Abstract 378: Using Lean Methodology to Reduce Variation in Care of Acute Coronary Syndrome Patients

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Guy Fradet ◽  
Carol Laberge ◽  
Andrew Kmetic ◽  
Ronnalea Hamman
Keyword(s):  
Decision Making ◽  
Acute Coronary Syndrome ◽  
Regional Variation ◽  
Coronary Revascularization ◽  
Patient Characteristics ◽  
Care Utilization ◽  
Process Of Care ◽  
Patient Journey ◽  
Coronary Syndrome ◽  
Decision Points

Background: Regional variation in the utilization of health services is a well-documented phenomenon in health care with numerous studies reporting substantial and unexplained variations in coronary revascularization. In the Canadian province of British Columbia (BC), five cardiac centers provide coronary revascularization services. In 2011 Cardiac Services BC (CSBC) undertook a study that identified substantial regional variation in coronary revascularization that could not be explained by patient characteristics or risk factors. Following this initial project, CSBC launched an initiative to help better understand the regional variations and possibly devise and implement strategies to reduce them. To get a better understanding of the different processes of care/utilization, one of the approaches used is the application of Lean methodology to the care of acute coronary syndrome (ACS) patients. Methods: Lean methodology is being applied to the patient journey of ACS patients. At each revascularization center Value Steam Maps process maps (VSM) are being prepared through a series of meetings with support, frontline, administrative and clinical staff (see attached example). For each VSM the goal is to identify key decision points in the process of care for ACS patients and to drill down on (Root Cause Analysis) on the decision making environment and criteria used to determine the utilization of coronary revascularization services. Once VSM have been completed they will be compared across sites for similarities and differences. The differences in decision making will then be assessed to determine their effect on variation in utilization across the centers. Discussion: BC is attempting to reduce unexplained variation in coronary revascularization using the Lean methodology to take a systematic approach to the analysis of the process of ACS care across the province. The next step will be to determine to what extent it is possible to standardize decision making at the key decision points across the HAs. Standardization will be achieved through a mix of best practices, evidence and application of guidelines. While the undertaking is still in the early stages it is expected that it will lead to, at the very least, ACS patients receiving the same care regardless of where they receive their care in BC.

Abstract 268: Using Lean Methodology to Reduce Variation in Care of Acute Coronary Syndrome Patients

2016 ◽  
Vol 9 (suppl_2) ◽  
Author(s):  
Andrew Kmetic ◽  
Guy Fradet ◽  
Ronnalea Hamman ◽  
Carol Laberge ◽  
Carol Galte
Keyword(s):  
Regional Variation ◽  
Best Practice ◽  
Point Of Care ◽  
Coronary Revascularization ◽  
Patient Characteristics ◽  
Care Staff ◽  
Multiple Sources ◽  
Patient Journey ◽  
Coronary Syndrome ◽  
Decision Points

Background: Regional variation in the utilization of health services is a well-documented phenomenon in health care with numerous studies reporting substantial and unexplained variations in coronary revascularization. In the Canadian province of British Columbia (BC), five cardiac centers provide coronary revascularization services. In 2011 Cardiac Services BC (CSBC) undertook a study that identified substantial regional variation in coronary revascularization that could not be explained by patient characteristics or risk factors. Following this initial project, CSBC launched an initiative to help better understand the regional variations and possibly devise and implement strategies to reduce them. Methods: Using Lean methodology, we are mapping the key processes of care for ACS patients across BC (initially excluding emergent STEMI and cardiogenic shock) at each cardiac centre. The ACS patient journey will be mapped from admission to discharge through several key decision points that determine whether they will continue through to diagnostic catheterization and revascularization or to be medically managed alone. The key decision points are: 1. Decision to refer to diagnostic catheterization and subsequent transfer if necessary. 2. Decision to continue to a revascularization procedure (PCI or CABG) after diagnostic catheterization. The map will summarized these key decision points using multiple sources of data: 1. Flow and patient volumes into and out of each of these decision 2. Times between decision points and key care processes 3. Clinical influencers (ex: standard orders, best practice, established patterns of referral, and consultations) and non-clinical influencers (ex: resource capacity, transportation) that are considered at each decision point (process mapping and interview data). Discussion: BC is attempting to reduce unexplained variation in coronary revascularization using the Lean methodology to take a systematic approach to the analysis of the process of ACS care across the province. Involving physicians and point of care staff in the detailed mapping process has proven to be a significant step in engaging key stakeholders in the project by allowing input into the process of describing the factors affecting variation of practice at each site. The next step is to convene provincially to determine where to improve standardized practice in order to improve patient outcomes at key points along the value stream.

