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Title: STEMI Care: National Perspective, Quality Reporting and Pay for Performance Washington State ACC Chapter Meeting Seattle


1
STEMI Care National Perspective, Quality
Reporting and Pay for PerformanceWashington
State ACC Chapter MeetingSeattle
  • Ralph Brindis, MD MPH FACC FSCAI
  • President-Elect, ACC
  • Senior Advisor for CV Disease, N.Cal. Kaiser
  • Clinical Professor of Medicine, UCSF
  • October 31, 2009

2
Conflicts of Interest
  • STEMI Care National Perspective, Quality
    Reporting and Pay for Performance
  • Ralph Brindis, MD MPH FACC FSCAI
  • NONE

3
ACC/AHA Guidelines Management of Patients with
STEMI TIME Recommendations
  • 1999 RECS Class 1A
  • Door to Needle 30 min
  • Door to Balloon lt90 min/-30min
  • 2004 RECS Class 1A
  • Door to Needle 30 min
  • Door to Balloon lt 90 min
  • Interhospital Transfer Door to Balloon lt 90 min

Antman, et al JACC 200444671-719
4
Options for Transport of Patients With STEMI and
Initial Reperfusion Treatment
Hospital fibrinolysis Door-to-Needle lt 30 min
Not PCI capable
Call 9-1-1 Call fast
  • EMS on-scene
  • Encourage 12-lead ECGs
  • Consider prehospital fibrinolytic if capable and
    EMS-to-needle within 30 min

Onset of symptoms of STEMI
9-1-1 EMS Dispatch
EMS Triage Plan
Inter-Hospital Transfer
PCI capable
GOALS
5 min
8 min
EMS Transport
Patient
EMS
Prehospital fibrinolysis EMS-to-needle lt 30 min
EMS transport EMS-to-balloon lt 90 min Patient
self-transport Hospital door-to-balloon lt 90
min.
Dispatch 1 min.
Total ischemic time within 120 min.
Golden Hour first 60 minutes
JACC 44 671,2004 Circ 110 588,2004
5
Clinical / Translational Research
Westfall JAMA 297 403,2007
6
Road Map for Transformation of Reperfusion
Therapy for STEMI
Step Key Aspects Reperfusion for STEMI
1 What care works ? Clinical Efficacy Research RCTs of Lysis vs PCI
2 Who benefits ? Outcomes Research Effectiveness Research Health Services Research ACTION Registry-GWTG
3 How Should Care Be Delivered ? Measurement accountability System redesign Spread of interventions Research in above domains ACC D2B Alliance AHA MissionLifeline
Dougherty D, Conway PH. JAMA 20082992319-21
Antman EM JACC 2008
7
The D2B Quality Alliance A Case Study in Success

8
D2B Alliance Goal
  • Goal
  • To achieve a door-to-balloon time of 90 minutes
    for at least 75 of non-transfer primary PCI
    patients with STEMI.

9
D2B Alliance - Hospitals
  • Over 1100 hospitals enrolled represents 48
    states, District of Columbia, Spain, India,
    Thailand, Canada, Brazil, Poland, Saudi Arabia,
    United Arab Emirates (and growing!)
  • ACC Chapters and Governors played a major role in
    recruiting local hospitals

