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Presenter Disc closure Information Jan Kornder MD FRC Jan Kornder MD, FRC CPC FACC CPC, FACC The following relationships s exist related to this presentation: Over the last 2 years: Advisory Boards: MODEST ( Less than n $5000 total): BMS,


slide-1
SLIDE 1

Presenter Disc

Jan Kornder MD FRC Jan Kornder MD, FRC

The following relationships Over the last 2 years: Advisory Boards: MODEST ( Less than BMS, Lilly, Servier, Sanofi Aventis, an Speaker Honoraria: MODEST ( Less th Boehringer-Ingelheim, Astra Zeneca, L R h R h A t Z M k Research: Roche, Astra Zeneca, Merck

All Honoraria and consulting fee

closure Information

CPC FACC CPC, FACC

s exist related to this presentation: n $5000 total): nd Astra Zeneca han $10000 total) Lilly, Pfizer, Sanofi Aventis, BMS k S h i BMS S fi k-Schering, BMS, Sanofi

es donated to charity

slide-2
SLIDE 2

Wh t i What is a

 A registry is a systemati  A registry is a systemati

patients with a specific c

 Registries do NOT test t

device compared to ano record real life data of w conditions or devices conditions or devices

 Registries can identify C

hypothesis generating q answer specific treatme

R i t ? Registry?

ic recording of data on ic recording of data on condition or device the benefits of one drug or

  • ther or placebo, they

what happens to pts with CARE GAPS or provide questions, but do NOT nt questions

slide-3
SLIDE 3

Wh t i l What is a cl

 Biomedical or health-relate

human beings that follow a

 Interventional studies are t  Interventional studies are t

research subjects are assig to a treatment or other inte

  • utcomes are measured.
  • utco

es a e easu ed

 Observational studies are t

are observed and their outc the investigators. g

i i l t i l? inical trial?

ed research studies in a pre-defined protocol. those in which the those in which the gned by the investigator ervention, and their those in which individuals comes are measured by

slide-4
SLIDE 4

Wh t i G Wh t i G What is G What is G

 Launched in 1999, The G

Launched in 1999, The G Coronary Events is an in Coronary Events is an in d i d t t k t d i d t t k t

 Launched in 1999, The G

Launched in 1999, The G Coronary Events is an in Coronary Events is an in d i d t t k t d i d t t k t designed to track outco designed to track outco presenting with acute co presenting with acute co including including myocardial inf myocardial inf designed to track outco designed to track outco presenting with acute co presenting with acute co including including myocardial inf myocardial inf g y angina. angina.

 GRACE includes hospita

GRACE includes hospita South America Europe South America Europe g y angina. angina.

 GRACE includes hospita

GRACE includes hospita South America Europe South America Europe South America, Europe, South America, Europe, Zealand. Zealand. South America, Europe, South America, Europe, Zealand. Zealand.

GRACE? GRACE? GRACE? GRACE?

Global Registry of Acute Global Registry of Acute nternational database nternational database f ti t f ti t Global Registry of Acute Global Registry of Acute nternational database nternational database f ti t f ti t mes of patients mes of patients

  • ronary syndromes,
  • ronary syndromes,

farction or unstable farction or unstable mes of patients mes of patients

  • ronary syndromes,
  • ronary syndromes,

farction or unstable farction or unstable als in North America, als in North America, Asia Australia and New Asia Australia and New als in North America, als in North America, Asia Australia and New Asia Australia and New Asia, Australia and New Asia, Australia and New Asia, Australia and New Asia, Australia and New

slide-5
SLIDE 5

Multinat Multinat Multinat Multinat

Argentina Argentina 7 sites 7 sites Australia Australia 5 sites 5 sites Austria Austria 5 sites 5 sites Belgium Belgium 6 sites 6 sites g Brazil Brazil 7 sites 7 sites Canada Canada 5 sites 5 sites France France 7 sites 7 sites

Adapted from Adapted from The GRACE I The GRACE I

France France 7 sites 7 sites

ional Site Network ional Site Network ional Site Network ional Site Network

Germany Germany 5 sites 5 sites Italy Italy 5 sites 5 sites New Zealand New Zealand 2 sites 2 sites Poland Poland 6 sites 6 sites Spain Spain 3 sites 3 sites UK UK 4 sites 4 sites USA USA 19 sites 19 sites

Investigators Investigators Am Heart J Am Heart J 2001;141:190 2001;141:190-

  • 9

USA USA 19 sites 19 sites

slide-6
SLIDE 6

What is G What is G What is G What is G

 Multinational, prospectiv

Multinational, prospectiv spectrum of acute coron spectrum of acute coron

 Multinational, prospectiv

Multinational, prospectiv spectrum of acute coron spectrum of acute coron spectrum of acute coron spectrum of acute coron

 Observational database

Observational database spectrum of acute coron spectrum of acute coron

 Observational database

Observational database practices and patient ou practices and patient ou

 14 countries in Europe,

14 countries in Europe, practices and patient ou practices and patient ou

 14 countries in Europe,

14 countries in Europe, America, Australia/New America, Australia/New

 First 10 consecutive cas

First 10 consecutive cas America, Australia/New America, Australia/New

 First 10 consecutive cas

First 10 consecutive cas First 10 consecutive cas First 10 consecutive cas qualifying symptoms qualifying symptoms plu plu artery disease artery disease First 10 consecutive cas First 10 consecutive cas qualifying symptoms qualifying symptoms plu plu artery disease artery disease

The GRACE I The GRACE I

GRACE? GRACE? GRACE? GRACE?

ve registry of the entire ve registry of the entire nary syndromes (ACS) nary syndromes (ACS) ve registry of the entire ve registry of the entire nary syndromes (ACS) nary syndromes (ACS) nary syndromes (ACS) nary syndromes (ACS)

  • f clinical management
  • f clinical management

nary syndromes (ACS) nary syndromes (ACS)

  • f clinical management
  • f clinical management

utcomes in ACS utcomes in ACS North and South North and South utcomes in ACS utcomes in ACS North and South North and South Zealand Zealand ses per centre/month with ses per centre/month with Zealand Zealand ses per centre/month with ses per centre/month with ses per centre/month with ses per centre/month with us us evidence of coronary evidence of coronary ses per centre/month with ses per centre/month with us us evidence of coronary evidence of coronary

nvestigators nvestigators Am Heart J Am Heart J 2001;141:190 2001;141:190-

  • 9
slide-7
SLIDE 7

Objec Objec

 Identify opportuniti

Identify opportuniti quality of care for p quality of care for p

 Identify opportuniti

Identify opportuniti quality of care for p quality of care for p q y p q y p

 Describe diagnosti

Describe diagnosti strategies and hosp strategies and hosp q y p q y p

 Describe diagnosti

Describe diagnosti strategies and hosp strategies and hosp strategies and hosp strategies and hosp associated outcom associated outcom

