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NICE Indicator ProgrammeConsultation on draft NICE CCG indicatorsConsultation dates: 25/11/2020 to 23/12/2020This consultation presents new clinical commissioning group (CCG) indicators that align with NICE guidance, based on indicators developed by the European Society of Cardiology (ESC) on the management of acute myocardial infarction. We welcome comments from stakeholders. Feedback from this consultation will be reviewed by the NICE Indicator Advisory Committee in March 2021. The introduction section outlines questions that may be useful to consider. The proposed indicators may change following consultation. If you have any questions about this consultation, please contact the NICE Indicator Team (indicators@.uk). How we develop indicators and the purpose of the consultationAll NICE indicators are developed in accordance with the NICE indicator process guide. A key part of this process is giving stakeholders the opportunity to comment on the proposed indicators and their intended use.Contents TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc56604586 \h 3IND2020-101: Reperfusion within 12h of symptom onset PAGEREF _Toc56604587 \h 4IND2020-102: Timely reperfusion PAGEREF _Toc56604588 \h 7IND2020-103: Time between first medical contact and arterial access PAGEREF _Toc56604589 \h 10IND2020-104: Left ventricular function recorded in notes PAGEREF _Toc56604590 \h 14IND2020-105: P2Y12 inhibitor on discharge PAGEREF _Toc56604591 \h 17IND2020-106: Dual antiplatelet therapy on discharge PAGEREF _Toc56604592 \h 20IND2020-107: High-intensity statins on discharge PAGEREF _Toc56604593 \h 23References PAGEREF _Toc56604594 \h 26Introduction This consultation paper includes proposals for CCG level acute myocardial infarction indicators. CCG level indicators measure outcomes at CCG level and aim to set priorities for quality improvement. These indicators aim to standardise and improve quality of care for people with acute myocardial infarction (AMI), both ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI)The NICE indicator process guide was updated in December 2019 and includes the option for the indicator programme to assess the validity of externally developed indicators for inclusion on the NICE menu. These AMI indicators are based on hospital level indicators originally developed by the ESC Acute Cardiovascular Care Association (ACCA) with a view to developing programmes to improve the management of AMI across Europe (Schiele et al, 2016). Work to understand the feasibility of their use in UK practice (Bebb et al, 2017) found that data for the indicators presented in this paper may be derived from the Myocardial Ischaemia National Audit Project (MINAP). Stakeholders are asked to consider the following questions when commenting on the proposed indicators:1.Do you think there are any barriers to implementing the care described by these indicators?2.Do you think there are potential unintended consequences to implementing/ using any of these indicators?3.Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.4.If you think any of these indicators may have an adverse impact in different groups in the community, can you suggest how the indicator might be delivered differently to different groups to reduce health inequalities?IND2020-101: Reperfusion within 12h of symptom onsetThe proportion of patients with STEMI who were reperfused among those eligible (onset of symptoms to diagnosis <12 h)Importance Considerations AssessmentThe NHS Long Term Plan identifies cardiovascular disease as a clinical priority, and the single biggest condition where lives can be saved by the NHS over the next 10 years. The indicator reflects a specific priority area identified by NHS England.Bebb et al (2017) analysis of MINAP data found that nationally 89.3% of patients with STEMI receive reperfusion less than 12 hours from onset of symptoms. Hospital variation showed a median achievement of 76.7% with an interquartile range of (33.3% - 91.4%). Analysis also showed an inverse association with 30-day mortality (OR 0.36 [0.32-0.41] p<=0.001). The MINAP summary report 2019 reports that 23.5% of STEMI patients did not receive reperfusion therapy and no reason for this was given for around 16% of these. The indicator relates to an area where there is known variation in practice.The indicator addresses under-treatment.In patients with STEMI admitted during the first few hours after symptom onset, the choice of reperfusion strategy and the speed with which it is implemented have an impact on preserving myocardial function and improving long-term survival (Schiele et al, 2016). ESC considers this quality indicator an essential element for assessment.The indicator will lead to a meaningful improvement in patient outcomes.Evidence base Considerations AssessmentESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (2017) European Society of Cardiology. Reperfusion is indicated in all patients with symptoms of ischaemia of less than or equal to 12 hours duration and persistent ST-segment elevation. (Class I Level A).Acute coronary syndromes. NICE guideline NG185 (2020), recommendation 1.1.3. Deliver coronary reperfusion therapy (either primary PCI or fibrinolysis) as quickly as possible for eligible people with acute STEMI. The indicator is derived from a high-quality evidence base. The indicator aligns with the evidence base.Specification Considerations AssessmentNumerator: The number of