Current State of Use of Evidence-Current State of Use of Evidence-

Based Therapies for Acute Based Therapies for Acute

Coronary SyndromesCoronary Syndromes

Current State of Use of Evidence-Current State of Use of Evidence-

Based Therapies for Acute Based Therapies for Acute

Coronary SyndromesCoronary Syndromes

Strategies to Improve Implementation of

Guidelines-Based Care

Strategies to Improve Implementation of

Guidelines-Based Care

AHA/ACC Guideline Recommendations AHA/ACC Guideline Recommendations

Aspirin Clopidogrel

Beta-Blocker

ACE-Inhibitor

Heparin (UFH or LMWH)

GP IIbIIIa Inhibitor High-risk patients All receiving PCI

Aspirin Clopidogrel

Beta-Blocker

ACE-Inhibitor

Heparin (UFH or LMWH)

GP IIbIIIa Inhibitor High-risk patients All receiving PCI

Aspirin Clopidogrel

Beta-Blocker

ACE-Inhibitor

Statin

Smoking Cessation

Cardiac Rehab

Aspirin Clopidogrel

Beta-Blocker

ACE-Inhibitor

Statin

Smoking Cessation

Cardiac Rehab

Acute TherapyAcute TherapyAcute TherapyAcute Therapy Discharge TherapyDischarge TherapyDischarge TherapyDischarge Therapy

JACC 2000;36:970-1062

ACC/AHA 2002 Update

JACC 2000;36:970-1062

ACC/AHA 2002 Update

NRMI-4 NSTE MI NRMI-4 NSTE MI AcuteAcute Care Care: 3rd Quarter 2001: 3rd Quarter 2001NRMI-4 NSTE MI NRMI-4 NSTE MI AcuteAcute Care Care: 3rd Quarter 2001: 3rd Quarter 2001

85%

71% 72%

24%

0%

20%

40%

60%

80%

100%

ASA Beta Blocker Heparin (all) GP IIb/IIIa

85%

71% 72%

24%

0%

20%

40%

60%

80%

100%

ASA Beta Blocker Heparin (all) GP IIb/IIIa

NRMI-4 NSTE MI NRMI-4 NSTE MI DischargeDischarge Care Care: 3rd Quarter 2001: 3rd Quarter 2001NRMI-4 NSTE MI NRMI-4 NSTE MI DischargeDischarge Care Care: 3rd Quarter 2001: 3rd Quarter 2001

84%75%

56%

71%

21%

0%

20%

40%

60%

80%

100%

ASA Beta Blocker ACEInhibitor *

Statins # CardiacRehab

* LVEF < 40%* LVEF < 40%# Known hyperlipidemia# Known hyperlipidemia* LVEF < 40%* LVEF < 40%# Known hyperlipidemia# Known hyperlipidemia

PerformanceQuality Indicator Bottom 10% Top 10%

ASA use < 24 h 54% 99%

-blocker use < 24 h 33% 98%

Heparin use <24 h 50% 92%

GP IIb-IIIa < 24 h 0% 51%

D/C ASA use 54% 99%

D/C -blocker use 44% 96%

D/C ACE-I use 21% 83%

D/C lipid lowering 33% 99%

PerformanceQuality Indicator Bottom 10% Top 10%

ASA use < 24 h 54% 99%

-blocker use < 24 h 33% 98%

Heparin use <24 h 50% 92%

GP IIb-IIIa < 24 h 0% 51%

D/C ASA use 54% 99%

D/C -blocker use 44% 96%

D/C ACE-I use 21% 83%

D/C lipid lowering 33% 99%

Gap between ‘Leading and Lagging’ US Hospitals

Gap between ‘Leading and Lagging’ US Hospitals

Evidence-Based Medicine:Evidence-Based Medicine:What’s the Problem?What’s the Problem?

Evidence-Based Medicine:Evidence-Based Medicine:What’s the Problem?What’s the Problem?

““There is an unsettling truth about the practice of medicine. …There is an unsettling truth about the practice of medicine. …

study after study shows that few physicians systematically study after study shows that few physicians systematically

apply to everyday treatment the scientific evidence about apply to everyday treatment the scientific evidence about

what works best.”what works best.”