 Develop hypothese

Develop hypothese strategies and hosp strategies and hosp associated outcom associated outcom

 Develop hypothese

Develop hypothese

 Develop hypothese

Develop hypothese research research

 Develop hypothese

Develop hypothese research research

ctives ctives

ies to improve the ies to improve the patients with ACS patients with ACS ies to improve the ies to improve the patients with ACS patients with ACS p c and treatment c and treatment pital and 6 pital and 6-month month p c and treatment c and treatment pital and 6 pital and 6-month month pital and 6 pital and 6 month month mes mes es for future clinical es for future clinical pital and 6 pital and 6 month month mes mes es for future clinical es for future clinical es for future clinical es for future clinical es for future clinical es for future clinical

slide-8
SLIDE 8

Patient Enr Patient Enr at e t at e t

60000 60000 80000 80000 Patients Enrolled ents ents 50000 50000 60000 60000 6 Month Follow-Up r of Patie r of Patie

28699 28699 38444 38444 27 27

30000 30000 40000 40000 Numbe Numbe

11543 11543 19453 19453 13245 13245 20303 20303

20000 20000 30000 30000

6689 6689

10000 10000 1999 1999-

  • 2000

2000 2001 2001 2002 2002 2003 2003

rolment + Follow rolment + Follow-

  • Up*

Up*

  • e t
  • o
  • e t
  • o

Up Up

62936 62936 70359 70359 46945 46945 55454 55454 43117 43117 50442 50442 57104 57104 7618 7618 35301 35301

Canada (n=4,161 + 3558) Canada (n=4,161 + 3558)

2-

  • yr:

yr: 6641 6641 * As of Aug 26/08 * As of Aug 26/08

3 2005 2005 2004 2004 2006 2006 2007 2007

slide-9
SLIDE 9

What is Expa What is Expa What is Expa What is Expa ( GRA ( GRA

 From 2001 to 2007, 3

From 2001 to 2007, 3 suspected ACS were suspected ACS were

 From 2001 to 2007, 3

From 2001 to 2007, 3 suspected ACS were suspected ACS were p GRACE at 184 hospit GRACE at 184 hospit

 The distribution of pa

The distribution of pa p GRACE at 184 hospit GRACE at 184 hospit

 The distribution of pa

The distribution of pa follows: Asia 16.7%, follows: Asia 16.7%, Europe 28.5%, North Europe 28.5%, North S th A i 11 2% S th A i 11 2% follows: Asia 16.7%, follows: Asia 16.7%, Europe 28.5%, North Europe 28.5%, North S th A i 11 2% S th A i 11 2% South America 11.2% South America 11.2% South America 11.2% South America 11.2%

anded Grace anded Grace anded Grace anded Grace ACE 2) ACE 2)

31,982 patients with a 31,982 patients with a e enrolled in expanded e enrolled in expanded 31,982 patients with a 31,982 patients with a e enrolled in expanded e enrolled in expanded p tals in 25 countries tals in 25 countries atients was as atients was as p tals in 25 countries tals in 25 countries atients was as atients was as Australia 3.8%, Australia 3.8%, h America 39.8%, and h America 39.8%, and % Australia 3.8%, Australia 3.8%, h America 39.8%, and h America 39.8%, and %. %. %. %.

slide-10
SLIDE 10

Expanded GRA Expanded GRA

Diabetes Substudy ECG Substudy Biological Marker Micr Biological Marker Substudy

Go Go

ACE = GRACE 2 ACE = GRACE 2

184 Hospitals 184 Hospitals 25 Countries 25 Countries 4 page CRF 4 page CRF *6 Month Follow *6 Month Follow-

  • Up

Up 87 Hospitals 87 Hospitals 13 Countries 13 Countries ≈50 ≈50-

  • 100 Patients/hospital

100 Patients/hospital 10,000 Patients/year 10,000 Patients/year 8 page CRF 8 page CRF 6 Month Follow 6 Month Follow-

  • Up

Up

roparticle Substudy Lipid Substudy Bleeding Substudy

* In Canada * In Canada

  • odman et al
  • odman et al Am Heart J

Am Heart J 2009;158:193 2009;158:193-

  • 201

201

slide-11
SLIDE 11

GRACE E GRACE E

Country Country Number of Sit Number of Sit Country Country Number of Sit Number of Sit Australia Australia 9 9 Austria Austria 5 5 Bangladesh Bangladesh 1 1 Brazil Brazil 6 Brazil Brazil 6 Bulgaria Bulgaria 23 23 Canada Canada 44 44 China China 14 14 Columbia Columbia 3 3 Ecuador Ecuador 1 1 El Salvador El Salvador 1 1 Germany Germany 20 20 Guatemala Guatemala 2 2 Italy Italy 14 14 Italy Italy 14 14 Latvia Latvia 1 1 Mexico Mexico 2 2 Panama Panama 1 1 Peru Peru 1 1 Poland Poland 10 10 Portugal Portugal 1 1 Romania Romania 3 3 Ukraine Ukraine 3 3 U it d A b E i t U it d A b E i t 1 United Arab Emirates United Arab Emirates 1 United States United States 11 11 Uruguay Uruguay 2 2 Venezuela Venezuela 5 5

Expansion Expansion

As of December 31, 2007 As of December 31, 2007

tes* tes* Number of Patients Number of Patients tes* tes* Number of Patients Number of Patients 1,225 1,225 533 533 100 100 671 671 671 671 398 398 11,265 11,265 3,809 3,809 1,157 1,157 271 271 18 18 2,234 2,234 99 99 732 732

