1 acute coronary syndromes and the role of critical pathway christopher cannon, m.d. brigham and...

1

Acute Coronary Syndromes and Acute Coronary Syndromes and the Role of Critical Pathwaythe Role of Critical Pathway

Christopher Cannon, M.D.

Brigham and Women’s Hospital

Boston

2

Aspirin and Thrombolysis in Acute MI

13.2

10.7 10.4

8.0

0

5

10

15

% o

f P

atie

nts

% o

f P

atie

nts

ISIS-2. Lancet 1988; 2:349-60.

35 Day Mortality35 Day Mortality

PlaceboPlacebo Aspirin Aspirin SK SK Aspirin + SK Aspirin + SK

3

TIMI 2: Effect of Time to Treatment

0

2

4

6

8

10

<1 h1-2 h2-3 h3-4 h

% o

f P

atie

nts

% o

f P

atie

nts

TIMM, et al. TIMM, et al. Circulation. Circulation. 1991;84:II-230. 1991;84:II-230.

**PP=0.05=0.051 hour faster 1 hour faster

treatmenttreatment

==10 lives saved 10 lives saved per 1000 patients per 1000 patients treatedtreated

6 Week Mortality6 Week Mortality

3.2*3.2*3.73.7

5.25.26.26.2

62

31

TIMI 1:Reperfusion

Occluded arteries

0

20

40

60

80

% o

f P

atie

nts

t-PASK

*P<0.001

Improving Thrombolysis: t-PA vs. SK

TIMI Study NEJM 1985;312:397-401.

0

2

4

6

8

GUSTO 1:MortalityMortality

7.37.3

6.36.3

GUSTO Inv. NEJM 1993; 329:673-682.

*P<0.001

5

Thrombolysis vs. Primary Angioplasty

6.5

4.4

7.2

4.2

0

5

10

% o

f P

atie

nts

% o

f P

atie

nts

Weaver WD, JAMA 1997; 278:2093-2098. Schomig A, N Engl J Med 2000; 343:385-91

30 Day Mortality30 Day Mortality

Thrombolysis PTCA t-PA Stent + IIb/IIIaThrombolysis PTCA t-PA Stent + IIb/IIIa

6

Medical Treatment After MI

12.010.7

8.16.1

11.5

8.2

0

5

10

15

% o

f P

atie

nts

% o

f P

atie

nts

ISIS-1 Lancet 1986; 2:57-66; HOPE N Engl J Med 2000; 4S. Lancet 1994; 344:1383-1389.

Mortality During Follow-upMortality During Follow-up

ACUTE MI GUIDELINES 11/96

Drug Rx Peri MI: Meta-Analyses

Beta blocker during MI

Beta blocker post MI

ACEI during MI

ACEI post MI if LV dysfxn

Nitrates during MI

Ca++ blockers

Magnesium

Lidocaine

Class I Antiarrhythmics

Number RR Death p value

28,970

24,298

100,963

5,986

81,908

20,342

61,860

9,155

6,300

.87 (.77-.98)

.77 (.70-.84)

.94 (.89-.98)

.78 (.70-.86)

.94 (.90-.99)

1.04 (.95-1.14)

1.02 (.96-1.08)

1.38 (.98-1.95)

1.21 (1.01-1.44)

0.02

<0.001

0.006

<0.001

0.03

NS

NS

NS

0.04

NEJM 335:1662, 1996

8

Continuing Ischemia/Other Clinical High-Risk FeaturesContinuing Ischemia/Other Clinical High-Risk Features

• Bed rest + continuous Bed rest + continuous

ECG monitoringECG monitoring

• 0022 to maintain Sa0 to maintain Sa02 2 >90%>90%

• NTG IVNTG IV

-Blockers, oral -Blockers, oral

(+IV if high risk)(+IV if high risk)

• Morphine IV for painMorphine IV for pain

• IABP if ischemia or IABP if ischemia or BP BP

• ACEI for HTN or ACEI for HTN or LVEF LVEF

(possibly all patients)(possibly all patients)

Braunwald et al. Braunwald et al. J Am Coll Cardiol.J Am Coll Cardiol. 2000;36:970-1062. 2000;36:970-1062.

