Download The Quality Imperative: Lessons from the Cath Lab

The Quality Imperative:
Lessons from the Cath Lab
Protecting Patients,
Meeting Reform Goals and
Assessing Performance
with Accuracy and Fairness
The Society for Cardiovascular Angiography and Interventions (SCAI)
October XX, 2010
T
he recently enacted health care reform
legislation promises profound change for our
health care system. Officially known as the
Patient Protection and Affordable Care Act (PPACA),
its main goal is to expand access to an additional 32
million Americans. PPACA also suggests the system is
marred by escalating costs without a corresponding
rise in quality. As a result, the act attempts to cut
costs without compromising care through a variety
of means, including payment reform, delivery of
care reform, provider reimbursement reductions,
and quality improvements that deliver better care at
lower costs.
As physicians closely involved in the current health
care system, we agree systemic changes are essential
to achieve the goals of the PPACA. But we believe it is
essential to safeguard quality of care so Americans can
continue to have faith that their physicians are first and
foremost concerned about their medical care.
It’s clear that policymakers
believe reimbursement
...we believe it is essential to
strategies can improve
safeguard quality of care so
health care quality and
outcomes and reduce
Americans can continue to
costs. This “pay-forhave faith that their physicians
performance” (P4P) focus
are first and foremost concerned
is manifest throughout
the legislation in elements
about their medical care.
such as the new “Center
for Medicare and
Medicaid Innovation,” the
“Medicare Shared Savings Program”, the “Hospital
Value Based Purchasing Program” and multiple pilot
programs, all designed to “improve quality” and “test,
evaluate, and expand in Medicare, Medicaid and
CHIP (Children’s Health Insurance Program) different
payment structures and methodologies to reduce
program expenditures...” 1
Integral to these P4P programs is the belief that
quality can be measured, tracked, and improved, and
that payment reform models based on quality will
2
not only deliver better care, they will “reduce the
rate of cost growth.” The clock is ticking, however, as
recommendations for a “national quality strategy”
that includes processes to develop quality measures
is due by Jan. 1, 2011; by 2012, PPACA will initiate
other changes, including a program to share cost
savings, a reduction in Medicare payments for “excess
(preventable) hospital readmissions” and “a hospital
value-based purchasing program” for Medicare.2
We share policymakers’ sense of urgency around
quality improvement as well as their belief that
quality can be improved, and used, potentially, as a
means to incentivize better performance.
Done well, quality improvement programs in the
hospital setting improve patient outcomes and value
to the health care system by:
• Driving new and better means to enhance care;
• Showing which interventions work and which do
not;
• Identifying specific areas in need of improvement
and targets for future research;
• Pinpointing specific systems, operators or
facilities with less than optimal outcomes or
problems that require remediation;
• Developing and supporting remediation through
corrective action planning to ensure patient
safety and preserve important health care
resources; and
• Reducing preventable complications and
hospital-acquired conditions.
Done poorly, however, quality improvement efforts
can wreak havoc within the health care system and
compromise access to and quality of patient care.
Scarce resources can be wasted if ineffective quality
of care programs “crowd out” outcomes-based
quality improvement efforts. Worse, proponents
of effective quality improvement can be alienated,
discouraged or even intimidated by a poorly run
process, resulting in lackluster support for quality
improvement efforts.
Most troubling, though, is that patient care could
suffer if highly skilled physicians are penalized simply
because they took on the toughest cases. It’s a rare
but feasible possibility that the ill-defined quality
improvement program could result in physicians
“cherry picking” the easier cases – and avoiding the
more complex ones – as a means of safeguarding
their performance. This unintended consequence of
measuring performance without adjusting for the
patient’s condition is to reduce access for the sickest
patients because they represent the highest risk.
Ironically, such a poorly-defined quality improvement
program would also undermine a candid and
objective assessment of care delivery processes
and systems, operator effectiveness, and patient
outcomes.
Given the complexity of quality improvement
programs, it is all too possible to unintentionally
create a program that would hamper quality
improvement rather than promote it. Our health
care system cannot afford the serious distractions
and repercussions that would result from this kind of
failure –and our patients certainly deserve more.