patients in the denominator who received reperfusion therapy.Denominator: The number of patients with STEMI eligible for reperfusion (<12 hours from onset of symptoms to diagnosis)Exclusions: Patients with contraindication to reperfusion treatment.The indicator has defined components necessary to construct the indicator, including numerator, denominator and exclusions. The construction proposed by the ESC ACCA has been adapted for publication on the NICE menu of indicators.Audit data is presented at hospital trust level. This is proposed to be a CCG level NICE menu indicator. NICE CCG level indicators are intended for use where there is an average of 50 patients or more per CCG. Data presented as part of the study by Bebb et al (2017) based on the MINAP database for the period 2012 to 2013 shows 33,151 eligible patients and this indicates an average number of 245 patients per CCG (135 CCGs April 2020).The indicator does outline minimum numbers of patients needed to be confident in the assessment of variation. Feasibility Considerations AssessmentData is collected annually as part of the Myocardial Ischaemia National Audit Project (MINAP). The indicator is repeatable.Details of the MINAP dataset, including definitions of the variables and guidance on applying options are also published by National Institute for Cardiovascular Outcomes Research (NICOR). Data fields collected include: Date and time of onset of symptoms Date and time of reperfusion treatment Initial reperfusion treatment Reason reperfusion not given.ECG determining treatmentDate and time of admission.The indicator is measuring what it is designed to measure. The indicator can use some of the existing data fields although date and time of diagnosis is not recorded in MINAP. Date and time of admission could be used as proxy for date and time of diagnosis. Acceptability Considerations AssessmentPatients presenting late to healthcare services would affect the effectiveness of reperfusion and so patients diagnosed greater than 12h after the onset of symptoms are excluded from the denominator. There are other contraindications to reperfusion therapy, and these should be detailed in the exclusions. The MINAP summary report 2019 detailed several reasons for no reperfusion including ineligible from ECG, risk of haemorrhage and uncontrolled hypertension. The indicator assesses performance that is attributable to or within the control of the audience.Data tables are published on the NICOR website to compare practice and assist in quality improvement cycles.This indicator was presented to the committee in December 2019 and the committee agreed it should progress to consultation.The results of the indicator can be used to improve practiceRiskConsiderations AssessmentMINAP was established in 1999 and is a domain with the National Cardiac Audit Programme and under the governance of the Healthcare Quality Improvement Partnership (HQIP). Robust governance structures are in place to ensure data quality and monitor appropriateness of audit measures. There is a minimum dataset against which each participating hospital is assessed for data completeness.There are reasons why a patient may not be eligible for reperfusion if they present within 12 hours of onset of symptoms. These exclusions from the denominator could impact the effectiveness of this indicator. The indicator has an acceptable risk of unintended consequences.Questions for consultationDate and time of diagnosis is not recorded in the MINAP dataset. Should admission date and time be used as a proxy measure for diagnosis?What contraindication to the use of primary percutaneous coronary intervention (primary PCI) or fibrinolysis as the reperfusion strategy in patients with STEMI presenting within 12 hours of onset of symptoms are used in clinical practice and should be used to exclude people from this indicator? IND2020-102: Timely reperfusionThe proportion of patients with STEMI who had arterial access for primary PCI in 60 minutes or less from time of presentation at a centre with catheterisation facilities. Importance Considerations AssessmentThe NHS Long Term Plan identifies cardiovascular disease as a clinical priority, and the single biggest condition where lives can be saved by the NHS over the next 10 years. In patients with STEMI admitted during the first few hours after symptom onset, the choice of reperfusion strategy and the speed with which it is implemented have an impact on preserving myocardial function and improving long-term survival (Schiele et al, 2016).ESC considers this quality indicator (QI) an essential element for assessment.The indicator reflects a specific priority area identified by NHS England.Bebb et al (2017) analysis of MINAP data found that 75% of patients with STEMI receive primary PCI within 60 minutes; hospital variation showed a median achievement of 69.9% (IQR 54.6 – 80.8%).Primary PCI within 60 minutes has an inverse relationship with 30-day mortality OR 0.52 (0.46, 0.59) p<0.001. The indicator relates to an area where there is known variation in practice.The indicator addresses timely treatment. In patients with STEMI admitted during the first few hours after symptom onset, the choice of reperfusion strategy and the speed with which it is implemented have an impact on preserving myocardial function and improving long-term survival (Schiele et al, 2016).The indicator will lead to a meaningful improvement in patient outcomes.Evidence base Considerations AssessmentESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (2017) European Society of Cardiology. This guideline summarises important time targets in acute STEMI. This recommends a target of 60 minutes or less for patients admitted to an interventional centre. Acute coronary syndromes. NICE guideline NG185 (2020), recommendations 1.1.3 and 1.1.6.1.1.3 Deliver coronary reperfusion therapy (either primary PCI or fibrinolysis) as quickly as possible for eligible people with acute STEMI.1.1.6 Offer coronary angiography, with follow-on primary PCI if indicated, as the preferred reperfusion strategy for people with acute STEMI if:Presentation is within 12 hours of onset of symptoms andPrimary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.The indicator is derived from a high-quality evidence base. The indicator aligns with the evidence base although NICE guidance does not specify a measurable timepoint for reperfusion. Recommendation 1.1.6 does specify that primary PCI be the method of choice if it can be given within 120 minutes of the time that fibrinolysis could have been given. Specification Considerations AssessmentNumerator: The number of patients in the denominator who had arterial access for primary PCI in 60 minutes or less from time of presentation.Denominator: The number of patients with STEMI treated with reperfusion by primary PCI.Exclusions: Patients diagnosed with STEMI >12 hours from onset of symptoms. Patients with contraindication to primary PCI. Patients not directly admitted to a centre with catheterisation laboratory facilities.The indicator has defined components necessary to construct the indicator, including numerator, denominator and exclusions.The specification has been updated to reflect the time targets in the ESC guidelines (60 minutes or less).The construction proposed by the ESC ACCA has been adapted for publication on the NICE menu of indicators.Audit data is presented at hospital trust level. This is proposed to be a CCG level NICE menu indicator. NICE CCG level indicators are intended for use where there is an average of 50 patients or more per CCG. Data presented as part of the study by Bebb et al (2017) based on the MINAP database for the period 2012 to 2013 shows 26,358 eligible patients and this indicates an average number of 195 patients per CCG (135 CCGs April 2020).The indicator does outline minimum numbers of patients needed to be confident in the assessment of variation.Feasibility Considerations AssessmentData is collected annually as part of the Myocardial Ischaemia National Audit Project. The indicator is repeatable.Details of the MINAP dataset, including definitions of the variables and guidance on applying options are also published by NICOR. Data fields collected include: Date and time of arrival at hospitalAdmission methodECG determining treatmentInitial reperfusion treatment Date and time of reperfusion treatment/ balloon inflation. Reason reperfusion not given The indicator is measuring what it is designed to measure. The indicator could use existing data fields. Time of arterial access is not recorded. Date and time of reperfusion treatment/ balloon inflation could be used as a proxy measure for this. Acceptability Considerations AssessmentPatients presenting late to healthcare services would affect the effectiveness of reperfusion and so patients diagnosed greater than 12h after the onset of symptoms are excluded for the denominator. This is an assessment of hospital response only as it measures the time from admission to intervention.The indicator assesses performance that is attributable to or within the control of the audience. Data tables are published on the NICOR website to compare practice and assist in quality improvement cycles.The results of the indicator can be used to improve practiceRiskConsiderations AssessmentMINAP was established in 1999 and is a domain with the National Cardiac Audit Programme and under the governance of HQIP. Robust governance structures are in place to ensure data quality and monitor appropriateness of audit measures. There is a minimum dataset against which each participating hospital is assessed for data completeness.The indicator has an acceptable risk of unintended consequences.Question for consultationTime of arterial access is not recorded in in the MINAP database. Should time of reperfusion treatment/ balloon inflation be used as proxy measure for this?IND2020-103: Time between first medical contact and arterial access The time between the first medical contact and arterial access (absolute value) for patients with STEMI undergoing primary PCIImportance Considerations AssessmentThe NHS Long Term Plan identifies cardiovascular disease as a clinical priority, and the single biggest condition where lives can be saved by the NHS over the next 10 years. ESC considers this a high impact quality indicator (QI).The indicator reflects a specific priority area identified by NHS England.Bebb et al (2017) analysis of MINAP data found that median time from diagnosis to wire passage is 185 minutes (interquartile range (IQR) 135 – 284 minutes). Hospital variation showed a median of 187.8 minutes (IQR 169.8 – 210 minutes).The indicator relates to an area where there is known variation in practice.The indicator addresses under-treatment.In patients with STEMI admitted during the first few hours after symptom onset, the choice of reperfusion strategy and the speed with which it is implemented have an impact on preserving myocardial function