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—— CPACS Experience WU Yangfeng The George Institute for Global Health China

Innovate Public Private Partnership to Meet the Common Goal of the Enterprises, Academics and Government. —— CPACS Experience WU Yangfeng The George Institute for Global Health China Peking University Clinical Research Institute and School of Public Health. Chinese Society of Cardiology.

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—— CPACS Experience WU Yangfeng The George Institute for Global Health China

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  1. Innovate Public Private Partnership to Meet the Common Goal of the Enterprises, Academics and Government —— CPACS Experience WU Yangfeng The George Institute for Global Health China Peking University Clinical Research Instituteand School of Public Health Chinese Society of Cardiology

  2. Management of ACS in Chinese • CHD is the leading cause of death and premature death in China. > 700 thousand Chinese die of acute coronary events each year • Half AMI patients will die before they arrive hospital. Mortality rate remains10% for those who were admitted to hospital • Since 1993, direct expenditure on CVD has increased by 17％ every year while GDP has increased by 9％ every year

  3. The Clinical Pathways for Acute Coronary Syndromes in China –Phase 1(CPACS-1) • Aim : Identify a number of important evidence-practice gaps relating to the diagnosis and treatment of patients with suspected ACS in China • Method: • 2004-2006 • Prospective register study • 51 hospitals from 18 provinces and municipalities, 2973 ACS in-hospital patients registered • Patient’s data during hospitalization, 6 months and 12 months after discharge were collected

  4. 16 14 12 10 8 6 4 2 STEMI NSTEMI UAP Total 0 CPACS 1：Prehospital Delaydelay to seek medical help among Chinese ACS patients • Mean time of onset to arrival of hospital is 9 hours, longer than GRACE study • Delay is more obvious among the patients arriving at tertiary hospitals due to the transfer from other hospitals Mean time, hour

  5. CPACS-1：Time to reperfusion

  6. CPACS 1：Diagnosis accuracy 20% final ACS diagnosis are inconsistent with ECG/biological markers Inconsistent ST segment deviation Inconsistent biomarkers* No inconsistence Biomarker not measured *includes <1% who had both inconsistent biomarkers and ST segment deviation

  7. CPACS-1： Investigation Exercise test is rarely used in low-risk patients; catheterization, UCG is less likely to be used in high risk patients

  8. CPACS-1： Invasive therapyLow- and median- risk patients were more likely to receive invasive therapy GRACE risk score Gao, et al. Heart 2008;94:554-60

  9. % CPACS-1： Medications Dual antiplatelet usage is relatively low

  10. CPACS -1：Reasons for not compliant to therapy Level 2 hospitals Level 3 hospitals

  11. CPACS-1： In hospital clinical outcome is suboptimal Rate of in hospital events was slightly higher than international reports，especially in level 2 hospitals Level 2 15 Level 3 10 Prevalence ,% 5 0 Bleeding Death CHF Stroke MI Clinical outcomes were different according to different risk stratification Prognosis was poorer among MI patients

  12. The Clinical Pathways for Acute Coronary Syndromes in China –Phase 2(CPACS-2) • Aim: Implement a quality improvement initiative (QCI) to improve ACS care in China and evaluate the effect of QCI • Method: • 2007-2011 • Cluster randomized trial, prospective registery study • 75 hospitals from 17 provinces and municipalities, more than 15 thousand ACS patients • Patient’s data were collected during hospitalization and at every 6 months follow up

  13. 北京 4/3, 4/2 黑龙江 2/3 辽宁 4/3, 1/2 内蒙古 3/3, 1/2 山西 2/3, 3/2 新疆 3/3, 1/2 河北 4/3 山东 3/3,1/2 江苏 3/3 陕西 3/3, 3/2 河南 2/3,2/2 四川 2/3 上海 3/3, 4/2 湖北 1/3, 4/2 浙江 2/3, 2/2 湖南 4/3 广东 4/3 CPACS-2：participating hospitals 75 hospitals 50 level 3 hospitals 25 level 2 hospitals