““There is an unsettling truth about the practice of medicine. …There is an unsettling truth about the practice of medicine. …

study after study shows that few physicians systematically study after study shows that few physicians systematically

apply to everyday treatment the scientific evidence about apply to everyday treatment the scientific evidence about

what works best.”what works best.”

Millenson, ML. Demanding Medical Excellence: Doctors Millenson, ML. Demanding Medical Excellence: Doctors and Accountability in the Information Age, 1997and Accountability in the Information Age, 1997Millenson, ML. Demanding Medical Excellence: Doctors Millenson, ML. Demanding Medical Excellence: Doctors and Accountability in the Information Age, 1997and Accountability in the Information Age, 1997

Physician Barriers to Guidelines AdherencePhysician Barriers to Guidelines Adherence

Lack of awareness or agreement with guidelinesLack of awareness or agreement with guidelines

Lack of outcome expectancyLack of outcome expectancy Uncertainty regarding impact of guidelines Uncertainty regarding impact of guidelines

adherence on patient outcomesadherence on patient outcomes

Overcoming established practice patternsOvercoming established practice patterns

External barriers to improved careExternal barriers to improved care Time constraints, lack of resources, no remindersTime constraints, lack of resources, no reminders

Cabana M, JAMA 1999Cabana M, JAMA 1999Cabana M, JAMA 1999Cabana M, JAMA 1999

Does it Matter?

Correlating Process of Care with Outcomes

Does it Matter?

Correlating Process of Care with Outcomes

Additional LivesAdditional LivesCurrent UseCurrent Use Saved per 1,000 Saved per 1,000

TherapyTherapy (ideal pts)(ideal pts) (ideal use)(ideal use)

AspirinAspirin 86%86% 99

Beta-BlockersBeta-Blockers 59%59% 1111

ACE-InhibitorsACE-Inhibitors 52%52% 2323

CaCa2+2+ Blockers * Blockers * 27%* 27%* 1313

TotalTotal 5656

Additional LivesAdditional LivesCurrent UseCurrent Use Saved per 1,000 Saved per 1,000

TherapyTherapy (ideal pts)(ideal pts) (ideal use)(ideal use)

AspirinAspirin 86%86% 99

Beta-BlockersBeta-Blockers 59%59% 1111

ACE-InhibitorsACE-Inhibitors 52%52% 2323

CaCa2+2+ Blockers * Blockers * 27%* 27%* 1313

TotalTotal 5656

Alexander K, JACC, 1998Alexander K, JACC, 1998Alexander K, JACC, 1998Alexander K, JACC, 1998

* Contraindicated use in low EF pts * Contraindicated use in low EF pts Ideal benefits from 0% useIdeal benefits from 0% use* Contraindicated use in low EF pts * Contraindicated use in low EF pts Ideal benefits from 0% useIdeal benefits from 0% use

Benefits of Using Evidence-Based Therapies Benefits of Using Evidence-Based Therapies (Non-ST (Non-ST ACS Patients from GUSTO IIb) ACS Patients from GUSTO IIb)

Benefits of Using Evidence-Based Therapies Benefits of Using Evidence-Based Therapies (Non-ST (Non-ST ACS Patients from GUSTO IIb) ACS Patients from GUSTO IIb)

US News and World Reports’ US News and World Reports’ “Top Ranked Hospitals”“Top Ranked Hospitals”

US News and World Reports’ US News and World Reports’ “Top Ranked Hospitals”“Top Ranked Hospitals”

Risk-Adjusted Mortality

15.6

18.3 18.6

0

10

20

Top-ranked

Similiarlyequipped

Notsimiliarlyequipped

Risk-Adjusted Mortality

15.6

18.3 18.6

0

10

20

Top-ranked

Similiarlyequipped

Notsimiliarlyequipped

Use of ASA and BB

91.5

63.8

82.7

47.6

75.7

43.5

0

50

100

ASA BB

Use of ASA and BB

91.5

63.8

82.7

47.6

75.7

43.5

0

50

100

ASA BB

Chen J, NEJM, 1999Chen J, NEJM, 1999Chen J, NEJM, 1999Chen J, NEJM, 1999

p < 0.01

Adherence to ACC/AHA Guidelines and Mortality:Adherence to ACC/AHA Guidelines and Mortality: Results from NRMI-4 (n= 57,806 Acute MI patients, 1185 hospitals)Results from NRMI-4 (n= 57,806 Acute MI patients, 1185 hospitals)