Class I Recommendations Class I Recommendations for Anti-Ischemic Therapyfor Anti-Ischemic TherapyUA/NSTEMI 9/00

9

AspirinAspirin++

IV heparinIV heparin++

IV platelet IV platelet GP IIb/IIIa antagonistGP IIb/IIIa antagonist

AspirinAspirin++

Subcutaneous Subcutaneous LMWHLMWH

ororIV heparinIV heparin

Possible Possible ACSACS

Likely/Definite Likely/Definite ACSACS

Definite ACSDefinite ACSWith Continuing Ischemia With Continuing Ischemia

or Other High-Risk Featuresor Other High-Risk Features†† or Planned PCIor Planned PCI

AspirinAspirin

* Clinical data on the combination of LMWH and platelet GP IIb/IIIa antagonists are lacking. * Clinical data on the combination of LMWH and platelet GP IIb/IIIa antagonists are lacking. Their combined use is not currently recommended.Their combined use is not currently recommended.†† High-risk features were previously listed; others include diabetes, recent MI, High-risk features were previously listed; others include diabetes, recent MI, and elevated cardiac TnT or Tnl.and elevated cardiac TnT or Tnl.


Class I Recommendations for Class I Recommendations for Antithrombotic Therapy*Antithrombotic Therapy*UA/NSTEMI 9/00

10

Class I Recommendations: Class I Recommendations: Early Invasive StrategyEarly Invasive Strategy

1. Early invasive strategy in patients with UA/NSTEMI and any of the following high-risk indicators:a. Recurrent angina/ischemia at rest or with low-level activities

despite intensive anti-ischemic rxb. Recurrent angina/ischemia with CHF symptoms, S3 gallop,

pulmonary edema, worsening rales, or new or worsening MRc. High-risk findings on noninvasive stress testingd. Depressed LV systolic functione. Hemodynamic instabilityf. Sustained VTg. PCI within 6 monthsh. Prior CABG

2. In the absence of these, either an early conservative or an early invasive strategy in hospitalized patients without contraindications for revascularization


11

Class I Recommendations: Class I Recommendations: Risk Factor Modification Risk Factor Modification

1. Smoking cessation and achievement or maintenance of optimal weight, daily exercise, and diet

2. HMG-CoA reductase inhibitors for LDL >130 mg/dL

3. Lipid-lowering agent if LDL after diet is >100 mg/dL

4. Hypertension control to a blood pressure of >130/85 mm Hg

5. Tight control of hyperglycemia in diabetes


UA/NSTEMI 9/00

Implementation of AHCPR Guidelines Implementation of AHCPR Guidelines for Unstable Angina in 1996:for Unstable Angina in 1996:

Unfortunate Differences Between Women and MenUnfortunate Differences Between Women and Men

Results from the GUARANTEE RegistryResults from the GUARANTEE Registry

ARANTEEARANTEEGUGU

6 Regions6 Regions 35 Hospitals35 Hospitals 2,948 Patients2,948 Patients

6 Regions6 Regions 35 Hospitals35 Hospitals 2,948 Patients2,948 Patients

GGlobal lobal UUnstable nstable AAngina ngina RRegistryegistry

ANANd d TTreatment reatment EEvaluationvaluation

ARANTEEARANTEEGUGU

No. PtsNo. Pts On AdmissionOn Admission

ASA (%)ASA (%)

Heparin (%)Heparin (%)

B-blockers (%)B-blockers (%)

At DischargeAt Discharge

ASA (or Warfarin) ASA (or Warfarin)

All of above (%)All of above (%)

17881788

8484

6666

5353

7777

3131

MenMen

1160 1160

8080

6060

4949

6969

2424

WomenWomen

0.0180.018

0.0010.001

0.0390.039

0.0010.001

0.0010.001

P valueP value

0.0160.016

0.0800.080

0.0860.086

0.0010.001

0.0070.007

AdjusteAdjusted d

P valueP value

Medical ManagementMedical ManagementARANTEEARANTEEGUGU

No. PtsNo. Pts

Cath (%)Cath (%)

PTCA (%)PTCA (%)

CABG (%)CABG (%)

In Pts Meeting AHCRP criteriaIn Pts Meeting AHCRP criteria

Cath (% done)Cath (% done)

CABG (% done)CABG (% done)

178817885353

1818

1010

5959

4646

MenMen

1160 1160 4444

1212

7%7%

5656

3636

WomenWomen

0.0010.001

0.0010.001

0.0020.002

0.150.15

0.160.16

P valueP value

0.0040.004

0.0170.017

0.0010.001

0.530.53

0.050.05

AdjusteAdjusted d

P valueP value

Catheterization / Catheterization / RevascularizationRevascularization

ARANTEEARANTEEGUGU


ASA (%)ASA (%)






