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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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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
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
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
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
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
Variations Among Hospitals430 CRUSADE hospitals Acute Discharge Peterson et al, JAMA 2006;295:1863-1912
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
Timely Care:Reperfusion among STEMI Patients Median Times • Thrombolytics – 33 min • Primary PCI – 98 min Q2 2006 CRUSADE STEMI data
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
Must Come Down: DES UseJuly 2006- March 2007 Data on File DCRI: CRUSADE/ACTION
Safe Care? Excessive Antithrombotic Dosing Alexander KA, et al. JAMA 2005;294:3108-3116
Lesson 9 Hospital Safety, Quality, and OutcomesN=318 Hospitals; 56,245 Patients - Peterson ACC 2006
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
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
Improvements in Guidelines Adherence And Rates of Drug Overdosing Over Time Rate of Excess Dosing Composite Adherence Rates Mehta RH, et al AHJ 2007
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
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
ACTION 2007 Cumulative Data Submission Number of records
Complexity of ACS PatientsSTEMI vs. NSTEMI ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007
In-Hospital OutcomesSTEMI vs. NSTEMI *Transfusion among non-CABG patients ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007
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
Acute Medications STEMI vs NSTEMI ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007 STEMI (n=11,854) NSTEMI (n=26,956)
Discharge Medications STEMI vs NSTEMI * Ideal Patients ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007 STEMI (n=11,854) NSTEMI (n=26,956)
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