Adherence to ACC/AHA Guidelines and Mortality:Adherence to ACC/AHA Guidelines and Mortality: Results from NRMI-4 (n= 57,806 Acute MI patients, 1185 hospitals)Results from NRMI-4 (n= 57,806 Acute MI patients, 1185 hospitals)

024

6

8

1012

14

16

30-50% 50-60% 60-70% >70%

% In

-ho

spit

al M

ort

alit

y

Rate of Hospital Composite Adherence (13 Indicators)Rate of Hospital Composite Adherence (13 Indicators)

Peterson E, ACC 2002Peterson E, ACC 2002Peterson E, ACC 2002Peterson E, ACC 2002

Local Quality Improvement InitiativeLocal Quality Improvement InitiativeLocal Quality Improvement InitiativeLocal Quality Improvement Initiative

Francis M. Fesmire, MDFrancis M. Fesmire, MD

Erlanger Medical CenterErlanger Medical Center

Chattanooga, TNChattanooga, TN

Francis M. Fesmire, MDFrancis M. Fesmire, MD

Erlanger Medical CenterErlanger Medical Center

Chattanooga, TNChattanooga, TN

Erlanger QI Project - ObjectivesErlanger QI Project - ObjectivesErlanger QI Project - ObjectivesErlanger QI Project - Objectives

Determine early utilization of GP IIb-IIIa Determine early utilization of GP IIb-IIIa

inhibitors use in ED in high-risk NSTE ACS inhibitors use in ED in high-risk NSTE ACS

patientspatients

Implement stepped QI programImplement stepped QI program

Re-measure effectiveness of QI programRe-measure effectiveness of QI program

Determine early utilization of GP IIb-IIIa Determine early utilization of GP IIb-IIIa

inhibitors use in ED in high-risk NSTE ACS inhibitors use in ED in high-risk NSTE ACS

patientspatients

Implement stepped QI programImplement stepped QI program

Re-measure effectiveness of QI programRe-measure effectiveness of QI program

Prospective Observational Study Prospective Observational Study

2,074 patients presenting with chest pain2,074 patients presenting with chest pain

Patients not undergoing urgent cardiac cath Patients not undergoing urgent cardiac cath underwent standard Chest Pain Evaluation underwent standard Chest Pain Evaluation Protocol at ErlangerProtocol at Erlanger

Prospective Observational Study Prospective Observational Study

2,074 patients presenting with chest pain2,074 patients presenting with chest pain

Patients not undergoing urgent cardiac cath Patients not undergoing urgent cardiac cath underwent standard Chest Pain Evaluation underwent standard Chest Pain Evaluation Protocol at ErlangerProtocol at Erlanger

Erlanger QI Project - MethodsErlanger QI Project - MethodsErlanger QI Project - MethodsErlanger QI Project - Methods

Control (months 1-4): No interventionControl (months 1-4): No intervention

Phase I (months 5-8): Posted eligibility criteria Phase I (months 5-8): Posted eligibility criteria for GP IIb/IIIa inhibitors in EDfor GP IIb/IIIa inhibitors in ED

Phase II (months 9-12): Mandated QI form for Phase II (months 9-12): Mandated QI form for completion by the evaluating ED physician completion by the evaluating ED physician with weekly review and feedbackwith weekly review and feedback

Control (months 1-4): No interventionControl (months 1-4): No intervention

Phase I (months 5-8): Posted eligibility criteria Phase I (months 5-8): Posted eligibility criteria for GP IIb/IIIa inhibitors in EDfor GP IIb/IIIa inhibitors in ED

Phase II (months 9-12): Mandated QI form for Phase II (months 9-12): Mandated QI form for completion by the evaluating ED physician completion by the evaluating ED physician with weekly review and feedbackwith weekly review and feedback

Erlanger QI Project - InterventionsErlanger QI Project - InterventionsErlanger QI Project - InterventionsErlanger QI Project - Interventions

