Innovate Public Private Partnership to Meet the Common Goal of the Enterprises, Academics and

Government

—— CPACS Experience

WU YangfengThe George Institute for Global Health China

Peking University Clinical Research Institute and School of Public Health

Chinese Society of Cardiology

Management of ACS in Chinese

CHD is the leading cause of death and premature death in China. > 700 thousand Chinese die of acute coronary events each year

Half AMI patients will die before they arrive hospital. Mortality rate remains 10% for those who were admitted to hospital

Since 1993, direct expenditure on CVD has increased by 17 ％ every year while GDP has increased by 9 ％ every year

The Clinical Pathways for Acute Coronary Syndromes in China –Phase 1(CPACS-1)

Aim : Identify a number of important evidence-practice gaps relating to the diagnosis and treatment of patients with suspected ACS in ChinaMethod:

– 2004-2006– Prospective register study– 51 hospitals from 18 provinces and municipalities, 2973

ACS in-hospital patients registered– Patient’s data during hospitalization, 6 months and 12

months after discharge were collected

CPACS 1 ： Prehospital Delaydelay to seek medical help among Chinese ACS patients

•Mean time of onset to arrival of hospital is 9 hours, longer than GRACE study

•Delay is more obvious among the patients arriving at tertiary hospitals due to the transfer from other hospitals

0

2

4

6

810

12

14

16

STEMI NSTEMI UAP Total

Me

an

tim

e, h

our

Non-tertiary hospitals

Tertiary hospitals

N Median (IQR) N Median (IQR)

Door to needle （ minutes ）

150 55 （ 30 － 100 ）

141 61 （ 26-120 ）

Door to balloon （ minutes ）

46 51 （ 30-180 ） 188 90 （ 60-175 ）

CPACS-1 ： Time to reperfusion

CPACS 1 ： Diagnosis accuracy

No inconsistence

*includes <1% who had both inconsistent biomarkers and ST segment deviation

Inconsistent ST segment deviation Inconsistent biomarkers*

Biomarker not measured

20% final ACS diagnosis are inconsistent with ECG/biological markers

Risk classification （ GRACE score）High risk Median risk Low risk

No cath lab N=157 N=144 N=149

Exercise test ，％ 0 1.4 4.0

UCG ，％ 48.4 59.4 60.4

Cath lab N=811 N=851 N=861

Exercise test ，％ 0.4 1.5 4.5

UCG ，％ 54.9 62.0 61.9

Catheterization ，％

34.0 54.1 58.2

CPACS-1 ： Investigation Exercise test is rarely used in low-risk patients; catheterization, UCG is less likely to be used in high risk patients

CPACS-1 ： Invasive therapyLow- and median- risk patients were more likely to receive invasive therapy

GRACE risk scoreGRACE risk score

Gao, et al. Heart 2008;94:554-60Gao, et al. Heart 2008;94:554-60

CPACS-1 ： Medications Dual antiplatelet usage is relatively low

%

Aspirin Clopidogrel β-Blockers ACEI Statin

No reason ，%

38.2 34.3 21.5 20.2

Refuse ， % 55.0 8.9 18.1 16.6 16.8Intolerance ，%

1.8 1.3 11.8 27.0 5.7

Cost ,% 23.0 26.7

Other ， % 17.4 10.6 6.6 4.9 4.0Unknown ,% 16.5 5.2 16.6 15.8 14.3

Aspirin Clopidogrel β-Blockers ACEI StatinNo reason ，%

30.1 23.7 16.7 10.0

Refuse ， % 36.6 15.0 26.1 18.6 27.3Intolerance ，%

3.8 1.9 15.1 23.8 9.1

Cost ,% 27.4 16.2

Other ， % 30.1 5.7 9.1 10.0 9.1Unknown ,% 10.8 10.8 18.9 22.0 20.3

Level 2

hospitals

Level 3

hospitals

CPACS -1 ： Reasons for not compliant to therapy

CPACS-1 ： In hospital clinical outcome is suboptimal

Pre

vale

nce

,%

0

5

10

15Level 2

Level 3

Death MI Stroke CHF Bleeding

Rate of in hospital events was slightly higher than international reports ， especially in level 2 hospitals

Prognosis was poorer among MI patientsClinical outcomes were different according to different risk stratification

The Clinical Pathways for Acute Coronary Syndromes in China –Phase 2(CPACS-2)

Aim: Implement a quality improvement initiative (QCI) to improve ACS care in China and evaluate the effect of QCI

Method:– 2007-2011– Cluster randomized trial, prospective registery study– 75 hospitals from 17 provinces and municipalities,

more than 15 thousand ACS patients– Patient’s data were collected during hospitalization

and at every 6 months follow up

CPACS-2 ： participating hospitals

75 hospitals50 level 3 hospitals25 level 2 hospitals

黑龙江2/3 辽宁

4/3, 1/2河北4/3

山东3/3,1/2

江苏3/3

上海3/3, 4/2

河南2/3,2/2

广东4/3

湖北1/3, 4/2

四川2/3

陕西3/3, 3/2

内蒙古3/3, 1/2

北京4/3, 4/2

浙江2/3, 2/2湖南

4/3

新疆3/3, 1/2

山西2/3, 3/2

• Clinical pathway is a tool used to optimize and systematize treatment. The three main clinical pathways are :

