CVD Critical Pathways Group  2005 Teleconferences This activity is supported by an educational grant from  the Bristol-Mye...
Faculty Gregg C. Fonarow, MD Eliot Corday Professor of Medicine  and Cardiovascular Science Director, Ahmanson-UCLA Cardio...
The Network for Continuing Medical Education requires that CME faculty disclose, during the planning of an activity, the e...
Gregg C. Fonarow, MD, has served as a consultant to and has received research support from GlaxoSmithKline, Pfizer Inc., a...
Polling Question #1 <ul><li>What is your institution’s status in terms of establishing critical pathways for ACS? </li></u...
Cost-effectiveness of CVD Therapies: Which Therapies Provide Good Value? Gregg C. Fonarow, MD
Cost-effectiveness <ul><li>The health economic evaluation of therapeutic and diagnostic strategies is of increasing import...
Cost-effectiveness <ul><li>There is no absolute standard for at what level a therapy is considered “cost-effective” and at...
13 million individuals in the US with prevalent coronary disease 6 million individuals with prevalent cerebral vascular di...
Reported C/E Ratios:  Cardiovascular Interventions $16,491/LYG Eptifibatide for ACS 7 $2080/LYG Lisinopril post-AMI 2 $32,...
HPS Simvastatin: Cause-Specific Mortality Risk ratio and 95% CI STATIN Better PLACEBO Better 17% SE 4 reduction (2P<0.0001...
Cost-effectiveness of Simvastatin in Patients at Different Levels of Vascular Disease Risk: British Heart Protection Study...
Reductions in 5-Year Vascular Event Costs  (and 95% CI) With Simvastatin Allocation  by Baseline Risk Subgroups Reproduced...
Discounted Incremental Costs, Effects,  and Cost-effectiveness During 5-Year Mean Follow-up by Risk Group and Overall Adap...
CURE Primary End Point:  MI/Stroke/CV Death Months of Follow-up *In addition to other standard therapies. Adapted with per...
Long-term Cost-effectiveness of Clopidogrel  in Patients With NSTEMI Adapted with permission from Weintraub WS, et al.  J ...
CREDO Study:  1-Year Primary Outcome 27% Relative Risk Reduction Months 3 0 6 9 12 0 5 15 10 Death, MI, or Stroke (%) P =....
CREDO Study: Benefit of Clopidogrel in PCI Patients at Various Time Intervals - 12  - - 8  - - 4  - - 0  - 4.6 Rand. to 1 ...
Cost-effectiveness of Prolonged  Clopidogrel Therapy After PCI Adapted with permission from Cowper PA, et al.  J Am Coll C...
Cost-effectiveness of Prolonged  Clopidogrel Therapy After PCI Adapted with permission from Cowper PA, et al.  J Am Coll C...
ISAR-REACT: Trial Design  2159 low- to intermediate-risk patients undergoing elective PCI with stent placement Abciximab +...
ISAR-REACT Primary End Point:  30-Day Death/MI/UTVR P  = NS Death/MI/UTVR  P  = NS UTVR P  = NS Death Abciximab + Clopidog...
High Cost of Post-MI Heart Failure Impact of Heart Failure on Cost of Managing Post-MI Patients $31,426 $44,997 0 5,000 10...
Impact of Eplerenone on Relative Risk of Total Mortality Post-MI With LVD Months Since Randomization Cumulative Incidence ...
Early Benefits of Eplerenone When Added to Standard Post-MI Patient Care Pitt B, et al.  N Engl J Med . 2003;348:1309-1321...
Cost-effectiveness of Eplerenone vs Placebo  in MI Patients With LV Dysfunction and HF Adapted with permission from Weintr...
Critical Pathways for UA/NSTEMI Unstable Angina/  Non–ST-elevation MI* ASA, Clopidogrel,   -blockers, ACEI, statin Hepari...
CHAMP Study: UCLA <ul><li>Designed to determine whether physician/patient compliance  with preventive therapies can be imp...
CHAMP Study: Clinical Events for the First Year After Discharge for Acute MI Fonarow GC, et al.  Am J Cardiol.  2001;87:81...
256 AMI pts discharged in 92/93 pre-CHAMP compared to 302 pts in 94/95 post-CHAMP UCLA Med Center Accounting Model, total ...
Variation in Acute MI Care Quality  in 1085 Hospitals and Its Association  With Mortality Rates 86,735 AMI patients in NRM...
