Table of Contents
STUDY DESIGN
Year : 2021  |  Volume : 6  |  Issue : 3  |  Page : 187-197

The national chest pain centers program: Monitoring and improving quality of care for patients with acute chest pain in China


1 Department of Cardiology, General Hospital of Southern Theatre Command, Guangdong, Guangzhou, China
2 Department of Global Health, School of Public Health, Institute for Global Health and Development, Peking University, Beijing, China
3 Department of Cardiology, Shanghai Chest Hospital, Shanghai, China
4 Department of Cardiology, Wuhan Asia Heart Hospital, Hubei, Wuhan, China
5 Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Helongjiang, Harbin, China
6 Department of Cardiology, Xiamen Cardiovascular Hospital, Xiamen University, Fujian, Xiamen, China
7 Department of Cardiology, Peking University People's Hospital, Peking University, Beijing, China
8 Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
9 Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
10 Department of Cardiology, The Second Hospital of Hebei Medical University, Hebei, Shijiazhuang, China
11 RTI International, Research Triangle Park, NC, USA
12 Peking University First Hospital, Beijing, China
13 Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China

Date of Submission05-May-2021
Date of Acceptance03-Sep-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Jun-Bo Ge
Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032
China
Yong Huo
Department of Cardiology, Peking University First Hospital, Peking University, Beijing 100034
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2470-7511.327239

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  Abstract 


Background: The National Chest Pain Centers Program (NCPCP) is the largest nationwide, hospital-based, multifaceted, continuous quality improvement initiative, which aims to monitor and improve the quality of care for patients with acute chest pain. The accreditation of the standardized chest pain center is central to the project. The purpose of establishing chest pain centers is to develop a mechanism for “sending acute chest pain patients to a hospital with capabilities for the best treatment in the shortest time possible.” Objectives: This study aims to evaluate the effectiveness and implementation of the chest pain center accreditation and to identify factors that may influence its implementation in local settings. Study Design and Methods: Hospitals that have been accredited between January 2016 and September 2020 will be recruited in this study. We will conduct a self-controlled retrospective cohort study by comparing the care performance before, during, and after the accreditation. Measures for care performance will be selected based on the American College of Cardiology/American Heart Association clinical practice guidelines, which will be divided into prehospital processes, in-hospital processes, and in-hospital outcomes. For the implementation of the chest pain center accreditation, we will use a modified reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework to investigate the implementation process, and the consolidated framework for implementation research will be used to identify factors that emerge within the local context and influence the implementation fidelity and feasibility. Progress to Date: As of September 2020, there were 4,621 hospitals that registered the NCPCP, of which 1,507 hospitals were accredited. A total of 5,228,973 patients with a primary diagnosis on admission were enrolled from the registered hospitals, among which 34.6% were acute coronary syndromes. Conclusions: In this study, we proposed recommendations for improving the implementation of chest pain center accreditation, which will improve the quality of care for patients with acute chest pain and promote the sustainable development of chest pain center.

Keywords: Acute coronary syndromes; Chest pain center accreditation; Implementation; National unified registry; Quality improvement


How to cite this article:
Xiang DC, Jin YZ, Fang WY, Su X, Yu B, Wang Y, Wang WM, Wang LF, Yan HB, Fu XH, Zheng ZJ, Labresh KA, Huo Y, Ge JB. The national chest pain centers program: Monitoring and improving quality of care for patients with acute chest pain in China. Cardiol Plus 2021;6:187-97

How to cite this URL:
Xiang DC, Jin YZ, Fang WY, Su X, Yu B, Wang Y, Wang WM, Wang LF, Yan HB, Fu XH, Zheng ZJ, Labresh KA, Huo Y, Ge JB. The national chest pain centers program: Monitoring and improving quality of care for patients with acute chest pain in China. Cardiol Plus [serial online] 2021 [cited 2021 Nov 27];6:187-97. Available from: https://www.cardiologyplus.org/text.asp?2021/6/3/187/327239

Authors Ding-Cheng Xiang, Yin-Zi Jin, Wei-Yi Fang contributed equally to this work.