and improving long-term survival (Schiele et al, 2016).The indicator will lead to a meaningful improvement in patient outcomes.Evidence base Considerations AssessmentESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (2017) European Society of Cardiology. Acute coronary syndromes. NICE guideline NG185 (2020), recommendation 1.1.3.The indicator is derived from a high-quality evidence base. The indicator aligns with the evidence base. Guidance recommends use of primary PCI in STEMI.Specification Considerations AssessmentReported as median time between first medical contact (FMC) and arterial access among patients with STEMI undergoing reperfusion with primary PCI.The indicator has defined components necessary to construct the indicator. Exclusions need to be specified.Audit data is presented at hospital trust level. This is proposed to be a CCG level NICE menu indicator. NICE CCG level indicators are intended for use where there is an average of 50 patients or more per CCG. Data presented as part of the study by Bebb et al (2017) based on the MINAP database for the period 2012 to 2013 shows 27,029 eligible patients and this indicates an average number of 200 patients per CCG (135 CCGs April 2020).The indicator does outline minimum numbers of patients needed to be confident in the assessment of variation.Feasibility Considerations AssessmentData is collected annually as part of the Myocardial Ischaemia National Audit Project. The indicator is repeatable.Details of the MINAP dataset, including definitions of the variables and guidance on applying options are also published by NICOR. Data fields collected include: Date and time of arrival in hospitalECG determining treatmentDate and time of reperfusion treatment/ date and time of balloon inflationProcedure performedDate and time of arrival at non-interventional centre (for transferred patients)The indicator is measuring what it is designed to measure. The indicator uses existing data fields although first medical contact and date and time of arterial access is not recorded. Date and time of arrival at hospital (admission time) could be used instead of first medical contact. Date and time of reperfusion treatment or balloon inflation could be used as proxy for arterial access. MINAP audit report states that door-to-balloon time measures the hospital response. This time includes confirmation of diagnosis, assessment of suitability for PCI and the time to prepare and begin to perform the PCI. Acceptability Considerations AssessmentPatients with contraindications to the interventional procedure are excluded from the denominator as it would be a risk to perform invasive treatment on some patients.Data tables are published on the NICOR website to compare practice and assist in quality improvement cycles.ESC considers this a secondary quality indicator (QI) that could be used to perform more advanced assessments, and/or may only be suitable for use in certain centres. Transferred patients are not excluded from this indicator.The indicator assesses performance that is attributable to or within the control of the audience when a patient is admitted to an interventional centre.This indicator may be out of control of the centre performing the intervention for transferred patients.Data tables are published on the NICOR website to compare practice and assist in quality improvement cycles.This indicator was presented for discussion at the committee meeting in December 2019. The committee agreed it should progress to consultation.The results of the indicator can be used to improve practiceRiskConsiderations AssessmentPatients who are treated after transfer from a non-interventional centre are likely to have longer times to wire passage. This is likely to skew the data. This QI is important in clinical terms so has been included within the QI set.MINAP was established in 1999 and is a domain with the National Cardiac Audit Programme and under the governance of HQIP. Robust governance structures are in place to ensure data quality and monitor appropriateness of audit measures. There is a minimum dataset against which each participating hospital is assessed for data completeness.The indicator has an acceptable risk of unintended consequences.Questions for consultationFirst medical contact is defined by the ESC guideline as the time point when the patients with acute myocardial infarction is initially assessed by a trained emergency medical service personnel who can obtain and interpret the ECG and deliver initial interventions. For the UK, is it more appropriate for this indicator to measure from arrival at hospital than the prehospital setting?We propose the use of time of reperfusion treatment/balloon inflation as a proxy measurement for arterial access. Is this an acceptable measurement?IND2020-104: Left ventricular function recorded in notesThe proportion of patients admitted with acute myocardial infarction with assessment of left ventricular ejection fraction before discharge.Importance Considerations AssessmentThe NHS Long Term Plan identifies cardiovascular disease as a clinical priority, and the single biggest condition where lives can be saved by the NHS over the next 10 years. ESC considers this quality indicator (QI) an essential element for assessment. The indicator reflects a specific priority area identified by NHS England.Bebb et al (2017) analysis of MINAP data found that nationally 54.5% of AMI patients have left ventricular (LV) function recorded in their