Abstract P232: Influence of Individualized Risk Prediction and Patient Preferences on Selection of Prasugrel Versus Clopidogrel at the Time of Percutaneous Coronary Intervention for an Acute Coronary Syndrome

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Adam C Salisbury ◽  
Kaijun Wang ◽  
David J Cohen ◽  
Yan Li ◽  
John A Spertus
Keyword(s):  
Decision Making ◽  
Acute Coronary Syndrome ◽  
Bleeding Risk ◽  
Patient Characteristics ◽  
Coronary Intervention ◽  
Bleeding Events ◽  
Coronary Syndrome ◽  
Alternative Outcome ◽  
History Of ◽  
The Impact

Introduction: Given the need to weigh prevention of ischemia against bleeding risk with prasugrel vs. clopidogrel at the time of PCI for an acute coronary syndrome (ACS), we developed risk models for both outcomes from TRITON-TIMI 38. We then applied these models to each TRITON patient and examined how preferences for outcomes could influence thienopyridine selection. Methods: We built separate multivariable regression models for ischemia (cardiac death, MI, stroke) and bleeding (TIMI major/minor) from 12,579 patients in TRITON-TIMI 38 with no history of stroke or TIA. For each patient, we calculated the probability of ischemic and bleeding events with prasugrel vs. clopidogrel and the associated benefit:risk ratio (predicted difference in ischemic events/predicted difference in bleeding). We then examined the impact of alternative outcome weights - benefit:risk preference thresholds - on individualized decision making. Results: Based on individualized risk predictions, the majority of ACS patients treated with PCI (66%) may choose prasugrel when preventing ischemia is considered equally important as avoiding bleeding (Figure), but this proportion varied from 32% to 80% when the benefit:risk preference threshold was varied from 3 (reflecting a 3-times greater preference for avoiding bleeding) to 0.25 (reflecting a 4-times greater preference for avoiding ischemia). Conclusions: Based on empirical analyses, the expected absolute benefits and risks of prasugrel vs. clopidogrel depend highly on patient characteristics and preferences. Presenting individualized predictions of benefits and risks with competing treatments may improve shared decision making.

Regional Differences in the Ratio of Observed and Expected In-hospital Mortality for Acute Coronary Syndrome Patients in China: The Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project Analysis

Angiology ◽  
2021 ◽  
pp. 000331972110313
Author(s):  
Jing Wen Yong ◽  
Yue Yan Xing ◽  
Meng Ge Zhou ◽  
Na Yang ◽  
Yong Chen Hao ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Acute Coronary Syndrome ◽  
Hospital Mortality ◽  
Regional Variation ◽  
Patient Characteristics ◽  
National Registry ◽  
Patient Specific ◽  
Improvement Project ◽  
Coronary Syndrome ◽  
The Difference

Previous studies reported regional variations in in-hospital acute coronary syndrome (ACS) mortality, but the reasons for that were not clearly defined. We explored whether differences in patient characteristics could explain regional variation. The Improving Care for Cardiovascular Disease in China (CCC)-ACS project is an ongoing national registry and quality improvement project, involving 150 tertiary hospitals from 30 provinces across China. We applied a prediction model that included patient-specific variables to calculate the expected in-hospital mortality. For each province, we reported the observed, expected in-hospital mortality and the risk-adjusted ratio which is based on the observed divided by the expected mortality. From 2014 to 2018, 79 585 ACS patients were enrolled. The average in-hospital mortality was 1.8%. There was a wide variation in the in-hospital mortality among different provinces (0.2-3.9%). Patient characteristics explained part of this variation because of differences in the expected in-hospital mortality (0.7-2.8%). There was a substantial variation in the risk-adjusted ratio among provinces (0.2-3.5), which suggests that the variations in the mortality cannot be completely explained by the differences in patient characteristics. In conclusion, we observed a wide regional variation in mortality for ACS, part of which could be explained by the difference in patient characteristics.