184 Hospitals 184 Hospitals 31,982 31,982

732 732 371 371 255 255 30 30 100 100

Patients Patients

4,159 4,159 153 153 319 319 215 215 1 420 1 420

*Enrolled ≥1 non *Enrolled ≥1 non-

  • transfer

transfer-

  • in pt

in pt

1,420 1,420 1,456 1,456 81 81 911 911

slide-12
SLIDE 12

GRACE GRACE

Monday Nov Monday Nov

GRACE GRACE

Monday, Nov Monday, Nov

30 countries 30 countries 30 countries 30 countries

■ ■ 30 countries

30 countries

■ ■ 247 hospitals

247 hospitals 102 341 patients (G 102 341 patients (G

■ ■ 30 countries

30 countries

■ ■ 247 hospitals

247 hospitals 102 341 patients (G 102 341 patients (G

■ ■ 102,341 patients (G

102,341 patients (G

■ ■ 118 Published Abs

118 Published Abs 114 P bli h d M 114 P bli h d M

■ ■ 102,341 patients (G

102,341 patients (G

■ ■ 118 Published Abs

118 Published Abs 114 P bli h d M 114 P bli h d M

■ ■ 114 Published Man

114 Published Man

■ ■ 114 Published Man

114 Published Man

E Status E Status

vember 1 2010 vember 1 2010

E Status E Status

vember 1, 2010 vember 1, 2010

GRACE + GRACE GRACE + GRACE2) GRACE + GRACE GRACE + GRACE2) GRACE + GRACE GRACE + GRACE2) stracts stracts i t i t GRACE + GRACE GRACE + GRACE2) stracts stracts i t i t nuscripts nuscripts nuscripts nuscripts

slide-13
SLIDE 13

Global Registry Global Registry E t E t Events Events

British British Columbia Columbia Saskatchewan Saskatchewan 2 sites 2 sites sites 12 sites 12 n=2674 n=2674 Alberta Alberta 2 sites 2 sites n=345 n=345 n=247 n=247

y of Acute Coronary y of Acute Coronary i C d i C d

17,241 ACS patients from 55 sites 17,241 ACS patients from 55 sites

in Canada in Canada

, p , p 1999 (GRACE); 2004 (GRACE 1999 (GRACE); 2004 (GRACE2

2)

) – – 2007; 2008 (CANRACE) 2007; 2008 (CANRACE) Newfoundland Newfoundland 1 it 1 it Ontario Ontario Quebec Quebec New Brunswick 3 New Brunswick 3 1 site 1 site N=30 N=30 Ontario Ontario 21 sites 21 sites n=7736 n=7736 14 sites 14 sites n=3545 n=3545 New Brunswick 3 New Brunswick 3 sites sites n=849 n=849

slide-14
SLIDE 14

247 C 247 C GRACE GRACE GRACE GRACE 30 30

*30 countries = 16 GRACE *30 countries = 16 GRACE2

2 + 7 core GRACE + 7

+ 7 core GRACE + 7

Core GRACE & Core GRACE & E2 Study Sites in Study Sites in E2 Study Sites in Study Sites in 0 Countries* 0 Countries*

both both

slide-15
SLIDE 15

Registry Man Registry Man F d F d Fund Fund

 Expanded GRACE is spo

Expanded GRACE is spo grant from grant from sanofi sanofi-

  • aventi

aventi th I t ti th I t ti

 Expanded GRACE is spo

Expanded GRACE is spo grant from grant from sanofi sanofi-

  • aventi

aventi th I t ti th I t ti serves as the Internation serves as the Internation Center for GRACE and e Center for GRACE and e serves as the Internation serves as the Internation Center for GRACE and e Center for GRACE and e

 GRACE is supported by

GRACE is supported by educational grant from educational grant from s f O t R h f O t R h

 GRACE is supported by

GRACE is supported by educational grant from educational grant from s f O t R h f O t R h for Outcomes Research for Outcomes Research Massachusetts Medical Massachusetts Medical for Outcomes Research for Outcomes Research Massachusetts Medical Massachusetts Medical

agement and agement and di di ding ding

  • nsored by an educational
  • nsored by an educational

is is to the COR. The COR to the COR. The COR l S i tifi C di ti l S i tifi C di ti

  • nsored by an educational
  • nsored by an educational

is is to the COR. The COR to the COR. The COR l S i tifi C di ti l S i tifi C di ti nal Scientific Coordinating nal Scientific Coordinating expanded GRACE. expanded GRACE. nal Scientific Coordinating nal Scientific Coordinating expanded GRACE. expanded GRACE. an unrestricted an unrestricted sanofi sanofi-

  • aventis

aventis to the Center to the Center U i it f U i it f an unrestricted an unrestricted sanofi sanofi-

  • aventis

aventis to the Center to the Center U i it f U i it f , University of , University of School. School. , University of , University of School. School.

slide-16
SLIDE 16

Data Man Data Man Data Man Data Man

Data were collected at each s Data were collected at each s using a standardized CRF. using a standardized CRF.

Demographic characteristics Demographic characteristics

Data were collected at each s Data were collected at each s using a standardized CRF. using a standardized CRF.

Demographic characteristics Demographic characteristics

Demographic characteristics Demographic characteristics symptoms, duration of preho symptoms, duration of preho ECG findings, treatment prac ECG findings, treatment prac

  • utcome data were collected
  • utcome data were collected

Demographic characteristics Demographic characteristics symptoms, duration of preho symptoms, duration of preho ECG findings, treatment prac ECG findings, treatment prac

  • utcome data were collected
  • utcome data were collected
  • utcome data were collected
  • utcome data were collected

Standardized definitions of a Standardized definitions of a clinical diagnoses were used clinical diagnoses were used

Completed CRFs were faxed Completed CRFs were faxed

  • utcome data were collected
  • utcome data were collected

Standardized definitions of a Standardized definitions of a clinical diagnoses were used clinical diagnoses were used

Completed CRFs were faxed Completed CRFs were faxed

Completed CRFs were faxed Completed CRFs were faxed (Center for Outcomes Resear (Center for Outcomes Resear Massachusetts Medical Scho Massachusetts Medical Scho

alternatively data were enter alternatively data were enter

Completed CRFs were faxed Completed CRFs were faxed (Center for Outcomes Resear (Center for Outcomes Resear Massachusetts Medical Scho Massachusetts Medical Scho

alternatively data were enter alternatively data were enter

alternatively, data were enter alternatively, data were enter CRF. CRF.

alternatively, data were enter alternatively, data were enter CRF. CRF.

nagement nagement nagement nagement

site by a trained coordinator site by a trained coordinator s medical history presenting s medical history presenting site by a trained coordinator site by a trained coordinator s medical history presenting s medical history presenting s, medical history, presenting s, medical history, presenting

  • spital delay, biochemical and
  • spital delay, biochemical and

ctices, and a variety of hospital ctices, and a variety of hospital . s, medical history, presenting s, medical history, presenting

  • spital delay, biochemical and
  • spital delay, biochemical and

ctices, and a variety of hospital ctices, and a variety of hospital . . all patient all patient-

  • related variables and

related variables and d. d. to the data coordinating center to the data coordinating center . . all patient all patient-

  • related variables and

related variables and d. d. to the data coordinating center to the data coordinating center to the data coordinating center to the data coordinating center rch [COR], University of rch [COR], University of

  • ol, Worcester, MA);
  • ol, Worcester, MA);

red into an electronic Web red into an electronic Web-based based to the data coordinating center to the data coordinating center rch [COR], University of rch [COR], University of

  • ol, Worcester, MA);
  • ol, Worcester, MA);

red into an electronic Web red into an electronic Web-based based red into an electronic, Web red into an electronic, Web-based based red into an electronic, Web red into an electronic, Web-based based

slide-17
SLIDE 17

DATA R DATA R DATA Repor DATA Repor

 Each hospital received a

Each hospital received a center's data as well as center's data as well as t ' d ll t ' d ll

 Each hospital received a

Each hospital received a center's data as well as center's data as well as t ' d ll t ' d ll country's and overall wo country's and overall wo basis. basis.

