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Closing the CHD Treatment GAP

Closing the CHD Treatment GAP. Saving Lives Through Better Implementation of Secondary Prevention Measures. The Impact of Coronary Heart Disease in the United States. 14 million Americans alive today have a history of myocardial infarction, angina, or both. 1

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Closing the CHD Treatment GAP

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  1. Closing the CHD Treatment GAP Saving Lives Through Better Implementation of Secondary Prevention Measures

  2. The Impact of Coronary Heart Disease in the United States • 14 million Americans alive today have a history of myocardial infarction, angina, or both.1 • 450,000 recurrent myocardial infarction occur each year, most of which could have been prevented • 25% of men and 38% of women will die within 5 years of presenting with a AMI2 • Studies suggest that a large number of CAD patients do not receive the therapies that can prevent recurrent events and save lives 3-5 1 AHA Heart and Stroke Facts: 1996 Statistical Supplement 2 Rossouw, et al., N Engl J Med, 323:1112-1119.1990 3 Cohen, et al., Circulation, 83(4):1294-1304, 1991 4 Nieto, et al., Arch Intern Med, 155:677-684, 1995 5 Giles, et al., JAMA, 269 (9):1131-1138, 1993

  3. AHA/ACC Guidelines to Risk Reduction For Patients With CHD and Other Vascular Disease • Cessation of smoking • Lipid Management Goals • Primary Goal: LDL < 100 mg/dl • Secondary: HDL > 35 mg/dl TG < 200 mg/dl • Physical activity: 30 minutes 3-4 times per week • Weight management • Antiplatelet/anticoagulants:ASA 80 to 325 mg/day • (or warfarin) • ACE inhibitors (post-MI for LVD) • Beta blockers for high-risk patients post-MI • Blood pressure control: goal < 140/90 mm Hg Adapted from Smith, Circulation 1995;92:3

  4. Comprehensive Medical Therapy For Patients with CHD or Other Vascular Disease Risk Reduction • ASA 20-30% • Beta Blockers 20-35% • ACE inhibitors 22-25% • Statins 25-42% The four medications every atherosclerosis patient should be treated with, unless contraindications exist and are documented Adapted from the UCLA CHAMP Guidelines 1994

  5. “Despite compelling scientific evidence and national treatment guidelines supporting the use of secondary prevention medical therapies, these treatments continued to be underutilized in CVD patients receiving conventional care”

  6. CAD Treatment Gap - Community Physician Awareness of NCEP Guideline Patient Treated to Goal Provider awareness does not equal successful implementation Pearson Arch Intern Med 2000;160:459-67

  7. CAD Treatment Gap - Academic Centers Brigham and Women’s Hospital: 2003 outpts with CAD Arch Intern Med 2001:161:53-58 LDS Hospital: 600 CAD patients discharged post cath Am J Card 2001;87:256-261 Cleveland Clinic: 537 Diabetics with CAD Post PTCA JACC 1999;33:1269-77 PURSUIT Trial Centers: 8515 ACS patients JACC 2000;35:411A Lipid Lowering Medication Treatment Rates The Brigham LDS Hospital Cleveland Clinic PURSUIT Trial Centers An academic environment does not equal successful implementation

  8. Quality Assurance Program (QAP) At Goal “On Therapy” 7% n = 48,586 At Goal “No Therapy” 4% No LDL-C Documented “No Therapy” 43% Not at Goal “On Therapy” 18% Not at Goal “No Therapy” 14% No LDL-C Documented “On Therapy” 14% Sueta C, et al. Am J Cardiol. 1999;83:1303-1307.

  9. CAD Treatment Gap - Hospital • ACC Evaluation of Preventive Therapeutics (ACCEPT) Data - Hospital data (N=50) 1996-97 • Treatment Gap of 80 % • NRMI 3 Data - 1998-1999 • 32 % of Post-MI patients discharged on a lipid lowering agent (N = 138,001) Treatment gap is not a deficit of knowledge, rather it is a deficit of implementation Pearson, T.A. et al., Supplement to Circulation: Oct, 1997;96:8:1733 Fonarow Circulation 2001;103:38-44.

