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

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Ccort ccs 2008 quality indicators for acute myocardial infarction ami care introduction
CCORT/CCS 2008 Quality Indicators for Acute Myocardial Infarction (AMI) Care - Introduction

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 Panel

Christopher 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

CIHR Team Grant in Cardiovascular Outcomes Research


Ccort ccs ami quality indicator expert panel
CCORT/CCS AMI Quality Indicator Expert Panel

CIHR Team Grant in Cardiovascular Outcomes Research


Outline
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
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
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



Continuous quality improvement
Continuous Quality Improvement

Concept

1 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
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

  • 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

2008 CCORT/CCS AMI Quality Indicator Expert Panel Process

CIHR Team Grant in Cardiovascular Outcomes Research


Acc aha attributes for quality indicators

Useful in improving patient outcomes

Evidence-based

Interpretable

Actionable

Measure implementation

Feasibility

Reasonable effort

Reasonable cost

Reasonable time period for collection

Measure Design

Denominator precisely defined

Numerator precisely defined

Validity

Face validity

Content validity

Construct validity

Reliability

ACC/AHA Attributes for Quality Indicators

Krumholz 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


Ccort ccs 2008 quality indicators for acute myocardial infarction ami care introduction

ACC/AHA Level of Evidence

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.



Ideal subset methodology

All cases

Cases not eligible

for process of care

Cases with contra-

indication to

process of care

Cases “ideal” to receive

process of care

“Ideal” Subset Methodology

CIHR Team Grant in Cardiovascular Outcomes Research




Benchmarks
Benchmarks Indicators

  • 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
Implementation Strategies Indicators

  • 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


Ccort ccs 2008 quality indicators for acute myocardial infarction ami care introduction

Thank You Indicators

For more information please visit

www.ccort.ca

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