69 ± 14 Female sex (%) 36 39 34 40 Diabetes mellitus (%) 23 23 29 33 Prior MI (%) 32 25 28 30 Prior CHF (%) 11 8 9 18 Prior PCI (%) 13 18* 20 21 Prior CABG (%) 12 18* 17 19 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 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

  6. Variations Among Hospitals430 CRUSADE hospitals Acute Discharge Peterson et al, JAMA 2006;295:1863-1912

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

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

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

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

  11. Must Come Down: DES UseJuly 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 OutcomesN=318 Hospitals; 56,245 Patients - Peterson ACC 2006

  14. 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;40:1895-901

  15. 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

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

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

  19. ACTION 2007 Cumulative Data Submission Number of records

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

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

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

  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

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