Appendix D. Detail on criteria for audit of the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes

Appendix D. Detail on criteria for audit of the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes

Possible objectives for the audit

An audit on the appropriateness of the use of GP IIb/IIIa inhibitors could be carried out to ensure the following.

  • Small-molecule GP IIb/IIIa inhibitors are provided as part of initial medical management for patients with unstable angina or with NSTEMI who are at high risk of subsequent MI or death.

  • A GP IIb/IIIa inhibitor (abciximab) is provided as an adjunct for patients at high risk for whom PCI is recommended but delayed beyond the initial medical management phase.

  • A GP IIb/IIIa inhibitor (abciximab) is considered as an adjunct to PCI for all patients with diabetes who are undergoing elective PCI or for those patients undergoing complex procedures.

  • A GP IIb/IIIa inhibitor (abciximab) is not provided for patients who are undergoing procedurally uncomplicated, elective PCI.

Possible patients to be included in the audit

An audit on the first objective above could be carried out on all patients presenting with unstable angina or NSTEMI over a suitable time period given the total number of patients with these conditions treated in 6 months or 1 year. If clinical coding is reliable, the patients can be identified through clinical or procedure codes. If clinical coding for these conditions is not entirely reliable, it may be necessary to retrieve cases of patients who are coded as unstable angina and those coded as myocardial infarction and screen these cases to find patients with NSTEMI.

An audit on the other objectives could be carried out using all patients booked and on the waiting list for PCI over a suitable time period given the total number of PCIs carried out in 6 months or 1 year.

Measures that can be used as a basis for the audit

Criterion

Standard

Exception

Definition of Terms

1. A patient in any one of the following groups receives a GP IIb/IIIa inhibitor:

a. The patient has unstable angina and is at high risk

b. The patient has NSTEMI and is at high risk.

100% of patients with unstable angina or NSTEMI who are at high risk.

None

Clinicians will have to agree locally how the initial medical management phase is identified for audit purposes.

High risk = of subsequent MI or death as determined by clinician judgement based on risk factors such as: clinical history (including age, previous MI, previous PCI or CABG); clinical signs including continuing pain despite initial treatment; and clinical investigations such as ECG changes, particularly dynamic or unstable patterns indicating myocardial ischaemia, haemodynamic changes and raised cardiac troponin level, if available at the appropriate time.

Clinicians will have to agree locally on how high risk is documented for audit purposes.

In this approach, the audit involves finding the patients in the audit group who are at high risk and determining if all those patients had a GP IIb/IIIa inhibitor.

Another way to audit appropriateness of the use of GP IIb/IIIa inhibitors in initial medical management is first to find patients in the audit group who have had small-molecule GP IIb/IIIa inhibitors in the initial medical management phase, then to screen those cases to see if the patient was at high risk.

The measures that could be used in an audit of appropriateness of the use of a GP IIb/IIIa inhibitor (abciximab) as an adjunct to PCI are as set out below:

Criterion

Standard

Exception

Definition of Terms

1. A GP IIb/IIIa inhibitor (abciximab) is provided for the patient who is at high risk and is recommended for PCI but the PCI is delayed beyond the initial medical management phase.

100% of patients who are at high risk and are scheduled for a PCI but the PCI is delayed beyond the initial medical management phase.

None

See above for a definition of high risk.

2. A GP IIb/IIIa inhibitor (abciximab) is considered for the patient who has diabetes and is undergoing an elective PCI.

100% of patients who have diabetes and are undergoing an elective PCI.

None

Clinicians will have to agree locally on what constitutes evidence that the treatment was considered for audit purposes.

3. A GP IIb/IIIa inhibitor (abciximab) is considered for the patient who is undergoing a complex procedure.

100% of patients who are undergoing a complex procedure.

None

Examples of complex procedures = multi-vessel PCI, insertion of multiple stents, vein graft PCI, PCI for bifurcation lesions.

Clinicians will have to agree locally on what constitutes evidence that the treatment was considered for audit purposes.

4. A GP IIb/IIIa inhibitor (abciximab) is not provided for a patient who is undergoing a procedurally uncomplicated, routine elective PCI.

100% of patients who are undergoing an uncomplicated routine elective PCI.

A. An unexpected immediate complication occurs.

Another way to audit the appropriateness of the use of a GP IIb/IIIa inhibitor (abciximab) as an adjunct to PCI is to screen all patients scheduled for or who have undergone PCI to find out whether, if a GP IIb/IIIa inhibitor (abciximab) was administered, the patient met the criteria listed in measures 1-3 above.

Calculation of compliance with the measure

Compliance with each measure described in the table is calculated as follows:

Number of patients whose care is consistent with the criterion plus the number of patients who meet any exception

/

Number of patients to whom the measure applies

X 100

Clinicians should review the findings of measurement, identify if practice can be improved, agree on a plan to achieve any desired improvement and repeat the measurement of actual practice to confirm that the desired improvement is being achieved.