  Introduction Top


Coronary heart disease is the leading cause of cardiovascular death in China.[1] Mortality due to coronary heart disease nearly doubled from 76/100,000 population in 1987 to about 120 in 2018, and the trend is predicted to further accelerate in China.[2] Acute coronary syndromes (ACS) are the deadliest and most time-sensitive coronary heart disease, and chest pain is the primary symptom of an ACS attack. ACS requires rapid recognition and coordination of care beginning at the time of symptom onset. Despite the widespread promulgation of the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations,[3],[4] their translation into clinical practice remained suboptimal in China. For ST-elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) within 120 min from onset is the typically recommended treatment. However, the proportion of cases receiving timely PCI therapy was below 30%.[5],[6] The fundamental reason is that cardiovascular disease prevention and control systems are not yet well established in China. For example, in the treatment of acute myocardial infarction, most hospitals have transport and treatment capabilities, but there are still widespread delays in patients seeking treatment, transportation, and treatment procedures. Moreover, there were marked regional variations in the implementation of standardized guideline-recommended treatments, partially owing to the unequal allocation of health resources and capacity of medical services in regions with different levels of economic development. Therefore, system implementation is more critical than the improvement of professional and technical capabilities. It is warranted to develop implementation strategies to ensure that hospitals provide standardized guideline-recommended treatments for reducing the mortality due to acute chest pain.

In several developed countries, accreditation of chest pain centers facilitates implementing strategies for improving care for patients with acute chest pain, especially ACS care.[7],[8],[9],[10] An increasing number of studies have shown that chest pain center accreditation is associated with improved processes and outcomes of patients with ACS.[11],[12],[13],[14] Under the support of the National Health Commission (NHC), the first Chinese Chest Pain Center was established in 2011, and the Chinese Society of Cardiology officially issued the first edition of China Chest Pain Center Accreditation Criteria in 2013.[15] Consequently, hospital-based chest pain centers were quickly established throughout China. However, there has been no unified national registry for garnering hospital participation, standardizing clinical practices, and facilitating quality improvement initiatives in China. To address these needs, the National Chest Pain Centers Program (NCPCP) was officially launched, and the headquarter of chest pain centers was established in 2016. The NCPCP is the largest nationwide, multifaceted, continuous quality improvement initiative in China, which aims to monitor and improve the quality of care for patients with acute chest pain. The implementation of standardized chest pain center accreditation is central to the project. In October 2017, the NHC issued the “Guiding Principles for Construction and Management of chest pain centers (trial implementation),” requiring that chest pain centers be established at all hospitals above the secondary level that receive patients with acute chest pain. In October 2019, the NHC authorized the establishment of the China Alliance of Chest Pain Centers to standardize chest pain center accreditation further and promote implementation of chest pain centers in China. The purpose of establishing chest pain centers is to develop a mechanism for sending acute chest pain patients to a hospital with capabilities for the best treatment in the shortest time possible. The ultimate goal is to improve the early diagnosis and treatment of ACS, aortic dissection, pulmonary embolism, and other acute cardiovascular diseases, and ultimately improve the clinical outcomes of patients. The general concept of the NCPCP is to develop a regional collaborative health-care network through integration of health resources, with hospitals with primary PCI capabilities to be the central component and hospitals without primary PCI capabilities as primary components, to improve the overall level of treatment for patients with acute chest pain.

This study will conduct a self-controlled retrospective cohort study based on the mixed-methods evaluation of effectiveness and implementation, (1) to evaluate the effectiveness of the chest pain center accreditation in terms of care performance for patients with acute chest pain, (2) to examine the implementation of the chest pain center accreditation, using measures of reach, adoption, implementation, and maintenance, and (3) to identify factors that may emerge in local settings, which can influence implementation.


  Study Design and Methods Top


Context

The operational structure of the NCPCP program primarily involves organization and management, accreditation, and quality control systems of China Chest Pain Centers. First, the organization and management system of China Chest Pain Centers is established under the uniform management of the China Alliance of Chest Pain Centers, conducted under the uniform guidance of the Department of Medical Administration of the NHC, and composed of a system of experts and collaborative working groups [Figure S1]. Second, since the independent development of the China Chest Pain Centers accreditation system in 2013, complete and rigorous construction criteria and review processes have been developed and incorporated into national policies. The implementation of chest pain center accreditation is under the direction and authorization of the Department of Medical Administration of the NHC, organized by the China Alliance of Chest Pain Centers, and specifically implemented by the Chinese Cardiovascular Association (CCA) and the headquarter of chest pain centers. Third, the quality control system of China Chest Pain Centers is the basis for sustainable development of chest pain centers. In 2019, the China Alliance of Chest Pain Centers issued the “China Chest Pain Center Quality Control Indicators and Assessment Measures (Second Edition),” which specified quality control assessment standards. In 2020, the “China Chest Pain Center Normalization Quality Control Plan” was released to form a national-provincial-prefectural three-level external quality control mechanism and promote normalization of the internal quality control mechanism of hospitals.