notes. Hospital variation showed a median achievement of 54.7% (interquartile range [IQR] 32.7 – 73.2%).Analysis of MINAP data shows that recording LV function in patient notes is inversely associated with 30-day mortality: odds ratio (95% CI) 0.56 (0.53, 0.58) p<0.001The indicator relates to an area where there is known variation in practice.The indicator addresses under-treatment.Clinical outcomes following AMI are highly variable due to differing baseline clinical risk levels. Risk assessment is a key step in management of AMI patients, including the assessment of left ventricular function to identify those who would benefit from additional treatments. Left ventricular systolic dysfunction is a predictor of heart failure and ventricular arrhythmia and those identified with reduced left ventricular ejection fraction (LVEF) require specific medical treatment, tailored clinical investigations and review (Schiele et al, 2016).The indicator will lead to a meaningful improvement in patient outcomes.Evidence base Considerations AssessmentESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (2017) European Society of Cardiology (class I C). ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (2015) European Society of Cardiology (class I C).Acute coronary syndromes. NICE guideline NG185 (2020), recommendations 1.1.27 and 1.2.26.The indicator is derived from a high-quality evidence base. The indicator aligns with the evidence base.Specification Considerations AssessmentNumerator: The number of patients in the denominator with a numerical value of LVEF recorded before discharge.Denominator: The number of patients discharged from hospital following an admission with acute myocardial infarction.Exclusions: Patients who died in hospital.The indicator has defined components necessary to construct the indicator, including numerator, denominator and exclusions. The indicator wording specifies that a numerical value should be recorded. The construction proposed by the ESC ACCA has been adapted for publication on the NICE menu of indicators.Audit data is presented at hospital trust level. This is proposed to be a CCG level NICE menu indicator. NICE CCG level indicators are intended for use where there is an average of 50 patients or more per CCG. Data presented as part of the study by Bebb et al (2017) based on the MINAP database for the period 2012 to 2013 shows 104,004 eligible patients and this indicates an average number of 770 patients per CCG (135 CCGs April 2020).The indicator does outline minimum numbers of patients needed to be confident in the assessment of variation.Feasibility Considerations AssessmentData is collected annually as part of the Myocardial Ischaemia National Audit Project. The indicator is repeatable.Details of the MINAP dataset, including definitions of the variables and guidance on applying options are also published by NICOR. Data fields collected include: Measurement of left ventricular ejection fraction and category Left ventricular ejection fraction not assessedThe indicator is measuring what it is designed to measure. The indicator uses existing data fields although record of LVEF is not included in the minimum data standard. MINAP records LVEF as good, moderate or poor dependent on measurement.Acceptability Considerations AssessmentMINAP records category of LVEF only although this is based on a numerical value (good: 50% or greater, moderate: 30 % to 49%, poor: less than 30%). The indicator assesses performance that is attributable to or within the control of the audienceData tables are published on the NICOR website to compare practice and assist in quality improvement cycles. This indicator was presented to the committee in December 2019 and committee agreed it should progress to consultation.The results of the indicator can be used to improve practiceRiskConsiderations AssessmentMINAP was established in 1999 and is a domain with the National Cardiac Audit Programme and under the governance of HQIP. Robust governance structures are in place to ensure data quality and monitor appropriateness of audit measures. There is a minimum dataset against which each participating hospital is assessed for data completeness.The indicator has an acceptable risk of unintended consequences.IND2020-105: P2Y12 inhibitor on dischargeThe proportion of patients with acute myocardial infarction prescribed a P2Y12 inhibitor at discharge. Importance Considerations AssessmentThe NHS Long Term Plan identifies cardiovascular disease as a clinical priority, and the single biggest condition where lives can be saved by the NHS over the next 10 years. ESC considers this quality indicator (QI) an essential element for assessment. The indicator reflects a specific priority area identified by NHS England.Bebb et al (2017) analysis of MINAP data found that nationally 87.1% of AMI patients have adequate P2Y12 inhibition on discharge. Hospital variation showed a median achievement of 89.3%% (interquartile range [IQR] 83.8 – 93.5%).Analysis of MINAP data shows that adequate P2Y12 inhibition on discharge is inversely associated with 30-day mortality: odds ratio (95% CI) 0.42 (0.38, 0.47) p<0.001The indicator relates to an area where there is known variation in practice.The indicator addresses under-treatment.Anti-thrombotic treatment is important in the management of AMI. The combination of anti-platelet drugs such as platelet receptor inhibitors (P2Y12) and anti-coagulant therapy in treatment in AMI reduces