 The goal of expanded G

The goal of expanded G country's and overall wo country's and overall wo basis. basis.

 The goal of expanded G

The goal of expanded G

 The goal of expanded G

The goal of expanded G additional hospitals with additional hospitals with GRACE countries as we GRACE countries as we number of participating number of participating

 The goal of expanded G

The goal of expanded G additional hospitals with additional hospitals with GRACE countries as we GRACE countries as we number of participating number of participating number of participating number of participating project and enroll appro project and enroll appro per year per year number of participating number of participating project and enroll appro project and enroll appro per year per year

ti t Sit ti t Sit rting to Sites rting to Sites

a profile of its own a profile of its own a summary of its a summary of its ld d t t l ld d t t l a profile of its own a profile of its own a summary of its a summary of its ld d t t l ld d t t l

  • rld data on a quarterly
  • rld data on a quarterly

RACE was to expand to RACE was to expand to

  • rld data on a quarterly
  • rld data on a quarterly

RACE was to expand to RACE was to expand to RACE was to expand to RACE was to expand to hin participating main hin participating main ell as to increase the ell as to increase the countries in the GRACE countries in the GRACE RACE was to expand to RACE was to expand to hin participating main hin participating main ell as to increase the ell as to increase the countries in the GRACE countries in the GRACE countries in the GRACE countries in the GRACE

  • ximately 5,000 patients
  • ximately 5,000 patients

countries in the GRACE countries in the GRACE

  • ximately 5,000 patients
  • ximately 5,000 patients
slide-18
SLIDE 18

Q 4 2008 FINAL DATA 18

slide-19
SLIDE 19

Q 4 2008 FINAL D 19 DATA

slide-20
SLIDE 20

Population Population-

 Defined Community

Defined Community Includes all hospita Includes all hospita

 Includes all hospita

Includes all hospita residents may seek residents may seek

 Ideally socio

Ideally socio demo demo

 Ideally, socio

Ideally, socio-demo demo characteristics matc characteristics matc as a whole as a whole as a whole as a whole

S

  • Based Sites

Based Sites

y als where community als where community als where community als where community k care k care

  • graphic and hospital
  • graphic and hospital
  • graphic and hospital
  • graphic and hospital

ch country or region ch country or region

slide-21
SLIDE 21

Represent Represent

  Convenience samp

Convenience samp considered represe considered represe hospitals in the reg hospitals in the reg

  Balance characteri

Balance characteri academic vs. comm academic vs. comm public vs. private s public vs. private s

S tative Sites tative Sites

ple of hospitals ple of hospitals entative of the entative of the gion/country gion/country stics such as size, stics such as size, munity hospital type, munity hospital type, status, facilities, etc. status, facilities, etc.

slide-22
SLIDE 22

C S C S Case Sele Case Sele

 Select first ~10 qualif

Select first ~10 qualif

 Confirm inclusion/exc

Confirm inclusion/exc

 Patient consent for fo

Patient consent for fo

 Enroll patient

Enroll patient

 Complete initial CRF

Complete initial CRF

 Complete 6

Complete 6-

  • month fo

month fo p

S ection Strategy ection Strategy

fying cases in each month fying cases in each month clusion criteria clusion criteria

  • llow
  • llow-up

up llow llow-up CRF up CRF p

slide-23
SLIDE 23

Wh t i C What is a C

 A CARE GAP is the d  A CARE GAP is the d

  • ptimal therapy as s

trials and the actual trials and the actual Hospital

CARE GAP? CARE GAP?

difference between difference between uggested by clinical care given at YOUR care given at YOUR

slide-24
SLIDE 24

Optimal ACS Optimal ACS Managemen Managemen

AC AC

GRACE GRACE Q Optima Optima

  • Curre

Curre C Quarterly Quarterly feedback feedback reports reports Care Care Interven Interven

Continuous Continuous

reports reports close Ca close Ca Patient Patient

Quality Quality Improvement Improvement

Patient Patient Outcomes Outcomes GRACE GRACE Evalu Evalu Follow Follow-

  • up data

up data

nt: Closing the Care Gap nt: Closing the Care Gap

CS CS

Evidence Evidence-based based al Care al Care nt nt Care Care G de ce de ce based based guidelines guidelines GRACE GRACE Data Data e Gap e Gap GRACE GRACE Data Data ntion to ntion to Hospital Hospital-

  • level

level activities activities are Gap are Gap Hospital Hospital activities activities Hospital Hospital Resources Resources uation uation

Goodman et al Goodman et al Am Heart J Am Heart J 2009; 2009;

slide-25
SLIDE 25

JAMA JAMA 2007;297:1892 2007;297:1892-

  • 1900

1900

slide-26
SLIDE 26

Wednesday, Wednesday, May 2nd 2007 May 2nd 2007 May 2nd, 2007 May 2nd, 2007 Edition of Edition of USA TODAY USA TODAY

slide-27
SLIDE 27

GRACE Risk GRACE Risk

60 60

% of Patients % of Patients Ri k F t Ri k F t

In In-

  • Hospita

Hospita

40 40 50 50

Risk Factor Risk Factor Age Age Diabetes Diabetes Hypertension Hypertension

C S C S 30 30 40 40

yp yp Heart rate (per 30 beat/min Heart rate (per 30 beat/min ) Systolic BP (per 20 mm Hg Systolic BP (per 20 mm Hg ) Killip Class (per Killip Class (per  in class) in class) Cardiac Arrest Cardiac Arrest