The program is made available to all tertiary and secondary hospitals nationwide, and hospitals voluntarily continue to register the program in a staggered manner. Registered hospitals need to undergo accreditation processes, and those qualified for the China Chest Pain Center Accreditation Criteria can be accredited. Registered hospitals should report data of cases at least 6 months before starting accreditation. The program requires registered hospitals to enroll consecutive cases presented with acute chest pain. Patients enrolled in our study have a primary diagnosis of STEMI, non-STEMI (NSTEMI), unstable angina (UA), aortic dissection, pulmonary embolism, and other acute cardiovascular diseases, as defined for registry inclusion by ischemic symptoms, electrocardiograph, or positive cardiac markers.

The program has set up a web-based unified register data system named CCA Database-Chest Pain Center. Each hospital is responsible for its own data collection and reporting to the CCA Database-Chest Pain Center. Cases should be reported based on the data elements abstracted from medical charts. The data elements in the CCA Database-Chest Pain Center include patient characteristics, prehospital treatment and presenting features, in-hospital medication and reperfusion therapy, and in-hospital outcomes and discharge [Table 1].
Table 1: Data elements of the Chinese Cardiovascular Association Database-Chest Pain Center

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Interventions

Chest pain center accreditation is the key intervention, which is applied at the hospital level. The accreditation process of the chest pain center is shown in [Figure S2]. China Chest Pain Center Accreditation Criteria, as a quality improvement tool, consist of five dimensions of qualification. These are in line with global best practices and also based on China's health system context: (1) conditions of facilities, (2) diagnosis and treatment process, (3) integration of prehospital and hospital care, (4) training and education, and (5) capacity of continues quality improvement [Table 2]. In China, based on the development of hospitals at all levels and their diagnosis and treatment capabilities, China Chest Pain Centers has two sets of accreditation criteria applicable to different levels of hospitals, namely the “China Chest Pain Center Accreditation Criteria” (referred to as the standard version) and the “China Basic Chest Pain Center Accreditation Criteria” (referred to as the basic version). The standard version is appropriate for hospitals with an annual PCI operation volume ≥200, an annual emergency PCI operation volume ≥50, at least two physicians who can independently perform emergency PCI operations, and hospitals that ensure that emergency PCI operations can be performed 24 h a day. The basic version is primarily aimed toward hospitals that do not meet the requirements of the standard version but receive or refer ≥30 patients with acute myocardial infarction per year. Basic chest pain centers can choose emergency PCI, transfer for primary PCI, or thrombolysis as the first reperfusion therapy after receiving a patient with STEMI.
Table 2: Five dimensions of qualification for chest pain center accreditation

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Accredited chest pain centers should follow the criteria for continuously improving the quality of care for ACS and other acute cardiovascular diseases. Improvement in adherence to the criteria is facilitated through external and internal quality control mechanisms. External quality control mechanisms include three levels: national, provincial, and prefecture-level. At the national level, the National Chest Pain Center Quality Control Expert Working Group was organized by the China Alliance of Chest Pain Centers, the China Chest Pain Center Executive Committee, and the headquarter of chest pain centers. National Chest Pain Center quality control indicators are formulated and issued in accordance with the “China Chest Pain Center Accreditation Criteria” and “China Basic Chest Pain Center Accreditation Criteria.” They guide and encourage provincial alliances to conduct quality control, organize national spot inspections as needed, and regularly release National Chest Pain Center quality control reports. At the provincial level, provincial chest pain center alliances and provincial health commissions jointly issue quality control documents for chest pain centers in the province, establish a provincial quality control center, form a quality control expert committee, and are responsible for formulating the province's quality control plan. They also organize the implementation of the province's normalized quality control work, supervise municipal-level alliances to conduct normalized quality control, and release provincial quality control reports. At the municipal level, the municipal-level chest pain center alliance establishes a municipal-level quality control center, and the municipal-level chest pain center alliance quality control expert committee is responsible for formulating the city's normalized quality control work plan, launching normalized quality control work in the city under the guidance of the provincial alliance, and releasing municipal quality control reports. For internal quality control mechanisms, each hospital formulates regular joint meetings, quality analysis meetings, and typical case seminar systems. A series of quality improvement analysis meetings and training activities are carried out at least once every quarter for sharing of clinical best practices.

