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

CIHR Team Grant in Cardiovascular Outcomes Research

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 PanelChristopher 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

CCORT/CCS AMI Quality Indicator Expert Panel

CIHR Team Grant in Cardiovascular Outcomes Research

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

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

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

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

Continuous Quality ImprovementConcept

Guidelines

Outcomes

Clinical Trials

Performance Indicators

Performance1 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

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

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

2008 CCORT/CCS AMI Quality Indicator Expert Panel Process

• 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

CIHR Team Grant in Cardiovascular Outcomes Research

ACC/AHA Attributes for Quality Indicators• Useful in improving

patient outcomes1. Evidence-based2. Interpretable3. Actionable

• Measure implementation1. Feasibility

a. Reasonable effortb. Reasonable costc. Reasonable time period

for collection

• Measure Design1. Denominator precisely

defined2. Numerator precisely

defined3. Validity

a. Face validityb. Content validityc. Construct validity

4. ReliabilityKrumholz 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

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.

ACC/AHA Level of Evidence

CIHR Team Grant in Cardiovascular Outcomes Research

“Ideal” Subset Methodology

All cases Cases not eligiblefor process of care

Cases with contra-indication to

process of careCases “ideal” to receiveprocess of care

CIHR Team Grant in Cardiovascular Outcomes Research

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

New/Revised In-hospital Process-of-Care and System IndicatorsPROCESS OF CARE QUALITY INDICATORSASA within 24 hours before hospital arrival or within 3 hours after hospital arrival

ACEI or ARB prescribed at hospital discharge

ECG within 10 minutes after hospital arrival

Primary PCI within 90 minutes after hospital arrival (measure separately for transferred / walk-in patients)Reperfusion therapy in eligible patients with ST segment elevation MI

Risk stratification (ie cardiac catheterization, exercise stress testing, etc )

Assessment of left ventricular functionSmoking advice, counselling or therapy during hospital stay

Referral for cardiac rehabilitation

SYSTEM INDICATORS

Fibrinolytic therapy within 60 minutes after call for emergency medical services

Primary PCI within 120 minutes after call for emergency medical services

Pre-hospital 12-lead ECG

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

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

Thank YouFor more information please visit

www.ccort.ca

CCORT welcomes feedback on these indicators. Please send comments or questions to Tara.ONeill@ices.on.ca