A novel APPROACH

The fall 2011 edition of UCalgary Medicine Magazine included a feature on APPROACH (Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease), a then 15-year-old registry of cardiac procedures in Alberta led by a research team at the Cumming School of Medicine (CSM). Years later, it’s clear the registry remains ‘a novel APPROACH’ with a bright future supporting the delivery of precision medicine.

When Dr. Merril Knudtson, MD’75, launched the APPROACH cardiac registry in 1995, he had a vision to improve care and transform outcomes for Albertans with heart disease. More than two decades later, the registry that tracks vital patient health data continues to deliver on the original vision as new opportunities to advance precision medicine are developed and implemented.

APPROACH (Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease) is one of the largest and most comprehensive cardiac registries in the world. Since its launch by Knudtson, a professor in the departments of Medicine and Cardiac Science and member of the Libin Cardiovascular Institute of Alberta and O’Brien Institute of Public Health at the Cumming School of Medicine, the registry has gathered information on more than 200,000 patients who have undergone more than 500,000 procedures in the province. Another 15,000 cardiac procedures performed annually in Alberta are added to the database each year. 

APPROACH electronically records key data such as hospital admission statistics, procedure rates, quality of life information, vital statistics and other data, providing a uniquely long-term view of the patient journey.

“APPROACH provides important insights about care for many groups of patients, including the elderly, women and patients with co-morbidities (additional conditions such as diabetes or kidney disease). It has provided information about the outcomes of these groups at a population level that’s not available elsewhere and this knowledge influences clinical practice,” explains Dr. Matthew James, MD, PhD’11, an associate professor and clinician scientist in the departments of Medicine and Community Health Sciences, and co-director of research for APPROACH since 2013, along with Dr. Stephen Wilton, MD’10. James and Wilton are both members of the Libin and O’Brien Institutes.

Older Albertans were among the first to benefit from the data collection and analysis. Decades ago, elderly Albertans with heart disease were less likely to be offered some heart procedures due to uncertainty about benefits and risks. 

“Before APPROACH data was available, it was assumed we shouldn’t give aggressive treatment to the elderly. Our early research showed that appropriately selected older people who go for angioplasty or cardiac bypass procedure can do well and have better health outcomes than heart patients of the same age who don’t,” says Wilton, an assistant professor in the Departments of Cardiac Sciences and Community Health Sciences.

APPROACH researchers also discovered that women in Alberta with heart disease were less likely than men to receive cardiac procedures, and not as likely to be referred to or participate in cardiac rehabilitation programs. 

“We raised the awareness of this discrepancy by identifying these barriers to treatment for women, such as caregiving responsibilities and low income, and showing access to cardiac procedures and rehab can improve quality of life and increase longevity,” says Wilton.

APPROACH data also revealed that patients with acute coronary syndromes (ACS) in rural Alberta are less likely to receive an important heart procedure than patients in cities, despite the increased risk of dying within 30 days if the procedure wasn’t done. “These findings about disparities in treatment for different groups are important for clinicians and patients, and they can help inform health policy decisions that improve access to appropriate care for all Albertans,” says James.

The APPROACH model is so successful that it was selected by the Canadian Institutes of Health Research in 2011 as one of six top achievements in health research and it has been adopted by other provincial health-care systems and at hospital sites in most provinces across Canada.
Wilton and James are also spearheading an exciting advance in research with APPROACH. Called clinical decision support, 
it uses the information collected in APPROACH in real-time to help clinicians make better, more informed and more personalized treatment decisions for individual patients. 

“This system is an example of a tool to deliver precision medicine. Information captured within APPROACH summarizes the experiences of many previously treated patients, and new tools can process this information rapidly to predict the risk of an event for a new patient receiving care. This helps inform decisions for each new individual receiving treatment,” says James. 

Impacting today’s precision medicine

The APPROACH platform is now being used as a tool to make heart procedures safer by helping clinicians prevent acute kidney injury in patients undergoing an angiogram or angioplasty (procedures to identify narrowing or blockages in arteries supplying blood to the heart and widen narrowed or blocked arteries). Exposure to dye injected during these procedures can lead to acute kidney injury, a common and costly complication for patients and the health system.

“The APPROACH system includes tools to warn clinicians when a patient is at risk of acute kidney injury. It then gives guidance specific to each patient on the amount of dye that can be used safely and the desired amount of intravenous fluid that can be used to flush out the dye and lower the risk of kidney injury, tailoring recommendations to each patient’s requirements,” explains James, noting that this cutting-edge project is being implemented across the province.