Effective tools for normalized quality control of China Chest Pain Centers include a quality control platform and quality control reports. The quality control platform is based on the CCA Database-Chest Pain Center and has free rein for normalized quality control at the provincial and municipal-level chest pain center alliance levels. Quality control reports are issued regularly by the China Alliance of Chest Pain Centers and the headquarter of chest pain centers to provide semi-annual and annual national and provincial quality control reports for guiding the development of quality control systems at all levels. The core set of indicators for measuring care performance is selected based on the ACC/AHA performance measures and class I recommendation of the ACC/AHA clinical practice guidelines.[3],[4] These indicators are used to define the quality of care presented in the semi-annual and annual quality control reports.

Evaluation method

Hospitals that have been accredited in the NCPCP between January 2016 and September 2020 will be recruited in our study. To evaluate the outcome and process of the chest pain center accreditation, this study will conduct a pragmatic hybrid type II effectiveness-implementation design, as this allows for simultaneous mixed-methods evaluation.[16] To assess the effectiveness of the chest pain center accreditation, we will conduct a self-controlled retrospective cohort study by comparing the care performance before, during, and after the chest pain center accreditation at the patient level. For the implementation of the chest pain center accreditation, we will use a modified reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework to investigate the implementation process at the hospital level,[17] and the consolidated framework for implementation research (CFIR) will be used to identify factors that emerge within the local context that influence the implementation of the chest pain center accreditation.[18]

Measures

Measures and data collection for intervention outcome

To evaluate the effectiveness of the chest pain center accreditation in terms of care performance for ACS, the indicators will be selected based on the ACC/AHA performance measures and Class I recommendation of the ACC/AHA Clinical Practice Guidelines.[3],[4] The selected indicators will be divided into three metrics of quality care, including prehospital processes, in-hospital processes, and in-hospital outcomes, which will be measured at the patient level [Table 3].
Table 3: Measures of effectiveness assessment, based on the American College of Cardiology/American Heart Association performance measures and class I recommendation of the American College of Cardiology/American Heart Association clinical practice guidelines

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Data will be collected via the CCA Database-Chest Pain Center. To be eligible, we will include those cases that meet the following criteria: (1) aged 18 years or older; (2) have a discharge diagnosis of STEMI, NSTEMI, and UA; and (3) are admitted by all kinds of modes including directly by self, via emergency medical services (EMS), transferred-in or in-hospital. The preaccreditation measure, the during-accreditation measure, and the postaccreditation measure will involve the cases enrolled when the status of hospitals is that have not applied for accreditation, have been applying for accreditation, and have been accredited, respectively.

Measures and data collection for intervention process

Study sites for implementation assessment will be selected in six cities, based on west/middle/east region, rural/urban area, population size, economic level, and traffic conditions. All hospitals that have been accredited in the NCPCP in the six cities will be included in our study.

The RE-AIM framework will be used to evaluate the implementation of the chest pain center accreditation. In the RE-AIM framework, the five measure elements follow a logical sequence, beginning with adoption and reach, followed by implementation and effectiveness, and maintenance [Table 4]. Effectiveness refers to the clinical effectiveness of the chest pain center accreditation in terms of care performance. Reach, adoption, implementation, and maintenance are measured according to the implementation process. Reach is the absolute number, proportion, and representativeness of individuals who are willing to participate in a given initiative. Adoption is the absolute number, proportion, and representativeness of settings and initiative agents who are willing to initiate a program. Implementation refers to the initiative agents' fidelity to the various elements of an initiative's protocol. Maintenance is the extent to which the initiative becomes institutionalized or part of routine organizational practices and policies.
Table 4: Measures and data collection of implementation assessment, by adapted reach, effectiveness, adoption, implementation, maintenance domains

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The implementation process of the chest pain center accreditation will be assessed via questionnaire surveys and key informant interviews in recruited hospitals. Health-care providers' experiences and perceptions will be assessed via questionnaire surveys to consider reach and adoption efforts. Questionnaire survey data will be collected from chest pain center coordinators, data managers, cardiologists, professionals in emergency departments, and hospital directors. Qualitative interviews will be conducted with key informants, such as implementing partners in the program and local governments and clinical and administrative employees in hospitals and EMS agencies, to assess adoption and maintenance.