16381638

8383

6464

5050

7171

2828

Age <65Age <65

13091309

8181

6262

5252

7878

2828

Age Age >>6565

0.170.17

0.250.25

0.460.46

0.0010.001

0.920.92

P valueP value

0.240.24

0.190.19

0.680.68

0.0030.003

0.600.60

AdjusteAdjusted d

P valueP value

Medical ManagementMedical Management

AgeAge

ARANTEEARANTEEGUGU


ASA (%)ASA (%)






26002600

8282

6161

4949

7373

2626

UAUA

300300

8787

8585

6363

8282

4545

NQWMINQWMI

0.0310.031

0.0010.001

0.0010.001

0.0010.001

0.0010.001

P valueP value

0.0690.069

0.0010.001

0.0010.001

0.0010.001

0.0010.001

AdjusteAdjusted d

P valueP value

Medical ManagementMedical Management

Non-Q wave MI vs. Unstable AnginaNon-Q wave MI vs. Unstable Angina

ARANTEEARANTEEGUGU


ASAASA

HeparinHeparin

B-blockersB-blockers

16781678

8282

6363

4141

MenMen

1640 1640

7777

5050

3535

WomenWomen

17881788

8484

6666

5353

MenMen

1160 1160

8080

6060

4949

WomenWomen

Pre GuidelinePre Guideline

TIMI III RegistryTIMI III Registry

Stone PH et al. JAMA 1996;275:1104; Scirica 1999 AHJ

Post GuidelinePost Guideline

ARANTEEARANTEEGUGU

Comparing Pre- to Post-:Comparing Pre- to Post-: Men Men WomenWomenP values :P values : ASAASA 0.300.30 0.050.05

HeparinHeparin 0.130.13 0.0010.001B-blockerB-blocker 0.0010.001 0.0010.001

Aspirin within 24 hoursAspirin within 24 hoursAspirin within 24 hoursAspirin within 24 hours

0

20

40

60

80

100

0 8 16 24 32 40 48

Aspirin ( n = 189 )

No aspirin ( n = 33 )

0

20

40

60

80

100

0 8 16 24 32 40 48

Aspirin ( n = 189 )

No aspirin ( n = 33 )

Weeks post discharge

% s

urv

ival

94%

78%P = .002

Giugliano RP,et al. Arch Intern Med 2000;160.

Heparin within 24 hoursHeparin within 24 hoursHeparin within 24 hoursHeparin within 24 hours

0

20

40

60

80

100

0 8 16 24 32 40 48

Heparin ( n = 181 )

No heparin ( n = 47 )

0

20

40

60

80

100

0 8 16 24 32 40 48

Heparin ( n = 181 )

No heparin ( n = 47 )


% s

urv

ival

93%

85%P = .06


Unadjusted One Year SurvivalUnadjusted One Year SurvivalUnadjusted One Year SurvivalUnadjusted One Year Survival

0

20

40

60

80

100

0 8 16 24 32 40 48

Guideline ( n = 189 )

Not guideline ( n = 86 )

0

20

40

60

80

100

0 8 16 24 32 40 48

Guideline ( n = 189 )

Not guideline ( n = 86 )


Per

cen

t su

rviv

ing

95%

81%P = .0001


NRMI-1: Medical Therapy In-hospitalNRMI-1: Medical Therapy In-hospital

Thrombolysis No Thrombolysis

No. Pts 84477 156512

ASA (%) 84 63

Heparin (%) 97 56

IV nitro (%) 76 50

IV B-Blockers (%) 17 6

Oral B-Blockers (%) 36 29

Ca-Blockers (%) 29 42

Rogers WJ, et al. Circulation 1994;90:2103-2114.

0-30 mins34%

31-45 mins25%

46-60 mins15%

61-90 mins14%

>90 mins12%

0-30 mins34%

31-45 mins25%

46-60 mins15%

61-90 mins14%

>90 mins12%

N=84,423N=84,423

NRMI-2: Distribution of Door-to-Needle Times

40%40%Cannon CP ACC 2000

24

Baseline CharacteristicsBaseline Characteristics

0-300-30 31-6031-60 61-9061-90 >90>90 P valueNo. Pts 28,176 33,635 11,531 10,244

Age (mean) 61.2 63.5 65.1 65.7 <0.0001Female (%) 26 34 39 42 <0.0001Non-white (%) 13 14 16 19 <0.0001DM (%) 16 20 23 27 <0.0001Prior MI (%) 16 19 21 21 <0.0001Anterior (%) 32 34 37 41 <0.0001