We are eager to work with policymakers and other
health care stakeholders to ensure that quality
improvement programs:
• Focus on outcome measures (did the individual
patient do as well or better than expected, based
on his or her health status?) as well as process
measures (did the physician and/or operator
follow evidenced-based guidelines appropriate
for the situation?);
• Rely on accurate and verified clinical data,
subject to random audits by competent and
objective reviewers -- not administrative claims
data that are designed for billing purposes;
• Use data that is risk adjusted to reflect the
individual patient’s health and condition;
• Benchmark against a national standard so that
observed outcomes versus expected results can
be tracked and evaluated; and
• Are dedicated to a continuous quality
improvement approach that seeks to improve
patient outcomes, not just show adherence to
protocols.
While quality improvement as a discipline is still in its
infancy, there are a number of programs in existence
today that can guide policymakers as they move
to implement the PPACA requirement to develop
its “national quality strategy” and its processes for
quality measures.
By the start of next year, PPACA requires the
development of “a national quality improvement
strategy that includes priorities to improve the
delivery of health care services, patient health
outcomes, and population health.”
This paper seeks to explore the essential components
of an effective quality improvement program, pitfalls
to anticipate and guard against, and issues that
policymakers should consider in the delivery of the
quality strategy recommendation.
Given the complexity of quality improvement programs,
it is all too possible to unintentionally create a program
that would hamper quality improvement rather than
promote it. Our health care system cannot afford the
serious distractions and repercussions that would result
from this kind of failure –and our patients certainly
deserve more.
3
The Urgent Need for Quality Improvement
– and the Pitfalls of Doing it Wrong
Consider this fact: Before the first angioplasty
procedure more than 30 years ago, if you had a heart
attack, you had a one in four chance of dying; today,
more than 95 percent of heart attack victims who
arrive at the hospital for treatment survive. Starting
with the introduction of angioplasty, there have
been a series of scientific innovations and medical
breakthroughs in cardiovascular medicine, including
stents, that have enhanced benefits and reduced risks
for heart patients.
Percutaneous coronary intervention (PCI) procedures
involve threading a slender tube into the arteries
of the heart, expanding a tiny balloon to widen the
artery and, usually, leaving an expandable metal
stent in place to hold the artery open. As a result,
interventional cardiologists are able to stop heart
attacks, prevent strokes, correct congenital heart
problems and improve quality of life, and have done
so for millions of heart disease patients.
Although “quality improvement” is often associated
with these significant scientific advances, continuous
quality improvement (CQI) describes an organized,
scientific process for evaluating, planning, improving
and reassessing quality.3 The end goal is to deliver
the right care at the right time to the right patient
by following best practices procedure by procedure,
providing timely care patient by patient, and striving,
physician by physician, to avoid unnecessary tests and
procedures, medical errors and complications.
The question is: how can quality be accurately
measured, especially at the ground level of individual
cath labs and interventional cardiologists? There have
been many attempts to answer this question; most,
for one reason or another, have fallen short.
4
Public assessments of a hospital’s quality often
rely on testimonials, rankings or self-proclaimed
“centers of excellence” designations. What may be
heart-warming and inspiring tributes are clearly not
objective, validated indications of quality. Likewise,
published hospital rankings and health grades
have, at best, a tenuous correlation with improved
outcomes, according to peer-reviewed studies. 4 5 6
A key obstacle to measuring quality is that most of the
available measuring sticks have flaws. For instance,
administrative data are often used to measure quality
because they are accessible and inexpensive. But
assessing quality based on information from insurance
claims or billing statements – designed for accountants,
not clinicians – is simply inadequate for the purposes
of scientific inquiry.
Nevertheless, many existing report cards and rating
systems depend on administrative data. Attempts to
“risk-adjust” those data have been shown to be highly
inconsistent.7 This has brought considerable danger
to the publication of data on individual physicians,
especially if it is used to rate performance in a P4P
reimbursement model. Many physicians will become
unduly discouraged by this unfair evaluation of their
performance, and, as previously noted, may avoid
taking on the most complex cases. Meanwhile, some
may be tempted to focus on “gaming the system” as a
means to improve their performance scores.
