1、Implementing the Guidelines:Critical PathwaysAwareness Is Not Enough!NCEP,National Cholesterol Education Program.Pearson TA,et al.Arch Intern Med.2000;160:459-467.95%38%020406080100Physician Awareness ofNCEP GuidelinePatient Treated to GoalSample(%)GUIDELINESCardiologyAcute CarePrimary CareSecondary
2、 PreventionSmooth Transition From Acute to Long-term ManagementWhy Develop Critical Pathways?“A treatment gap between therapy that is dictated by evidence-based medicine and therapy that occurs in practice is not a deficit of knowledge;rather,it is a deficit of implementation.”Sidney Smith,MDChief S
3、cientific Officer,American Heart AssociationStandardized protocols Goal:optimize careEmerging Evidence Pathways work:CHAMPGuidelines Applied in Practice(GAP)AHA Get with the Guidelines CHAMP,Cardiac Hospitalization Atherosclerotic Management Program.UCLA:CHAMP Study Designed to determine whether phy
4、sician/patient compliance with preventive therapies can be improved through a hospital-initiated program Tracked initiation of ASA,-blocker,ACE inhibitor,and statins Used preprinted orders,guidelines,lectures,discharge forms Population:Patients with symptomatic atherosclerosis treated at university-
5、associated teaching hospitalASA,acetylsalicyclic acid;ACE,angiotensin-converting enzyme.Fonarow GC,et al.Am J Cardiol.2000;85;10A-17A.Cardiac Hospitalization Atherosclerosis Management ProgramCHAMP Study:Treatment Rates at Discharge and 1-Year Follow-upCHAMP,Cardiac Hospitalization Atherosclerotic M
6、anagement Program.*P.01 pre-vs post-CHAMP at discharge and at 1 year.Fonarow GC,et al.Am J Cardiol.2001;87:819-822.050100Pre-CHAMP DischargePost-CHAMP DischargePre-CHAMP Follow-upPost-CHAMP Follow-upAspirin-BlockerTreatment Rates(%)7892*6894*1261*1857*CHAMP Study:Clinical Events for the First Year A
7、fter Discharge for Acute MICHAMP,Cardiac Hospitalization Atherosclerotic Management Program.Fonarow GC,et al.Am J Cardiol.2001;87:819-822.051015Pre-CHAMPPost-CHAMP7.84.714.87.03.1*2.67.63.3*Recurrent MIHeart FailureHospitalizationTotal MortalityEvent Rates(%)*P.05Guidelines Applied in Practice(GAP)L
8、aunched by ACC in February 2000 toBridge gap between ideal therapy and treatment practiceCreate/implement guideline tools/processesInitial projectMichigan hospitalsImplemented 1999 ACC/AHA AMI GuidelineDetermine whether quality of care can be improved via guideline toolsStatus:pilot completed,expans
9、ion now in progressACC,American College of Cardiology;AHA,American Heart Association;AMI,acute myocardial infarction.GAP:Adherence Improves With Tool UseLDL-C,low-density lipoprotein cholesterol.Mehta RH,et al.JAMA.287;1269-1276.(with permission)Quality Adherence(%)Pre-interventionNo Tool UseTool Us
10、ePost-intervention020406080100Aspirin-BlockerLDL-CIdeal Patients(n)818693657377646482343 308 96213 174 71131 165 87P=.004P=.001Demographics 6 clicksClinical/Lab 8 clicksDischargemeds and interventions 7 clicksInteractivelychecks patientsdata with theAHA guidelines Importance of Data-Collection Regis
11、triesTrack adherence to guidelinesSupport local quality improvement programsCompare practice patterns/outcomes with benchmarksComply with regulatory requirementsProvide research dataMajor Data Collection RegistriesNRMIAHA Get With the Guidelines ACC NCDRGRACECRUSADENRMI,National Registry of Myocardi
12、al Infarction;AHA,American Heart Association;ACC NCDR,American College of Cardiology National Cardiovascular Data Registry;GRACE,Global Registry of Acute Coronary Events;CRUSADE,Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/A
13、HA Guidelines.Current Use of ACS Rx in US(Jan-July 2002)300 Hospitals19,000 PatientsACS,acute coronary syndrome;ACC,American College of Cardiology;AHA,American Heart Association.Roe,et al.ESC 2002.Discharge Medication Use PCI,percutaneous coronary intervention;ASA,acetylsalicylic acid;ACE,angiotensi
14、n-converting enzyme;LVEF,left ventricular ejection fraction;CHF,coronary heart disease;DM,diabetes mellitus;HTN,hypertension;TC,total cholesterol;LDL,low-density lipoprotein.*LVEF 40%,CHF,DM,HTNKnown hyperlipidemia,TC,LDL Roe,et al.ESC.2002.8880597749020406080100ASA-BlockersACEInhibitors*Lipid-Lower
15、ingAgentClopidogrel35 had PCIDischarge Rx Use(%)Conclusions Gap between knowledge of guidelines and current practice Several studies show:Critical pathway interventions improve care Suggestion of improved outcomes CQI important:Monitor performance Need local champions,implementation plan,and action!Need tools/strategies to ensure smooth transition from acute care to long-term managementCQI,continuous quality improvement.