Performance Matters! Reprinted with permission from Peterson ED. Presented at: Annual Scientific Sessions of the AHA; Nove...
Featured Institution Aurora Sinai Medical Center Milwaukee, Wisconsin
Polling Question #2 <ul><li>1) We are currently on the same item </li></ul><ul><li>2) We have since moved to the next chec...
Progress Checklist: Immediate Goals Circulate discharge plan and other tools to all cardiology, ED, and CV nursing staff f...
Progress Checklist: Short-term Goals/Activities Grand rounds/conference: Cardiology/IM  Grand rounds/conference: Emergenc...
Progress Checklist: Long-term Goals/Activities    NRMI    AHA Get With The Guidelines    ACC National Cardiovascular Da...
Question-and-Answer Session
Concluding Remarks Gregg C. Fonarow, MD Next program:  Wednesday, September 14, 2005 at 12:00 Noon Eastern Time (9:00 AM P...
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  • Strive Teleconf Presentation Aug10 2005

    1. 1. CVD Critical Pathways Group 2005 Teleconferences This activity is supported by an educational grant from the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership. August 10, 2005
    2. 2. Faculty Gregg C. Fonarow, MD Eliot Corday Professor of Medicine and Cardiovascular Science Director, Ahmanson-UCLA Cardiomyopathy Center UCLA Division of Cardiology UCLA Medical Center Los Angeles, California
    3. 3. The Network for Continuing Medical Education requires that CME faculty disclose, during the planning of an activity, the existence of any personal financial or other relationships they or their spouses/partners have with the commercial supporter of the activity or with the manufacturer of any commercial product or service discussed in the activity. Disclosure Statement
    4. 4. Gregg C. Fonarow, MD, has served as a consultant to and has received research support from GlaxoSmithKline, Pfizer Inc., and Scios Inc. He has also received honoraria from Merck & Co., Inc. The team from Aurora Sinai Medical Center reports no such relationships.   Faculty Disclosure Statement
    5. 5. Polling Question #1 <ul><li>What is your institution’s status in terms of establishing critical pathways for ACS? </li></ul><ul><ul><li>1) ACS pathways are not in place </li></ul></ul><ul><ul><li>2) ACS pathways are in place, but not updated per current ACC/AHA UA/NSTEMI and STEMI Guidelines </li></ul></ul><ul><ul><li>3) ACS pathways are up-to-date, but not regularly implemented </li></ul></ul><ul><ul><li>4) ACS pathways are up-to-date and regularly followed </li></ul></ul>
    6. 6. Cost-effectiveness of CVD Therapies: Which Therapies Provide Good Value? Gregg C. Fonarow, MD
    7. 7. Cost-effectiveness <ul><li>The health economic evaluation of therapeutic and diagnostic strategies is of increasing importance </li></ul><ul><li>The use of incremental cost-effectiveness estimates provides a rationale for health economic allocation discussions and funding decisions </li></ul><ul><li>The cost per quality life-year gained is a commonly reported measurement in outcomes research </li></ul>
    8. 8. Cost-effectiveness <ul><li>There is no absolute standard for at what level a therapy is considered “cost-effective” and at what level a therapy is not “cost-effective” </li></ul><ul><li>Many consider therapies at or below $50,000 per quality adjusted life-year gained to be “cost-effective” relative to other accepted therapies such a hemodialysis. Above $100,000 per QALY gained, many consider as indicating the therapy is less attractive </li></ul><ul><li>A therapy that reduces total medical costs while adding QALY is described as cost dominant (less than $0) </li></ul>
