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CCORT/CCS 2008 Quality Indicators for
Acute Myocardial Infarction (AMI) Care-Indicator Definitions
Jack V. Tu MD PhD FRCPC, Laila Khalid MD, Linda Donovan
BScN MBA, Dennis T. Ko MD MSc for the
CCORT/CCS AMI Quality Indicator Panel
Christopher E. Buller MD, Virginia F. Flintoft BN MSc, Thao Huynh MD
MSc, Cynthia A. Jackevicius PharmD MSc, Laurie J. Lambert PhD,
Michael P. Love MB ChB MD, Michael J. Schull MD MSc, Heather
Sherrard BScN MHA, Edward Y.K. Tsoi MD,
Alain Vadeboncoeur MD
1
CIHR Team Grant in Cardiovascular Outcomes Research
CCORT/CCS 2008 Quality Indicators for AMI Care
Indicator Category
#
Indicators from chart review
17
I
13
In-hospital process-of-care indicators
- 6 pharmacological & 7 nonpharmacological
II
Outcome indicator
1
III
System indicators
3
Indicators from administrative data
21
I
13
Out-of-hospital process-of-care indicators
- 9 pharmacological & 4 nonpharmacological
II
Outcome indicators
Total 2008 Indicators
8
38
2
CCORT/CCS 2008 Quality Indicators for AMI Care
1
In-hospital Process-of-Care Indicator /Chart Abstracted (Pharmacological)
1.1
ASA within 24 hrs before hospital arrival or within 3 hrs after hospital arrival
1.2
ASA prescribed at hospital discharge
1.3
Beta blocker prescribed at hospital discharge
1.4
ACEI or ARB prescribed at hospital discharge
1.5
Statin prescribed at hospital discharge
1.6
Fibrinolytic therapy within 30 minutes after hospital arrival
3
CIHR Team Grant in Cardiovascular Outcomes Research
CCORT/CCS 2008 Quality Indicators for AMI Care
In-hospital Process-of-Care Indicators/Chart Abstracted (Nonpharmacological)
2
2.1 ECG within 10 minutes after hospital arrival
2.2 Primary percutaneous coronary intervention (PCI) within 90 minutes after hospital
arrival
2.3 Reperfusion therapy in eligible patients with ST-segment elevation MI
2.4 Risk stratification (i.e. cardiac catheterization, exercise stress test, perfusion
imaging, stress echocardiography)
2.5 Assessment of left ventricular function
2.6 Smoking cessation advice, counselling or therapy during hospital stay
2.7 Referral to cardiac rehabilitation
4
CCORT/CCS 2008 Quality Indicators for AMI Care
3
In-hospital Outcome Indicator/Chart Abstracted
3.1
In-hospital mortality
4
In-hospital System Indicators/Chart Abstracted
4.1
Fibrinolytic therapy within 60 minutes after call for emergency medical services
4.2
Primary PCI within 120 minutes after call for emergency medical services
4.3
Pre-hospital 12-lead ECG
5
CIHR Team Grant in Cardiovascular Outcomes Research
CCORT/CCS 2008 Quality Indicators for AMI Care
1
Out-of-Hospital Process-of-Care Indicators/Administrative Data (Pharmacological)
1.1 Prescription for Beta Blocker filled within 30 days after discharge
1.2 Prescription for Beta Blocker filled within 90 days after discharge
1.3 Adherence to Beta Blocker therapy 1 year after discharge
1.4 Prescription for ACEI or ARB filled within 30 days after discharge
1.5 Prescription for ACEI or ARB filled within 90 days after discharge
1.6 Adherence to ACEI or ARB 1 year after discharge
1.7 Prescription for Statin filled within 30 days after discharge
1.8 Prescription for Statin filled within 90 days after discharge
1.9 Adherence to Statin therapy 1 year after discharge
6
CCORT/CCS 2008 Quality Indicators for AMI Care
2
Out-of-Hospital Process-of-Care Indicators/Administrative Data
(Nonpharmacological)
2.1 Physician visit within 4 weeks after discharge
2.2 Median wait time (in days) for cardiac catheterization after MI
2.3 Median wait time (in days) for percutaneous coronary intervention (PCI) after MI
2.4 Median wait time (in days) for coronary artery bypass graft (CABG) surgery after MI
7
CIHR Team Grant in Cardiovascular Outcomes Research
CCORT/CCS 2008 Quality Indicators for AMI Care
3
Out-of-Hospital Outcome Indicators/ Administrative Data
3.1
30-day mortality
3.2
1-year mortality
3.3
30-day readmission rate because of AMI
3.4
1-year readmission rate because of AMI
3.5
30-day readmission rate because of congestive heart failure
3.6
1-year readmission rate because of congestive heart failure
3.7
30-day readmission rate because of unstable angina
3.8
1-year readmission rate because of unstable angina
8
CIHR Team Grant in Cardiovascular Outcomes Research
1. In-hospital Process-of-Care Indicators—Pharmacological
1.1 ASA within 24 hours before hospital arrival or within 3 hours
after hospital arrival
Numerator
Patients with AMI who received ASA within 24 hrs before hospital
arrival or within 3 hours after hospital arrival
Denominator
Inclusions: Confirmed AMI
Exclusions:
1. Active Bleeding on arrival
2. Allergy to ASA
3. Documented reason for nonuse of ASA (e.g. high risk of bleeding
