NRMI data impacts care on many different levels

Moving with the times makes data more relevant

For more than 11 years, the National Registry of Myocardial Infarction (NRMI) has been collecting data on heart attack patients around the country. It is one of the largest patient registries in the world, with information on more than 1.8 million patients and 1,600 hospitals, says NRMI project manager Kathee Litrell, PhD, RN.

"This is a prime example of providing value-added services for the cardiovascular community," she says. "We provide frequent feedback for hospitals to assess their own practices, as well as information on how heart attack patients are being taken care of. We have aligned what we do to the needs of our customers."

Recently, Litrell shared what NRMI — funded by biotech company Genentech in South San Francisco, CA, but run independently of the company — does with others interested in and involved in patient registries at a conference on the subject. She says among the things NRMI does particularly well is changing with the times. "Every iteration of NRMI changes as guidelines change," she notes. "We keep current with what people should be tracking — whether it is aspirin use, the use of ACE inhibitors and beta blockers, or how many patients get primary PTCA [percutaneous transluminal coronary angioplasty]. All of these therapies show survival benefit and are tracked for all hospitals in our study."

Hospitals using the data can look at those elements for their state, the nation, or just for like hospitals. "We provide ample benchmarking opportunities," says Litrell. 

Knowing that the work of creating a registry never is finished also is one of the key elements to making one successful, according to Litrell. "It is critical to listen to customers and see what they perceive as their needs and then go out and meet them." For instance, NRMI recently heard from pharmacists that they wanted information on every drug therapy collected by the registry. "So we went out and developed a report," she says.

When customers said they wanted the ability to capture data electronically, NRMI implemented such a feature. Now users say they want a data analysis tool so that hospitals can analyze data for subpopulations that aren’t part of the NRMI’s routine reports — older women, for instance. As of April, Litrell says, that feature will be added to NRMI.

For those who want to avoid duplicate data collection and reporting, NRMI has altered its database so that it is will be available to users for reporting core measures to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Final verification by JCAHO is anticipated before hospitals have to start reporting core measures data in July.

There isn’t a cost for any of the routine quarterly reports on all of the acute myocardial infarction (AMI) measures. For some of the extra reports or new services, there are fees, although Litrell says they are nominal — about $50 for data diskette services, for example. "This is just a great partnership for us with cardio hospitals," she says.

What makes a good registry is having information that applies to a large number of hospitals and collecting data that they can use, Litrell says. "Any hospital that sees a lot of AMIs and provides cardiac services will be interested in this data," she notes. "If the focus is women’s health, maybe they aren’t interested. But otherwise, it offers great opportunities."

Looking at the trends over time can show just how much having this data available can impact patient care. Since NRMI began in 1990, median door-to-drug times have decreased from 60 to 34 minutes. Many hospitals now are within the national goal of treating patients in less than 30 minutes. As health care organizations become more efficient and effective at treating patients with AMI, hospital lengths of stay have become shorter, with patients receiving reperfusion treatments such as thrombolytic therapy, primary PTCA, and early coronary artery bypass graft surgery benefiting the most.

And hospitals also have been successful at using risk-reduction therapies for coronary artery disease for secondary prevention of future cardiac events. One reason: improved use of several important medications within the first 24 hours after diagnosis. 

Hospitals have used the data to improve several key areas of operation, Litrell says, from decreasing the time from onset of symptoms to hospital arrival and treatment, to increasing the use of beta-blockers by creating critical pathways.

"The data has been important because it has increased awareness in the hospitals of all the key therapies that an AMI patient should receive — not just the drugs [Genentech] produces, but all the class-one indications for AMI," she says. "It even looks at glycoprotein 2b/3a inhibitors. And knowing where you stand compared to national, state, and like hospitals helps to drive quality improvement and improve the impact you have on patients."

There have been other efforts to influence AMI treatment, she continues. "In the early 1990s, HCFA did a project where they did a one-time review of charts. But doing that and getting a report later doesn’t necessarily have an impact on how you treat patients. We provide routine feedback. And with our new data analysis feature, you can check where you are whenever you input data."

The data from the registry also has influenced research. There are more than 50 studies and more than 100 abstracts based on the NRMI, Litrell says. "Because the database is so large, you can look at areas that are hard to view in a randomized control trial — minorities and women, for example. I know that we have helped hospitals and the whole cardiovascular community with the publications we have generated."

[For more information, contact:

  • Kathee Litrell, PhD, RN, Project Manager for NRMI, One DNA Way, Genentech, Mail Stop 44, South San Francisco, CA 94080. Telephone: (650) 225-1034.]

Data Collected by NRMI

  • Demographics and Medical History
  • Event Timeline
  • Presentation Characteristics
  • Transfer-In
  • Reperfusion Strategies
  • Reasons Reperfusion Strategies Not Utilized
  • GP IIb/IIIa Inhibitor
  • Other Procedures
  • Stroke
  • Clinical Events
  • Medication/Therapies
  • Contraindications to Key Therapies
  • Information on Discharge
  • Discharge Status

Atlanta

  • Fifty-two percent of invited hospitals (16 of 31) responded to the survey.
  • Fifty-six percent have fully implemented at least one of Leapfrog’s recommended patient safety practices.