    9. 9. 13 million individuals in the US with prevalent coronary disease 6 million individuals with prevalent cerebral vascular disease 5 million individuals with prevalent peripheral vascular disease <ul><li>40 million office visits annually </li></ul><ul><li>5 million hospitalizations annually </li></ul><ul><li>226 billion dollars in direct costs in 2004 </li></ul><ul><li>368 billion dollars in total costs in 2004 </li></ul>Average direct costs over a 5-year period $ 51,211 MI $ 34,581 Unstable angina $ 9,780 Sudden death $ 62,524 CABG $ 58,453 PTCA Heart and Stroke Facts: 2004 Statistical Supplement, American Heart Association. Cost of Atherosclerosis
    10. 10. Reported C/E Ratios: Cardiovascular Interventions $16,491/LYG Eptifibatide for ACS 7 $2080/LYG Lisinopril post-AMI 2 $32,678/LYG t-PA vs SK 10 $5400-$32,000/LYG Statin 8,9 $6318/LYG Clopidogrel – CURE 5 $5910/LYG Clopidogrel – PCI-CURE 4 $3685/LYG Clopidogrel – CREDO 3 $220/LYG Smoking cessation post-AMI 1 C/E Ratio Intervention <ul><ul><li>1. Krumholz HM, et al. J Am Coll Cardiol . 1993;22:1697-1702. </li></ul></ul><ul><ul><li>2. Franzosi MG, et al. Pharmacoeconomics . 1998;13:337-346. </li></ul></ul><ul><ul><li>3. Beinart S, et al. AHA Scientific Sessions; 2003. </li></ul></ul><ul><ul><li>4. Mahoney EM, et. al. AHA Scientific Sessions; 2003. </li></ul></ul><ul><ul><li>5. Weintraub WS, et al. AHA Scientific Sessions; 2003. </li></ul></ul><ul><ul><li>6. Mahoney EM, et al. JAMA . 2002;288:1851-1858. </li></ul></ul><ul><ul><li>7. Hillegass WB, et al. Pharmacoeconomics . 2001;19:41-55. </li></ul></ul><ul><ul><li>8. Tsevat J, et al. Am Heart J. 2001;141:727-734. </li></ul></ul><ul><ul><li>9. Johannesson M, et al. N Engl J Med . 1997;336:332-336. </li></ul></ul><ul><ul><li>10. Mark DB, et al. N Engl J Med . 1995;332:1418-1424. </li></ul></ul>LYG = life-year gained. Early invasive strategy 6 $12,739/LYG
    11. 11. HPS Simvastatin: Cause-Specific Mortality Risk ratio and 95% CI STATIN Better PLACEBO Better 17% SE 4 reduction (2P<0.0001) 5% SE 6 reduction (NS) 13% SE 4 reduction (2P<0.001) Heart Protection Study Collaborative Group. Lancet. 2002;360:7 - 22. Reprinted with permission from Elsevier Science. 570 (5.6%) 547 (5.3%) NONVASCULAR 21 16 Nonmedical 90 82 Other medical 345 359 Neoplastic 114 90 Respiratory 1507 (14.7%) 1328 (12.9%) ALL CAUSES 230 194 Other vascular 707 587 Coronary 937 (9.1%) 781 (7.6%) ANY VASCULAR Placebo (10,267) Nonvascular Vascular Simvastatin (10,269) Cause of Death 0.6 0.8 1.0 1.2 1.4 0.4
    12. 12. Cost-effectiveness of Simvastatin in Patients at Different Levels of Vascular Disease Risk: British Heart Protection Study <ul><li>Purpose: Determine the range of cost-effectiveness of statin therapy in persons ranging from intermediate to high vascular event risk </li></ul><ul><li>Methods: </li></ul><ul><ul><li>20,536 adults (aged 40-80 years) with vascular disease or diabetes </li></ul></ul><ul><ul><li>Randomly assigned to 40 mg simvastatin daily or placebo for an average of 5 years </li></ul></ul><ul><li>Results: Simvastatin use was associated with a highly significant 22% (95% CI 16-27; P <.001) proportional reduction in hospitalization costs for all vascular events </li></ul>Mihaylova B, et al. Lancet. 2005;365:1779-1785.