10
D2B Alliance Member US Hospitals
11
Evidenced Based Strategies That Reduce Delay
1. ED physician activates the cath lab 2. One
call activates the cath lab 3. Cath lab team
ready in 20 30 minutes 4. Prompt data
feedback 5. Senior management commitment
6. Team-based approach. A pre-hospital ECG to
activate the cath lab is optional. While other
strategies exist, including having a cardiologist
in the hospital 24/7, they are not required for
participation in the D2B campaign.
http//www.d2balliance.org/
12
of D2B Alliance Hospitals Use of Recommended
Strategies
Baseline and Follow-up Surveys
Cath Team lt 30 min
Data Feedback
ED Activate
Pre- Hospital EKG
Single Call
13
D2B lt 90 MinutesApril 2005 to April 2008
76
63
53
D2B Launch November 2006
14
Distribution of Proportion of Hospitals by pts
receiving Primary PCI
D2B lt 90 Minutes
15
D2B Alliance/Registry Participation
16
Timeline of building a true
PAD Registry
ICD Long
National CardioVascularDataRegistry
IC3
SPECT MPI
EP Registry
IMPACT Registry
ACTION Registry
CARE Registry
ICD Registry
CathPCI Registry
17
Participants and Patient Records
Name of Participants of Patient Records
Hospital CathPCI 1200 10 million
Hospital ICD 1500 400,000
Hospital ACTION-GWTG 425 150,000
Hospital CARE 160 15,000
Hospital IMPACT Launched July 2009 --
Practice IC3 600 400,000
18
(No Transcript)
19
Current Site Distribution
Active Sites 365
WA (11)
ME (2)
VT (0)
ND (1)
MT (2)
MI
NH (1)
OR (9)
MN (5)
NY (11)
MA (3)
WI (11)
SD (1)
ID (1)
MI (12)
RI (0)
WY (0)
CT (3)
PA (23)
IA (6)
NJ (4)
NE (4)
OH (22)
DE (0)
NV (1)
IL (23)
IN (14)
WV (1)
MD (10)
VA (9)
UT (0)
CO (7)
KY (2)
KS (8)
MO (12)
DC (0)
CA (20)
NC (23)
TN (10)
SC (4)
OK (4)
AR (1)
AZ (2)
NM (1)
AL (1)
GA (10)
MS (3)
LA (2)
TX (26)
FL (17)
AK (1)
HI (0)
Last updated 12/31/08
20
Use of Reperfusion Therapy for STEMI
STEMI N 20,998
Reperfusion N 16,374 (78)
Not Eligible for Reperfusion Therapy
Contraindication Listed N 3,011 (14)
No Reperfusion No Contraindication Listed N
1163 (6)
Primary PCI 86 Fibrinolytics 13 Both PCI
Lytics 1
ACTION Registry-GWTG DATA January 1 December
31, 2008
Among patients receiving reperfusion
21
STEMI Primary PCI Results -Non-Transfer Patients
with DTB ? 90 mins
73 of the primary PCI patients are not
transferred in
22
In-Hospital Outcomes - STEMI
ACTION Registry-GWTG DATA January 1 December
31, 2008
Unadjusted mortality Transfusion among
non-CABG patients
23
Excessive Dosing of Anticoagulants by Age
Alexander KP, et. al. JAMA 2005
24
Why does it matter? Mortality falls even with
decreases in already low times!CathPCI Registry
2005-06 (N43,801) Rathore et al, Circulation,
AHA08 abstract 6174)
In-hospital Mortality
?D2B from 90 to 60 minutes associated with ?0.8
Mortality ?D2B from 60 to 30 minutes associated
with ?0.5 Mortality
25
Pre-Hospital ECG
treated within goal
  • ACTION registry - 2007
  • 27 (1,941 of 7,098) EMS transported patients had
    pre-hospital ECG
  • Trend for lower mortality 0.85 (0.63-1.01)

Diercks DB, J Am Coll Cardiol 2009531616
26
Quality can save Money!U. M. Khot et. Al.,
Emergency Department Activation of the
Catheterization Laboratory and Immediate Transfer
to an Immediately Available Catheterization
Laboratoryto Reduce Door to Balloon Time in ST
Elevation Myocardial Infarction. Circulation.
2007 116
  • Ed activation of Cath Lab Immediate transfer by
    Care Team
  • D2B decreased 113 min to 75 minutes
  • Transfer in 147 minutes to 85 minutes
  • Infarct size reduced (creatinine kinase)
  • LOS 5 /- 7 days to 3 /- 2 days
  • Cost 26K (/- 29k) to 18K (/- 9K)

27
STEMI Discharge Medications
Use
ACTION Registry-GWTG DATA January 1 December
31, 2008
28
10 Top Practical Suggestions !!
  • 10. STEMI tool Box in the ED
  • 9. Pre-printed MD Orders
  • 8. Pre-printed RN Check List
  • 7. STEMI On-call Parking
  • 6. Well Scripted Plan- Mock Drills, different
    shifts !
  • 5. Communication- avoid multiple pages
  • 4. Elevator Control
  • 3. ED transport to the Cath Lab
  • 2. Prompt Feedback evaluation of each STEMI
  • 1. Monthly meetings- communication