mortality, reinfarction and stroke. Platelet receptor inhibitors in conjunction with aspirin reduce mortality from STEMI (Schiele et al, 2016).The indicator will lead to a meaningful improvement in patient outcomes.Evidence base Considerations AssessmentESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (2017) European Society of Cardiology recommends DAPT in the form of aspirin plus ticagrelor or prasugrel (or clopidogrel if ticagrelor or prasugrel are not available or are contraindicated), is recommended for 12 months after PCI, unless there are contraindications such as an excessive risk of bleeding (class I level A). DAPT for 12 months in patients who did not undergo PCI should be considered unless there are contraindications such as excessive risk of bleeding (class IIa level C)ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (2020) European Society of Cardiology A P2Y12 receptor inhibitor is recommended in addition to aspirin, and maintained over 12 months unless there are any contraindications or an excessive risk of bleeding (class I level A).Acute coronary syndromes. NICE guideline NG185 (2020), recommendations 1.4.1, 1.4.13, 1.1.11, 1.1.24, 1.1.25, 1.2.17, 1.2.20 and 1.2.21The indicator is derived from a high-quality evidence base. The indicator aligns with the evidence base.Specification Considerations AssessmentNumerator: The number of patients in the denominator prescribed a P2Y12 inhibitor at discharge.Denominator: The number of patients discharged from hospital following an admission with acute myocardial infarction.Inclusions: Patients prescribed ticagrelor, prasugrel or clopidogrel.Exclusions: Patients on long term anticoagulants. Patients with contraindication to P2Y12 inhibitor use. Patients who died in hospital.The indicator has defined components necessary to construct the indicator, including numerator, denominator and exclusions.The construction proposed by the ESC ACCA has been adapted for publication on the NICE menu of indicators.Audit data is presented at hospital trust level. This is proposed to be a CCG level NICE menu indicator. NICE CCG level indicators are intended for use where there is an average of 50 patients or more per CCG. Data presented as part of the study by Bebb et al (2017) based on the MINAP database for the period 2012 to 2013 shows 106,157 eligible patients and this indicates an average number of 786 patients per CCG (135 CCGs April 2020).The indicator does not outline minimum numbers of patients needed to be confident in the assessment of variation.Feasibility Considerations AssessmentData is collected annually as part of the Myocardial Ischaemia National Audit Project. The indicator is repeatable.Details of the MINAP dataset, including definitions of the variables and guidance on applying options are also published by NICOR. Data fields collected include: Discharge on thienopyridine platelet inhibitor treatmentDischarged on Ticagrelor** data field not included in MINAP minimum data standard. Recorded separately as not strictly classed as thienopyridine platelet inhibitor.The indicator is measuring what it is designed to measure. The indicator uses existing data fields. Contraindication to medication is also recorded.Acceptability Considerations AssessmentExclusions are defined and acceptable. There is an additional proposed indicator for dual antiplatelet therapy on discharge.There is a NICE indicator (GP indicator suitable for QOF) NM79: The percentage of patients who had a myocardial infarction in the preceding 1 April to 31 March and who are currently being treated with ACE-I (or ARB of ACE-I intolerant), dual anti-platelet therapy, beta-blocker and a statin.The indicator assesses performance that is attributable to or within the control of the audience. Note the overlap with additional indicator on DAPT on discharge. Data tables are published on the NICOR website to compare practice and assist in quality improvement cycles. This indicator was presented to the committee in December 2019 and committee agreed it should progress to consultation.The results of the indicator can be used to improve practiceRiskConsiderations AssessmentMINAP was established in 1999 and is a domain with the National Cardiac Audit Programme and under the governance of HQIP. Robust governance structures are in place to ensure data quality and monitor appropriateness of audit measures. There is a minimum dataset against which each participating hospital is assessed for data completeness.The indicator has an acceptable risk of unintended consequences.Questions for consultationIs this indicator feasible considering the number of medications and contraindication to these included in the indicator specification?IND2020-106: Dual antiplatelet therapy on dischargeThe proportion of patients with acute myocardial infarction discharged on dual antiplatelet therapy. Importance Considerations AssessmentThe NHS Long Term Plan identifies cardiovascular disease as a clinical priority, and the single biggest condition where lives can be saved by the NHS over the next 10 years. The indicator reflects a specific priority area identified by NHS England.Bebb et al (2017) analysis of MINAP data found that nationally 88.1% of AMI patients received dual antiplatelet therapy (DAPT) on discharge. Hospital variation showed a median achievement of 90.5% (interquartile range [IQR] 85.4 – 94.1%). Analysis of MINAP data shows that DAPT prescription on discharge is inversely associated with 30-day mortality: odds