该幻灯为美国哈佛医学院B&W医院心血管科“动脉硬化血栓”系列幻灯之一，共15张，探讨了心血管指南对动脉粥样硬化血栓性疾病治疗的重要性和必要性。
Implementing the Guidelines: Critical Pathways
Awareness Is Not Enough!
NCEP, National Cholesterol Education Program.
Pearson TA, et al. Arch Intern Med. 2000;160:459-467.
95%
38%
0
20
40
60
80
100
Physician Awareness of
NCEP Guideline
Patient Treated to Goal
Sample (%)
GUIDELINES
Cardiology
Acute Care
Primary Care
Secondary Prevention
Smooth Transition From Acute to Long-term Management
Why 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, MD
Chief Scientific Officer, American Heart Association
Standardized protocols
Goal: optimize care
Emerging Evidence— Pathways work:
CHAMP
Guidelines Applied in Practice (GAP)
AHA Get with the Guidelines program
www.critpathcardio.com
CHAMP, Cardiac Hospitalization Atherosclerotic Management Program.
UCLA: CHAMP Study
Designed to determine whether physician/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-associated teaching hospital
ASA, acetylsalicyclic acid; ACE, angiotensin-converting enzyme.
Fonarow GC, et al. Am J Cardiol. 2000;85;10A-17A.
Cardiac Hospitalization Atherosclerosis Management Program
CHAMP Study: Treatment Rates at Discharge and 1-Year Follow-up
CHAMP, Cardiac Hospitalization Atherosclerotic Management Program.
* P<.01 pre- vs post-CHAMP at discharge and at 1 year. Fonarow GC, et al. Am J Cardiol. 2001;87:819-822.
CHAMP Study: Clinical Events for the First Year After Discharge for Acute MI
CHAMP, Cardiac Hospitalization Atherosclerotic Management Program. Fonarow GC, et al. Am J Cardiol. 2001;87:819-822.
Guidelines Applied in Practice (GAP)
Launched by ACC in February 2000 to
Bridge gap between ideal therapy and treatment practice
Create/implement guideline tools/processes
Initial project
Michigan hospitals
Implemented 1999 ACC/AHA AMI Guideline
Determine whether quality of care can be improved via guideline tools
Status: pilot completed, expansion now in progress
ACC, American College of Cardiology; AHA, American Heart Association; AMI, acute myocardial infarction.
GAP: Adherence Improves With Tool Use
LDL-C, low-density lipoprotein cholesterol.
Mehta RH, et al. JAMA. 287;1269-1276. (with permission)
Quality Adherence (%)
Pre-intervention
No Tool Use
Tool Use
Post-intervention
0
20
40
60
80
100
Aspirin
b-Blocker
LDL-C
Ideal Patients (n)
343
308
96
213
174
71
131
165
87
P =.004
P =.001
Demographics
6 clicks
Clinical/Lab
8 clicks
Discharge
meds and
interventions
7 clicks
Interactively
checks
patient’s
data with the
AHA guidelines
Importance of Data-Collection Registries
Track adherence to guidelines
Support local quality improvement programs
Compare practice patterns/outcomes with benchmarks
Comply with regulatory requirements
Provide research data
Major Data Collection Registries
NRMI
AHA Get With the Guidelines
ACC NCDR
GRACE
CRUSADE
NRMI, National Registry of Myocardial 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/AHA Guidelines.
Current Use of ACS Rx in US (Jan-July 2002)
Can Rapid Risk Stratification of Unstable Angina Patients
Suppress ADverse Outcomes with Early Implementation
of the ACC/AHA Guidelines
300 Hospitals
19,000 Patients
ACS, 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, angiotensin-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, HTN
? Known hyperlipidemia, ? TC, ? LDL Roe, et al. ESC. 2002.
88
80
59
77
49
0
20
40
60
80
100
ASA
?-Blockers
ACE Inhibitors*
Lipid-
Lowering
Agent?
Clopidogrel
35 had PCI
Discharge 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 management
CQI, continuous quality improvement.