20 20

Cardiac Arrest Cardiac Arrest Initial Cardiac Marker + Initial Cardiac Marker + Initial Creatinine (per 88.4 µmol/L Initial Creatinine (per 88.4 µmol/L ) ST ST-

  • segment deviation

segment deviation

0.3 0.3 0.4 0.4 0.6 0.6 0.8 0.8 1.1 1.1 1.6 1.6 2.1 2.1 2.9 2.9 3.9 3.9 0 0.2 0.2 10 10 Download PDA vers Download PDA vers umassmed.org/g umassmed.org/g Gra Gra ≤60 ≤60 70 70 80 80 90 90 100 100 110 110 120 120 130 130 140 140 150 150

Risk Score Risk Score

g g g g

k Score For All k Score For All ACS ACS

11 389 11 389

al Mortality al Mortality

44 44 52 52 Statistic = 0.84 Statistic = 0.84

n=11,389 n=11,389

29 29 36 36 44 44 13 13 18 18 23 23 29 29 9 5.4 5.4 7.3 7.3 9.8 9.8 13 13 ion at www.outcomes ion at www.outcomes-

  • grace/acs risk.cfm

grace/acs risk.cfm anger et al anger et al Arch Int Med Arch Int Med 2003;163:2345 2003;163:2345-

  • 53

53 0 160 160 170 170 180 180 190 190 200 200 210 210 220 220 230 230 240 240≥250 ≥250

e (Points) e (Points)

g _ g _

slide-28
SLIDE 28

Tren Tren R f R f

50 50 % of Patients

% of Patients

Reperfu Reperfu

3 40 40 20 20 26 26 3 20 20 30 30 15 15 10 10 20 20 Primary PCI (n Primary PCI (n April 1999 April 1999- July 2000 July 2000- July 2001 July 2001- July July

* Including non * Including non-

  • transfer

transfer-

  • in patients wit

in patients wit hrs of symptom onset eligib hrs of symptom onset eligib

April 1999 April 1999- June 2000 June 2000 July 2000 July 2000- June 2001 June 2001 July 2001 July 2001- June 2002 June 2002 July July June June

nds in Acute nds in Acute i Th i Th

44 44

usion Therapy usion Therapy

31 31 37 37 40 40 44 44 31 31 n=3,235) n=3,235) *Median Time: *Median Time: 34 (27 34 (27-

  • 62) min

62) min 80 (45 80 (45-

  • 119) min

119) min 2002 2002- July 2003 July 2003- July 2004 July 2004- July 2005 July 2005-

th STEMI or presumed new LBBB th STEMI or presumed new LBBB ≤12 ≤12 ble for reperfusion therapy ble for reperfusion therapy

2002 2002- e 2003 e 2003 July 2003 July 2003- June 2004 June 2004 July 2004 July 2004- June 2005 June 2005 July 2005 July 2005- June 2006* June 2006* Eagle et al Eagle et al Eur Heart J Eur Heart J 2008;29:609 2008;29:609-

  • 17

17

slide-29
SLIDE 29

Tren Tren R f R f

50 50 % of Patients

% of Patients

Reperfu Reperfu

3 41 41 39 39 36 36 40 40 20 20 26 26 3 2 20 20 30 30 15 15 10 10 20 20 Fibrinolysis (n Fibrinolysis (n Primary PCI (n Primary PCI (n April 1999 April 1999- July 2000 July 2000- July 2001 July 2001- July July

* Including non * Including non-

  • transfer

transfer-

  • in patients wit

in patients wit hrs of symptom onset eligib hrs of symptom onset eligib

April 1999 April 1999- June 2000 June 2000 July 2000 July 2000- June 2001 June 2001 July 2001 July 2001- June 2002 June 2002 July July June June

nds in Acute nds in Acute i Th i Th

44 44

usion Therapy usion Therapy

31 31 37 37 40 40 44 44 31 31 27 27 24 24 20 20 16 16 n=2,887) n=2,887) n=3,235) n=3,235) *Median Time: *Median Time: 34 (27 34 (27-

  • 62) min

62) min 80 (45 80 (45-

  • 119) min

119) min 2002 2002- July 2003 July 2003- July 2004 July 2004- July 2005 July 2005-

th STEMI or presumed new LBBB th STEMI or presumed new LBBB ≤12 ≤12 ble for reperfusion therapy ble for reperfusion therapy

2002 2002- e 2003 e 2003 July 2003 July 2003- June 2004 June 2004 July 2004 July 2004- June 2005 June 2005 July 2005 July 2005- June 2006* June 2006* Eagle et al Eagle et al Eur Heart J Eur Heart J 2008;29:609 2008;29:609-

  • 17

17

slide-30
SLIDE 30

Tren Tren R f R f

50 50 % of Patients

% of Patients

Reperfu Reperfu

No Reperfusi No Reperfusi 3 40 40 35 35 32 32 3 41 41 39 39 36 36 40 40 No Reperfusi No Reperfusi 20 20 26 26 3 32 32 2 20 20 30 30 15 15 10 10 20 20 Fibrinolysis (n Fibrinolysis (n Primary PCI (n Primary PCI (n April 1999 April 1999- July 2000 July 2000- July 2001 July 2001- July July

* Including non * Including non-

  • transfer

transfer-

  • in patients wit

in patients wit hrs of symptom onset eligib hrs of symptom onset eligib

April 1999 April 1999- June 2000 June 2000 July 2000 July 2000- June 2001 June 2001 July 2001 July 2001- June 2002 June 2002 July July June June

nds in Acute nds in Acute i Th i Th

44 44

usion Therapy usion Therapy

  • n Therapy
  • n Therapy

31 31 37 37 40 40 44 44 35 35 33 33 33 33

  • n Therapy
  • n Therapy

31 31 33 33 27 27 24 24 20 20 16 16 n=2,887) n=2,887) n=3,235) n=3,235) *Median Time: *Median Time: 34 (27 34 (27-

  • 62) min

62) min 80 (45 80 (45-

  • 119) min

119) min 2002 2002- July 2003 July 2003- July 2004 July 2004- July 2005 July 2005-

th STEMI or presumed new LBBB th STEMI or presumed new LBBB ≤12 ≤12 ble for reperfusion therapy ble for reperfusion therapy

2002 2002- e 2003 e 2003 July 2003 July 2003- June 2004 June 2004 July 2004 July 2004- June 2005 June 2005 July 2005 July 2005- June 2006* June 2006* Eagle et al Eagle et al Eur Heart J Eur Heart J 2008;29:609 2008;29:609-