29
Door-to-Balloon TimePercent treated in lt 90
Minutesby Transfer Status
41
Non-transfer
33.1
Percent of Patients
Transfer
5.4
3.9
Year of Discharge
30
STEMI Door to Balloon and Door to Needle
TimesCumulative 12 Month Data
ACTION Registry-GWTG DATA January 1 December
31, 2008
DTB 1st Door to Balloon for Primary PCI DTN
Door to Needle for Lytics
31
STEMI Primary PCI Results - DTB Benchmarks for
Transfer-In Patients
1st Door to Balloon lt 90 Minutes

1st Door to Balloon lt 120 Minutes

27 of the primary PCI patients are transferred in
32
Obstacles to Rapid Transfer in STEMI
  • Delay in triage, evaluation, and diagnosis
  • Limiting staffing during off-hours
  • Fragmented and/or inadequate EMS services
  • Lack of integrated medical services
  • Limited experience with centralized AMI networks
  • Greater distances between community and tertiary
    hospitals
  • Inclement weather

33
Jacobs et al Circ. 116 217, 2007
  • National initiative
  • Improve quality of care outcomes in STEMI
  • Improve health care system readiness and response
    to STEMI.

www.americanheart.org/missionlifeline
34
www.americanheart.org/missionlifeline
  • The Need
  • The Goal
  • Guiding Principles
  • Implementation Plan
  • Guidelines,  Certification Recognition
  • History
  • FAQ
  • Protocols
  • Case Studies
  • Leaders Partners
  • News Publications

Social Networking Website
35
Improving Access to Timely Care for STEMI
THE IDEAL SYSTEM
Jacobs et al Circ. 116 217, 2007
36
  • Survey of Existing Systems Administration Locale
    (Urban, Rural) Processes of Care Financial
    Considerations
  • Construct Templates for System Development to Be
    Used by Other Providers

Point of Entry
EMS
Circ 116 e64, 2007
37
(No Transcript)
38
Mission Lifeline Collaborating Organizations
NHAAP CDC
Patient
NAEMT NAEMSP NASEMSO NEMSIS ACEP American
Ambulance Assn AACCN ENA
CMS Aetna UnitedHealth Networks
Payers
EMSED
AHRQ FDA JCAHO
Evaluation Outcomes
STEMIReferral
ACC ACTION/GWTG NRHA SCAI Society of Chest Pain
Centers ACP STS AACCN
Policy Makers
Center of Care
STEMIReceiving
PCI capable
CMS
Adapted from Jacobs et al. Circulation.
2007116217-230.
39
STEMI System Definition A "STEMI system" is an
integrated group of separate entities focused on
reperfusion therapy for STEMI within a region
that typically includes emergency medical
services (EMS) providers, at least one community
(non-PCI) hospital, and at least one tertiary
(PCI) center.   The system may include one or
more of the following elements 1.
Leadership teams of EMS, emergency medicine,
cardiology, nursing and administration
2. Standardized communication (i.e. STEMI
alert system) 3. Standardized transportation
4. Data collection and feedback.  
40
Percent of Vehicles with 12 Lead ECG Capability
What percentage of your vehicles
responding to suspected cardiac
patients in your Agency/organization
have 12 lead ECG acquisition devices?
41
Communication of Pre-hospital 12- Lead
Does your organization communicate pre-hospital
12-lead information? Check all that apply
40
42
12 Lead Activates the Cath Lab
In your Agency/Organization, is the field
providers 12-lead ECG information used to
activate the cath lab prior to arrival at the
receiving facility?
43
Destination Protocols
Are there destination protocols (i.e. bypass
non-PCI hospitals to go directly to PCI centers)
for patients that have had a pre-hospital
identification of a STEMI?
42
44
Systems Survey
45
260 systems
46
Mission Lifeline Metrics
  • May 2007
  • Eleven manuscripts were published in
    Circulation
  • Mission Lifeline was formally launched

45
47

Proposed Process Measures
EMS Process Characteristics
Time from Symptom Onset to 9-1-1 Call
Time from 9-1-1 Call to Ambulance Arrival
Proportion of patients for whom adequate ECGs were obtained and transmitted
Numerator PH ECG transmitted/Denominator PH ECGs obtained
PH ECGs/all EMS STEMI patients
Predictive accuracy (false-positive and false negative) of field dx

