Transcript Bridging the gap between acute care and community care

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
Overview







Background
Purpose
Objectives
Methods
Analysis
Results
Conclusions
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
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
CADILLAC risk score for 30-day and one-year mortality
after primary PCI for STEMI
Risk factor
Points
LVEF <40 percent
4
Killip class 2/3
3
Renal insufficiency (estimated creatinine clearance <60 mL/min)
3
TIMI flow grade after PCI of 0 to 2
2
Age >65 years
2
Anemia (hematocrit <39 percent in men and <36 percent in women)
2
Triple-vessel disease
2
Risk score
30-day mortality
One-year mortality
Low risk (score 0 to 2)
0.1 to 0.2 percent
0.8 to 0.9 percent
Intermediate risk (score 3 to 5)
1.3 to 1.9 percent
4.0 to 4.5 percent
High Risk >6)
6.6 to 8.1 percent
12.4 to 13.2 percent
Halkin, A, Singh, M, Nikolsky, E, et al, J Am Coll Cardiol 2005; 45:1397.
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
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
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?
Objectives
1.
2.
3.
4.
5.
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
STEMI II Clinic Model
Identification of all STEMI Patients In Hospital
-identified through STEMI database/nurse clinician/phone referral
Primary Cardiologist
Interventionalist
Primary Cardiologist
Non-Interventionalist
Initial In-Hospital Visit day 1-3
Usual care
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
Identification of all STEMI Patients In Hospital
-identified through STEMI database/nurse clinician/phone referral
Identification of all STEMI Patients In Hospital
-identified through STEMI database/nurse clinician/phone referral
Primary Cardiologist
Interventionalist
Primary Cardiologist
Non-Interventionalist
Initial In-Hospital Visit day 1-3
Usual care
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
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
STEMI II Clinic Model
Primary Cardiologist
Interventionalist
Identification of all STEMI Patients In Hospital
-identified through STEMI database/nurse clinician/phone referral
Primary Cardiologist
Interventionalist
Primary Cardiologist
Non-Interventionalist
Initial In-Hospital Visit day 1-3
Usual care
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
Primary Cardiologist
Non-Interventionalist
STEMI II Clinic Model
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
Identification of all STEMI Patients In Hospital
-identified through STEMI database/nurse clinician/phone referral
Primary Cardiologist
Interventionalist
Primary Cardiologist
Non-Interventionalist
Initial In-Hospital Visit day 1-3
Usual care
Follow-up phone call day 7
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
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)
STEMI Patient Flow
STEMI patients treated with
1º PCI
th
Jan 15 – June 23rd 2007
(n=200)
In-hospital death (n= 14)
Clinic participants (n=36)
Allocated but did not participate (n=1)
Lost to follow-up (n=1)
Final (n=34)
Clinic visit (n=25) Telephone visit (n=9)
Non-participants (n=150)
Lost to follow-up (n=39)
Outcome evaluation (n=111)
Low Risk
(Cadillac Risk Score 0-2)
STEMI Population
(n=74)
Clinic Participant
(n=25)
Control (clinic nonparticipants)
(n=49)
Age (years)
53.2 C.I.( 49.3-57.0)
56.2 C.I.(53.4-59.1)
Sex (male)
92.0% (23)
71.4% (35)
Length of stay (days)*
3.7 C.I. (3.0- 4.4)
5.0 C.I. (3.8-6.2)
Cadillac Risk Score*
0.3 C.I. (0.01- 0.6)
0.7 C.I.( 0.4-0.9)
Diabetic
12% (3)
12.2% (6)
Hypertension
32.0% (8)
38.7% (19)
Smoker
44.0% (11)
46.9% (23)
Family History
60% (15)
34.7% (17)
Previous Myocardial
Infarction
12% (3)
10.2% (5)
*P=0.03
*P=0.03
Moderate-High Risk
(Cadillac Risk Score >2-18)
STEMI Population
(n=71)
Clinic Participant
(n=9)
Control
(clinic non-participants)
(n=62)
Age (years)
53.2 C.I.( 49.3-57.0)
61.7 C.I.(59.0-64.4)
Sex (male)
66.7% (6)
71.0% (44)
Length of stay (days)*
6.6 C.I. (3.4- 9.9)
8.0 C.I. (6.7-9.3)
Cadillac Risk Score*
5.0 C.I. (3.8-6.2)
5.5 C.I.(5.1-6.1)
Diabetic
11% (1)
26.3% (16)
N/S
Hypertension
33.0% (3)
60.0% (37)
N/S
Smoker
66.7% (6)
38.7% (24)
N/S
Family History
33.0% (3)
32.5% (20)
Previous Myocardial
Infarction
11.0% (1)
11.3% (7)
Medication Therapy
Baseline
100
90
80
70
60
%
50
40
30
20
10
0
Control (n=111)
Clinic (n=34)
ASA
Plavix
B-B
ACE-I Statin
Medication Therapy
at 30 days
100
90
80
70
%
60
50
40
30
20
10
0
Control (n=111)
Clinic (n=34)
ASA
B-B
Clopidogrel
Statin
ACE
Emergency Room Visits and
Hospital Readmissions at 30 days
16
14
12
10
% 8
6
4
2
0
Control (n=111)
Clinic (n=34)
Low
Risk
Mod- Low
High Risk
Risk
ER Visits
ModHigh
Risk
Hospital Readmission
Cardiac Rehabilitation
Participation at 30 days
70
60
50
%
40
Control (n=108)
Clinic (n=31)
30
20
10
0
Low Risk
Mod-High Risk
Clinic Visit Documentation &
Telephone Help Line Log
Themes:
1.
