Registry and benchmarking as device for Quality appraisal in STEMI patients

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Registry and benchmarking as apparatus for Quality appraisal in STEMI patients Belgian Interdisciplinary Working Group on Acute Cardiology (BIWAC) College of Cardiology April 2007

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Background Reperfusion technique STEMI enrollment in Belgium Electronic CRF Analysis and report Practical association

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AMI - Prognosis MEN WOMEN 51% (34-70%) 49% (35-60%) 28 d. Case Fatality WHO-MONICA 1985-1990

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Case-Fatality in Ghent in men 25-69 years Case-Fatality Rate (%) Year Prof. G. De Backer, Ghent

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Lethality of AMI 2000-2003: MKG information N= 44782 AMI in healing center lethality: 15.9% From dr W Aelvoet, RIZIV/ENAMI

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Lethality of AMI 2000-2003: MKG information

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What are the reasons of variety in lethality? Diverse patient hazard profile ? Stun – age - ischemic time Correction with TIMI hazard score Different reperfusion modalities? trombolysis versus PCI versus no reperfusion

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Background Reperfusion technique STEMI enlistment in Belgium Electronic CRF Analysis and report Practical association

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Optimalisation of reperfusion treatment (ESC report) Reperfusion treatment (thrombolysis – PCI) in STEMI positively impacts short and long haul tolerant result 2. Up to 40% of all STEMI patients don't get reperfusion treatment in Europe (ESC-ACS registry 2001). (Belgian information?) 3. Optimalisation of reperfusion treatment can be accomplished by sorting out gathering gatherings, giving rules and setting up registries. 4. Significance of systems of reperfusion (counting transport association) to farthest point time delay between onset of side effects and start of reperfusion treatment.

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Time issue and reperfusion treatment 30 minutes postpone expands 1-year mortality by 7.5% Meta-examination essential PCI: De Luca, Circulation 2004

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Time issue and reperfusion technique If PCI-related time delay >60 min, the advantage of PCI over thrombolyis vanishes

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ST height MI (<12 h after onset of agony) Aspirin – heparin – nitrate * Admission in non-PCI-focus or first restorative contact outside doctor's facility Admission in PCI-focus Hemodynamic shakiness (stun/cardiovascular disappointment/threatening arrythmias) contra-sign thrombolysis YES Transfer ** PCI focus NO Thrombolysis begin clopidogrel Transfer to PCI focus OR Pro exchange : exchange time<60', ischemia >3u Pro thrombolysis : exchange time>60', ischemia<3u Primary PCI ** First medicinal contact-to-inflatable time < 90  30 min Consider IIB-IIIa opponents Failed *** Rescue PCI * nitrate SL unless systolic bloodpressure<100mmHg and additionally heart rate<50bpm ** Consider pre-PCI lytic treatment if exchange time>60 min *** Electrocardiographic and clinical assessment 60-90 min after start of thrombolysis

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Background Reperfusion system STEMI enrollment in Belgium Electronic CRF Analysis and report Practical association

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STEMI registry in Belgium: AIM Prospective registry of all ST rise myocardial areas of localized necrosis conceded in Belgian doctor's facilities (basic care program A) Quality appraisal of basic care by method for on-line reports permitting benchmarking. Assessment of indicators of in doctor's facility mortality for STEMI in Belgium

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STEMI registry : Organization Ministry of Public Health College of Cardiology BIWAC * Steering board of trustees: 16 individuals local representation Local Investigators: one (two) responsibles/doctor's facility Belgian Interdisciplinary working gathering of intense cardiology

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STEMI registry : Steering advisory group Antwerpen : M Claeys – S Hellemans - C Convens Oost-Vlaanderen : H De Raedt - S Gevaert West – Vlaanderen: P Coussement – K Dujardin Limburg: P Vranckx - J Dens Vlaams Brabant: P Sinnaeve - Brussel: M Renard - B Faoding Hainaut: P Dubois – A de Meester Liege: J Boland Namur – Luxembourg: P Evrard - C Beauloye Braband - Wallon

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STEMI registry : association Q1-2 2006 : Pilot study ( one patient/focus) assessment of substance of CRF Q3-Q4 2006: establishment of online registry Independent programming organization Lambda-in addition to ( ) Q1 2007 : Application of registry by controlling panel individuals enlistment 20/4: n= 300 STEMI quiet Q2 2007: Implementation of registry in every Belgian doctor's facility association of local beginning up gatherings Q3 2007: Interim examination Q4 2007 : investigation and report 2007