% of patients who received GP IIb/IIIa inhibitors:% of patients who received GP IIb/IIIa inhibitors:

Control Phase: 6%Control Phase: 6%

Phase I QI Intervention: 16%Phase I QI Intervention: 16%

Phase II QI Intervention: 45%Phase II QI Intervention: 45%

% of patients who received GP IIb/IIIa inhibitors:% of patients who received GP IIb/IIIa inhibitors:

Control Phase: 6%Control Phase: 6%

Phase I QI Intervention: 16%Phase I QI Intervention: 16%

Phase II QI Intervention: 45%Phase II QI Intervention: 45%

Erlanger QI Project - Results (1)Erlanger QI Project - Results (1)Erlanger QI Project - Results (1)Erlanger QI Project - Results (1)

Reasons for not treatment in Phase IIReasons for not treatment in Phase II 63% - ED Physician Never Realized Eligibility63% - ED Physician Never Realized Eligibility 24% - Treatment was perceived to delay 24% - Treatment was perceived to delay

transfer to the cardiac cath labtransfer to the cardiac cath lab 10% - Admitting Physician did not want 10% - Admitting Physician did not want

GP IIb/IIIa inhibitors to be administeredGP IIb/IIIa inhibitors to be administered 3% - Contraindication3% - Contraindication

Reasons for not treatment in Phase IIReasons for not treatment in Phase II 63% - ED Physician Never Realized Eligibility63% - ED Physician Never Realized Eligibility 24% - Treatment was perceived to delay 24% - Treatment was perceived to delay

transfer to the cardiac cath labtransfer to the cardiac cath lab 10% - Admitting Physician did not want 10% - Admitting Physician did not want

GP IIb/IIIa inhibitors to be administeredGP IIb/IIIa inhibitors to be administered 3% - Contraindication3% - Contraindication

Erlanger QI Project - Results (2)Erlanger QI Project - Results (2)Erlanger QI Project - Results (2)Erlanger QI Project - Results (2)

UCLA Cardiovascular Hospitalization UCLA Cardiovascular Hospitalization Atherosclerosis Management Program Atherosclerosis Management Program

(CHAMP)(CHAMP)

UCLA Cardiovascular Hospitalization UCLA Cardiovascular Hospitalization Atherosclerosis Management Program Atherosclerosis Management Program

(CHAMP)(CHAMP)

Gregg C. Fonarow, MD; Anna Gawlinski, DNScGregg C. Fonarow, MD; Anna Gawlinski, DNSc

Am J Cardiol 2000;85:10A-17AAm J Cardiol 2000;85:10A-17AAm J Cardiol 2001;87:819-822Am J Cardiol 2001;87:819-822

CHAMP - Program Overview (1)CHAMP - Program Overview (1)CHAMP - Program Overview (1)CHAMP - Program Overview (1)

CHAMP focused on the in-hospital initiation of:CHAMP focused on the in-hospital initiation of: AspirinAspirin Cholesterol-lowering therapy (statins)Cholesterol-lowering therapy (statins) Beta-blockersBeta-blockers ACE-InhibitorsACE-Inhibitors

Medical interventions were done together with diet, Medical interventions were done together with diet, exercise, and smoking cessation counseling before exercise, and smoking cessation counseling before discharge in patients with acute MIdischarge in patients with acute MI

CHAMP focused on the in-hospital initiation of:CHAMP focused on the in-hospital initiation of: AspirinAspirin Cholesterol-lowering therapy (statins)Cholesterol-lowering therapy (statins) Beta-blockersBeta-blockers ACE-InhibitorsACE-Inhibitors

Medical interventions were done together with diet, Medical interventions were done together with diet, exercise, and smoking cessation counseling before exercise, and smoking cessation counseling before discharge in patients with acute MIdischarge in patients with acute MI

Am J Cardiol 2000;85:10A-17AAm J Cardiol 2000;85:10A-17A

CHAMP - Program Overview (2)CHAMP - Program Overview (2)

Implementation of CHAMP involved the use of:Implementation of CHAMP involved the use of: Focused treatment guidelinesFocused treatment guidelines Standardized admission ordersStandardized admission orders Educational lectures by local thought leadersEducational lectures by local thought leaders Tracking and reporting of medication treatment ratesTracking and reporting of medication treatment rates

