Aderence to treatment guidelines for NSTEMI: the role of a network between hospitals

(1)

Aderence to treatment guidelines for NSTEMI:

the role of a network between hospitals

Antonio Manari

U.O. Cardiologia Interventistica

Arcispedale Santa Maria Nuova

(2)

Short term risk of death or non

-fatal MI in patients with

-

fatal MI in patients with

UA/NSTEMI

2007 ACC/AHA NSTEACS Guidelines

(3)

(4)

NSTEMI patients

Early Risk

Stratification

Optimal timing

of intervention

Selection of Invasive

option

(5)

(6)

(7)

(8)

Hospital Link Between Overall Guidelines

Adherence and Mortality

Hospital Link Between Overall Guidelines

Adherence and Mortality

Peterson et al, JAMA 2006;295:1863

-

1912

5,95

5,16

4,97

4,16

5,06

4,63

4,15

6,31

0

1

2

3

4

5

6

7

<=25%

25 - 50%

50 - 75%

>=75%

Hospital Composite Quality Quartiles

%

In-H

os

p M

o

rt

a

lit

y

Adjusted

Unadjusted

Every 10%



in guidelines adherence



10%

(9)

Are We Performing Interventional Procedures in

the Right Patients

20

25

30

35

40

45

50

55

60

65

70

75

80

20

02Q

1

20

02Q

2

20

02

Q3

20

02Q

4

200

3Q

1

20

03Q2

20

03Q

3

20

03Q

4

20

04

Q1

20

04Q

2

20

04Q3

20

04Q4

Low Risk

Mod Risk

High Risk

26.6

32.2

53.5

63.2

64.1

75.5

Tricoci et al, AHA 2005 Abstract

(10)

(11)

(12)

55

45

36

64

74

26

0

10

20

30

40

50

60

70

80

%

all

H without CL

H with CL

Invasive

Conservative

(13)

20,0% < 48 ore

46,2% > 48 ore

19.238 pts admitted to Spoke Centers

(14)

(15)

Low-risk (+ 15%)

Moderate-risk (+17%)

High-risk (+5%)

Transfer patterns based upon

CRUSADE inhospital mortality model

(16)

“…

Establishing

networks of reperfusion

at

regional and national level

…

is a key issue.

”

NSTEMI

Inter

(17)

Inter

-

hospital network?

NSTEMI

•

Is the STEMI inter

-

hospital network able

to guarantee the right treatment of patients

with NSTEMI ?

(18)

(19)

Variables 2004 (year) 2005 (year) 2006 (first semester) Emilia-Romagna Region p-PCI:

On-site p-PCI, (n) 879 985 580

Transfer p-PCI, (n) 281 359 212

Network door-to-balloon time: On-site p-PCI, (min),

(median 25th_-75th₎

73 (50-102) 69 (43-100) 74 (47-115)

Transfer p-PCI, (min), (median 25th_-75th₎

114 (90-146) 111 (90-150) 107 (81-140)

Manari A et al .

Manari A et al . Eur Heart JEur Heart J, 2008, 2008 Variables 2004 (year) 2005 (year) 2006 (first semester) Emilia-Romagna Region p-PCI:

On-site p-PCI, (n) 879 985 580

Transfer p-PCI, (n) 281 359 212

Non-transferred STEMI patients admitted to non-PCI centres (%)

26.0 19.5 15.5

Age, (yrs), mean SD 77 13 78 13 81 12 Charlson index, mean SD 1.4 1.7 1.6 1.7 1.7 1.8

(20)

Clinical Impact of an Inter

-

hospital Transfer Strategy

in pts. with STE

-

MI treated with Primary PCI

The Emilia

-

Romagna STEMI network

Manari A et al. Eur Heart J

2008;29:1834

0

2

4

6

8

10

12

14

16

18

20

0

1

2

3

4

5

6

7

8

9

10 11 12

On

On--site psite p--PCIPCI Transfer p Transfer p--PCIPCI

9.2% 9.2% 7.4% 7.4% HR: 0.82 HR: 0.82 95% CI: 0.62 95% CI: 0.62 ––1.08; P=0.161.08; P=0.16

Months

11

--Year --Year

Cardiac Mortality (

%

)

Cardiac Mortality (

%

)

(21)

UTIC

Correggio

UTIC

C Monti

Montecchio

14 Km

50 Km

13 Km

32 Km

UTIC

Lab. Emo

Cardio Chir

18 Km

UTIC

Guastalla

Scandiano

(22)

DISTRIBUZIONE DEI PRESIDI OSPEDALIERI

NELLA PROVINCIA DI MANTOVA

PS,UTIC,Emodinamica h24, CaCh PS,UTIC,Emodinamica h24, CaCh PS,UTIC PS,UTIC PS, degenza PS, degenza Ospedali riabilitativi Ospedali riabilitativi 39 K m 39 Km 21 K m

Estensione: 2300 Kmq

Popolazione: 370000 abitanti

21 Km 38 Km 22 K m

(23)

La rete di Massa-Carrara

P.S.

I° LIVELLO

P.S.

I° LIVELLO

U.T.I.C.

II° LIVELLO

U.T.I.C.

II° LIVELLO

IFC CNR

Osp. “G. Pasquinucci” Telemedicina + Cath Lab

(24)

(25)

Registry

Guidelines

Performance

Indicators

Performance

Indicators

Data collection

&

Analysis

Data collection

&

Analysis

Quality Improvement Processes

Intervention

Action

(26)

Risk profile in patients undergoing

Angiography

27

36

37

0

5

10

15

20

25

30

35

40

45

50

%

HUB

SPOKE

Basso

Intermedio

Elevato

(27)

Angiography

27

36

37

25

28

47

0

5

10

15

20

25

30

35

40

45

50

%

HUB

SPOKE

Basso

Intermedio

Elevato

(28)

0

5

10

15

20

25

30

35

40

Pa ti e n ts , %

Low risk

Intermediate

High risk

(Grace Score)

27%

36%

37%

Angiography in Hub Centers

(29)

0

5

10

15

20

25

30

35

40

P a tie n ts , %

Low risk

Intermediate

High risk

ECG/Tn +

ECG/Tn

-(Grace Score)

11,1%

16,7%

5,4%

Angiography in Hub Centers

(30)

0

10

20

30

40

50

P a ti ent s, %

Low risk

Intermediate

High risk

(Grace Score)

22%

29%

49%

Angiography in Spokes Centers

(31)

0

10

20

30

40

50

P a tie n ts , %

Low risk

Intermediate

High risk

ECG/Tn +

ECG/Tn

-(Grace Score)

37,5%

23,8%

14,3%

Angiography in Spokes Centers

(32)

Admission

–

Angio delay

28

32

52

0

10

20

30

40

50

60

70

80

90

100

H

our

s

(

m

e

dia

n)

HUB

SPOKE

Low

Intermediate

High

(Grace Score)

53

years

75

years

68

years

(33)

Admission

–

Angio delay

28

32

52

61

75

98

0

10

20

30

40

50

60

70

80

90

100

H

our

s

(

m

e

d

ia

n)

HUB

SPOKE

Low

Intermediate

High

(Grace Score)

56

years

77

years

67

years

53

years

75

years

68

years

(34)

Conclusions

• In the real world setting, patients with the

highest predicted risk mortality are least likely to

be transferred early and do not undergo risk

stratification with guideline-recomended

diagnostic procedures.

• A running STEMI inter-hospital network is not

enough to improve a right application of

guidelines for NSTEMI (in particular for patients

first admitted to the community Hospital

(35)

0

20

40

60

80

100

120

140

160

180

200

0

50

100

150

200

250

Grace

or

e