CCORT/CCS 2008 Quality Indicators for Acute Myocardial Infarction (AMI) Care - Introduction

1. CCORT/CCS 2008 Quality Indicators for Acute Myocardial Infarction (AMI) Care - Introduction Jack V. Tu MD PhD FRCPC, Laila Khalid MD, Linda Donovan BScN MBA, Dennis T. Ko, MD MSc for the CCORT/CCS AMI Quality Indicator Panel Christopher E. Buller MD, Virginia F. Flintoft BN MSc, Thao Huynh MD MSc, Cynthia A. Jackevicius PharmD MSc, Laurie J. Lambert PhD, Michael P. Love MB ChB MD, Michael J. Schull MD MSc, Heather Sherrard BScN MHA, Edward Y.K. Tsoi MD, Alain Vadeboncoeur MD CIHR Team Grant in Cardiovascular Outcomes Research

2. CCORT/CCS AMI Quality Indicator Expert Panel CIHR Team Grant in Cardiovascular Outcomes Research

3. Outline • The Practice Gap • What are Quality Indicators? • Canadian AMI Quality Indicators • 2003 CCORT/CCS AMI Quality Indicators • Update process • 2008 CCORT/CCS AMI Quality Indicators – What’s New? • Implementation strategies CIHR Team Grant in Cardiovascular Outcomes Research

4. The Practice Gap • Many new life-saving treatments developed for heart disease over the past three decades (fibrinolytics, PCI, statins, etc.) • Uptake of these advances in routine clinical practice has been slow and varied across jurisdictions • Result - A gap between ideal care and actual practice patterns CIHR Team Grant in Cardiovascular Outcomes Research

5. What are Quality Indicators? • ‘Quality indicators’ or ‘performance measures’ are intended to be a tool for measuring and improving the quality of care delivered • Based on: • Scientific evidence from clinical practice guidelines, clinical trials or expert panel consensus • Health system performance indicators have become very popular in Canada and other countries recently Sackett DL, et al. Evidence-Based Medicine: How to practice and teach EBM, 2nd edition. London: Churchill Livingstone, 2000. CIHR Team Grant in Cardiovascular Outcomes Research

6. Publication of AMI Indicators is mandated in the U.S. and the U.K.

7. Continuous Quality Improvement Concept 1 Roe MT, et al. Changing the model of car e for patents with ACS. Am Heart J 2003; 146: 605-12. CIHR Team Grant in Cardiovascular Outcomes Research

8. Canadian Quality Indicators for AMI • CCORT (a CIHR-funded outcomes research team) & the Canadian Cardiovascular Society (CCS) began development of the first Canadian AMI quality indicators in 2001 • Joint CCORT/CCS expert panel • Multi-disciplinary, national representation • 37 AMI Quality Indicators developed • First published in the CJC 2003

9. CCORT • CCORT is a group of over 30 outcomes researchers from 5 provinces (NS, QC, ON, AB, BC) who are working together on projects to measure and improve the quality of cardiac care in Canada • Funded by a CIHR Team Grant in Cardiovascular Outcomes Research • Institute for Clinical Evaluative Sciences (ICES) in Toronto is the national coordinating centre for CCORT • www.ccort.ca

10. Delphi Process Two-staged modified Delphi Panel Technique 3 key features: Anonymity; Iterative & Controlled feedback; Aggregation of responses 2 rounds of ratings of potential indicators Highest rated indicators included in final set Multi-disciplinary, national panel Work plan May 2007-Oct 2008 Literature Review Sept 07 Independent Rating (Round 1) Analysis of ratings Oct 07 Expert Panel Meeting (Round 2) Complete analysis & prepare summary Dec 07 Follow-up teleconference Draft paper Mar 08 Circulate for comments Finalize paper Oct 21 08 Publish paper 2008 CCORT/CCS AMI Quality Indicator Expert Panel Process CIHR Team Grant in Cardiovascular Outcomes Research

11. Useful in improving patient outcomes Evidence-based Interpretable Actionable Measure implementation Feasibility Reasonable effort Reasonable cost Reasonable time period for collection Measure Design Denominator precisely defined Numerator precisely defined Validity Face validity Content validity Construct validity Reliability ACC/AHA Attributes for Quality Indicators Krumholz HM, et al. ACC/AHA clinical performance measures for adults with STEMI and NSTE MI. J Am Coll Cardiol 2006;47:236-265. CIHR Team Grant in Cardiovascular Outcomes Research

12. ACC/AHA Level of Evidence Antman EM, et al. ACC/AHA guidelines for the management of patients with STEMI-Executive summary: A report of the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the management of patients with AMI). Circulation 2004;110;588-636.

13. CIHR Team Grant in Cardiovascular Outcomes Research

14. All cases Cases not eligible for process of care Cases with contra- indication to process of care Cases “ideal” to receive process of care “Ideal” Subset Methodology CIHR Team Grant in Cardiovascular Outcomes Research

15. In-hospital process-of-care, outcome and system indicators

16. New/Revised In-hospital Process-of-Care and System Indicators

18. Benchmarks • Expert panel unanimously set benchmark at 90% for all process of care indicators (vs. 70-90% in original set of AMI indicators) • Panel recognized that 90% might be unrealistic for some centres, and suggested setting an initial benchmark, to be increased by 10% increments annually to reach 90% CIHR Team Grant in Cardiovascular Outcomes Research

19. Implementation Strategies • Establish a system to support measurement and feedback of AMI quality indicators at your local hospital (e.g. clinical registry, chart audits, etc.) • Assemble a multidisciplinary team (e.g. EMS, ER docs, cardiologists, nurses, etc.) to discuss performance and develop strategies for achieving target benchmarks • Consider introduction or modification of standardized admission order sets, care pathways, and discharge plans for each patient • Participate in national, regional or local AMI quality improvement initiatives CIHR Team Grant in Cardiovascular Outcomes Research

20. Thank You For more information please visit www.ccort.ca CCORT welcomes feedback on these indicators. Please send comments or questions to Tara.ONeill@ices.on.ca