    13. 13. Reductions in 5-Year Vascular Event Costs (and 95% CI) With Simvastatin Allocation by Baseline Risk Subgroups Reproduced with permission from Mihaylova B, et al. Lancet. 2005;365:1779-1785. <ul><li>Estimated absolute reductions in vascular event costs per person allocated simvastatin ranged from UK £847 (US $1524) in the highest-risk quintile to £264 ($475) in the lowest-risk quintile </li></ul><ul><li>Mean excess cost of statin therapy among participants allocated simvastatin was £1497 ($2694) </li></ul>US dollar figures computed at a conversion rate of $1.80 per British pound. MVE = major vascular event. 1500 1125 750 375 0 1(12%) 2(18%) 3(22%) 4(28%) 5(42%) Risk subgroup (5-year MVE risk) Cost reductions ( £ ) % of statin cost (2001 prices) 100 75 50 25 0
    14. 14. Discounted Incremental Costs, Effects, and Cost-effectiveness During 5-Year Mean Follow-up by Risk Group and Overall Adapted with permission from Mihaylova B, et al. Lancet. 2005;365:1779-1785. US dollar figures computed at a conversion rate of $1.80 per British pound. MVE Vascular deaths Cost per Risk Group Incremental avoided per Cost per avoided per vascular death (5-year MVE risk) cost 1000 persons MVE avoided 1000 persons avoided 1 (12%) £ 1164/$2095 37 £ 31,100/$55,980 4 £ 296,300/$533,340 2 (18%) £ 1062/$1912 58 £ 18,300/$32,940 7 £ 147,800/$266,040 3 (22%) £ 987/$1777 80 £ 12,300/$22,140 13 £ 78,900/$142,020 4 (28%) £ 893/$1607 93 £ 9600/$17,280 18 £ 46,600/$89,280 5 (42%) £ 630/$1134 141 £ 4500/$8100 29 £ 21,400/$38,520 Overall £ 947/$1705 82 £ 11,600/$20,880 14 £ 66,600/$119,880 *Discounted at 3.5% per annum. MVE = major vascular event.
    15. 15. CURE Primary End Point: MI/Stroke/CV Death Months of Follow-up *In addition to other standard therapies. Adapted with permission from Yusuf S, et al. N Engl J Med. 2001;345:494-502. Clopidogrel + Aspirin* (n=6259) Placebo + Aspirin* (n=6303) P <.001 N=12,562 20% Relative Risk Reduction 0.12 0.14 0.10 0.06 0.08 0.00 0.04 0.02 Cumulative Hazard Rate 3 6 9 0 12
    16. 16. Long-term Cost-effectiveness of Clopidogrel in Patients With NSTEMI Adapted with permission from Weintraub WS, et al. J Am Coll Cardiol. 2005;45:838-845. *Based on Medicare costs and Framingham and Saskatchewan life expectancy estimates; N=12,562. ICER = incremental cost-effectiveness ratio; LYG = life-year gained. Cost-effectiveness of Clopidogrel* 93.9% $6318 0.0699 $442 Framingham Medicare 97.7% $6475 0.0682 $442 Saskatchewan Medicare No direct costs beyond trial period % <50,000/LYG ICER ∆ Life-Years ∆ Cost
    17. 17. CREDO Study: 1-Year Primary Outcome 27% Relative Risk Reduction Months 3 0 6 9 12 0 5 15 10 Death, MI, or Stroke (%) P =.02 8.5% 11.5% Clopidogrel n=1053 Placebo n=1063 Adapted with permission from Steinhubl SR, et al. JAMA. 2002;288:2411-2420. NNT=33
    18. 18. CREDO Study: Benefit of Clopidogrel in PCI Patients at Various Time Intervals - 12 - - 8 - - 4 - - 0 - 4.6 Rand. to 1 Year Rand. to Day 28 Day 29 to 1 Year Combined Endpoint Occurrence (%) MI, Stroke, or Death – ITT Population Clopidogrel* Placebo* 37.4% RRR P =.04 19.7% RRR P =.21 26.9% RRR P =.02 *Plus aspirin and other standard therapies. † Steinhubl S, et al. JAMA. 2002;288:2411-2420. ‡ Steinhubl S. 75th Scientific Sessions of the AHA; November 18, 2002; Chicago, Ill. 8.5 † 11.5 † 5.5 ‡ 6.9 ‡ 2.9 ‡ 4.6 ‡
    19. 19. Cost-effectiveness of Prolonged Clopidogrel Therapy After PCI Adapted with permission from Cowper PA, et al. J Am Coll Cardiol. 2005;45:369-376. Modeled Outcomes and Cost-effectiveness N=3976. Total Sample Variable Clopidogrel No Clopidogrel Total Cost* $3,715 $2,819 Outcomes MI (1 month to 1 yr) 3.24% 5.80% Cost-effectiveness $/MI avoided $34,336 $/yr of life saved $15,696 *Between 1 and 12 months following PCI.
