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10 Lessons Learned from CRUSADE: A National Quality Improvement Initiative

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10 Lessons Learned from CRUSADE: A National Quality Improvement Initiative

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  1. What Have We Learned from the CRUSADE Registry? Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC and AHA GuidelinesEric D. Peterson, MD, FACCProfessor of MedicineAssociate Vice Chair for Quality Duke University Medical CenterAssociate Director and Director of CV ResearchDuke Clinical Research InstituteDurham, NC

  2. 10 Lessons Learned from CRUSADE:A National Quality Improvement Initiative Eric D. Peterson, MD, MPH Professor of Medicine Vice Chairman of Quality, Dept of Medicine Duke University Medical Center Director of CV Research Duke Clinical Research Institute Disclosures: Research support from Schering Plough, BMS, Sanofi-Aventis, Merck-Schering,PDL Pharma

  3. 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

  4. Aspirin Clopidogrel Beta Blocker Reperfusion Rx (STEMI) Timely PCI, Lytics Heparin (NSTEMI) GP IIb-IIIa (NSTEMI) Targeted for Trop + Aspirin Clopidogrel Beta Blocker ACE Inhibitor Statin/Lipid Lowering Smoking Cessation Cardiac Rehabilitation Goals for CRUSADE: Improve Adherence to ACC/AHA Guidelinesfor Acute Coronary Syndrome Acute Therapies Discharge Therapies Circulation, JACC 2002 and 2004 - ACC/AHA Guidelines updates

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

  6. Lesson 1: Complexity of NSTEMI PtsSTEMI vs. NSTEMI Characteristics Variable CRUSADE STEMI CRUSADE NSTEMI (n = 8,011) (n = 180,842) Mean age ± SD (yrs) 62 ± 12 69 ± 14 Female sex (%) 31 40 Diabetes mellitus (%) 22 33 Prior MI (%) 18 30 Prior CHF (%) 6 18 Prior PCI (%) 17 21 Prior CABG (%) 7 19 CRUSADE through June 30, 2007

  7. Lesson 1 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

  8. 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

  9. Lesson 2: Acute Medications NSTEMI vs STEMI Use CRUSADE DATA: July 1, 2005 – June 30, 2006 (n=31,665)

  10. Lesson 2 Variations Among Hospitals430 CRUSADE hospitals Acute Discharge Peterson et al, JAMA 2006;295:1863-1912

  11. 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

  12. Lesson 4 Timely Care:Reperfusion among STEMI Patients • Median Times • Thrombolytics – 33 min • Primary PCI – 98 min Q2 2006 CRUSADE STEMI data

  13. Lesson 5: Invasive Cardiac Procedures(Excluding Patients with Contraindications to Cath) CRUSADE DATA: July 1, 2005 – June 30, 2006 (n=31,665)

  14. Lesson 6: Interventional Care Trends in Early Cath Use by Risk Status 75.5 64.1 63.2 53.5 32.2 26.6 Tricoci et al, AHA 2005 Abstract

  15. Trends in Type of Revascularization Strategy for 3-Vessel CAD in CRUSADE Gogo P, ACC Scientific Sessions, 2006

  16. Recent Decline in DES Use: CRUSADEJuly 2006- March 2007

  17. Lesson 7: Discharge Care Gaps % Use *LVEF < 40%, CHF, DM, HTN# Known hyperlipidemia,  TC, LDL CRUSADE DATA: July 1, 2005 – June 30, 2006 (n=31,665)

  18. Proportion of Patients Receiving 100% of All Guidelines-Recommended Therapies* Mehta et al, AHA 2005 *In patients without contraindications

  19. Challenges To Healthcare Delivery Medical Errors • Errors of omission • Failure to use therapies proven to be beneficial • Errors of commission • Inappropriate or incorrect use of treatment strategies, dose, procedures

  20. Lesson 8 Safe CareHospital Variation in RBC Transfusion Rates Percentage of Hospitals (%) Percentage of Patients Receiving Blood Transfusions (%) Yang X, J Am Coll Cardiol 2005;46:1490-5.

  21. Safety Concerns in ACS Care: Need for Blood Transfusions Yang X, JACC 2005;46:1490-5.

  22. Excessive Antithrombotic Dosing by Age Alexander KA, et al. JAMA 2005;294:3108-3116

  23. Lesson 9: Adjusted Risk By Transfusion Status* Death Death or Re-MI 1 2.0 * Non-CABG patients only Yang X, JACC 2005;46:1490-5.

  24. 1.09 (0.99, 1.26) 1.40 (1.12, 1.75) 1.38 (1.12, 1.70) 1.42 (1.16, 1.73) 2.02 (1.51, 2.69) Lesson 9: Likelihood of Major Bleeding with Excess Anti-thrombotic Dose Excess v. Recommended UF Heparin LMWH GP IIb/IIIa inhibitor One Excessive Agent Both Excessive 1 0 2 Adjusted* Odds of Major Bleeding Adjusted for age, sex, SBP, CHF, renal insufficiency Alexander KA, JAMA 2005

  25. 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

  26. Lesson 10 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

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

  28. CRUSADE to NCDR ACTION™ • Need for Growth • Many US hospitals not in CRUSADE • Need for Alignment • Several similar US registries (AHA GWTG, ACCPCI registry, NRMI) • Hospitals wanted single source answer • Need for National Policy Change: • Live under the direction of professional societies • Be single source answer for ACS for providers, payers and policy makers

  29. 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

  30. 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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