ratio (95% CI) 0.50 (0.44, 0.56) p<0.001.The indicator relates to an area where there is known variation in practice.The indicator addresses under-treatment.The prescription of DAPT at discharge for 12 months is linked to positive outcomes for people with AMI including reduction in composite ischaemic outcomes and mortality from STEMI (Schiele et al, 2016). The indicator will lead to a meaningful improvement in patient outcomes.Evidence base Considerations AssessmentESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (2017) European Society of Cardiology (class I A). ESC Guidelines for the management of acute coronary syndromes in patients without persistent ST-segment elevation (2020) European Society of Cardiology (Class I A).Acute coronary syndromes. NICE guideline NG185 (2020), recommendation 1.4.1.The indicator is derived from a high-quality evidence base (ESC class I level A). The indicator aligns with the evidence base.Specification Considerations AssessmentNumerator: The number of patients in the denominator discharged on dual antiplatelet therapy.Denominator: The number of patients discharged from hospital following an admission with acute myocardial infarction. Exclusions: Patients treated with chronic anticoagulants are excluded. Patients with contraindication to P2Y12 inhibitors or aspirin. Patients who died in hospital.The indicator has defined components necessary to construct the indicator, including numerator, denominator and exclusions.The construction proposed by the ESC ACCA has been adapted for publication on the NICE menu of indicators.Audit data is presented at hospital trust level. This is proposed to be a CCG level NICE menu indicator. NICE CCG level indicators are intended for use where there is an average of 50 patients or more per CCG. Data presented as part of the study by Bebb et al (2017) based on the MINAP database for the period 2012 to 2013 shows 101,582 eligible patients and this indicates an average number of 752 patients per CCG (135 CCGs April 2020).The indicator does not outline minimum numbers of patients needed to be confident in the assessment of variation.Feasibility Considerations AssessmentData is collected annually as part of the Myocardial Ischaemia National Audit Project. The indicator is repeatable.The indicator can be constructed using data fields collected in the Myocardial Ischaemia National Audit Project including: Discharged on aspirinDischarged on thienopyridine inhibitorDischarged on Ticagrelor*.Details of the MINAP dataset, including definitions of the variables and guidance on applying options are also published by NICOR.*Not part of the MINAP minimum data standard.The indicator is measuring what it is designed to measure. The indicator uses existing data fields. Contraindication is also recorded.Acceptability Considerations AssessmentNote the overlap with additional indicator for P2Y12 inhibitor on discharge.There is an existing NICE menu indicator (NM79). This is a GP indicator suitable for QOF: The percentage of patients who had a myocardial infarction in the preceding 1 April to 31 March and who are currently being treated with ACE-I (or ARB if ACE-I intolerant), dual antiplatelet therapy, beta-blocker and a statin. The indicator assesses performance that is attributable to or within the control of the audienceData tables are published on the NICOR website to compare practice and assist in quality improvement cycles. This indicator was presented to the committee in December 2019 and committee agreed it should progress to consultation.ESC considers this a secondary quality indicator (QI) that could be used to perform more advanced assessments, and/or may only be suitable for use in certain centres.The results of the indicator can be used to improve practiceRiskConsiderations AssessmentMINAP was established in 1999 and is a domain with the National Cardiac Audit Programme and under the governance of HQIP. Robust governance structures are in place to ensure data quality and monitor appropriateness of audit measures. There is a minimum dataset against which each participating hospital is assessed for data completeness.The indicator has an acceptable risk of unintended consequences.IND2020-107: High-intensity statins on dischargeThe proportion of patients with acute myocardial infarction discharged on high-intensity statin therapy. Importance Considerations AssessmentThe NHS Long Term Plan identifies cardiovascular disease as a clinical priority, and the single biggest condition where lives can be saved by the NHS over the next 10 years. ESC considers this quality indicator (QI) an essential element for assessmentThe indicator reflects a specific priority area identified by NHS England.The MINAP summary report 2019 shows that 97.7% of participants were discharged on a statin. Variation in practice for individual medications is not reported. This report does not specify if this is high-intensity statin.Variation in practice cannot be assessed.The indicator addresses under-treatment.Patients remain at high risk of further CV events following AMI. Evidence supports the use of high-intensity statins to reduce LDL cholesterol levels (Schiele et al, 2016)The indicator will lead to a meaningful improvement in patient outcomes.Evidence base Considerations AssessmentESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (2017) European Society of Cardiology. It is recommended to start high-intensity statin therapy as early as possible, unless contraindicated, and