    20. 20. Cost-effectiveness of Prolonged Clopidogrel Therapy After PCI Adapted with permission from Cowper PA, et al. J Am Coll Cardiol. 2005;45:369-376. N=3976. Modeled Outcomes and Cost-effectiveness High-Risk Subset Low-Risk Subset No No Variable Clopidogrel Clopidogrel Clopidogrel Clopidogrel Total Cost* $4,082 $3,307 $3,311 $2,328 Outcomes MI (1 month to 1 yr) 4.46% 8.0% 2.06% 3.70% Cost-effectiveness $/MI avoided $21,893 $59,939 $/yr of life saved $10,333 $26,568 *Between 1 and 12 months following PCI
    21. 21. ISAR-REACT: Trial Design 2159 low- to intermediate-risk patients undergoing elective PCI with stent placement Abciximab + 70 U/kg heparin (n=1079) Placebo + 140 U/kg heparin (n=1080) <ul><li>End Points: </li></ul><ul><ul><li>Primary 30-day death/MI/urgent target-vessel revascularization </li></ul></ul><ul><ul><li>Secondary 30-day bleeding complications </li></ul></ul>Clopidogrel* (600-mg loading dose) Randomized *In addition to aspirin. Kastrati A, et al. N Engl J Med . 2004;350:232-238. Clopidogrel 150 mg/d until discharge, then 75 mg/d for 4 wk* Clopidogrel 150 mg/d until discharge, then 75 mg/d for 4 wk* 325-500 mg Aspirin
    22. 22. ISAR-REACT Primary End Point: 30-Day Death/MI/UTVR P = NS Death/MI/UTVR P = NS UTVR P = NS Death Abciximab + Clopidogrel Placebo + Clopidogrel Abciximab + Clopidogrel Placebo + Clopidogrel Abciximab + Clopidogrel Placebo + Clopidogrel UTVR = urgent target-vessel revascularization. Adapted with permission from Kastrati A, et al. N Engl J Med . 2004;350:232-238. % of Patients
    23. 23. High Cost of Post-MI Heart Failure Impact of Heart Failure on Cost of Managing Post-MI Patients $31,426 $44,997 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 Post-MI Patients Post-MI Patients With Heart Failure Mean Annual Cost of Management 50,000 $13,571 per year for patients who develop heart failure Akhras KS, et al. Abstract presented at: Heart Failure Society of America 2003 Scientific Meeting; September 21-24, 2003; Las Vegas, Nev. Dollars (n=5298) (n=2345)
    24. 24. Impact of Eplerenone on Relative Risk of Total Mortality Post-MI With LVD Months Since Randomization Cumulative Incidence (%) 22 0 2 20 16 18 14 12 10 8 6 4 RR=.85 (95% CI, .75-.96) P =.008 Placebo (n=3,313) Eplerenone (n=3,319) 36 33 30 27 24 21 18 15 12 9 6 3 0 Pitt B, et al. N Engl J Med . 2003;348:1309-1321. CI = confidence interval; RR = relative risk.
    25. 25. Early Benefits of Eplerenone When Added to Standard Post-MI Patient Care Pitt B, et al. N Engl J Med . 2003;348:1309-1321. All Cause Mortality Cardiovascular Mortality Sudden Cardiac Death Heart Failure Hospitalization 30 Days -31 -32 -37 -18 -50 -45 -40 -35 -30 -25 -20 -15 -10 -5 0 5 10 Relative Risk (%)
    26. 26. Cost-effectiveness of Eplerenone vs Placebo in MI Patients With LV Dysfunction and HF Adapted with permission from Weintraub WS, et al. Circulation. 2005;111:1106-1113. Cost-effectiveness of Eplerenone N=6632. ∆ Cost, $ ∆ Effectiveness ICER, $ <50,000/LYG, % No added costs resulting from life-years saved Life-years Framingham 1391 0.1014 13,718 96.7 Saskatchewan 1391 0.0636 21,876 93.8 Worcester 1391 0.1337 10,402 98.8 LYG indicates life-years gained.
