Philippine Heart Association Acute Coronary Syndrome Registry (PHA ACSR) Updates 5/31/2013 Edsa Shangrila. PHA 44 th Annual Convention

Transcription

1 Philippine Heart Association Acute Coronary Syndrome Registry (PHA ACSR) Updates 5/31/2013 Edsa Shangrila PHA 44 th Annual Convention

2 Importance of doing a registry Measures healthcare delivery (trends of practices or patterns of care) Evaluate healthcare effectiveness and safety Outcomes when guidelines are followed Registries provide unselected real world data hence can evaluate patients normally excluded in clinical trials such as those with multiple co-morbidities, elderly

3 Importance of doing a registry Supports quality improvement (do performance measures) Modify/change practice trends improve clinical outcomes.

4 Local Setting Unclear how research-based evidence applies to real world practice in the Philippines Management and outcomes of ACS patients after the acute phase have not been well described in the Philippines for the past decade

5 PHA ACS Registry November 2011

6 PHA ACS registry multicenter, prospective, observational registry of clinical management practices and patient outcomes in ACS Designed to collect, analyze, and disseminate data on ACS patients

7 Organizational Structure PHA- ACS Registry Steering Committee Technical Committee Consultant coordinators/pi Chief/Senior Fellows Research assistants

8 Clinical Registry: PHA ACS registry Participating hospitals: 12 hospitals Angeles University Web Based Registry Hospitals can extract their own data but not data of other hospitals

9 PHA-ACS Registry Data From November March 2013 (16 months) 13 Hospitals

10 Baseline Demographics Total # of patients enrolled 1044 Male 693 (66.4) Mean Age 61 ± 12.2

11 Number of ACS Patients Enrolled/Hospital

12 Baseline Demographics (n= 1044) Classification of Cases n= (49.3) 393 (37.5) (13.1) STEMI NSTEMI UA

13 Distribution of ACS Patients according to Age Group n= % % 27.5 % Age < >80

14 Risk Factor Profile n= 1044 Prior Angina, 32.40% Family History of CAD, 28.30% Hypertensi on, 76.10% Smoking History, 34.70% Diabetes, 36.20%

15 Clinical Presentation Distribution of Presenting symptom among ACS patients: n (%) chest pain or chest heaviness/ heavy 816 (78.2) pressure on the chest Atypical/ Anginal equivalents 221 (21.2) dyspnea (242/(23.2%) Epigastric pain (55 (5.3%) cardiac arrest/ aborted sudden death 7 (0.7)

16 Clinical Presentation Time Presentation (in minutes) Time from Sx to ER presentation Time from ER presentation to ECG (69 hrs) (3 hours) 15 mins

17 Laboratory Profile of ACS Patients in Mean ± SD:,n= 1044 Lipid Profile Mean (SD) TC ± 66.4 LDL ±7.4 HDL 40.8 ±15.4 Triglycerides ±78.3

18 EF values among ACS patient <30` 30 < 50 >50 EF Mean ± SD 54 ± 15.5

19 Clinical Presentation n=645 (62%) n=399 (38.2%) 0 # of Patients Managed Medically # of Patients Managed with Invasive approach

20 Clinical Presentation: Management Strategy % % 0 # of Patients Managed Medically n=645 (62%) # of Patients Managed with Invasive approach n=399 (38.2%) UA n=137 NSTEMI n= 515 STEMI n= 392

21 Clinical Presentation # of Patients Advised Invasive Strategy but was not done n=112 (10.7%) Common reason: Financial Constraints: UA : 88% NSTEMI: 79% STEMI: 88% UA NSTEMI STEMI

22 Data: Hospital Management Time Component Door to needle time (1.8 Door to balloon time hours) (20 hours) 60 and 90 minutes!!

23 Reasons for Delay in the recommended 90 mins DTB Time, n=44 (28.5%) % Delay in the referral Awaiting informed consent Awaiting funds for deposit Other reasons

24 Agents used for Preloading prior to PCI n= 143/154 (93%) Clopidogrel Dose, n= Prasugrel Dose, n= < <600 >

25 Adherence Rate to Class 1 Drugs for ACS (%)

26 Early and Late Mortality and Complications in ACS PHA-ACSR

27 Mortality Rate among ACS Patients n=73 /1044 (7.1%) % 7.3% 3 2.2% STEMI n=392 NSTEMI n= 515 UA n= 137

28 Bleeding Rate among ACS Patients n=14 /1044 (1.3%) 7 7 Major Minor

29 Complications: Definition of Bleeding problems: Bleeding (TIMI criteria as: 1. Major: Overt clinical bleeding (or documented intracranial or retroperitoneal hemorrhage) associated with a drop in Hb > 5 g/dl (0.5 g/l) or in Hct >15% (absolute) 2. Minor: Overt clinical bleeding associated with a fall in Hb 3 5 g/dl (0.5 g/l) or in Hct 9% 15% (absolute) 3. None: No bleeding event that meets the major or minor definition

30 Discharge advised n (%) Weight management counseling N= (45.2) Smoking counseling 318(30.5) Exercise 494 (47.3) Diet Counseling 559 (53.5) Cardiac Rehabilitation Program 321 (30.7)

31 Follow-up

32 Follow-up 1 month N = 971 (74.3% 3 months N =952 (62.9% 6 months N = 668 (56.4%) Deaths Cardiovascular deaths year N= % GRACE REGISTRY has a ff up rate of 85%

33 What have we learned and what can we do to improve Clinical Outcomes? 1. Good Adherence rate with regards to utilization of Class 1 Drugs 2. Delays: 1. Late Arrival in the ER (69 hours): strong patient info campaign 2. Delay in the diagnosis Delay in the performance of ECG (3 hours): clinical pathways?, increase personnel?

34 What have we learned and what can we do to improve clinical Outcomes? 2. Delays continuation DTN 108 minutes DTB 30 hours (1,817 minutes) Common reason is financial constraints Philhealth active involvement 3. Poor in Discharge Counseling: advocacy campaigns/staff training Clinical Pathways

35 Threats: 1.Low percentage of enrollment if we compare the ratio of total ACS admitted and those enrolled in the registry ave 21%. 1.Enroll patients that would also include those who are considered very high risk 2. Fair Follow-up rate 67-75%: only phone calls are being utilized,other strategies should be sought

36 Things that currently are working on: 1.Internal Validity check of datarandom checking of charts 2. Invite other hospitals to participate in the program : address population bias 3. Invite other stakeholders such as DOH: mandate other hospitals to participate and increase funding

37 Summary 1 st registry that participated in by all PHA accredited hospitals NSTEMI is the most common condition among ACS years of age is the most common age group Elderly group 20% Prolonged Door to ER, Door to ECG time, DTB and DTN time

38 Summary Good Adherence rate with regards to Class 1 Drugs Poor counseling on Lifestyle Modification

39 Thank you!!