  • 17

17

slide-31
SLIDE 31

No No

NSTEMI (n NSTEMI (n 100 100 % of Patients

% of Patients

Trends in Aspirin Trends in Aspirin

( 80 80 92 92 91 91 90 90 92 92 90 90 88 88 60 60 88 88 20 20 40 40 20 20 NSTEMI NSTEMI Unstable Angina Unstable Angina 1999 1999-

  • 2001

2001 2002 2002 2003 2003 20 20

  • n
  • n-
  • ST Elevation ACS

ST Elevation ACS

n=28,431) + Unstable Angina (n=26,134) n=28,431) + Unstable Angina (n=26,134)

Use at Admission Use at Admission

, ) g ( , ) , ) g ( , ) 91 91 94 94 94 94 93 93 91 91 92 92 91 91 93 93 004 004 2005 2005 2006 2006 2007 2007

slide-32
SLIDE 32

No No

NSTEMI (n NSTEMI (n 100 100 % of Patients

% of Patients

Trends in Trends in Clopidogre Clopidogre

( 80 80 NSTEMI NSTEMI Unstable Angina Unstable Angina 60 60 20 20 40 40

21 21 36 36 42 42

28 28 38 38 20 20

21 21

18 18 1999 1999-

  • 2001

2001 2002 2002 2003 2003 20 20

* 1 * 1st

st 24 hours

24 hours

  • n
  • n-
  • ST Elevation ACS

ST Elevation ACS

n=28,431) + Unstable Angina (n=26,134) n=28,431) + Unstable Angina (n=26,134)

el el Use at Admission* Use at Admission*

, ) g ( , ) , ) g ( , )

48 48 58 58 62 62 68 68

52 52 57 57 56 56

48 48

43 43 004 004 2005 2005 2006 2006 2007 2007

slide-33
SLIDE 33

Trends in Cardiac Trends in Cardiac

100 100

% of Patients

80 80 100 100 NSTEMI NSTEMI Unstable Angina Unstable Angina STEMI/LBBB STEMI/LBBB 60 60 Unstable Angina Unstable Angina 20 20 40 40 2001 2001 2002 2002 2003 2003 2004 2004 20 20 2001 2001 2002 2002 2003 2003 2004 2004

c Catheterization c Catheterization

n=17,241 (55 hospitals) 2005 2005 2006 2006 2008 2008 2007 2007 2005 2005 2006 2006 2008 2008 2007 2007

slide-34
SLIDE 34

Trends Trends

100 100

% of Patients

80 80 100 100 NSTEMI NSTEMI Unstable Angina Unstable Angina STEMI/LBBB STEMI/LBBB 60 60 Unstable Angina Unstable Angina 20 20 40 40 2001 2001 2002 2002 2003 2003 2004 2004 20 20 2001 2001 2002 2002 2003 2003 2004 2004

in PCI in PCI

n=17,241 (55 hospitals) 2005 2005 2006 2006 2008 2008 2007 2007 2005 2005 2006 2006 2008 2008 2007 2007

slide-35
SLIDE 35

What are we do What are we do What are we do What are we do Memorial Hosp Memorial Hosp to British Colu to British Colu and the Rest o and the Rest o and the Rest o and the Rest o ing at Surrey ing at Surrey ing at Surrey ing at Surrey pital compared pital compared umbia, Canada, umbia, Canada,

  • f the World?
  • f the World?
  • f the World?
  • f the World?
slide-36
SLIDE 36

As of Q4 2007 As of Q4 20071 and Q4 2008 and Q4 20082

Presenting ECG* and C Presenting ECG* and C

As of Q4 2007 As of Q4 2007 and Q4 2008 and Q4 2008 N=93,092 N=93,092

World World1

Non Non-

  • ST

ST  MI MI 31% 31% ST ST  MI MI

N 93,092 N 93,092

Unstable Unstable Angina Angina Other Other 8% 8% 29% 29% ST ST  MI MI 32% 32% 8% 8% 29% 29%

242 sites 30 countries 242 sites 30 countries 242 sites, 30 countries 242 sites, 30 countries * based on site * based on site

Cardiac Marker Status Cardiac Marker Status

Canada Canada2

N=17,144 N=17,144

Non Non-

  • ST

ST  MI MI 40% 40%

N 17,144 N 17,144

Unstable Unstable Angina Angina Other Other 14% 14% 22% 22% ST ST  MI MI 24% 24% 14% 14%

55 sites 55 sites e interpretation e interpretation 55 sites 55 sites

slide-37
SLIDE 37

N=total; % as of Q4 2008 N=total; % as of Q4 2008

Presenting ECG* and C Presenting ECG* and C

N=total; % as of Q4 2008 N=total; % as of Q4 2008 N=771 N=771

Surrey Memorial Hospital Surrey Memorial Hospital

Non Non-

  • ST

ST  MI MI 52% 52%

N 771 N 771

Unstable Unstable Angina Angina ST ST  MI MI 31% 31% Other Other 7% 7% Other Other 10% 10%

* based on site interpretation * based on site interpretation

Cardiac Marker Status Cardiac Marker Status

British Columbia British Columbia

N=2,315 N=2,315

Unstable Unstable A i A i Non Non-

  • ST

ST  MI MI 41% 41%

N 2,315 N 2,315

Angina Angina Other Other 22% 22% 16% 16% ST ST  MI MI 21% 21% 22% 22%

12 sites 12 sites + non non-

  • ACS

ACS final final diagnosis diagnosis 12 sites 12 sites

slide-38
SLIDE 38

As of Q4 2007 As of Q4 20071 and Q4 2008 and Q4 20082

Patient Cha Patient Cha

As of Q4 2007 As of Q4 2007 and Q4 2008 and Q4 2008

World World1

Median Age Median Age (years) (years) n=93,092 n=93,092 66 66 g (y ) (y ) >75 years (%) >75 years (%) 27 27 Female (%) Female (%) Prior MI (%) Prior MI (%) 33 33 29 29 Prior MI (%) Prior MI (%) 29 29

aracteristics aracteristics

Canada Canada2 SMH SMH2 B.C. B.C.2

2 n=17,144 n=17,144 67 67 n=771 n=771 61 61 n=2,315 n=2,315 66 66 30 30 21 21 27 27 35 35 33 33 27 27 26 26 31 31 24 24 33 33 26 26 24 24

slide-39
SLIDE 39

N= total; % as of Q4 2007 N= total; % as of Q4 20071 and Q4 2008 and Q4 20082

In In-

  • Hospital

Hospital

N= total; % as of Q4 2007 N= total; % as of Q4 2007 and Q4 2008 and Q4 2008

World World1

n=93,092 n=93,092 (%) (%)

