I. REASON FOR IMPLEMENTING THE PROJECT
Coronary artery disease (CAD) is the leading cause of mortality, affecting approximately 1.72% of the global population, resulting in 9 million deaths per year (1). [NTT(V1] Asia bore the brunt of coronary artery disease in 2019, with a shocking 58% of the world's 18.6 million deaths concentrated in the region. (2[NTT(V2] ). In addition, health expenditure for coronary artery disease is fast rising, for example, the costs incurred increased by 50% over the last 5 years.
There exist several challenges in managing patients with coronary artery disease in Vietnam:
Insufficient data on monitoring compliance with guideline-directed medical therapy prior to invasive procedure.
Insufficient data on treatment outcomes for PCI patients
Pre and in-hospital delay that lengthen the door-to-reperfusion time and in-hospital length of stay.
For conquering these difficulties, Vinmec Times City (VMTC) International Hospital and Vinmec Central Park (VMCP) International Hospital has taken the lead in establishing a coronary artery management program (Cardiac Cath Lab), which follows the Integrated Practice Unit (IPU) model in accordance with the quality standards of the American College of Cardiology (ACC). The aim of the program is to improve the overall quality of CAD treatment and to enhance the quality of life for post-PCI patients.
II. TARGET
To evaluate the effectiveness of the CAD program, the CAD IPU team focused on the following indicators as below:
- Reducing the median length of hospital stay to below 3 days (ACC’s target threshold);
- Ensuring Door to balloon time (PIC for STEMI patients) less than 60 minutes (ACC’s target threshold);
- Reducing the rate of complications associated with kidney function decline during inpatient treatment and improving the quality of treatment outcomes reported by Patients’ Reported Outcome Measures (PROM) with the Seattle Angina Questionnaire (SAQ);
- Reducing the average cost associated with the CAD treatment during inpatient care by at least 10% between pre-accreditation and post-accreditation.
III. IMPROVEMENT SOLUTIONS
Phase 1: PROGRAM DEVELOPMENT (01/2022 – 03/2022)
- Establishing a multidisciplinary team for the Cardiac Cath Lab program.
-Formulating specialty documents in adherence to ACC guidelines, including STEMI pathways, PCI-related protocols, quality improvement projects, training materials, and assessment checklists.
Phase 2: IMPLEMENTATION AND EVALUATION (03/2022 – 10/2022)
- Providing Cath Lab-specific training courses for IPU members to standardize knowledge and practice in compliance with CAD clinical pathways and protocols.
- Organizing quarterly multidisciplinary meetings to review the program performance through quality metrics results on National Cardiovascular Data Registry (NCDR). These benchmarks provided by NCDR will allow comparison with other US hospitals, facilitating collaborative identification of areas for improvement.
- Conducting quarterly cost-free cardiovascular health counseling sessions and screening for heart diseases in Hanoi and Ho Chi Minh City on the prevention and early detection of stroke and myocardial infarction.
Phase 3: ACCREDITATION AND SUSTAINABILITY (11/2022 – ONWARDS)
The CAD programs at VMTC and VMCP hospitals consistently demonstrated tangible accomplishments through monthly data analysis and quarterly multi-disciplinary meetings. Therefore, in November 2022, the two hospitals officially became the first hospitals in Southeast Asia and the second in Asia to be accredited by the ACC for the Cardiac Cath lab Program in recognition of their adherence to the ACC standards and substantial advancements in quality.
IV. RESULTS
1.Inpatient Length of Stay (days): After the implementation of the ACC standards, VMCP has stabilized the average LOS under 3 days while LOS in VMTC observed a significant decline from 4.5 days in Quarter 4 of 2021 to 2.7 days gradually in Quarter 3 of 2024.
2.Median door-to-balloon for STEMI patients having immediate PCI (minutes): Median time from arrival to first device activation time of PCI dropped to 54 minutes and 53 minutes in Quarter 4, 2023 at VMTC and VMCP, respectively. These times are well-below the ACC's 75th percentile benchmark of 57 minutes, demonstrating efficient treatment initiation for PCI patients.
3.Rate of contrast-associated kidney failure (%): The incidence of contrast-induced kidney injury (CI-AKI) among PCI patients has showed a noticeable reduction at both hospitals.
4.Quality of life of PCI patients according to Seattle Angina Questionnaire (SAQ) score:
- The indicators related to the quality of life of post-PCI patients all improved after 3 months of treatment.
- The most noticeable improvement was in physical limitation scores, particularly those involving physical exertion like walking indoors, gardening, vacuuming, carrying groceries, and lifting heavy objects.
5.Cost optimization: The adoption of ACC standards in 2022-2023 was associated with a substantial 19% decrease in average inpatient treatment costs for PCI patients, demonstrating a positive impact on healthcare affordability compared to the previous year in 2021. That is because both hospitals have implemented new practices that contribute to shorter patient stays, including:
- Comply with ACC standards for early initiation of cardiovascular rehabilitation programs;
- Comply with ACC discharge criteria and ensure patients meet specific benchmarks before leaving the hospital;
- Minimize intervention-related complications during the procedure
V. CLOSING ARGUMENT
The Vinmec Healthcare System’s Coronary Artery Disease Management Program, in accordance with the prestigious standards of the American College of Cardiology (ACC), has enhanced the quality of treatment and care for post-PCI patients. The improvement is shown by the following outcomes:
- A decrease in the average length of hospital stay to below 3 days;
- A reduction in median door-to-balloon for STEMI patients having immediate PCI (minutes) to under 57 minutes, which falls in the 75th percentile among hospitals within the ACC’s registry;
- A decrease in the incidence of contrast-induced kidney injury;
- An improved quality of life in post-PCI patients.
- A decrease in the treatment costs.
These achievements helped Vinmec Times City and Vinmec Central Park become the first hospitals in South East Asia to obtain ACC certification in Coronary Artery Disease Management. The Cardiovascular Centers of both hospitals are recognized as the first Centers of Excellence in Cardiology in Asia, officially accredited by the ACC in November 2022.
We believe that these promising results serve as a beacon for other Vietnamese hospitals, encouraging them to adopt ACC standards and elevate the quality of care for cardiac patients, particularly those with coronary artery disease.
REFERENCES:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384703/
https://www.jacc.org/doi/10.1016/j.jacasi.2021.04.007#bib2