or patient refusal)
CIHR Team Grant in Cardiovascular Outcomes Research
1. In-hospital Process-of-Care Indicators—Pharmacological
1.2 ASA prescribed at hospital discharge
Numerator
Patients with AMI who are prescribed ASA at hospital discharge
Denominator
Inclusions: Confirmed AMI and alive at discharge
Exclusions:
1. Evidence of i) Active bleeding on arrival or ii) Active bleeding
during hospital stay
2. Allergy to ASA
3. Documented reason for nonuse of ASA (e.g. high risk of bleeding
or patient refusal)
CIHR Team Grant in Cardiovascular Outcomes Research
1. In-hospital Process-of-Care Indicators—Pharmacological
1.3 Beta Blocker prescribed at hospital discharge
Numerator
Patients with AMI who are prescribed a Beta Blocker at hospital
discharge
Denominator
Inclusions: Confirmed AMI and alive at discharge
Exclusions:
1. Bradycardia (heart rate <60 bpm) on day of discharge or day before
discharge while not taking beta blocker
2. Conduction disorder defined as a second- or third-degree heart block on
ECG on arrival or during hospital stay while not on a pacemaker
3. Allergy or intolerance to beta blocker
4. Documented reason for nonuse of beta blocker (e.g. symptomatic
hypotension, systolic blood pressure < 100 mm Hg, severe chronic
obstructive pulmonary disease, asthma or patient refusal)
1. In-hospital Process-of-Care Indicators—Pharmacological
1.4 Angiotensin-converting enzyme (ACE) inhibitor or
Angiotensin-receptor blocker prescribed at hospital discharge
Numerator
Patients with AMI who are prescribed ACEI or ARB at hospital
discharge
Denominator
Inclusions: 1. Patients with AMI alive at discharge and 2. Left
ventricular ejection fraction <40% and 3. Patients with diabetes,
hypertension, heart failure or chronic kidney disease
Exclusions:
1. Severe aortic stenosis
2. Allergy or intolerance to ACEI or ARB
3. Documented reason for nonuse of ACEI or ARB at discharge (e.g.
symptomatic hypotension, severe renal dysfunction, hyperkalemia,
bilateral renal artery stenosis or patient refusal)
1. In-hospital Process-of-Care Indicators—Pharmacological
1.5 Statin prescribed at hospital discharge
Numerator
Patients with AMI who are prescribed a statin at
hospital discharge
Denominator Inclusions: Confirmed AMI and alive at discharge
Exclusions: Documented reason for nonuse of statins
(e.g. statin intolerance, liver disease or patient refusal)
CIHR Team Grant in Cardiovascular Outcomes Research
1. In-hospital Process-of-Care Indicators—Pharmacological
1.6 Fibrinolytic therapy within 30 minutes after hospital arrival
Numerator
Patients with AMI who received fibrinolytic therapy within 30
minutes after hospital arrival
Denominator
Inclusions: 1. Confirmed AMI and 2. ST-segment elevation or new
LBBB on ECG and 3. Fibrinolytic therapy received within 6 hrs after
hospital arrival and 4. Fibrinolytic therapy documented as primary
reperfusion therapy
Exclusions:
1. Fibrinolytic therapy received in ambulance or in field
2. Documented reason for delay in receiving fibrinolytic therapy
(e.g. nondiagnostic ECG or patient refusal)
2. In-hospital Process-of-Care Indicators—Nonpharmacological
2.1 ECG within 10 minutes after hospital arrival
Numerator
Patients with AMI who had an ECG within 10 minutes after hospital
arrival (triage time or registration time whichever occurs earlier)
Denominator
Inclusions: Confirmed AMI
Exclusions:
Documented reason for delay in ECG (e.g. atypical signs or
symptoms, ongoing cardiac arrest or patient refusal)
CIHR Team Grant in Cardiovascular Outcomes Research
2. In-hospital Process-of-Care Indicators—Nonpharmacological
2.2 Primary percutaneous coronary intervention (PCI) within 90
minutes after hospital arrival
Numerator
Patients with AMI who received primary percutaneous coronary
intervention (PCI) within 90 minutes after first hospital arrival
Denominator
Inclusions: 1. Confirmed AMI and 2. ST-segment elevation or new
LBBB on ECG, and 3. Primary percutaneous coronary intervention
performed within 24 hours after hospital arrival
Exclusions:
1. Patients who received fibrinolytic therapy before PCI
2. Documentation of PCI as non-primary
3. Documented reason for delay in PCI (e.g. patient refusal)
2. In-hospital Process-of-Care Indicators—Nonpharmacological
2.3 Reperfusion therapy in eligible patients with ST-segment
elevation MI
Numerator
Patients with AMI who received reperfusion therapy (fibrinolytic
therapy or primary percutaneous coronary intervention [PCI])
Denominator
Inclusions: 1. Patients with ST-segment elevation MI or new LBBB
on ECG who are eligible for fibrinolytic therapy or primary PCI and
2. Patients who present within 12 hours after symptom onset
Exclusions:
Documented reason for not receiving reperfusion therapy (e.g.