Of the hospitals responding:

  • None has fully implemented computerized physician order entry (CPOE), but six say they plan to by 2004.
  • None has fully implemented the intensive-care unit (ICU) physician staffing practice, but three say they plan to staff intensivists by 2004.

Evidence-based hospital referral:

— Four meet the coronary artery bypass recommended annual volume.

— Four meet the coronary angioplasty volume recommendation.

— Three meet the abdominal aortic aneurysm repair volume recommendation.

— Three meet the carotid endarterectomy volume recommendation.

— Two meet the esophageal cancer surgery volume recommendation.

— Six meet Leapfrog specifications for neonatal intensive-care units (NICUs).

California

  • Fourty-four percent of invited hospitals (150 of 338) responded to the survey.
  • Responding hospitals account for an estimated 60% of total discharges from hospitals invited to participate in the survey (this statistic is not available for other regions).
  • Fifty-two percent of hospitals in California submitting responses have fully implemented at least one of Leapfrog’s recommended patient safety practices.

Of the hospitals responding:

  • CPOE: Six have fully implemented CPOE, and 33 say they plan to implement CPOE fully by 2004.
  • IPS: 14 have fully implemented the IPS practice and 13 say they plan to staff intensivists by 2004.

Evidence-based hospital referral:

— Ten meet the coronary artery bypass recommended annual volume (many California hospitals voluntarily report outcomes data for this procedure — see www.HealthScope.org).

— Thirty-nine meet the coronary angioplasty volume recommendation.

— Twenty-five meet the abdominal aortic aneurysm repair volume recommendation.

— Twenty-four meet the carotid endarterectomy volume recommendation.

— Twenty-three meet the esophageal cancer surgery volume recommendation.

— Thirty-two meet Leapfrog specifications for the NICU.

East Tennessee

  • Ninety-two percent of invited hospitals (23 of 25) responded to the survey.
  • Fifteen — 65% — of hospitals in the region submitting responses have fully implemented at least one of Leapfrog’s recommended patient safety practices.

Of the hospitals responding:

  • CPOE: One has fully implemented CPOE, but 12 say they plan to implement CPOE by 2004.
  • IPS: One meets the IPS practice, and six say they plan to staff intensivists by 2004.

Evidence-based hospital referral:

— Five meet the coronary artery bypass recommended annual volume.

— Eleven meet the coronary angioplasty volume recommendation.

— Ten meet the abdominal aortic aneurysm repair volume recommendation.

— Nine meet the carotid endarterectomy volume recommendation.

— Three meet the esophageal cancer surgery volume recommendation.

— Five meet Leapfrog specifications for the NICU.

Minnesota

  • Sixty percent of invited hospitals (28 of 47) responded to the survey.
  • Thirty-nine percent of hospitals in Minnesota submitting responses have fully implemented at least one of Leapfrog’s recommended patient safety practices.

Of the hospitals responding:

  • CPOE: One has fully implemented CPOE and nine say they plan to implement CPOE by 2004.
  • IPS: Five have fully implemented the IPS practice and nine say they plan to staff intensivists by 2004.

Evidence-based hospital referral:

— Four meet the coronary artery bypass recommended annual volume.

— Ten meet the coronary angioplasty volume recommendation.

— Four meet the abdominal aortic aneurysm repair volume recommendation.

— Five meet the carotid endarterectomy volume recommendation.

— Six meet the esophageal cancer surgery volume recommendation.

— Three meet Leapfrog specifications for the NICU.

St. Louis

  • Three percent of invited hospitals (one of 31) responded to the survey.
  • That hospital has fully implemented the ICU physician staffing practice and meets five of the volume standards.

For the one hospital responding to date:

  • CPOE: It does not meet the CPOE standard, but it plans to implement CPOE by 2004.
  • IPS: It does meet the IPS standard.

Evidence-based hospital referral:

— It meets the coronary artery bypass recommended annual volume.

— It meets the coronary angioplasty volume recommendation.

— It meets the abdominal aortic aneurysm repair volume recommendation.

— It meets the carotid endarterectomy volume recommendation.

— It does not meet the esophageal cancer surgery volume recommendation.

— It meets Leapfrog specifications for the NICU.

Seattle-Tacoma-Everett

  • Ninety-two percent of invited hospitals (23 of 25) responded to the survey.
  • Fifty-seven percent of hospitals in the Seattle area submitting responses have fully implemented at least one of Leapfrog’s recommended patient safety practices.

Of the hospitals responding:

  • CPOE: None has fully implemented CPOE, but 12 say they plan to implement CPOE by 2004.
  • IPS: Three have fully implemented the IPS practice, and 12 say they plan to staff intensivists by 2004.

Evidence-based hospital referral:

— Four meet the coronary artery bypass recommended annual volume.

— Nine meet the coronary angioplasty volume recommendation.

— Eight meet the abdominal aortic aneurysm repair volume recommendation.

— Five meet the carotid endarterectomy volume recommendation.

— Three meet the esophageal cancer surgery volume recommendation.

— Five meet Leapfrog specifications for the NICU.