    27. 27. Critical Pathways for UA/NSTEMI Unstable Angina/ Non–ST-elevation MI* ASA, Clopidogrel,  -blockers, ACEI, statin Heparin or LMWH Conservative Strategy Invasive Strategy DC Home or ETT Hour 8-12 Cath/PCI Hour (0-6) D/C Home Hour 8-16 D/C Day Hour 18-24 + Rest pain Adapted from UCLA Clinical Pathway for ACS. Available at: www.med.ucla.edu/champ. ECG + and/or Troponin + Troponin - 6-hr Troponin - / ECG - ASA, clopidogrel,  -blockers, ACEI, statin, omega 3, and exercise
    28. 28. CHAMP Study: UCLA <ul><li>Designed to determine whether physician/patient compliance with preventive therapies can be improved through a hospital- initiated program </li></ul><ul><li>Tracked initiation of aspirin, β -blocker, ACE inhibitor, statins </li></ul><ul><li>Used preprinted orders, guidelines, lectures, discharge forms </li></ul><ul><li>Population: patients with symptomatic atherosclerosis treated at university-associated teaching hospital </li></ul><ul><li>Methods: no specific algorithms used before CHAMP (1992-1993) </li></ul><ul><li>National guidelines (ACC/AHA, NCEP ATP I and ATP II) used in CHAMP (1994-1995) </li></ul><ul><li>Evaluation: treatment rates and clinical outcomes pre-CHAMP and CHAMP in patients hospitalized for AMI </li></ul>Fonarow GC, Gawlinski A. Am J Cardiol. 2000;85(3A):10A-17A. Cardiac Hospitalization Atherosclerosis Management Program
    29. 29. CHAMP Study: Clinical Events for the First Year After Discharge for Acute MI Fonarow GC, et al. Am J Cardiol. 2001;87:819-822. Event Rate, % Recurrent MI Heart Failure Hospitalization Total Mortality Pre-CHAMP Post-CHAMP 7.8 4.7 14.8 7.0 3.3* 2.6 7.6* 3.3* * P <0.05
    30. 30. 256 AMI pts discharged in 92/93 pre-CHAMP compared to 302 pts in 94/95 post-CHAMP UCLA Med Center Accounting Model, total costs averaged over each pt dc; meds at AWP Fonarow GC, et al. Am J Cardiol. 2001;87:819-822. CHAMP: Economic Analysis P <0.001
    31. 31. Variation in Acute MI Care Quality in 1085 Hospitals and Its Association With Mortality Rates 86,735 AMI patients in NRMI IV treated between 7/00 and 3/01. ACC/AHA Class I therapy. Hospitals divided into quartiles to composites of quality. Peterson ED. Circulation. 2002;106:II-722. Abstract. Median Performance Lagging Hospitals Leading Hospitals on Care Processes (n=271) (n=271) Aspirin <24 h 73% 93% β - blocker <24 h 50% 86% Reperfusion 50% 71% DC ACEI 40% 70% DC Lipid Therapy 58% 80% Smoking Advice 7% 65% Mortality 17.6% 11.9%
    32. 32. Performance Matters! Reprinted with permission from Peterson ED. Presented at: Annual Scientific Sessions of the AHA; November 17-20, 2002; Chicago, Ill. Relationship Between Process and Outcome in CRUSADE 5.9 5.0 4.6 3.6 0 1 2 3 4 5 6 7 Hospital Composite Adherence Quartiles In-hospital Mortality (%) <65% 65%-75% 75%-80% >80%
    33. 33. Featured Institution Aurora Sinai Medical Center Milwaukee, Wisconsin
    34. 34. Polling Question #2 <ul><li>1) We are currently on the same item </li></ul><ul><li>2) We have since moved to the next checkbox on the checklist </li></ul><ul><li>3) We have progressed by more than one item on the checklist </li></ul><ul><li>4) ACS pathways are up-to-date and regularly followed </li></ul>If you participated in a previous teleconference, how much progress have you made since then? (Please refer to the checklists on the next 3 slides.)
    35. 35. Progress Checklist: Immediate Goals Circulate discharge plan and other tools to all cardiology, ED, and CV nursing staff for comments  Circulate pathways to all cardiology, ED, and CV nursing staff for comments  Develop draft pathways  Assemble team and set up meeting of working group 
    36. 36. Progress Checklist: Short-term Goals/Activities Grand rounds/conference: Cardiology/IM  Grand rounds/conference: Emergency Dept.  Grand rounds/conference: Nursing  Circulate memo  Launch critical pathways  Finalize critical pathways 
    37. 37. Progress Checklist: Long-term Goals/Activities  NRMI  AHA Get With The Guidelines  ACC National Cardiovascular Data Registry  CRUSADE  GRACE  REACH  Other Monitor data: which registry? 
    38. 38. Question-and-Answer Session
    39. 39. Concluding Remarks Gregg C. Fonarow, MD Next program: Wednesday, September 14, 2005 at 12:00 Noon Eastern Time (9:00 AM Pacific) Topic: The CRUSADE National Quality Improvement Initiative: 2005 Update Faculty: Christopher P. Cannon, MD
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