Approach to the ongoing assessment of contextual elements that contributed to the success, failure, efficiency, and cost

Assessment of contextual elements that contribute to the application of the chest pain center accreditation will be conducted in the selected six cities, at the hospital and city level. Measures to assess the influence of contextual elements on the application of the chest pain center accreditation will be selected based on the CFIR framework. In the CFIR framework, five dimensions of indicators will be included: intervention characteristics, inner setting, outer setting, and characteristics of individuals involved in implementation. Intervention characteristics will include evidence strength, relative advantage, adaptability, complexity, and cost. Inner setting will include operational structure, networks and communications, culture, and readiness for implementation. Outer setting will include patient needs, cosmopolitanism, peer pressure, external policies, and incentives. Individuals involved will share their knowledge and beliefs, self-efficacy, and individual identification with the organization.

Stakeholder-based participatory research will be conducted in recruited hospitals to focus on partnerships, engagement, co-learning, and building on existing assets in the local context. Major stakeholder agencies and organizations will be invited to participate in this exercise, including staff from the CCA, China Alliance of Chest Pain Centers, the headquarter of chest pain centers, health administrators from local governments, directors from recruited hospitals, and EMS agencies. The exercise will help identify barriers and facilitators that influence the implementation fidelity and feasibility while also documenting contextual elements, investigate core requirements for implementing the chest pain center accreditation, and identify gaps between the current experience in practice and optimal practice standards.

Methods employed for assessing completeness and accuracy of data

The completeness and accuracy of data submitted to the ACC Database-Chest Pain Center are supported by several strategies. First, data managers from each register hospital should complete training on definitions of data elements, data collection, data abstraction, and data reporting procedures. All trainees can obtain a working manual of data management. Additional support is available through on-call training and online services from personnel of the headquarter of chest pain centers. In addition, the China Chest Pain Center Congress is held every year by the CCA, China Alliance of Chest Pain Centers, and the headquarter of chest pain centers to provide a platform for networks among registered hospitals, share experiences in data abstraction and reporting, and allow registered hospitals to learn skills to collect high-quality data.

Second, data quality is monitored semi-annually, and review reports are sent to registered hospitals to ensure data completeness. Cases should be enrolled within 7 days once patients receive first medical contact, and online data reporting for cases should be finished within 30 days since the patients are discharged. Hospitals can receive data quality review reports semi-annually and annually. These reports provide detailed information on records that fail to meet enrollment criteria including duplicate case entries, display missing data elements, and possess invalid and illogical values. Registered hospitals need to reconcile these data problems before the CCA Database-Chest Pain Center closes the data record.

Third, the CCA Database-Chest Pain Center sets a series of internal data checks to improve the point-of-entry data quality. Specifically, automatic data check is performed consistently for invalid and illogical values to identify potential errors and trace the relevant records. Most data modules are structured, so that valid data must be entered before the case can be saved as a complete record and reported to the CCA Database-Chest Pain Center.

Analysis

Statistical analysis for effectiveness assessment

We will assess the changes in quality care metrics before, during, and after the chest pain center accreditation. First, the propensity score matching method will be used to match confounding factors for patient clinical outcomes. The confounding factors include patient demographics, medical history and risk factors, and presenting features. Second, to analyze the impact of chest pain center accreditation on quality of care, generalized estimating equation models will be used to account for the clustering within hospitals. The primary model will include a fixed effect for time and a ternary variable for the impact of the chest pain center accreditation. The effects will be summarized as the resulting odds ratios and difference of proportions for ternary outcomes or mean differences for continuous outcomes. We will also conduct two-level generalized linear mixed models with patient and hospital as the first and second levels, respectively, using covariate-adjusted analyses.