Treatment rates and clinical outcomes were compared Treatment rates and clinical outcomes were compared in patients with acute MI discharged in the 2-year in patients with acute MI discharged in the 2-year periods before and after CHAMP was implementedperiods before and after CHAMP was implemented

Implementation of CHAMP involved the use of:Implementation of CHAMP involved the use of: Focused treatment guidelinesFocused treatment guidelines Standardized admission ordersStandardized admission orders Educational lectures by local thought leadersEducational lectures by local thought leaders Tracking and reporting of medication treatment ratesTracking and reporting of medication treatment rates

Treatment rates and clinical outcomes were compared Treatment rates and clinical outcomes were compared in patients with acute MI discharged in the 2-year in patients with acute MI discharged in the 2-year periods before and after CHAMP was implementedperiods before and after CHAMP was implemented

Am J Cardiol 2000;85:10A-17AAm J Cardiol 2000;85:10A-17A

Medication Utilization Rates at DischargeMedication Utilization Rates at DischargeMedication Utilization Rates at DischargeMedication Utilization Rates at Discharge

Pre-CHAMPPre-CHAMP Post-CHAMPPost-CHAMP(1992-1993)(1992-1993) (1994-1995)(1994-1995)

Discharge TherapyDischarge Therapy (n=256) (n=256) (n=302)(n=302) p-valuep-value

AspirinAspirin 78 78 92 92 <0.001<0.001

Beta-BlockersBeta-Blockers 12 12 61 61 <0.001<0.001

NitratesNitrates 62 62 34 34 <0.01<0.01

Calcium AntagonistsCalcium Antagonists 68 68 12 12 <0.001<0.001

ACE-InhibitorsACE-Inhibitors 4 4 56 56 <0.001<0.001

StatinsStatins 6 6 86 86 <0.0001<0.0001

Am J Cardiol 2000;85:10A-17AAm J Cardiol 2000;85:10A-17A

68

12

4 6

92

68

52

8891

72

64

8994

78

70

90

ASA Beta Blocker ACEI Statin0

20

40

60

80

100

92/93

94/95

96/97

98/99

68

12

4 6

92

68

52

8891

72

64

8994

78

70

90

ASA Beta Blocker ACEI Statin0

20

40

60

80

100

92/93

94/95

96/97

98/99

7777

NRMI Data from UCLA compared to 1437 other NRMI HospitalsNRMI Data from UCLA compared to 1437 other NRMI Hospitals

28

4141

5959

UCLA

CHAMP - Sustained Impact Over 6 YearsCHAMP - Sustained Impact Over 6 Years

Regional Quality Improvement Initiative:Regional Quality Improvement Initiative:

The Guidelines Applied in Practice (“GAP”)The Guidelines Applied in Practice (“GAP”)Initiative in Southeast MichiganInitiative in Southeast Michigan

Kim A. Eagle, M.D.Kim A. Eagle, M.D.University of MichiganUniversity of Michigan

Partnership GAP Committee AMI Committee

GDAHC

Michigan Peer Review Organization

QI Network Measurement

Greater Detroit Area Health Council Employers, Insurers Providers

MPRO

ACC

GAP Toolkit for AMI CareGAP Toolkit for AMI Care

Standard Orders

Pocket Guidelines Cards

Clinical Pathways

Patient Information Forms

Patient Discharge Forms (Flight plan)

Hospital Performance Charts

Chart Stickers

Standard Orders

Pocket Guidelines Cards

Clinical Pathways

Patient Information Forms

Patient Discharge Forms (Flight plan)

Hospital Performance Charts

Chart Stickers

Hospital Selection

Project Kick-off

Presentation

Individual Hospital Kick-off

Project Implementation

Hospital Remeasurement

Data Analysis

Major Results Presentation

March 2001

January – February 2001

September – December 2000

March – September 2000

March 2000

February 2000

 

April- June 2000

GAP Rapid Cycle Change

64%64%65%65%

81%81%70%70%

87%87%74%74%

0%0%

20%20%

40%40%

60%60%

80%80%

100%100%

(343) (404) (213) (245) (131) (252)(343) (404) (213) (245) (131) (252)