  10. Risk Factor Goal On At Discharge 6 mo. Post Admission Discharge LDL-C < 100mg/dL 0% 0% 24% Lipid Lowering Drug 21% 24% 59% Aspirin 44% 86% 87% Beta Blocker 34% 58% 63% ACCEPT: Most Hospitalized CHD Patients are Not at Goal 6 Months Post Discharge Pearson, T.A. et al., Supplement to Circulation: Oct, 1997;96:8:1733.

  11. Utilization of Lipid-Lowering Medications at Discharge in Patients with AMI Independent Predictors Catheterization Use of Beta Blocker Smoking Cessation CABG Teaching Hospital decreased increased 138,001 patients discharged post AMI from 1470 US hospitals, July 1998 to June 1999 Fonarow Circulation 2001;103:38-44

  12. Utilization of Lipid-Lowering Medications at Discharge in Patients with AMI 100 Male (N=83,806) Female (N=54,195) 80 60 P<0.0001 % Discharged on Lipid Therapy P<0.0001 P<0.0001 40 P=NS P=NS 20 0 <55 55-64 65-74 75-84 85+ Age (Years) "Use of Lipid-Lowering Medications at Discharge in Patients With Acute Myocardial Infarction" Fonarow Circulation 2001;102:38-44

  13. CVD Treatment Gap OFFICE SETTING QAP DATA • 30-40% Documented Treatment Rate • Treatment Gap of 66% BURDEN OF DISEASE • 23 million CHD patients in the US HOSPITAL SETTING NRMI / ACCEPT DATA • 20-32% Documented Treatment Rate • Treatment Gap of 68-80% BURDEN OF DISEASE • 2.7 million annual CHD discharges in the US

  14. National Hospital Discharge Ratesfor Secondary Prevention Cessation Report from 7/99 to 6/00 NRMI Registry Discharge Medications at 1552 National NRMI III Hospitals (n=167,312) Includes all patients (no exclusions for contraindications or intolerance)

  15. Physician is focused on acute problems Time constraints and lack of incentives, including reimbursement Lack of training including inadequate knowledge of benefits and lack of prescription experience Lack of resources and facilities Lack of specialist-generalist communication; passing on responsibility Barriers to Implementing Risk Factor Management in Patients with Documented Coronary Artery Disease Guidelines and treatment pathways which delay therapy and call for multiple steps, laboratory tests, and time points

  16. Incentives for Change • NCQA/HEDIS/JCAHO/GOA reporting measures • Hospitals • Managed Care • Physicians • Consumer demand for quality care / report cards Graded on • ASA after AMI • Beta blocker after AMI • ACEI after AMI and CHF • LDL evaluated/Rxed post cardiac hospitalization

  17. CVD Treatment System Goals • Implement initiatives to put evidence based guidelines into action • Improve the quality of care for patients with established cardiovascular disease • Reduce secondary events - and save lives

  18. Optimal Hospital Discharge Ratesfor Secondary Prevention Indicator Rate Optimal ASA 85%* 100% Beta Blocker 72%* 100% ACE-I 71%* 100% Smoking Cessation 40%* 100% Lipid Lowering 32%** 100% *HCFA 1998 and **NRMI 1999 Optimal: UCLA Cardiology Performance Improvement Committee (patients without contraindications or medical intolerance)

  19. Why a Hospital Based System? • Patients • Patient Capture Point • Have patients/family attention: “teachable moment’ • Predictor of care in community • Hospital Structure • Standardized processes/protocols/orders/teams • JCAHO • Process Improvement Examples • HCFA--Peer Review Organizations • Six Scope of Work

  20. In-Hospital Initiation of Risk Factor Modification and Cardioprotective Therapies Initiation of interventions for smoking cessation while patients are hospitalized with AMI has been shown to result in higher cessation rates then similar interventions initiated in the outpatient setting (1 year cessation rate of 71% vs 45%, P<0.01) The UCLA Comprehensive Heart Failure Management Program demonstrated a 96% utilization rate of ACEI at 6 months when treatment was initiated at the time of hospitalization, a rate which was significantly higher as compared to conventionally managed outpatients Taylor Annals Intern Med 1990;113:118-123 Fonarow JACC 1997;30:725-732