Statistical analysis for implementation assessment

We will use a mixed-effects generalized linear model to compare pre-, during- and postaccreditation proportions for each metric of reach and adoption while adjusting for clustering at the hospital level and time, and allowing for hospital-level estimates to be random effects. Evaluation of implementation and maintenance will be completed using questionnaires and interviews following the CFIR framework. The CFIR framework will be used to identify barriers and facilitators to program implementation fidelity and feasibility. In the CFIR framework, five dimensions of factors will be included: Initiative characteristics, inner setting, outer setting, characteristics of individuals involved in implementation, and implementation process. The results of CFIR domains will generate knowledge on core requirements for implementing the chest pain center accreditation and identifying gaps between the current experience in practice and optimal practice standards.

Ethical considerations

Ethics approvals for this study were obtained from the Institutional Review Boards of the Peking University First Hospital Ethics Committee (2020-242, approved December 14, 2020). Informed consent was obtained from registered hospitals for research approval to collect data in the NCPCP without requiring patient informed consent. Patient confidentiality will be protected in the following ways: (1) data are de-identified before their use in research, and (2) the use of data for these purposes is closely overseen by the headquarter of chest pain centers.


  Progress to date Top


Hospital distribution

[Figure 1] shows the provincial distribution of accredited hospitals. As of September, 2020, there were 4,621 hospitals across 31 provinces that registered the NCPCP, of which 1,507 hospitals were accredited, and the number of accredited chest pain centers per million population was 1.07 [Figure 1]a. Of the accredited hospitals, 814 (54.1%) had standard chest pain centers [Figure 1]b. The western and northern provinces had a higher density of accredited hospitals than the eastern and southern provinces. The east appeared to have a relatively high percentage of standard chest pain centers among the accredited hospitals.
Figure 1: Distribution of accredited hospitals in the NCPCP by province, January 2016 to September 2020
A, Density of accredited hospitals by province,/million population (number). B, Percentage of standard chest pain centers among accredited hospitals by province, % (number).
NCPCP: National Chest Pain Centers Program


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Patient characteristics

A total of 5,228,973 cases were enrolled and had valid information from the 4,621 registered hospitals from January 2016 to September 2020, among which 2,311,978 cases have specific discharge diagnoses. The enrolled cases with primary diagnosis on admission included 791,176 (12.8%) STEMI, 348,213 (6.8%) NSTEMI, 749,072 (15.0%) UA, 55,887 (1.1%) aortic dissection, 19,949 (0.4%) pulmonary embolism, 1,255,489 (24.7%) non-ACS cardiogenic chest pain, 1,710,692 (33.6%) noncardiogenic chest pain, and 287,676 (5.6%) other chest pain cases needed for specific check.


  Discussions Top


The NCPCP is unique in that it focuses on the establishment of regional collaborative health-care networks by integrating prehospital and in-hospital care for ACS and other acute cardiovascular diseases, of which chest pain is the main primary symptom. To the best of our knowledge, this study is the first to examine the implementation of chest pain center accreditation in China and to identify barriers and facilitators to the implementation fidelity and feasibility. The outcomes of this program will generate knowledge that can inform replication and scale-up activities in other settings. The actionable knowledge could be translated into a systematic solution for implementing chest pain center accreditation in other low- and middle-income countries.

The central element of chest pain center accreditation is to streamline clinical guidelines and formulate standardized procedures for guiding diagnosis and treatment by health-care professionals, thereby minimizing delays, misdiagnosis, and missed diagnosis, and improving the outcomes of patients with acute chest pain. Using this as a foundation, the general concept of the NCPCP is to establish a regional collaborative health-care system that integrates prehospital emergency systems and in-hospital green passages, coordination and division of labor between different hospital departments, and connections between health-care institutions of different levels. However, specific implementation varies greatly among different regions and hospitals. For example, hospitals can formulate methods and details of cooperation with prehospital emergency systems based on the characteristics of the regional prehospital mode to achieve a seamless connection between prehospital and in-hospital treatment. Each hospital can establish a coordination and management mechanism based on its organizational structure and mode of operation; effectively coordinate clinical departments such as cardiology, emergency, cardiac surgery, and thoracic surgery, and auxiliary examination departments such as radiology, ultrasound, and laboratory. In addition, continuous quality improvement is a core value in chest pain center accreditation, and hospitals can formulate various implementation plans to promote continuous improvement of the treatment process. This demonstrates that the NCPCP adopts objective-oriented management approach, and each hospital will formulate its corresponding quality improvement measures and institutional arrangements based on actual conditions to achieve the objectives specified in the chest pain center accreditation criteria.