ASA ASA BBBB LDL CHOLLDL CHOL

**

111130

38 40

0

50

100

150

Time in MinutesTime in Minutes

(40) (24) (32) (45)

LYSISLYSIS PTCAPTCA

PRE

POST

GAP Results: Early Indicators (Aggregate)GAP Results: Early Indicators (Aggregate)

* p * p << 0.05 0.05

** p ** p << 0.01 0.01

68%68%

53%53%

80%80%84%84% 89%89%

75%75%

65%65%

86%86%92%92% 93%93%

0%0%

20%20%

40%40%

60%60%

80%80%

100%100%

GAP Results: Late Indicators (Aggregate)GAP Results: Late Indicators (Aggregate)

(267) (406) (106) (146) (139) (173) (159) (226) (112) (209)(267) (406) (106) (146) (139) (173) (159) (226) (112) (209)

ASA BB ACE SMOKING CHOL RXASA BB ACE SMOKING CHOL RX

*

**

PRE

POST

* p * p << 0.05 0.05

** p ** p << 0.01 0.01

GAP ConclusionsGAP Conclusions

Performance regarding early quality indicators is Performance regarding early quality indicators is enhanced when AMI-specificenhanced when AMI-specific standard order standard order setssets are used are used

Adherence to late quality indicators is enhanced Adherence to late quality indicators is enhanced by use of an AMI-specific by use of an AMI-specific standard discharge toolstandard discharge tool

Further studies are underway to compare the Further studies are underway to compare the performance levels achieved in GAP hospitals to performance levels achieved in GAP hospitals to non-GAP hospitals in the regionnon-GAP hospitals in the region

Performance regarding early quality indicators is Performance regarding early quality indicators is enhanced when AMI-specificenhanced when AMI-specific standard order standard order setssets are used are used

Adherence to late quality indicators is enhanced Adherence to late quality indicators is enhanced by use of an AMI-specific by use of an AMI-specific standard discharge toolstandard discharge tool

Further studies are underway to compare the Further studies are underway to compare the performance levels achieved in GAP hospitals to performance levels achieved in GAP hospitals to non-GAP hospitals in the regionnon-GAP hospitals in the region

Challenges to Improved Patient CareChallenges to Improved Patient Care

Poor knowledge of best treatments

Poor knowledge of best treatments

Lack of use of Lack of use of best treatmentsbest treatments

Lack of systems to Lack of systems to collect and understand collect and understand

clinical informationclinical information

Lack of knowledge of Lack of knowledge of how to influence how to influence

practicepractice

ConceptConcept

OutcomesOutcomes

Clinical Trials

Clinical Trials

GuidelinesGuidelines

PerformanceIndicators

PerformanceIndicators

PerformancePerformancePerformancePerformance

The Cycle of Clinical TherapeuticsThe Cycle of Clinical Therapeutics

MobilizationMobilizationIdentify Physician ChampionsIdentify Physician Champions

Establish Local ConsensusEstablish Local Consensus

PlanningPlanningLocal EducationLocal Education

Develop Hospital PlanDevelop Hospital PlanBuild Local QI TeamBuild Local QI Team

ImplementationImplementationCollect Baseline DataCollect Baseline Data

Care PathwaysCare Pathways

Feedback Feedback Intervention InterventionReview local treatment dataReview local treatment data

Determine need for improvementDetermine need for improvement

Develop targeted interventionsDevelop targeted interventions

Process of Continuous Quality Improvement (CQI)Process of Continuous Quality Improvement (CQI)Process of Continuous Quality Improvement (CQI)Process of Continuous Quality Improvement (CQI)

Strategies to Improve Patient CareStrategies to Improve Patient CareStrategies to Improve Patient CareStrategies to Improve Patient Care

Physician Continuing Medical EducationPhysician Continuing Medical Education

Local Opinion Leaders/ChampionsLocal Opinion Leaders/Champions

Regular Feedback on PerformanceRegular Feedback on Performance

Reminders, Care Pathways, AlgorithmsReminders, Care Pathways, Algorithms

Patient-Oriented InterventionsPatient-Oriented Interventions

Total Quality Management - Multifaceted Total Quality Management - Multifaceted InterventionsInterventions