patient refusal)
CIHR Team Grant in Cardiovascular Outcomes Research
2. In-hospital Process-of-Care Indicators—Nonpharmacological
2.4 Risk stratification (i.e. cardiac catheterization, exercise
stress testing, perfusion imaging or stress echocardiography)
Numerator
Patients with AMI who underwent risk stratification (i.e. cardiac
catheterization, exercise stress testing, perfusion imaging or stress
echocardiography) during hospital stay or were referred for risk
stratification (e.g. outpatient or transfer to another hospital) after
discharge
Denominator
Inclusions: Confirmed AMI
Exclusions:
1. Primary or rescue percutaneous coronary intervention (PCI)
2. Documented reason for no cardiac catherterization or
noninvasive stress test (e.g. physical limitations, do-not-resuscitate
status or patient refusal)
2. In-hospital Process-of-Care Indicators—Nonpharmacological
2.5 Left Ventricular Function Assessment
Numerator
Patients with AMI who had assessment of left ventricular function
(e.g. via echocardiography, radionuclide angiography or left
ventriculography) during their hospital stay or were referred for
assessment after hospital discharge
Denominator
Inclusions: Confirmed AMI
Exclusions:
1. Primary or rescue percutaneous coronary intervention (PCI )
2. Documented reason for no assessment of left ventricular
function (e.g. recent assessment of left ventricular function or
patient refusal)
2. In-hospital Process-of-Care Indicators—Nonpharmacological
2.6 Smoking cessation advice, counselling or therapy during
hospital stay
Numerator
Patients with AMI who are smokers and who received
smoking cessation advice, counselling or therapy
during hospital stay
Denominator Inclusions: 1. Confirmed AMI and 2. Active smoker or
history of smoking in the past year
Exclusions:
Documented reason for no smoking cessation advice,
counselling or therapy (e.g. patient refusal)
2. In-hospital Process-of-Care Indicators—Nonpharmacological
2.7 Referral to cardiac rehabilitation
Numerator
Patients with AMI who are referred to cardiac rehabilitation during
hospital stay or at discharge
Denominator
Inclusions: Confirmed AMI
Exclusions:
Documented reason for no referral to cardiac rehabilitation (e.g.
patient-associated factors [e.g. patient refusal], provider-associated
factors [e.g. patient with a high-risk condition or a contraindication
to exercise], health care system-associated factors [e.g. financial
obstacles or absence of a cardiac rehabilitation program near
patient’s home])
3. Outcome Indicator
3.1 In-hospital mortality
Numerator
Patients with AMI who died in hospital during this
encounter/stay
Denominator Inclusions: Confirmed AMI
Exclusions:
None
CIHR Team Grant in Cardiovascular Outcomes Research
4. System Indicators
4.1 Fibrinolytic therapy within 60 minutes after call for
emergency medical services
Numerator
Patients with AMI who were eligible for fibrinolytic therapy and
received it within 60 minutes after call for emergency medical
services
Denominator
Inclusions: 1. Confirmed AMI and 2. ST-segment elevation or new
LBBB on ECG and 3. Fibrinolytic therapy within 6 hours after
hospital arrival and 4. Fibrinolytic therapy is primary reperfusion
therapy 5. Call made to emergency medical services (EMS)
Exclusions:
1. In-field fibrinolysis
2. Walk-in patients
3. Documented reason for delay in receiving finbrinolytic therapy
(e.g. patient refusal)
4. System Indicators
4.2 Primary percutaneous coronary intervention (PCI) within 120
minutes after call for emergency medical services
Numerator
Patients with AMI who were eligible for PCI and received primary PCI
within 120 minutes after call for emergency medical services
Denominator
Inclusions: 1. Confirmed AMI and 2. ST-segment elevation or new
LBBB on ECG and 3. PCI performed within 24 hours after hospital
arrival 4. Call made to emergency medical services (EMS)
Exclusions:
1. Patients who received fibrinolytic therapy before PCI
2. Documentation of PCI as non-primary
3. Documented reason for delay in PCI (e.g. patient refusal)
4. System Indicators
4.3 Pre-hospital 12-lead ECG
Numerator
Patients with AMI who had a prehospital 12-lead ECG
done by emergency medical services personnel
Denominator Inclusions: 1. Confirmed AMI and 2. Ambulance
transportation
Exclusions:
1. Walk-in patients
2. Documented reason for no prehospital ECG (e.g.
patient refusal)
This work was supported, in part, by a grant from
The Heart and Stroke Foundation of Ontario
CIHR Team Grant in Cardiovascular Outcomes Research
CCORT welcomes feedback on these
indicators. Please send comments or
questions to [email protected]
CIHR Team Grant in Cardiovascular Outcomes Research