maintain it long-term (class I level A). ESC Guideline for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (2020) European Society of Cardiology. Statins are recommended in all NSTE-ACS patients. The aim is to reduce LDL-C by ≥50% from baseline and/or to achieve LDL-C <1.4mmol/L (<55mg/dL). (class I A).Acute coronary syndromes. NICE guideline NG185 (2020), recommendation 1.4.1.Cardiovascular disease: risk assessment and reduction, including lipid modification. NICE guideline CG181 (2016), recommendations 1.3.2 and 1.3.20. Recommendation 1.3.2 states when a decision is made to prescribe a statin use a statin of high intensity and low acquisition cost. This guideline defines high-intensity statin based on the percentage reduction in LDL cholesterol they can produce (atorvastatin 20 – 80 mg, rosuvastatin 10 – 40 mg, simvastatin 80 mg). Recommendation 1.3.20 recommends statin treatment in people with CVD with atorvastatin 80 mg. The indicator is derived from a high-quality evidence base. The NICE guideline and the proposed indicator have different definitions of a high-intensity statin. The indicator wording and the specification could be amended to remove reference to the dose of a statin and to allow alignment with the ESC and NICE guidelines.Specification Considerations AssessmentNumerator: The number of patients in the denominator discharged on high intensity statin therapy.The ESC defines high intensity statin as atorvastatin ≥40 mg or rosuvastatin ≥20 mg.Denominator: The number of patients discharged from hospital following an admission with acute myocardial infarction.Exclusions: Patients who died in hospital. Patients with contraindication to high-intensity statin therapy. The indicator has defined components necessary to construct the indicator, including numerator, denominator and exclusions.The construction proposed by the ESC ACCA has been adapted for publication on the NICE menu of indicators.Audit data is presented at hospital trust level. This is proposed to be a CCG level NICE menu indicator. NICE CCG level indicators are intended for use where there is an average of 50 patients or more per CCG. Data presented as part of the MINAP summary report 2019 shows 92,233 confirmed cases of heart attack in the period 2017 to 2018 and this indicates an average number of 683 patients per CCG (135 CCGs April 2020).The indicator does outline minimum numbers of patients needed to be confident in the assessment of variation.Feasibility Considerations AssessmentData on high-intensity statin is not collected annually as part of the Myocardial Ischaemia National Audit Project. The indicator is not repeatable using MINAP data.Details of the MINAP dataset, including definitions of the variables and guidance on applying options are also published by NICOR. Data fields collected include: Statin on dischargeAlso includes declined treatment and contraindication.The indicator is measuring what it is designed to measure. The indicator does not use existing data fields. The data field in MINAP does not specify high-intensity statin therapy or named drugs. It does record contraindication to statin.Acceptability Considerations AssessmentHigh-intensity statin therapy only should be included in the numerator. This is not captured by MINAP and so this indicator could involve additional burden of data collection. The indicator assesses performance that is attributable to or within the control of the audienceData tables are published on the NICOR website to compare practice and assist in quality improvement cycles.The results of the indicator can be used to improve practiceRiskConsiderations AssessmentMINAP was established in 1999 and is a domain with the National Cardiac Audit Programme and under the governance of HQIP. Robust governance structures are in place to ensure data quality and monitor appropriateness of audit measures. There is a minimum dataset against which each participating hospital is assessed for data completeness.The indicator has an acceptable risk of unintended consequences.Questions for consultationPrescription of high-intensity statins or named formulations/doses are not collected by the MINAP dataset. Should the data field of ‘statin on discharge’ be used as a proxy for high-intensity statin?NICE guidance recommends that a statin of high intensity and low acquisition cost be used when a decision has been made to prescribe a statin. There is misalignment between the definition of a high-intensity statin in the indicator specification based on the ESC guidance and that in NICE guidance. Would rewording of the indicator to measure prescription of a statin on discharge, not restricted to high intensity, alter the intent of the indicator?97.7% of participants in the MINAP audit received a statin on discharge in the summary report from 2019. Do you think this is an area for quality improvement in England?ReferencesBebb O, Hall M, Fox KAA et al (2017) Performance of hospitals according to the ESC ACCA quality indicators and 30-day mortality for acute myocardial infarction: national cohort study using the United Kingdom Myocardial Ischaemia National Audit Project (MINAP) register. European Heart Journal 38: 974-982Schiele F, Gale CP, Bonnefoy E et al. (2016) Quality indicators for acute myocardial infarction: A position paper of the Acute Cardiovascular Care Association. European Heart Journal: Acute Cardiovascular Care 6(1): 34-59 ................
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