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Background Reperfusion procedure STEMI enrollment in Belgium Electronic CRF Analysis and report Practical association

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Minimal Data Base Patient attributes (TIMI chance score) Reperfusion technique In Hospital Outcome Electronic CRF

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Minimal Data Base Patient qualities (TIMI chance score) Reperfusion methodology In Hospital Outcome Electronic CRF

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Minimal Data Base Definition ST Elevation Myocardial Infarction: Clinical picture of intense myocardial dead tissue with noteworthy ST-T rise in no less than two ECG –leads (>0.1 mV in fringe leads, >0.2mv in precordial leads) STEMI as an intense inconvenience of a coronary mediation is rejected from the STEMI registry

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Minimal Data Base HOSPITAL IDENTIFICATION: The main doctor's facility where patient is conceded and where he remains for over 24 hours Example: 1. STEMI tolerant conceded in healing facility An exchange for PCI to doctor's facility B and back release in doctor's facility A > doctor's facility A finishes the e-CRF 2. STEMI persistent conceded in healing facility A move for PCI in doctor's facility B release (or demise) in doctor's facility B > doctor's facility B finishes the e-CRF

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Minimal Data Base PATIENT IDENTIFICATION: Informed assent (cf protection law) case of archive on the site No moral records required Identification on the neighborhood CRF: free content (won't show up in the examination)

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Minimal Data Base CARDIOVASCULAR HISTORY Ischemic coronary illness: history of MI, angina, PCI, CABG Peripheral vascular disease(arterial): history of claudicatio, CVA, TIA, fringe revascularisation Arterial Hypertension: Bloodpressure >140/90 or under treatment Diabetes mellitus fasting glycemia >120 mg% or under treatment

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Minimal Data Base Hemodynamic status on confirmation: Systolic bloodpressure < or > 100mmHg Heart rate < or > 100 bpm Killip Class 1: no indications of cardiovascular disappointment 2: crepitations at the lung bases 3: pneumonic edema 4: cardiogenic stun ECG : foremost - non-front - LeftBBB

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Minimal Data Base Reperfusion technique in intense stage: Thrombolysis Primary PCI/CABG = pressing angiography with PCI if necessary Facilitated PCI = critical PCI taking after lytic treatment (thrombolyis or GP IIb/IIIa opponents) Rescue PCI = earnest PCI after disappointment of thrombolytic treatment No reperfusion treatment

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Minimal Data Base Time and transport issues Total ischemic time: <2h, 2-4h, 4-8, 8-12, 12-24, >24h time from onset of agony until begin of reperfusion treatment (thrombolysis or first inflatable expansion) Door-to inflatable/needle time: <30min, 30-60, 60-90, 90-120, >120 min, NA time from determination until start of reperfusion treatment (thrombolysis or first inflatable swelling) Transfer starting with one doctor's facility then onto the next Use of pre-doctor's facility thrombolysis

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TIMI hazard score (naturally ascertained) Circulation: 2000;102:2031

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Minimal Data Base Clinical result In doctor's facility mortality (up to one month) Elective coronarography (outside the intense stage) Mortality at one month (facultatif)

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Background Reperfusion system STEMI enrollment in Belgium Electronic CRF Analysis and report Practical association

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Report – investigation – benchmarking: on-line !! Enlistment diagrams: number of included patients every month number of included patients per locale (area) number of included patients per doctor's facility (unknown) Graph: mortality versus TIMI hazard score (see figure) Benchmarking: Belgian information versus district versus centrum

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Benchmarking: mortality

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Mortality versus TIMI chance score mortality • TIMI chance score INTIME II (n=14114) N= 300 - avg mortality: 6%, avg TIMI chance score= 4

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Background Reperfusion system STEMI enrollment in Belgium Electronic CRF Analysis and report Practical association

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Practical issues Minimal PC prerequisites Website: Username and secret word will be sent to you Website: distinctive things STEMI: e-CRF – rundown of included patients of the healing center Reports (charts, information benchmarking) Documents (e.g. blanco CRF, clarification, rules) Contact address of the guiding panel individuals

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