Physician Continuing Medical EducationPhysician Continuing Medical Education

Local Opinion Leaders/ChampionsLocal Opinion Leaders/Champions

Regular Feedback on PerformanceRegular Feedback on Performance

Reminders, Care Pathways, AlgorithmsReminders, Care Pathways, Algorithms

Patient-Oriented InterventionsPatient-Oriented Interventions

Total Quality Management - Multifaceted Total Quality Management - Multifaceted InterventionsInterventions

Grol R, JAMA 2001Grol R, JAMA 2001Grol R, JAMA 2001Grol R, JAMA 2001

Quality Improvement Interventions:Quality Improvement Interventions:Predictors of SuccessPredictors of Success

Quality Improvement Interventions:Quality Improvement Interventions:Predictors of SuccessPredictors of Success

Shared goals among health care providers Shared goals among health care providers regarding use of evidence-based therapiesregarding use of evidence-based therapies

Administrative support for CQI projectsAdministrative support for CQI projects

Strong leadership by physician “champions” Strong leadership by physician “champions” for improved patient care for improved patient care

High-quality data feedback mechanismsHigh-quality data feedback mechanisms

Shared goals among health care providers Shared goals among health care providers regarding use of evidence-based therapiesregarding use of evidence-based therapies

Administrative support for CQI projectsAdministrative support for CQI projects

Strong leadership by physician “champions” Strong leadership by physician “champions” for improved patient care for improved patient care

High-quality data feedback mechanismsHigh-quality data feedback mechanisms

Bradley E, JAMA 2001 - Use of Beta-Blockers Post-MIBradley E, JAMA 2001 - Use of Beta-Blockers Post-MIBradley E, JAMA 2001 - Use of Beta-Blockers Post-MIBradley E, JAMA 2001 - Use of Beta-Blockers Post-MI

Practical Steps to Improve the Use of Practical Steps to Improve the Use of Evidence-Based Therapies for Non-ST Evidence-Based Therapies for Non-ST ACS ACS

Practical Steps to Improve the Use of Practical Steps to Improve the Use of Evidence-Based Therapies for Non-ST Evidence-Based Therapies for Non-ST ACS ACS

Improve physicians’ knowledge of the Improve physicians’ knowledge of the ACC/AHA practice guidelinesACC/AHA practice guidelines

Encourage cooperation between Emergency Encourage cooperation between Emergency Medicine physicians and CardiologistsMedicine physicians and Cardiologists

Accurately track adherence to treatment Accurately track adherence to treatment recommendations from the guidelines recommendations from the guidelines

Secure institutional commitment to improved Secure institutional commitment to improved patient care with guidelines implementationpatient care with guidelines implementation

Improve physicians’ knowledge of the Improve physicians’ knowledge of the ACC/AHA practice guidelinesACC/AHA practice guidelines

Encourage cooperation between Emergency Encourage cooperation between Emergency Medicine physicians and CardiologistsMedicine physicians and Cardiologists

Accurately track adherence to treatment Accurately track adherence to treatment recommendations from the guidelines recommendations from the guidelines

Secure institutional commitment to improved Secure institutional commitment to improved patient care with guidelines implementationpatient care with guidelines implementation

Steps for Improved ACS CareSteps for Improved ACS CareSteps for Improved ACS CareSteps for Improved ACS Care

Utilize simple data collection toolsUtilize simple data collection tools

Encourage multi-disciplinary collaborationEncourage multi-disciplinary collaboration

Study entire spectrum of ACSStudy entire spectrum of ACS

Continuously update clinical practice guidelinesContinuously update clinical practice guidelines

Mandate quality monitoring for all hospitalsMandate quality monitoring for all hospitals

Tie financial reimbursement to quality of careTie financial reimbursement to quality of care

Utilize simple data collection toolsUtilize simple data collection tools

Encourage multi-disciplinary collaborationEncourage multi-disciplinary collaboration

Study entire spectrum of ACSStudy entire spectrum of ACS

Continuously update clinical practice guidelinesContinuously update clinical practice guidelines

Mandate quality monitoring for all hospitalsMandate quality monitoring for all hospitals

Tie financial reimbursement to quality of careTie financial reimbursement to quality of care