Bridging the gap between acute and community care services for angioplasty treated ST elevation myocardial infarct patie

1. Bridging the gap between acute and community care services for angioplasty treated ST elevation myocardial infarct patients Andrea J. Lavoie MD FRCPC, Debra Lundberg BN, Karen Parker BN, Luana Mychaluk BN, Dean Traboulsi MD FRCPC, Kathryn King RN PhD, David Goodhart MD, FRCPC

2. Overview • Background • Purpose • Objectives • Methods • Analysis • Results • Conclusions

3. Background • Secondary prevention strategies initiated upon diagnosis of coronary artery disease (CAD) –cornerstone to effective CAD management • Emphasis on CAD risk management post acute care episode is imperative • Gap in literature and service delivery within early recovery period

4. Background • Trend towards early discharge post primary angioplasty • Cadillac Risk Score • Impacts on transition to community • Education in hospital • Coordinating services • Family Physician • Cardiologist • Cardiac Rehabilitation

5. CADILLAC risk score for 30-day and one-year mortality after primary PCI for STEMI Halkin, A, Singh, M, Nikolsky, E, et al, J Am Coll Cardiol 2005; 45:1397.

6. Background • Trend towards early discharge post primary angioplasty • Cadillac Risk Score • Impacts on transition to community • Education in hospital • Coordinating services • Family Physician • Cardiologist • Cardiac Rehabilitation

7. Background STrategic Evaluation and Management of ST Elevation Myocardial Infarctions (STEMI) Program • Purpose: • Improve care in STEMI population in Calgary Health Region • STEMI II Initiative • Address transitional care from hospital to community

8. Research Question • What are the barriers and challenges of patients treated with primary percutaneous coronary intervention (PCI) for a STEMI in the early recovery period post hospital discharge? • Is participation in an early discharge follow-up clinic associated with improved medical therapy, hospital readmission rates, and cardiac rehabilitation participation at 30 days post discharge following a PCI treated STEMI?

9. Objectives • Improve CAD risk management among PCI treated STEMI patients • Facilitate smooth transition between acute and community care setting – identify and address patient needs • Provide CAD management education to patients and family • Provide a communication bridge with family physician (GP) and cardiologist • Minimize preventable emergency room (ER) visits and re-hospitalization

10. STEMI II Clinic Model

11. STEMI II Clinic Model Identification of all STEMI Patients In Hospital -identified through STEMI database/nurse clinician/phone referral • Inclusion Criteria: • Primary PCI for treatment of STEMI • Treated in the Foothills Medical Centre, • Calgary AB between Jan 15 – June 23/07 • Interventional cardiologist – primary cardiologist • Exclusion: • Cadillac Risk Score >2** • Received thrombolytics or coronary artery bypass graft • as adjunct therapy for STEMI hospitalization • Diagnosis of NSTEMI/UA

12. Primary Cardiologist Interventionalist Primary Cardiologist Non-Interventionalist STEMI II Clinic Model

13. Initial In-Hospital Visit day 1-3 Contact before leaving hospital Reviewed in FICS STEMI Clinic day 3-7 Further follow-up if required - may be before/after day 7 visit Follow-up phone call day 7 STEMI II Clinic Model

14. Methods Data Collection – Prospective • 30 day phone follow-up • ER visit • Readmission • Cardiac Rehab participation • Medication • Clinic charts recorded patients needs • STEMI II telephone-help line logs – Retrospective • Survey with phone follow-up at 4-8 months post clinic participation • Chart review (missing data)

15. STEMI Patient Flow

16. Low Risk (Cadillac Risk Score 0-2) *P=0.03 *P=0.03

17. Moderate-High Risk (Cadillac Risk Score >2-18) N/S N/S N/S

18. Medication TherapyBaseline

19. Medication Therapyat 30 days Clopidogrel ACE

20. Emergency Room Visits and Hospital Readmissions at 30 days % ER Visits Hospital Readmission

21. Cardiac Rehabilitation Participation at 30 days %

22. Clinic Visit Documentation & Telephone Help Line Log Themes: • Access to health care provider (family physician) (n=4) 11.7% needed assistance in securing a family physician at clinic visit. • Lack of education and support for spouses. • 25 calls to help-line, 18 unique callers • Medication questions- 32% (n=8) • Symptom checks – 24% (n=6) • Coordinating community care services 28% (n=7) • Clarification of discharge instructions by pharmacists and family doctors 8% (n=2)

23. Clinic Survey Results N=32/34

24. Strengths • Descriptive • Addresses a gap in the literature • Identify patient needs in early discharge period • Inform practice • Develop interventions • Evaluate or design in-hospital education programming, discharge planning, clinic programming, home support • Stimulate future research questions

25. Limitations • Design • Protocol changes to limit patients to low risk STEMI after 2 months due to staff and resource constraints • Measurement Bias • Survey not validated • Recall bias of survey • Selection Bias • Selected only interventional cardiologist patients • Convenience sampling – Calgary Health Region • Loss to follow-up (control group)

26. Conclusions • Gaps in acute to community care transition period • Access to family physician • Education and support for spouses • Access to cardiac rehabilitation • Medication use questions (patients/GP/pharmacists) • Help-line and clinic were important to patients in their transition to the community • Apparent improvement in CAD management with evidence-based medication use in clinic patients • Clopidogrel + B-blockers + Statins • Trend to reduced 30 day ER visits among clinic patients • CR access continues to be a challenge within early recovery period

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