HMO (%) 14 13 12 11 <0.0001Urban Hosp 87 88 87 86 0.0005Pre-hosp ECG 7 4 3 3 <0.0001Onset-door (hr) 1.4 1.7 1.9 2.0 <0.0001(Median)

Door-to-needle time (mins)Door-to-needle time (mins)

0.6

0.8

1

1.2

1.4

0-30 31-60 61-90 >90

Door-to-Needle Time (minutes)

MV

Ad

just

ed

Od

ds

of

De

ath

Cannon CP ACC 2000

NRMI-2: Thrombolysis Door-to-Needle Time vs. Mortality

N=28,624 33,867 11,616 10,316

P=0.01P=0.0001

P=NS

1.03

1.11

1.23

0.2

0.6

1

1.4

1.8

2.2

0-60 61-90 91-120 121-150 151-180 >180

Door-to-Balloon Time (minutes)

MV

Ad

just

ed

Od

ds

of

De

ath

P=0.01 P=0.0007 P=0.0003P=NSP=NS

1.14 1.15

1.41

1.62 1.61

N=2,230 5,734 6,616 4,461 2,627 5,412

NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality

Cannon CP, et al JAMA 2000;283:2941-2947.

8.2

21.224.4

16.5

9.7

20.0

0

5

10

15

20

25

30

0-60 61-90 91-120 121-150 151-180 >180

% o

f Pat

ient

s

8.2

21.224.4

16.5

9.7

20.0

0

5

10

15

20

25

30

0-60 61-90 91-120 121-150 151-180 >180

% o

f Pat

ient

s

N=27,080N=27,080

NRMI-2: Primary PCI Distribution of Door-to-Balloon times

Door-to-Balloon Time (minutes)

US News and World ReportUS News and World Report30-day mortality by hospital category*30-day mortality by hospital category*

0%

5%

10%

15%

20%

25%

30%

US News Invasive Non-invasive

Stars

* 25th, 50th and 75th percentile for each category

29

US News and World Report US News and World Report Aspirin in ideal candidatesAspirin in ideal candidates

0%

20%

40%

60%

80%

100%

Top-ranked Invasive Non-invasive

30

US News and World Report US News and World Report Beta-blockers in ideal candidatesBeta-blockers in ideal candidates

0%

20%

40%

60%

80%

100%

Top-ranked Invasive Non-invasive

30-day Mortality30-day MortalityUS News Top-ranked vs Other HospitalsUS News Top-ranked vs Other Hospitals

0.7

0.8

0.9

1

1.1

Adjusted* +ASA Adjusted* +BB Adjusted* +RPF

* Adjusted for patient, hospital and physician characteristics

Odds ratio

32

Quality implicationsQuality implications

– The lower mortality observed in “America’s Best Hospitals” appear to be explained in part by their higher use of aspirin and beta-blockers

– Any hospital can be one of “America’s Best” by increasing their use of aspirin and beta-blockers

EUROASPIRE II

European Action on Secondary and Primary

Prevention through Intervention to Reduce Events

Euro Heart Survey Programme European Society of Cardiology-ESC

European Society of Cardiology ESC

Wood et al. Wood et al. Lancet Lancet 2001; 357: 995-10012001; 357: 995-1001

% reaching goal* at interview among those using lipid-lowering medication

by center

EUROASPIRE

39

31

70

44

41

42

48

55

49

66

49

41

52

65

54

51

0 20 40 60 80 100

BEL/GHE

CZE/PP

FIN/KUO

FRA/LLRT

GER/MUNS

GRE/ATCI

HUN/BUD

IRE/DUB

ITA/TV

NET/ROT

POL/CRA

SLO/LJU

SPA/BAR

SWE/MAL

UK/HL

ALL

* total cholesterol < 5 mmol/l

Therapeutic control of total cholesterol at interview


% aspirin/other anti-platelets at interview

by center EUROASPIRE

90

88

82

86

86

92

75

93

92

81

87

82

86

92

81

86

0 20 40 60 80 100

BEL/GHE

CZE/PP

FIN/KUO

FRA/LLRT

GER/MUNS

GRE/ATCI

HUN/BUD

IRE/DUB

ITA/TV

NET/ROT

POL/CRA

SLO/LJU

SPA/BAR

SWE/MAL

UK/HL

ALL



% beta-blockers at interviewby center

EUROASPIRE

7774

8860

6855

84

4761

4862

6647

6444

63

0 20 40 60 80 100

BEL/GHE

CZE/PP

FIN/KUO

FRA/LLRT

GER/MUNS

GRE/ATCI

HUN/BUD

IRE/DUB

ITA/TV

NET/ROT

POL/CRA

SLO/LJU

SPA/BAR

SWE/MAL

UK/HL

ALL



Conclusions

EUROASPIRE II

EUROASPIRE

A high prevalence of unhealthy lifestyles, modifiable risk factors and inadequate use of prophylactic drug therapies is found in coronary patients across Europe