  21. CHD Patient Flow in the Hospital Advocate/Champion Inpatient Care Group Practice Outpatient Care Lab Quality Control Cath Cardiologist 2.7 Million 6 Million ICU/CCU Acute Coronary Event Discharge Nurse Family Practice ER Cardiology Medicine LOST Discharged Telemetry Inpatient Rehab Pharmacy Outpatient Rehab 10% Protocol development process Implementation

  22. BARRIERS 1. Communication gaps - cardiologists vs PCPs 2. Lack of ownership - acute vs chronic disease dilemma 3. Poor lab standardization and reporting 4. Lack of financial incentives 5. Lack of tools/resources 6. Lack of proof of concept SOLUTIONS 1. Education and mobilizing case management teams 2. Hospital is the capture point for patients with acute disease 3. Routine lipid testing for CHD patients by protocol 4. Joint Commission, NCQA, PROs will be measuring and reporting 5. HCFA - 6 scope of work, Joint Commission, ORYX are standardizing measurement tools 6. UCLA CHAMP demonstrates improved treatment rates and outcomes Challenges to In-Hospital Initiation of Lipid Lowering Treatment

  23. Challenges to a Hospital Based System this will not work in a community hospital the cardiologists will not agree to this we can not get a consensus the primary care physicians will not agree to this the managed care organization will not pay for it patients do not want to be on a lot of medications there is not enough time the lipid panel in not accurate when drawn in the hospital it may not be safe to start lipid lowering medications in hospitalized patients it will cost too much this will benefit the competition what about the liability the hospital administration will not pay for it there are exceptions x, y, and z it will take too much time it is too hard to get things through the hospital committee the patients should all be followed in my lipid clinic the physicians at my hospital do not like cookbook medicine we do not have anyone to collect this data

  24. Design of the UCLA Cardiovascular Hospitalization Atherosclerosis Management Program :CHAMP • Based on hypothesis that physician use of and patient compliance with secondary prevention therapies could be improved with a hospital based treatment initiation program • Focused on initiation of aspirin, beta blocker, ACE inhibitor, and statin dosed to achieve LDL < 100 mg/dl in all cardiovascular disease patients prior to hospital discharge • Use of preprinted orders, simple guidelines, educational lectures, discharge forms, and prospective monitoring of treatment use. • Started in 1994 and continues to be the standard of care at UCLA Fonarow Circulation 1997;96(8):I-67

  25. CHAMP Algorithm for Patients with Clinically Evident Atherosclerosis

  26. Implementation of CHAMP Fonarow Circulation 1997;96(8):I-67

  27. Standardized Admission Order Sheets Patient ID #

  28. Implementation of CHAMP

  29. Impact of CHAMP on Treatment Rates

  30. Proof of Concept The UCLA-CHAMP Experience CAD Patient Treatment Rates *Fonarow, G. et al. “Improved Treatment of Cardiovascular Disease by Implementation of a Cardiac Hospitalization Atherosclerosis Management Program: CHAMP,” Abstract #364 from the 70th Scientific Sessions, American Heart Association, November, 1997.

  31. Results: Adherence to NCEP Treatment Goals in Patients One Year Post Myocardial Infarction Fonarow Am J Cardiol 2001;87:819-822

  32. Pre and Post CHAMP Clinical Event Rates * * * * P < 0.05 * Follow-up for one year after discharge after acute myocardial infarction Fonarow Am J Cardiol 2001;87:819-822

  33. CHAMP ~ Impact on Clinical Outcomes in the First Year Post Hospital Discharge RR 0.43 p<0.01 256 AMI pts discharged in 92/93 pre-CHAMP compared to 302 pts in 94/95 post-CHAMP ASA 78% vs 92%; Beta Blocker 12% vs 61%; ACEI 4% vs 56%; Statin 6% vs 86% Fonarow Am J Cardiol 2001;87;819-822

  34. CHAMP ~ Sustained Impact Over a 6 Year Period UCLA 77 59 41 Comparison to National Rx Rates 28 NRMI 98/99 NRMI Registry Discharge Medications at UCLA compared to 1437 NRMI Hospitals