  14. CPACS-2: Intervention • Clinical pathway is a tool used to optimize and systematize treatment. The three main clinical pathways are : • Risk stratification • Clinical pathway of UA/NSTEMI • Clinical pathway of STEMI • The previous studies have confirmed that clinical pathway can improve quality of health care • But most of the studies are conducted in high-income counties. No reliable data are documented in China

  15. Pathway implement 基线 baseline 6 个月 6 months 12 个月 12 months 18 个月 18 months 24 months + 24 个月 + HOSPITAL HOSPITAL hospital 医院 X X X X collection of data for 50 patients 记录50个病人 的临床资料 记录50个病人 的临床资料 collection of data for 50 patients 记录50个病人 的临床资料 collection of data for 50 patients collection of data for 50 patients 记录50个病人 的临床资料* collection of data for 50 patients 记录50个病人 的临床资料* Alive patients Follow up every 6 months CPACS-2: intervention • 50 consecutive patients were recruited in every 6 months • Summary feedback information is then made available to each hospital • Based on feedback information, hospital modify the clinical pathway • The modified clinical pathways are used in the next cycle Alive patients Alive patients Alive patients Alive patients

  16. CPACS-2: Study design

  17. CPACS 2－key performance indicators Expected results: improve the accuracy of clinical diagnosis, significantly shorten the time receive treatment, improve hospital management of ACS, improve compliance to the guidelines. • Proportion of STEMI patients receive thrombolysis or primary PCI • Door-to-needle time and Door-to-balloon time • Proportion of patients with final diagnosis consistent with ECG/biomarker findings • Proportion of high-risk patients undergoing coronary angiography • Proportion of low-risk patients undergoing functional testing • Proportion of patients discharged on appropriate medical therapy • Hospital length-of-stay • Effective clinical pathway intervention reduce evidence-practice gap

  18. CPACS-2: Preliminary results • Significantly improved KPIs: • Proportion of patients discharged on appropriate medical therapy • Proportion of high-risk patients undergoing coronary angiography • Length of hospital stay • Not improved KPIs: • Proportion of low-risk patients undergoing function testing

  19. The Clinical Pathways for Acute Coronary Syndromes in China –Phase 3 (CPACS-3) • Aim: Develop and evaluate the effects of quality care initiative (QCI) system to reduce acute events and death of patients with ACS in level 2 hospitals with limited resources. • Method: • 2011-2014 • Registry-based cluster randomized step-weddged controlled trial • 96 hospitals from 15 provinces and municipalities, more than 25 thousand ACS patients • Patient’s data will be collected during hospitalization and at 6 months and 12 months follow up • Outcomes ： • Major adverse cardiovascular events（MACE）

  20. Academic achievements Heart2008;94:554-60. Am Heart J 2009;157:509-516

  21. Changes in organization and management in different stages of CPACS

  22. Changes in organization and management in different stages of CPACS

  23. The common interests of enterprise, academia and government For CPACS, how to transfer the scientific evidence into practice to improve the outcomes of ACS patients?

  24. CPACS is still going forward，please keep your eyes on our progress!

  25. Acknowledgment • CPACS-1administration committee： • AnushkaPatel，高润霖 • 高炜、胡大一、黄德嘉、孔灵芝、戚文航、武阳丰、杨跃进、Phillip Harris • CPACS-2 administration committee ： • AnushkaPatel，高润霖 • 高炜、胡大一、黄德嘉、孔灵芝、沈卫峰、吕树铮、韩雅玲、林曙光、武阳丰、葛均波、杨跃进、马爱群 • CPACS-3 administration committee ： • 高润霖、武阳丰 • 胡大一、霍勇、孔灵芝、焦亚辉、 AnushkaPatel、Eric Peterson、Kalipso Chalkidou、Mark Woodward、Fiona Turnbull

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