Considerable potential to raise the standard of preventive cardiology exists throughout Europe in order to reduce coronary morbidity and mortality



National Heart Attack

Alert Program (NHAAP)

CRITICAL PATHWAYS FOR THE TREATMENT OF

PATIENTS WITH ACUTE CORONARY SYNDROMES

39

Critical Pathways - DefinitionsCritical Pathways - Definitions

• Standardized protocols for care

• Strict definition

– Full list of all tasks, tracks variances

• Broader definition

– Includes clinical protocols (NHAAP 4D’s)

• Diagnostic pathways - Chest Pain Centers

• Treatment pathways - Thrombolysis

40

Goals of Critical PathwaysGoals of Critical Pathways

• Increase use of recommended medical therapies (e.g., aspirin)

• Decrease use of unnecessary tests.

• Decrease hospital length of stay

• Increase participation in clinical research

• Improve patient care and decrease costs.

41

Need and Rationale for Critical Need and Rationale for Critical PathwaysPathways

• Underutilization of recommended medications (e.g. Aspirin)

• Overutilization of procedures

• Length of stay, # ICU days

• Quality of care measures (door-to-drug, door-to-balloon times)

42

Development And Implementation Of Development And Implementation Of Critical PathwaysCritical Pathways

• Identify problems ( practice variation)

• Identify working committee/task force to develop path

• Distribute draft Critical Pathway to all personnel and departments involved. Revise based on approach.

• Implement pathway

• Collect and monitor data on pathway performance.

• Modify the pathway as needed to further improve performance.

43

Methods of Implementation of Methods of Implementation of PathwaysPathways

• Specific case manager for each Pt

– High compliance, high cost

• Standardized order sheets, Pocket guides

• “Championing” - Grand rounds

• Recent study -> similar improvements in care with either formal or simpler pathways (Holmboe, ES et al. Am J Med 1999;107:324-31.)

44

Initial Treatment Strategy in Acute ST Elevation MI

Initial Treatment Strategy in Acute ST Elevation MI

Tlysis60%

1 PTCA9%

Non-Rep.31%

Tlysis65%

1 PTCA10%

Non-Rep.25%

All patients Pts. presenting < 12h

o

o

N=705N=837

TIMI 9TIMI 9RegistryRegistry

45

Goal: < 30 MinutesNHAAP Ann Emerg Med 1994;23:311-29.

46

35

40

45

50

55

60

65

Minutes (median)

NRMI 1 & 2 Trends:NRMI 1 & 2 Trends: Door to Drug (t-PA) IntervalDoor to Drug (t-PA) Interval

All Hospitals, t-PA-treated Patients (N = 241,757)

W. Rogers, personal communication

47

Speeding Time to Treatment: Brigham and Speeding Time to Treatment: Brigham and Women’s Hospital Acute MI Critical Pathway in EDWomen’s Hospital Acute MI Critical Pathway in ED

Pt. with Chest Pain. ED Arrival Time

Obtain ECG. Assess for ST Elevation

Assess for Contraindications to Thrombolysis:Active Bleeding Prior StrokeConfirmed BP > 190/110 Major Surgery <2 Mos.Other Major Illness (cancer, etc.)

Mix and Give Thrombolytic:

Double-Bolus r-PA

Primary PCI:1. Patient with high

stroke/bleeding risk2. Cardiogenic shock3. (All patients)

Door-to-Drug TimeGoal: <30 Mins

NO YES

10 mins

10 mins

10 mins

_ _ : _ _Door

_ _ : _ _Data

_ _ : _ _Decision

_ _ : _ _Drug

o

Cannon CP et al. J Thromb Thrombolysis 1994;1:27-34.