C

n 70 70 34 34 Angiography Angiography PCI PCI 34 34 4 PCI PCI CABG CABG

Procedures Procedures

Canada Canada2

n=17,144 n=17,144

SMH SMH2

n=771 n=771

B.C. B.C.2

n=2,315 n=2,315 67 67 33 33 94 94 8 87 87 46 46 33 33 4 58 58

  • 46

46 2

slide-40
SLIDE 40

N=total; % as of Q4 2008 N=total; % as of Q4 2008

Selected Admis Selected Admis in ST Ele in ST Ele

N=total; % as of Q4 2008 N=total; % as of Q4 2008

in ST Ele in ST Ele

95 95 92 92 97 97 80 80 100 100 % of Patients % of Patients 99 99 60 60 80 80 40 40 Surrey Memorial (n=265) Surrey Memorial (n=265) 20 20 British Columbia (n=456) British Columbia (n=456) Canada (n=4,045) Canada (n=4,045) ASA ASA Clo Clo

ssion Therapies ssion Therapies vation MI vation MI vation MI vation MI

92 92 84 84 84 84 32 32 46 46 24 24

  • pidogrel
  • pidogrel

LMWH* LMWH* * during hospitalization * during hospitalization

slide-41
SLIDE 41

In In-

  • Hospita

Hospita

30 30 % of Patients % of Patients 25 25 22 22 25 25 16 16 22 22 15 15 20 20 16 16 10 10 2 1 6 3 5 5 5 5 5 5 D th D th M di l M di l R t I h i R t I h i C Death Death Myocardial Myocardial (re)infarction (re)infarction Recurrent Ischemic Recurrent Ischemic Symptoms Symptoms C Pulm Pulm Ed Ed

As of Q4 2007 As of Q4 20071 and Q4 2008 and Q4 20082

al Events al Events

British Columbia (n=2,315) British Columbia (n=2,315)2

2

Canada (n=17,144) Canada (n=17,144)2

2

World (n=89 383) World (n=89 383)1

1

World (n 89,383) World (n 89,383) 10 10 12 12 2 2 2 2 2 2 1 4 2 1 CHF/ CHF/ C di i C di i M j Bl di M j Bl di Stroke Stroke CHF/ CHF/ monary monary dema dema Cardiogenic Cardiogenic Shock Shock Major Bleeding Major Bleeding

slide-42
SLIDE 42

How Can GRAC How Can GRAC How Can GRAC How Can GRAC Quality of Care Quality of Care

 You need to know what y

You need to know what y compare yourself to othe compare yourself to othe i t i t

 You need to know what y

You need to know what y compare yourself to othe compare yourself to othe i t i t inprovement inprovement

 Quarterly reports of

Quarterly reports of your your key performance indicato key performance indicato inprovement inprovement

 Quarterly reports of

Quarterly reports of your your key performance indicato key performance indicato key performance indicato key performance indicato rapid continuous quality rapid continuous quality

 Networking with others in

Networking with others in key performance indicato key performance indicato rapid continuous quality rapid continuous quality

 Networking with others in

Networking with others in g quality of ACS care quality of ACS care

 Allows for development o

Allows for development o g quality of ACS care quality of ACS care

 Allows for development o

Allows for development o for other projects for other projects for other projects for other projects

E 2 Improve the E 2 Improve the E 2 Improve the E 2 Improve the at My Hospital? at My Hospital?

you are doing so you can you are doing so you can rs and strive for rs and strive for you are doing so you can you are doing so you can rs and strive for rs and strive for r hospital data (including hospital data (including

  • rs) allows a sequence of
  • rs) allows a sequence of

r hospital data (including hospital data (including

  • rs) allows a sequence of
  • rs) allows a sequence of
  • rs) allows a sequence of
  • rs) allows a sequence of

improvement cycles improvement cycles nterested in improving the nterested in improving the

  • rs) allows a sequence of
  • rs) allows a sequence of

improvement cycles improvement cycles nterested in improving the nterested in improving the p g p g

  • f research infrastructure
  • f research infrastructure

p g p g

  • f research infrastructure
  • f research infrastructure
slide-43
SLIDE 43

Management and Management and P ti t B GR P ti t B GR Patients By GR Patients By GR

% of Patients % of Patients

In In-

  • Hospital Cath.

Hospital Cath.

% of Patient % of Patient

In In-

  • Hospita

Hospita

75.3 75.3 75 75 % of Patients % of Patients 90 90

p<0.001 (3 p<0.001 (3-

  • group

group comparison) comparison)

75 75 % of Patient % of Patient 90 90

p<0.001 p<0.001 comp comp

52.5 52.5 45 45 60 60 69.8 69.8 45 45 60 60 47 47 15 15 30 30 45 45 35.1 35.1 15 15 30 30 15 15 Low Low Intermed Intermed High High

n=8063 n=8063 n=8063 n=8063 n=8063 n=8063

15 15 Inter Inter High High GRACE Risk GRACE Risk Low Low Intermed. Intermed. High High Inter Inter High High

d Outcomes in ACS d Outcomes in ACS RACE Ri k S RACE Ri k S RACE Risk Score RACE Risk Score

s

al Revasc. al Revasc.

% of Patients % of Patients

In In-

  • Hospital Death*

Hospital Death*

s

1 (3 1 (3-

  • group

group parison) parison)

15 15 % of Patients % of Patients 18 18

p<0.001 (trend) p<0.001 (trend)

* Not including unstable * Not including unstable angina patients angina patients

55.6 55.6 7.9 7.9 13 13 9 12 12 3 6 3 3 3 3 Low Low rmed. rmed. 1.2 1.2 3 Low Low Intermed. Intermed. High High 3.3 3.3 Score Tertiles Score Tertiles Low Low rmed. rmed. Low Low Intermed. Intermed. High High Fox et al Fox et al Heart Heart 2007;93:177 2007;93:177-

  • 82

82

slide-44
SLIDE 44

% of Patients % of Patients

100 100

6 Month Follow 6 Month Follow-

  • Up S

Up S

91 91 75 75 94 94 80 80 100 100 Overall Overall From Discharge From Discharge n~ ~ 50 50 75 75 74 74 60 60 50 50 20 20 40 40 20 20 ASA/ ASA/ Cl id l Cl id l B t B t ASA/ ASA/ Anticoagulant Anticoagulant Clopidogrel Clopidogrel Beta Beta

