Aderence to treatment guidelines for NSTEMI: the role of a network between hospitals

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1 Antonio Manari U.O. Cardiologia Interventistica Arcispedale Santa Maria Nuova Reggio Emilia Aderence to treatment guidelines for NSTEMI: the role of a network between hospitals

2 Short term risk of death or non-fatal MI in patients with UA/NSTEMI 2007 ACC/AHA NSTEACS Guidelines

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4 NSTEMI patients Early Risk Stratification Optimal timing of intervention Selection of Invasive option

5

6

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8 Hospital Link Between Overall Guidelines Adherence and Mortality % In-Hosp Mortality ,31 5,95 5,16 5,06 4,97 4,63 4,16 4,15 Every 10% in guidelines adherence 10% in mortality (OR=0.90, 95% CI: ) 0.97) <=25% 25-50% 50-75% >=75% Hospital Composite Quality Quartiles Adjusted Peterson et al, JAMA 2006;295: Unadjusted

9 Are We Performing Interventional Procedures in the Right Patients Low Risk Mod Risk High Risk Q1 2002Q2 2002Q3 2002Q4 2003Q1 2003Q2 2003Q3 2003Q4 2004Q1 2004Q2 2004Q3 2004Q4 Tricoci et al, AHA 2005 Abstract

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11 Il Rischio non guida la procedura

12 % all H without CL H with CL Invasive Conservative

13 pts admitted to Spoke Centers 20,0% < 48 ore 46,2% > 48 ore Am Heart J 2008;156:185

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15 Transfer patterns based upon CRUSADE inhospital mortality model Low-risk (+ 15%) Moderate-risk (+17%) High-risk (+5%) Am Heart J 2008;156:185

16 Establishing networks of reperfusion at regional and national level is a key issue. NSTEMI Inter-hospital networks?

17 NSTEMI Inter-hospital network? Is the STEMI inter-hospital network able to guarantee the right treatment of patients with NSTEMI?

18

19 Emilia-Romagna Region p-pci: Variables 2004 (year) 2005 (year) 2006 (first semester) On-site p-pci, (n) Transfer p-pci, (n) Network door-to-balloon time: On-site p-pci, (min), (median 25 th -75 th ) Transfer p-pci, (min), (median 25 th -75 th ) 73 (50-102) 69 (43-100) 74 (47-115) 114 (90-146) 111 (90-150) 107 (81-140) Emilia-Romagna Region p-pci: Variables 2004 (year) 2005 (year) 2006 (first semester) On-site p-pci, (n) Transfer p-pci, (n) Non-transferred STEMI patients admitted to non-pci centres (%) Age, (yrs), mean SD Charlson index, mean SD Mortality, (%) Manari A et al. Eur Heart J, 2008

20 Clinical Impact of an Inter-hospital Transfer Strategy in pts. with STE-MI treated with Primary PCI The Emilia-Romagna STEMI network 20 1-Year Cardiac Mortality (%) HR: % CI: ; P= % 7.4% 4 2 On-site p-pcip Transfer p-pcip Manari A et al. Eur Heart J 2008;29:1834 Months

21 Provincia di Reggio Emilia ( abitanti) UTIC Guastalla 32 Km 13 Km UTIC Correggio 14 Km UTIC Lab. Emo Cardio Chir 50 Km 18 Km Montecchio Scandiano UTIC C Monti

22 DISTRIBUZIONE DEI PRESIDI OSPEDALIERI NELLA PROVINCIA DI MANTOVA Estensione: 2300 Kmq Popolazione: abitanti 22 Km 39 Km PS,UTIC,Emodinamica h24, CaCh PS,UTIC PS, degenza 39 Km Ospedali riabilitativi 38 Km 21 Km 21 Km

23 La rete di Massa-Carrara P.S. I LIVELLO P.S. I LIVELLO U.T.I.C. II LIVELLO U.T.I.C. II LIVELLO IFC CNR Osp. G. Pasquinucci Telemedicina + Cath Lab III LIVELLO

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25 Quality Improvement Processes Registry Performance Indicators Intervention Action Guidelines Data collection & Analysis Clinical audits

26 Risk profile in patients undergoing Angiography % HUB SPOKE Basso Intermedio Elevato (Grace Score)

27 Risk profile in patients undergoing Angiography % HUB SPOKE 47 Basso Intermedio Elevato (Grace Score)

28 Risk profile in patients undergoing Angiography in Hub Centers Patients, % % 36% 37% Low risk Intermediate High risk (Grace Score)

29 Risk profile in patients undergoing Angiography in Hub Centers Patients, % ,1% 16,7% 5,4% Low risk Intermediate High risk ECG/Tn + ECG/Tn - (Grace Score)

30 Risk profile in patients undergoing Angiography in Spokes Centers 50 49% 40 Patients, % % 29% 0 Low risk Intermediate High risk (Grace Score)

31 Risk profile in patients undergoing Angiography in Spokes Centers 50 14,3% 40 Patients, % ,5% 23,8% 10 0 Low risk Intermediate High risk ECG/Tn + ECG/Tn - (Grace Score)

32 Admission Angio delay Hours (median) years years HUB years SPOKE Low Intermediate High (Grace Score)

33 Admission Angio delay Hours (median) years years HUB years years years SPOKE years Low Intermediate High (Grace Score)

34 Conclusions In the real world setting, patients with the highest predicted risk mortality are least likely to be transferred early and do not undergo risk stratification with guideline-recomended diagnostic procedures. A running STEMI inter-hospital network is not enough to improve a right application of guidelines for NSTEMI (in particular for patients first admitted to the community Hospital centers).

35 Relazione Angiografia-Score di rischio ore Grace

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