ED Process Characteristics
Door-to-first ECG
Proportion of STEMI-eligible pts receiving reperfusion (PCI, Lytic)
Door-to Cath lab time( for non-transfer) or door-to disposition time (For TI)
Proportion of patients ineligible for lytics but eligible for PCI who are not transferred acutely


Primary PCI Hospital Process Characteristics
Door to balloon time (from arrival at PPCI to balloon inflation, non TI)
First hospital door-to-balloon time (for TI)
Total patient ischemic time (symptom onset to balloon) stratifed by transfer status
Proportion of eligible pts administered guideline-based class I therapies
Proportion of suspected STEMI patients undergoing coronary angiography found not to have STEMI
48
Proposed Outcomes Measures
Hospital STEMI outcome measures
In-hospital (risk- adjusted) mortality
Longitudinal outcomes 30-day, 1-year (risk- adjusted) mortality
Morbidity events (in-hospital stroke, vascular complications)
PCI procedural success
Regional STEMI outcomes (aggregated across regional hospitals)
In-hospital (risk- adjusted) mortality
Longitudinal outcomes 30-day, 1-year (risk- adjusted) mortality
49
(N)STEMI Performance Measures
50
(N)STEMI Performance Measures
51
New Performance Measures
52
Mission Lifeline Bridging Form
Mission Lifeline Bridging Form
Powered by ACTION Registry-GWTG
53
A. DemographicsB. Time/Means of
AdmissionC. Cardiac Status- First
ContactD. Hx/RiskFactorsE. D/C Data
Web Based Entry Tool Available January 2010
54
E. MedicationsF. Procedures Tests Times
55
G. Reperfusion Strategy/TimesH.
In-Hospital Clinical ResultsI. Lab
ResultsJ. Optional Data AMI Core Measure
Reporting
56
Mission Lifeline Reporting Goals
  • Reports/graphics that emphasize System process
    measures
  • Reporting that features Points Of Entry for
    specific STEMI groupings
  • EMS
  • Non-PCI transfer-in
  • Direct Presenters Non-Transfer-In
  • State/Nation Reports

57
Reperfusion Options for the Patients With
Expected Delays
  • 1. Full-dose fibrinolytic, admission to the
    non-PCI hospital with selective transfer for
    rescue PCI
  • 2. Full-dose fibrinolytic, routine transfer to
    PCI hospital with aggressive rescue PCI
  • 3. Facilitated or pharmaco-invasive PCI
  • 4. Primary PCI (no matter how long it takes)
  • 5. Any of the above depending on the PCI facility
  • available and the cardiologist

CARESS-AMI and TRANSFER-AMI, and FINESSE suggest
that early Pharmaco-invasive approach preferred
in these patients Henry, JACC Interventions
October 2009
Henry, JACC Interventions October 2009
58
Minneapolis Regional SystemPharmaco-invasive
  • 30 institutions, 1 PCI center in a 210-mile
    radius
  • DX in ED of participating hospitals.
  • Single phone call to PCI hospital.
  • 11 hospitals 60 miles from PCI center (Zone 1)
  • None or one-half-dose tenecteplase (if no
    contraindication).
  • Direct transfer to cath lab (bypassing PCI center
    ED)
  • 19 hospitals 60210 miles from PCI center (Zone
    2)
  • One-half or full-dose tenecteplase (if no
    contraindication)
  • Direct transfer to cath lab (bypassing PCI
    center ED)
  • 70 transported by helicopter cardiac arrest in
    2

59
Regional STEMI System for PCIMinneapolis Mar
2003 - Nov 2006 N 1345
N297
N620
N396
Henry et al Circ 2007
60
MAYO Clinic Pharmaco-invasive
  • Regional system of care
  • 28 institutions, 1 PCI center, 150-mile radius
  • Dx local center. Single phone call to PCI
    hospital
  • A. If symptoms lt3 h full-dose fibrinolysis, if
    no contraindication (reteplase or tenecteplase)
  • Evaluation on admission at PCI center
  • if no reperfusion rescue PCI
  • otherwise, systematic coronary angiography in
    2448 hrs
  • B. If symptoms gt3 h Primary PCI.
  • Direct transfer to cath lab (bypassing PCI center
    ED)

