Antiplatelet Therapy in Patients with Unstable Angina and Non-ST-Segment-Elevation Myocardial Infarction: Findings from the CRUSADE National Quality Improvement Initiative

Michael B. Bottorff, Pharm.D.; Edith A. Nutescu, Pharm.D.; Sarah Spinler, Pharm.D.


Pharmacotherapy. 2007;27(8):1145-1152. 

In This Article

The CRUSADE Initiative: Goal and Scope

Implementing clinical practice guidelines for unstable angina and NSTEMI requires linking of risk stratification strategies and early therapeutic intervention. The cooperative efforts of emergency department physicians and cardiologists are needed, and various treatment biases and institutional obstacles that may hinder the use of evidence-based therapies must be overcome. These factors have been recognized in the development of the CRUSADE quality and education initiative.

The CRUSADE, an ongoing, voluntary, observational data collection and quality improvement initiative, began in 2001 with the goal of improving the care of patients with unstable angina or NSTEMI. The specific objectives of the CRUSADE program are to track the state of adherence to the ACC-AHA guidelines in high-risk patients and provide feedback about performance; to implement a cycle of continuous quality improvement to promote the guideline recommendations; and to reduce in-hospital mortality among patients with unstable angina or NSTEMI through early risk stratification and implementation of evidence-based care.

The CRUSADE program specifically targets high-risk patients with unstable angina or NSTEMI by adopting the following clinical inclusion criteria: chest pain or anginal equivalent at rest, more than 10 minutes in duration and occurring less than 24 hours before presentation; ischemic ECG changes (ST-segment depression 8E 0.5 mm, transient ST-segment elevation 0.5−1.0 mm lasting for < 10 min); and/or elevated markers of myocardial necrosis (creatine kinase myocardial band and/or troponin I or T greater than the upper limit of normal for the local laboratory assay used at each institution). Patients must arrive at a hospital that is participating in the CRUSADE initiative within 24 hours of symptom onset to be eligible for inclusion in the program.

The CRUSADE program is a distinctive quality improvement tool in that it provides an innovative and multifaceted approach to the education of personnel involved in the care of high-risk patients.[29] The initiative combines a multidisciplinary (emergency physicians and cardiologists), multicenter, anonymous ACS registry with a coordinated national education program to reinforce compliance with the ACC-AHA guidelines for unstable angina and NSTEMI management.

The NSTEMI ACS registry analyzes patient records to determine compliance with the ACC-AHA guidelines. Hospitals participating in the CRUSADE initiative collect detailed process of care and in-hospital outcomes data for consecutive eligible patients through retrospective chart review. Information is captured regarding use of early drug therapy (within 24 hrs of presen-tation), use and timing of invasive procedures, laboratory results, and discharge therapies and procedures. Data are also collected for physician and hospital characteristics and patient variables including age, race or ethnicity, sex, insurance status, comorbid illnesses, medical history, clinical presentation, medical therapies, and associated major contraindications to recom-mended therapies. Data collection is performed by a trained abstractor at each site, and data collection forms are submitted to the Duke Clinical Research Institute through a secure internet-based platform.

An important function of the CRUSADE initiative is to provide benchmark data on hundreds of quality points. The CRUSADE program is a rapid-cycle quality improvement initiative in which data for each participating hospital are compiled from the registry regarding rates of utilization of specific drugs and procedures. This information and comparisons with national benchmarks, best practice centers (top 10%), and similar hospitals are made available to participating centers as quarterly reports. Data are also presented with a breakdown by patient subgroups and are collated into early intervention care and discharge care to allow targeted feedback to the emergency department and cardiology physicians. In addition to the quarterly reports, online reports are available that allow real-time, on-demand access to performance and treatment data. Also available is a data download tool that provides raw data for reviewing site-driven queries and slide sets of site-specific and national data for use in promoting awareness of adherence results, encouraging local and national quality improve-ment efforts. In addition, site coordinator focus groups provide opportunities to network with other sites regarding local quality improvement efforts and initiatives.

All CRUSADE participants attend a half-day education session on the ACC-AHA guidelines and have access to the CRUSADE Initiative Toolbox. The toolbox includes a number of tools to remind participants of the salient features of the ACC-AHA NSTEMI guidelines regarding risk stratification, patient classification, appropriate therapies and their dosages, and discharge planning programs. Specific materials included in the toolbox are posted placards, pocket cards, order sets, discharge planning forms, and chart indicators. Another aspect of CRUSADE is the opportunity for participating institutions and physician groups to attend education sessions provided by expert faculty and steering committee members.

More than 400 sites have taken part in the initiative, and data have been collected from more than 170,000 patients.[30]


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