  35. The CHAMP Protocol was associated with a significant increase in treatment utilization at the time of hospital discharge of medications previously demonstrated to improve survival in patients with CAD. Initiation of cholesterol lowering medications prior to hospital discharge is safe, results in a high rate of utilization during longer term follow-up, and results in a significant increase in patients reaching LDL < 100 mg/dl. CAD risk factor modification and treatment can be systematically integrated into the treatment received during cardiac hospitalizations without additional resources or medical personnel and is considerably more effective than conventional guidelines and care. Implementation of a Cardiovascular Hospitalization Atherosclerosis Management Program: CHAMP

  36. Early Statin Treatment and Survival in AMI 25% Risk Reduction RR 0.75 (0.63-0.89) P=0.001 19,599 men and women < 80 yo discharged post AMI, 58 Swedish Hospitals, 1995-1998 5528 (28%) statin rx vs 14071 (72%) no statin rx, highest hospital rates of use 48%; lowest 12% Stenestrand JAMA 2001;285;430-436

  37. In-Hospital Lipid Lowering Therapy is Associated with Markedly Lower Mortality

  38. Clinical Implications At present, a large number of patients with coronary artery and other atherosclerotic vascular disease are not receiving treatments that have been demonstrated to reduce recurrent cardiovascular events and mortality. Widespread application of hospital based treatment programs such as GWTG could dramatically effect CVD treatment rates with proven cost-effective therapies and thus substantially reduce the risk of future coronary events and prolong life in the large number of patients hospitalized each year with CVD.

  39. Problem: Large CVD treatment gap and poor patient compliance with conventional management Solution: In-hospital initiation of therapy with excellent treatment rates and long term patient compliance Simple, Rapid, and Most Importantly Effective

  40. “The CHAMP study shows that the key to keeping heart disease patients alive is providing them with immediate and thorough treatment before they walk out of the hospital” “This study provides the scientific foundation for programs similar to CHAMP such as the AHA’s new hospital-based quality improvement program called Get With The Guidelines” Sidney Smith MD AHA Chief Science Officer

  41. What’s Involved in Starting a Hospital Based Treatment Program • Collect baseline data or use existing data source • i.e. NRMI IV or collect data with discharge nurse, medical student, etc. • Appoint team to develop treatment algorithm, preprinted orders, discharge forms • Present at lectures and staff in-services • present results • review successes and failures • lead discussion regarding recommendations on protocol improvement • Revise Protocol to close Gaps • Communicate Revisions to Key departments • Repeat cycle every quarter = CQI

  42. Continuous Quality Improvement (CQI) Process Assess CHD Treatment Rates Implement Refined Protocol Evaluate Assessment Refine Protocol

  43. Hospital BasedContinuous Quality Improvement (CQI) Process • Mobilize GWTG Initiative • Establish “Buy In” • Identify “Champions” • Build Team • Plan & Prep Program • Attend CME Program • Develop Hospital Plan • Assign Roles & Responsibilities • Monitor & Support • Collect & Report f/u Data • Review & ImproveProcess • Implement Program • Establish D/C Protocol • Collect Baseline Data • Obtain consensus

  44. What is the AHA“Get With the Guidelines” Program ? Implemented by AHA Affiliates/Volunteers who will mobilize advocacy networks at the Affiliate level to: • Implement CME-driven educational programs • Provide workshops for dissemination of guidelines • Develop care maps • Formalize a national discharge protocol • Implement discharge protocols in hospital setting • Identify best practices for AHA recognition awards • Develop and disseminate reports and publications • Measure changes and report outcomes data • Drive impact into communities

  45. GWTG Tools and Resources • AHA/ACC Guidelines • AHA National Discharge Protocol/Discharge Form Template • Care maps - ED, cath lab, etc. • CME programs • AHA National teleconferences • Public Service Announcements • National and regional advocates

  46. www.med.ucla.edu/champ www.americanheart.org

  47. Secondary Prevention: Making it a Reality • A major CHD treatment gap still exists • The hospital is the ideal capture point, provides a teachable moment, and predicts care in the community • Programs like CHAMP improve treatment rates and saves lives, making it essential that each hospital implement a prospective process to help improve CHD patient care immediately • Measure and report treatment rates to ensure CHD patient care is optimal

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