Access to health care provider (family physician)
(n=4) 11.7% needed assistance in securing a
family physician at clinic visit.
2.
Lack of education and support for spouses.
3. 25 calls to help-line, 18 unique callers
4.
Medication questions- 32% (n=8)
5.
Symptom checks – 24% (n=6)
6.
Coordinating community care services 28% (n=7)
7. Clarification of discharge instructions by
pharmacists and family doctors 8% (n=2)
Clinic Survey Results
STEMI Clinic Recommendations Survey
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
N=32/34
Access to GP Education for Access to Early access Participation
Spouses
STEMI helpto CR
in STEMI
line
Clinic
Extremely Important
Somewhat Important
Not Very Important
Unimportant
Not Sure
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
Limitations
•
Design

•
Measurement Bias


•
Protocol changes to limit patients to low risk STEMI after
2 months due to staff and resource constraints
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)
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 evidencebased 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
References
Argulian, E., Patel, A. D., Abramson, J. L., Kulkarni, A., Champney, K., Palmer, S. et al.
(2006). Gender Differences in Short-Term Cardiovascular Outcomes After
Percutaneous Coronary Interventions. The American Journal of Cardiology, 98, 4853.
Assmann, G., Benecke, H., Neiss, A., Cullen, P., Schulte, H., & Bestehorn, K. (2006). Gap
between guidelines and practice: attainment of treatment targets in patients with
primary hypercholesterolemia starting statin therapy. Results of the 4E-Registry
(Efficacy Calculation and Measurement of Cardiovascular and Cerebrovascular Events
including Physicians' Experience and Evaluation). European Journal of Cardiovascular
Prevention & Rehabilitation, 13, 776-783.
Cortas, O. R. & Arthur, H. M. R. (2006). Determinants of referral to cardiac rehabilitation
programs in patients with coronary arterydisease: A systematic review. American
Heart Journal, 151, 249-256.
Gaziano, M. (2005). Global Burden of Cardiovascular Disease. In D.Zipes, P. Libby, R.
Bonow, & E. Braunwald (Eds.), Braunwald's Heart Disease: A Textbook of
Cardiovascular Medicine (7 ed., pp. 1-19). Philadelphia, PA.: Elsevier Saunders.
Giannuzzi, P., Temporelli, P. L., Maggioni, A. P., Ceci, V., Chieffo, C., Gattone, M. et al.
(2005). GlObal Secondary Prevention strategiEs to Limit event recurrence after
myocardial infarction: the GOSPEL study. A trial from the Italian Cardiac
Rehabilitation Network: rationale and design. European Journal of Cardiovascular
Prevention & Rehabilitation, 12,
Heidrich, J., Behrens, T., Raspe, F., & Keil, U. (2005). Knowledge and perception of
guidelines and secondary prevention of coronary heart disease among general
practitioners and internists. Results from a physician survey in Germany. European
Journal of Cardiovascular Prevention & Rehabilitation, 12, 521-529.
Refernces
Heidrich, J., Behrens, T., Raspe, F., & Keil, U. (2005). Knowledge and perception of
guidelines and secondary prevention of coronary heart disease among general
practitioners and internists. Results from a physician survey in Germany. European
Journal of Cardiovascular Prevention & Rehabilitation, 12, 521-529.
Jackson, L., Leclerc, J., Erskine, Y., & Linden, W. (2005). Getting the most out of cardiac
rehabilitation: a review of referral and adherence predictors. Heart, 91, 10-14.
Johnson, N. A. & Heller, R. F. (1998). Prediction of patient nonadherence with homebased exercise for cardiac rehabilitation: the role of perceived barriers and perceived
benefits. Preventive Medicine, 27, 56-64.
Jolliffe, J. A., Rees, K., Taylor, R. S., Thompson, D., Oldridge, N., & Ebrahim, S. (2006).
Exercise-based rehabilitation for coronary heart disease [Systematic Review].