61
Regional STEMI System for PCIMayo Clinic May
2004 - Dec 2006 N 597
N258
N105
N131
Ting et al Circ 2007
62
Percutaneous Coronary Interventions in
Facilities without On-Site Cardiac Surgery A
Report from the National Cardiovascular Data
Registry (NCDR)
  • Kutcher, MA, Klein LW, Ou F, Wharton TP, Dehmer
    GJ, Singh M, Anderson HV, Rumsfeld JS, Weintraub
    WS, Shaw RE, Sacrinty MT, Woodward A, Peterson
    ED, Brindis RG. J Am Coll Cardiol 20095416-24.

63
Background
  • The ACC/AHA/SCAI 2005 PCI Guidelines designated
    the following indications for PCI at centers that
    do not have surgery on-site
  • Primary PCI Class IIb may be considered
  • 36/year minimum volume
  • Elective PCI Class III not recommended
  • Smith SC Jr. et al. J Am Coll Cardiol
    200647216-35.
  • The 2007 Focused PCI Guideline Update did not
    address or change these designations.
  • King SB III et al. J Am Coll Cardiol
    200851172-209.

64
Study Population
65
Institutional Characteristics
Two sites had missing CMS bed data
66
Risk Adjusted Outcomes
Safety and Efficacy of PCI Without On-site
Surgical Back-up
67
Is P4P related to PCI mortality data a good or
bad thing- NO??
  • Unintended consequences -
  • Case selection creep
  • The patients with most potential benefit denied
    therapy
  • PCI in Cardiogenic shock and s/p Cardiac arrest,
  • Salvage CABG
  • The patients with the least potential benefit
    encouraged for treatment ?
  • Risk averse behavior, improve operator results,
    financial incentives
  • Negative incentive for Appropriate Use

68
Is P4P related to PCI Process data a good or bad
thing- NO??
  • Negative unintended consequences related to
    Door-to-Balloon time measure -
  • No reperfusion if would fall outside 90 minutes!
  • Transfer to another hospital- not my metric!
  • Perversion of measure
  • Balloon inflation in Aorta!
  • Affecting Clinical decision making
  • IABP delayed in Cardiogenic shock
  • Good news - Changing Reperfusion Performance
    Measures Masoudi , JACC 2008522100-12

69
Pay 4 Performance Principles
  • Built on established evidence-based performance
    measures
  • valid, current, comparable, risk-adjusted,
    standard definitions
  • 2. Create a business case for investing in
    structure, best practices, and tools that can
    lead to improvement
  • Reward process, outcome, improvement and
    sustained high performance
  • Brush ,
    JACC 2006482603-9
  •  

70
Pay 4 Performance Principles
  • Assign attribution to physicians in ways that
  • are credible and encourage collaboration
  • 5. Favor the use of clinical data over
  • administrative claims data
  • Physician review and correction
  • Validation if administrative data used
  • Set targets for performance through a national
  • consensus process
  • 7. Address appropriateness

Brush ,
JACC 2006482603-9
71
Pay 4 Performance Principles
  • 8. Positive, not punitive
  • 9. Audit performance measure data
  • 10. Establish transparent provider rating
    methods
  • 11. Not create perverse incentives.
  • Invest in outcomes and health services
  • research

Brush ,
JACC 2006482603-9
72
Final Thoughts
  • Are there enough high quality physicians and
    hospitals? (Need to move the curve)
  • What are the opportunity costs? (True reform in
    health care delivery including practice redesign
    and improved physician payment models)
  • Bottom Line ACC will always be AT THE TABLE so
    that cardiologists are not ON THE MENU!

73
STEMI System Process
  • Develop leadership,
  • funding, data structure

2) Establish REGIONAL PCI CENTERS (primary, lytic
ineligible, rescue)
Measurement Feedback
  1. Improve system

3a) HOSPITAL by hospital establishment of STEMI
plan (review, consensus, training)
3b) EMS by EMS establishment of STEMI
plan(review, consensus, training)
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