Selected Medications Selected Medications

5 85 85 86 86 87 87 93 93 ~ ~6,400 6,400 5 71 71 Bl k Bl k ACEi/ARB ACEi/ARB St ti / Oth li id St ti / Oth li id a Blocker a Blocker ACEi/ARB ACEi/ARB Statin/ Other lipid Statin/ Other lipid lowering agent lowering agent

slide-45
SLIDE 45

6 month Follow u 6 month Follow u Curren Curren

100 60 80 40 60

%

20 ACE/ARB Beta Block ACE/ARB Beta Block SMH BC

Q 4 2008 FINAL D

up MEDs Maintenance up MEDs Maintenance p nt nt vs vs DC RX DC RX

ASA Statin Clopidrogel ASA Statin Clopidrogel Canada World

45 DATA

slide-46
SLIDE 46

6 month 6 month C

100 60 80 100 40 60

%

20 ACE/ARB Beta Block ACE/ARB Beta Block SMH BC C

Q 4 2008 FINAL D

h Follow up MEDS h Follow up MEDS p Current RX Current RX

ASA Statin Clopidrogel ASA Statin Clopidrogel Canada World

46 DATA

slide-47
SLIDE 47

Leading and Leading and Leading and Leading and Quartile Quartile Quartile Quartile

100 100 % of Patients

% of Patients

95 95 86 86 90 90 85 85 80 80 100 100 67 67 60 60 20 20 40 40 ASA <24 hrs ASA <24 hrs  Blocker Blocker <24 hrs <24 hrs H Adapted from Adapted from Peterson et al Peterson et al J Am J Am & Ohman et al & Ohman et al Am Heart Am Heart

d Lagging Hospital d Lagging Hospital d Lagging Hospital d Lagging Hospital es: Acute Care es: Acute Care es: Acute Care es: Acute Care

Leading Centers Leading Centers Lagging Centers Lagging Centers 46 46 48 48 69 69 n=65,426 n=65,426 46 46 48 48 24 24 21 21 21 21 Heparin Heparin Clopidogrel Clopidogrel GP IIb/IIIa GP IIb/IIIa I hibi I hibi Coll Cardiol Coll Cardiol 2004;43(suppl.):406A 2004;43(suppl.):406A J 2004;148(suppl.):S34 2004;148(suppl.):S34-

  • 9

9 Inhibitors Inhibitors

slide-48
SLIDE 48

Performa Performa Performa Performa

Relationship betwee Relationship betwee Relationship betwee Relationship betwee

% of Patients % of Patients

In In-

  • hospita

hospita

6 36 6 36 6 8

% of Patients % of Patients

p<0 p<0 n=64,775 with NSTEACS, 350 U n=64,775 with NSTEACS, 350 U 6.36 6.36 5.06 5.06 4 6 2 <66% <66% 66 66-

  • 74%

74% Hospital Composite Hospital Composite p p p p

* Use of 9 ACC/AHA Class I care indicators (ASA, ß * Use of 9 ACC/AHA Class I care indicators (ASA, ß-

  • blocker, h

blocker, h clopidogrel, ACEi, lipid clopidogrel, ACEi, lipid-

  • lowering med use) among eligible pts w

lowering med use) among eligible pts w

ance Matters! ance Matters! ance Matters! ance Matters!

en Process and Outcome en Process and Outcome en Process and Outcome en Process and Outcome

l Mortality l Mortality

0.001 0.001 U.S. hospitals, Jan 2001 U.S. hospitals, Jan 2001-

  • Sept 2003

Sept 2003 4.63 4.63 4.17 4.17 75 75-

  • 79%

79% ≥ ≥80% 80% Adherence* Quartiles Adherence* Quartiles Peterson et al Peterson et al JAMA JAMA 2006;295:1912 2006;295:1912-

  • 20

20

heparin, GP IIb/IIIa inhib. ≤24 hrs; discharge ASA, ß heparin, GP IIb/IIIa inhib. ≤24 hrs; discharge ASA, ß-

  • blocker,

blocker, without contraindications (adjusted for pt + hospital features) without contraindications (adjusted for pt + hospital features)

slide-49
SLIDE 49

Factors Asso Factors Asso Improved Guidel Improved Guidel

 Survey of 316 hospitals p

Survey of 316 hospitals p

 Survey of 316 hospitals p

Survey of 316 hospitals p

 Survey of 316 hospitals p

Survey of 316 hospitals p

 Correlation with guideline

Correlation with guideline

 Independent predictors a

Independent predictors a

 Survey of 316 hospitals p

Survey of 316 hospitals p

 Correlation with guideline

Correlation with guideline

 Independent predictors a

Independent predictors a

 Independent predictors a

Independent predictors a guideline adherence: guideline adherence:

  Moderate

Moderate-

  • to

to-

  • strong admin

strong admin Q lit I t (QI) Q lit I t (QI)

 Independent predictors a

Independent predictors a guideline adherence: guideline adherence:

  Moderate

Moderate-

  • to

to-

  • strong admin

strong admin Q lit I t (QI) Q lit I t (QI) Quality Improvement (QI) Quality Improvement (QI)

  Moderate

Moderate-

  • to

to-

  • strong collab

strong collab physicians and hospital a physicians and hospital a Quality Improvement (QI) Quality Improvement (QI)

  Moderate

Moderate-

  • to

to-

  • strong collab

strong collab physicians and hospital a physicians and hospital a p y p p y p

  Adequate nursing and ph

Adequate nursing and ph

  Use of a specified protoco

Use of a specified protoco l ith f ACS l ith f ACS p y p p y p

  Adequate nursing and ph

Adequate nursing and ph

  Use of a specified protoco

Use of a specified protoco l ith f ACS l ith f ACS algorithm for ACS algorithm for ACS algorithm for ACS algorithm for ACS

  • ciated with
  • ciated with

lines Adherence lines Adherence

participating in CRUSADE participating in CRUSADE participating in CRUSADE participating in CRUSADE participating in CRUSADE participating in CRUSADE e adherence e adherence associated with improved associated with improved participating in CRUSADE participating in CRUSADE e adherence e adherence associated with improved associated with improved associated with improved associated with improved

nistrative commitment to nistrative commitment to

associated with improved associated with improved

nistrative commitment to nistrative commitment to boration between emergency boration between emergency administration administration boration between emergency boration between emergency administration administration armacist support armacist support

  • l
  • l-
  • driven management

driven management armacist support armacist support

  • l
  • l-
  • driven management

driven management

Mehta et al Mehta et al Am Heart J Am Heart J 2006;152:648 2006;152:648-

  • 60

60