Cochrane Database of Systematic Reviews.
Jolly, K., Bradley, F., Sharp, S., Smith, H., & Mant, D. (1998). Follow-up care in general
practice of patients with myocardial infarction or angina pectoris: initial results of the
SHIP trial. Southampton Heart Integrated Care Project. Family practice, 15, 548-555.
Kaul, P., Newby, L. K., Fu, Y., Mark, D. B., Califf, R. M., Topol, E. J. et al. (2004).
International differences in evolution of early discharge after acute myocardial
infarction. Lancet, 363, 511-517.
Khot, U. N. M., Khot, M. B. M., Bajzer, C. T. M., Sapp, S. K. M., Ohman, E. M. M., Brener,
S. J. M. et al. (2003). Prevalence of Conventional Risk Factors in Patients With
Coronary Heart Disease. JAMA, 290, 898-904.
References
Khot, U. N. M., Khot, M. B. M., Bajzer, C. T. M., Sapp, S. K. M., Ohman, E. M. M., Brener,
S. J. M. et al. (2003). Prevalence of Conventional Risk Factors in Patients With
Coronary Heart Disease. JAMA, 290, 898-904.
King, K. M. & Teo, K. K. (1998). Cardiac rehabilitation referral and attendance: not one
and the same. Rehabilitation Nursing, 23, 246-251.
Lindgren, P., Borgstrom, F., Stalhammar, J., Alemao, E., Yin, D. D., & Jonsson, L. (2005).
Association between achieving treatment goals for lipid-lowering and cardiovascular
events in real clinical practice. European Journal of Cardiovascular Prevention &
Rehabilitation, 12, 530-534.
Maron, D. M., Grundy, S. M., Ridker, P. M., & Pearson, T. P. (2004). Dyslipidemia, Other
Risk Factors, and the Prevention of Coronary Heart Disease. Hurst's The Heart [Online]. Retrieved Aug 22, 2007
Oldridge, N., Gottlieb, M., Guyatt, G., Jones, N., Streiner, D., & Feeny, D. (1998).
Predictors of health-related quality of life with cardiac rehabilitation after acute
myocardial infarction. Journal of Cardiopulmonary Rehabilitation, 18, 95-103.
Rasalingam, R. & Pearson, T. (2002). An integrated approach to risk-factor modification.
In E.Topol (Ed.), Textbook of Cardiovascular Medicine (2 ed., Books@Ovid.
Reid, R. D., Morrin, L. I., Pipe, A. L., Dafoe, W. A., Higginson, L. A. J., Wielgosz, A. T. et
al. (2006). Determinants of physical activity after hospitalization for coronary artery
disease: the Tracking Exercise After Cardiac Hospitalization (TEACH) Study. European
Journal of Cardiovascular Prevention & Rehabilitation, 13, 529-537.
References
Smith, K. M., Harkness, K., & Arthur, H. M. (2006). Predicting cardiac rehabilitation
enrollment: the role of automatic physician referral. European Journal of
Cardiovascular Prevention & Rehabilitation, 13, 60-66.
Smith, S. C., Jr., Allen, J., Blair, S. N., Bonow, R. O., Brass, L. M., Fonarow, G. C. et al.
(2006). AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and
Other Atherosclerotic Vascular Disease: 2006 Update: Endorsed by the National
Heart, Lung, and Blood Institute. Circulation, 113, 2363-2372.
The Heart and Stroke Foundation of Canada (2003). The Growing Burden of Heart
Disease and Stroke in Canada 2003. Heart and Stroke Foundation of Canada website
[On-line]. Retrieved from
http://www.cvdinfobase.ca/cvdbook/CVD_En03.pdf.
Thompson, D. R. & Oldridge, N. B. (2004). Secondary prevention and cardiac
rehabilitation: have we got the terms right? European Journal of Cardiovascular
Prevention & Rehabilitation, 11, 183-184.
van, d., V, Pedersen, S. S., Boersma, E., Erdman, R. A. M., Leenders, C. M., Pop, G. A. M.
et al. (2001). Early discharge of patients with acute myocardial infarction has no
adverse psychological consequences. Coronary Health Care, 5, 73-79.Thom, T.,
Haase, N., Rosamond, W., Howard, V. J., Rumsfeld, J., Manolio, T. et al. (2006). Heart
Disease and Stroke Statistics--2006 Update: A Report From the American Heart
Association Statistics Committee and Stroke Statistics Subcommittee. Circulation,
113, e85-151.
Yusuf, S., Hawken, S., Ôunpuu, S., Dans, T., Avezum, A., Lanas, F. et al. (2004). Effect of
potentially modifiable risk factors associated with myocardial infarction in 52
countries (the INTERHEART study): case-control study. Lancet, 364, 937-952.