Coronary revascularization in acute coronary syndrome: does the choice of the conduit matter?

2021 ◽  
Author(s):  
Jasmin. H. SHAHINIAN ◽  
Mertan GÜRLEYEN ◽  
Marlon GRODD ◽  
Martin WOLKEWITZ ◽  
Friedhelm BEYERSDORF ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Coronary Revascularization ◽  
Coronary Syndrome

P5524Influence of bundle branch block in the long-term outcome of patients with acute coronary syndrome

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J M Garcia Acuna ◽  
A Cordero Fort ◽  
A Martinez ◽  
P Antunez ◽  
M Perez Dominguez ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Acute Coronary Syndrome ◽  
Right Bundle Branch Block ◽  
Coronary Revascularization ◽  
Bundle Branch Block ◽  
Coronary Syndrome ◽  
Worse Prognosis

Abstract The new European Society of Cardiology guideline for ST-segment elevation myocardial infarction recommends that left and right bundle branch block should be considered equal for recommending urgent angiography in patients with suspected myocardial infarction. This consideration is not taken into account in the management of patients with coronary syndrome without ST elevation (NSTEMI). We evaluate the evolution of patients with acute coronary syndrome and long-term bundle branch block. Patients and methods We included 8771 patients admitted to two tertiary hospitals between 2003 and 2017 with an acute coronary syndrome, 5673 NSTEMI (64.3%) and 3098 STEMI (35.7%). All patients had an ECG recorded immediately upon admission. Patients were classified as having right bundle branch block (RBBB), left bundle branch block (LBBB). Long-term follow-up was performed (median 55 months) to assess mortality. Results A total of 8771 patients were included with a mean age of 66.1 years, 72.5% males, 4.1% (362) with LBBB and 5% (440) with RBBB. Patients with BBB were older, with more previous history of myocardial infarction and coronary revascularization and higher prevalence of cardiovascular risk factors. Medical treatment was similar but they were less often submitted to angioplasty. During the acute phase, patients with RBBB and LBBB presented a higher rate of heart failure than those without branch block (4.8% vs 9.1% vs 3.5%, p=0.0001); higher mortality (8.4% vs 10.5% vs 3.0%, p=0.0001); higher stroke rate (2.5% vs 1.4% vs 0.8%, p=0.001); higher rate of renal failure (8.2% vs 9.7% vs 3.9%, p=0.0001) and higher rate of reinfarction (3.0% vs 4.1% vs 1.7%, p=0.001). Patients who had a RBBB or an LBBB had a worse prognosis throughout the follow-up. Heart failure was present in 17.7% of the group with RBBB, 29.6% of LBBB and 11% in the group without branch block (p=0.0001). Mortality during follow-up was 31% in RBBB, 40.6% in LBBB and 18.7% without branch block (p=0.0001). In multivariate analysis of Cox, both RBBB (HR 1.55, 95% CI 1.23–1.98, p=0.0001) and LBBB (HR 1.48, 95% CI 1.22–1.53, p=0.001) were an independent predictors of all-cause mortality (adjustment for GRACE score, gender, treatment with betablockers, angiotensin conversor enzym inhibitors, statin and coronary revascularization). Cox regression model multivariate Conclusions The presence of RBBB or LBBB in the ECG of patients with an ACS is associated with a worse prognosis both during the hospital phase and in the long term. In addition, both bundle branch blocks are independent predictors of long-term mortality in patients with ACS.

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