0

10

20

30

40

50

60

70

80

Jun-93

Jul-Sep93

Oct-Dec93

Jan-Mar94

Apr-Jun94

Jul-Sep94

Oct-Dec94

Jan-Mar95

Apr-Jun95

Jul-Sep95

Oct-Dec95

Min

utes

0

10

20

30

40

50

60

70

80

Jun-93

Jul-Sep93

Oct-Dec93

Jan-Mar94

Apr-Jun94

Jul-Sep94

Oct-Dec94

Jan-Mar95

Apr-Jun95

Jul-Sep95

Oct-Dec95

Min

utes

BWH Thrombolysis Critical Pathway: BWH Thrombolysis Critical Pathway: Effect on Door-to-Drug timesEffect on Door-to-Drug times

Door-to-Drug Time

Pre-Pre- Post-PathwayPost-Pathway Cannon CP, Clin Cardiol 1999;22:17-22

49

BWH Thrombolysis Critical Pathway: Initial BWH Thrombolysis Critical Pathway: Initial ExperienceExperience

0

20

40

60

80

100

120

Jun-Nov 20, 93 Nov 21, 93-June 94

July 94- Dec 94 Jan 95- June 95

Doo

r-to

-Nee

dle

Tim

e (M

ins) Women

Men

*P=0.013

Cannon CP, et al. Clin Cardiol 1999;22:17-22

BEFORE

50

2/94 - 1/95 2/95 - 7/95 P value

No Pts. 27 35

Door-Balloon Time

205+/- 130 97 +/- 57 0.02

Adverse Outcome

41% 17% 0.04

Death 26% 0% 0.004

Effect of CQI on Primary PCI Outcome

Caputo RP, Am J Cardiol 1997;79:1159-1164.

PAMI II: Early Discharge Critical Pathway for Low-PAMI II: Early Discharge Critical Pathway for Low-Risk MI Patients treated with Primary AngioplastyRisk MI Patients treated with Primary Angioplasty

6 month outcomes6 month outcomes Early D/CEarly D/C StandardStandard P valueP value(%)(%) (%)(%)

DeathDeath 0.80.8 0.40.4 NSNSMIMI 0.80.8 0.40.4 NSNSUnstable AnginaUnstable Angina 10.110.1 12.012.0 NSNSD/MI/UA/CHF/strokeD/MI/UA/CHF/stroke 15.215.2 17.517.5 NSNS

Length of stay (days)Length of stay (days) 4.24.2 7.17.1 p<0.001p<0.001Hospital CostsHospital Costs $9,658$9,658 $11,604$11,604 p=0.002p=0.002

++ 5,287 5,287 ++ 6,125 6,125

Early Discharge for Low Risk Patients: Randomized Trial Following Thrombolysis

Early D/CConventional

D/C

No. Pts. 40 40

Death 0 0

MI 0 5

Angina 3 8

Readmission 6 10

Topol, et al. NEJM 1988;318:1083-8.

53

BWH ED Checklist Orders for BWH ED Checklist Orders for UA/NSTEMIUA/NSTEMI

UA/NSTEMI

Hx. Good Story and/or + ECG, or + CKMB/TnI Hx MI, PCI/CABG

Tests CBC, CMP, PT/PTT CK-MB, TnI Lipid profile

Meds ASA 325mg chew Metoprolol IV/PO

Discuss with Cards B - Heparin IV + IIb/IIIa - Enoxaparin SQ - Cath Lab NTG PRN

54

Effect of Critical Pathway on Effect of Critical Pathway on Median Length of StayMedian Length of Stay

5

4

3 3

4

3

5

2 2

0

1

2

3

4

5

6

Feb(Pre)

July Sept. Oct. Nov.

Hos

pita

l Len

ght o

f Sta

y (D

ays)

Not On Path

On Path

55

CHAMP Program to improve CHAMP Program to improve Secondary PreventionSecondary Prevention

• Jan 1992- Dec 1995 N=256 pre- and 302 post

Pre-CHAMP post-CHAMPD/C 1 yr D/C 1 yr

ASA 78% 68% 92% 94%

B-blocker 12% 18% 61% 57%

ACE 4% 16% 56% 48%

Statin 6% 10% 86% 91%

LDL <100 6% 58%

Fonarow GC et al. Am J Cardiol 2001;87:819-822.Fonarow GC et al. Am J Cardiol 2001;87:819-822.

56

ConclusionsConclusions

• Critical pathways hold great promise to improve

– Quality of care,

– Clinical outcomes

– Cost-effectiveness

• Initial studies show better quality of care and suggest improved outcomes

1 acute coronary syndromes and the role of critical pathway christopher cannon, m.d. brigham and...

Documents

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