• Risk stratification

• Clinical pathway of UA/NSTEMI

• Clinical pathway of STEMI

• The previous studies have confirmed that clinical pathway can improve quality of health care

• But most of the studies are conducted in high-income counties. No reliable data are documented in China

CPACS-2: Intervention

•50 consecutive patients were recruited in every 6 months•Summary feedback information is then made available to each hospital•Based on feedback information, hospital modify the clinical pathway•The modified clinical pathways are used in the next cycle

CPACS-2: intervention

18 个月

HOSPITAL X

6 个月 12 个月 24 个月 + 基线

Pathway implement

记录 50 个病人的临床资料

医院 X 记录 50 个病人

的临床资料记录 50 个病人的临床资料

记录 50 个病人的临床资料 *

记录 50 个病人的临床资料 *

18 months

Follow up every 6 months

HOSPITAL X

6 months 12 months 24 months + baseline

collection of data for 50 patients

Alive patients

hospitalX

collection of data for 50 patients

collection of data for 50 patients

collection of data for 50 patients

collection of data for 50 patients

Alive patients Alive patients Alive patients Alive patients

CPACS-2: Study design

75 hospitals

Baseline3750

patients

6 months3750

patients

12 months3750

patients

18 months1850

patients

24 months1850

patients

Baseline vs12 months

Baseline vs18 months

Summary data from 15000 patients available for evaluation of trend over time

Baseline vs24 months

75 hospitals

5 pilot centers

randomize

32 early intervention

hospitals（group A）

38 late intervention hospitals (group B）

12 month

Group A intervention 12 months Vs Group B baseline

Group A intervention 24 months

Group A intervention 12 months

CPACS 2 － key performance indicatorsExpected results: improve the accuracy of clinical diagnosis, significantly

shorten the time receive treatment, improve hospital management of ACS, improve compliance to the guidelines.

Proportion of STEMI patients receive thrombolysis or primary PCI

Door-to-needle time and Door-to-balloon time

Proportion of patients with final diagnosis consistent with ECG/biomarker findings

Proportion of high-risk patients undergoing coronary angiography

Proportion of low-risk patients undergoing functional testing

Proportion of patients discharged on appropriate medical therapy

Hospital length-of-stay

Effective clinical pathway intervention reduce evidence-practice gap

CPACS-2: Preliminary results

• Significantly improved KPIs:– Proportion of patients discharged on appropriate

medical therapy– Proportion of high-risk patients undergoing

coronary angiography– Length of hospital stay

• Not improved KPIs:– Proportion of low-risk patients undergoing

function testing

The Clinical Pathways for Acute Coronary Syndromes in China –Phase 3 (CPACS-3)

Aim: Develop and evaluate the effects of quality care initiative (QCI) system to reduce acute events and death of patients with ACS in level 2 hospitals with limited resources.Method:

– 2011-2014– Registry-based cluster randomized step-weddged controlled trial– 96 hospitals from 15 provinces and municipalities, more than 25

thousand ACS patients– Patient’s data will be collected during hospitalization and at 6 months

and 12 months follow up

Outcomes ：– Major adverse cardiovascular events （ MACE ）

Academic achievements

Am Heart J 2009;157:509-516

Heart 2008;94:554-60.

Changes in organization and management in different stages of CPACS

Phase Initiator Organizer SC Financial Support CPACS-1 The George

Institute for Global Health (GI), Austraila

Chinese Society of Cardiology (CSC)

GI, ChinaCSC

Experts from both sides and officials from MOH

Sanofi - Aventis (China), the Royal Australian Institute of Physicians, National Heart Foundation of Australia, the United States Guidant Corp.

CPACS-2 GI, AustraliaCSC

GI, China;CSC;With support from Division of Medical Administration, MOH

Experts from both sides and officials from MOH

Sanofi - Aventis (China)

CPACS-3 GI, ChinaCSC

Division of Medical Administration, MOH

Experts from China, USA, Australia, UK,and officials from MOH

Sanofi - Aventis (China)

Changes in organization and management in different stages of CPACS

CPACS-1 CPACS-2 CPACS-3

Academic achievements Increased

Government Involvement/policy impact

increased

Corporate social responsibility/business development

increased

The common interests of enterprise, academia and government

Common interest Specific interest

Enterprise Whether the product is effective /helpful?

Profit

Academia Which measures are effective /helpful?

Innovation

Government Which measures are effective /helpful?

Political achievements

For CPACS, how to transfer the scientific evidence into practice to improve the outcomes of ACS patients?

CPACS is still going forward ， please keep your eyes on our progress!

Acknowledgment

• CPACS-1 administration committee ：– Anushka Patel ，高润霖– 高炜、胡大一、黄德嘉、孔灵芝、戚文航、武阳丰、杨跃

进、 Phillip Harris• CPACS-2 administration committee ：

– Anushka Patel ，高润霖– 高炜、胡大一、黄德嘉、孔灵芝、沈卫峰、吕树铮、韩雅玲、林

曙光、武阳丰、葛均波、杨跃进、马爱群 • CPACS-3 administration committee ：

– 高润霖、武阳丰– 胡大一、霍勇、孔灵芝、焦亚辉、 Anushka Patel 、 Eric Peterson

、 Kalipso Chalkidou 、 Mark Woodward 、 Fiona Turnbull