In practice, accreditation of chest pain centers may be challenged by local contexts in terms of socioeconomic development, health policies, health systems, and health resources.[19],[20],[21],[22] Standardized development of chest pain centers may fail to be adopted or translated into effective outcomes, of which the reasons are likely multifactorial and vary across settings. The implementation strategy must tackle the barriers in specific contexts. However, little is known regarding the identification of the best policy options based on China's real-world situations to facilitate the implementation strategies. Therefore, it is warranted to design an implementation strategy to enhance the adoption, implementation, and sustainability of chest pain center accreditation in China. This requires us to analyze the implementation of chest pain center accreditation from the perspective of implementation science, compare implementation plans of different regions and hospitals, and investigate major strategies to promote effectiveness of chest pain center accreditation, thereby expanding the establishment of chest pain centers across the country and achieve the objectives of the program.

Beyond quality improvement, the NCPCP shows vast potential for scientific research. First, the unified registry system can serve as a national surveillance system to evaluate the characteristics, treatments, and outcomes of patients with ACS and other acute cardiovascular diseases. Second, the CCA Database-Chest Pain Center can provide a “real world” platform for tracking new drugs or devices in routine clinical practice. Such postmarket information is of great importance to assure that the safety and effectiveness of these medicines or devices are maintained as they move outside of selected trial populations and settings. Third, the CCA Database-Chest Pain Center can be merged with other national databases, such as the National Death Cause Registry Database, National Health Service Survey, and claims data from hospital electronic medical systems, to link the treatment with the downstream clinical events and health expenditures. Fourth, the CCA Database-Chest Pain Center has been categorized into different information modules to pave the way for further integration with databases of the Atrial Fibrillation Center, Heart Failure Center, and Rehabilitation Center, thereby forming a big-data center for cardiac care.

The NCPCP has several limitations. First, the voluntary participation of hospitals limits our generalization to those not participating in this program, although hospital recruitment remains ongoing. At the start of the program, the majority of registered hospitals were tertiary hospitals that may have better baseline care performance than subsequently registered hospitals with higher proportion of secondary hospitals. Second, the database in the first version before August 2019 lacks some data elements (e.g. medical history, risk factors, discharge counseling). Fortunately, these data elements have been added to the current, second version of database. Third, the internal quality assurance tools such as the web-based built-in settings of logic validation of data need to be improved for identifying the potential error to reduce the rate of missing, erroneous, or illogical data reporting. Continued training for data managers will be conducted to increase the data reliability.



We proposed recommendations for improving the implementation of chest pain center accreditation in this study, which will improve the quality of care for patients with acute chest pain and promote the sustainable development of chest pain center. The NCPCP will facilitate the implementation of chest pain center accreditation by developing a systematic solution for continuously improving the quality of care for ACS and other acute cardiovascular diseases. Actionable knowledge is a critical need for implementors of scale-up activities in China and other low- and middle-income settings.

Acknowledgments

We thank the headquarter of chest pain centers, who helped guide this study. We appreciate Junxiong Ma and Zhebin Wang, two Ph.D. candidates at the Department of Global Health, School of Public Health, Peking University, for their integral assistance in data management and analysis. We also acknowledge Xiaoyu Guan, Yi Wang, and Ruoci Ni from the Chinese Cardiovascular Association for their help in organizing this study.

Availability of data and materials

The associated study protocol and data collection tools will be made available upon request from the corresponding author. Datasets are partly available from the corresponding author upon reasonable request after the completion of primary analyses and results dissemination.

Financial support and sponsorship

This study is funded by the National Natural Science Foundation of China (No. 71904004 and No. 92046020). The study sponsor has no role in study design, data analysis and interpretation of data, the writing of the manuscript, or the decision to submit the paper for publication.

Conflicts of interest

Ding-Cheng Xiang, Zhi-Jie Zheng, Yong Huo and Jun-Bo Ge are the Editorial Board member of Cardiology Plus. The article was subject to the journal's standard procedures, with peer review handled independently of the Editorial Board member and their research groups.



 
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