Clearly, such report cards or rating systems will
provide a disincentive to physicians when it comes to
taking on patients with severe or costly conditions.
For instance, after the New York State Department
of Health Cardiac Surgery Reporting System began
making public disclosure of individual surgeons’
mortality rates following coronary artery bypass,
researchers sent 150 New York State cardiac surgeons
an anonymous mail survey in 1997. Of the 104
respondents, 62% refused to operate on at least one
high-risk patient within the last 12 months due to
public reporting.8
...researchers found that report
cards in New York and Pennsylvania
led to higher Medicare expenditures
and adverse outcomes relative to
nearby states that did not have
similar report cards.
Corroborating this survey are studies showing this
public reporting of cardiac surgery outcomes in New
York – and Pennsylvania, which also had a coronary
artery bypass surgery report card – resulted in an
increasing number of high-risk patients being referred
out of state.9 10 In addition, not only did the illness
severity of patients receiving the surgery decline
in Pennsylvania and New York compared to states
without report cards, there were more surgeries
performed on healthier patients.11 And consistent
with increased sorting of patients related to report
cards were delays in treatment for both healthy and
sick patients due to time required for the sorting
process. Finally, researchers found that report cards
in New York and Pennsylvania led to higher Medicare
expenditures and adverse outcomes relative to
nearby states that did not have similar report cards.12
In addition, physicians fear that such flawed reporting
systems may end up misleading patients, misdirecting
them at a time of critical decision making about their
health.13 For instance, last year, a national newspaper
cited an analysis of Medicare data to conclude that
Massachusetts General Hospital in Boston had a
death rate among angioplasty patients that was
twice the state’s rate.14 Although the story included
the fact that an independent audit showed most of
the deaths resulted from the hospital’s willingness
to treat patients with a slim chance of survival, one
may rightly wonder how many heart patients or their
families balked at going to Massachusetts General
because of that story.
Likewise, process measures, which assess the
activities performed when health care professionals
provide care to patients (physical exams, diagnostic
testing, staffing ratios, etc), ignore critical elements
to providing optimal patient care, such as the
physician’s clinical judgment and the patient’s overall
health condition. In fact, recent studies show a lack
of correlation between most process measures and
risk-adjusted outcomes.15 16 Clearly, there are some
guidelines and best practices, such as giving aspirin
to heart attack patients or shortening the so-called
“door-to-balloon” time for those patients, that play
an important role in improving quality; but most
outcomes have many associated processes associated
and perfecting any one – or even a few – of them may
not result in measurable improvement in outcomes.
There is also concern that quality improvement
programs that do not see improving quality as a
continuous process may stifle innovation. Linking
performance measurement and reimbursement to
an existing standard will, by its nature, encourage the
status quo. Such programs encourage compliance to
the detriment of the patient. Likewise, there is the
danger that aggressive treatment may be deemed
“inappropriate use” despite the circumstances of the
procedure and the condition of the patient. In the
end, we must avoid quality improvement programs
that put a chilling effect on innovation – after all,
it is innovation that has repeatedly been proven to
improve care, save lives, and advance the quality of
medical care.
Fortunately, there are outcomes-based quality
programs that use risk-adjusted information gathered
by trained clinicians from medical charts to create
a prospective, peer-controlled, validated database
that takes into consideration the patient’s condition
in assessing outcomes and can help pinpoint a
program’s specific strengths and weaknesses.
They provide a continuous process of measuring
performance and providing feedback to the clinician,
which numerous studies have found lead to
improvements in performance.17
5
In Michigan, for instance, a statewide CQI initiative
for cath labs showed demonstrable decreases in
bleeding,18 transfusion requirements, vascular
complications, and a reduction in contrast
nephropathy. Likewise, peer-reviewed studies have
shown that a surgical quality improvement program is
effective in improving the quality of surgical care and
in reducing complications. Higher quality and lower
rates of complications translate into lower costs – a
not insignificant by-product, given that health care
costs continue to escalate at a time when we are
increasingly strapped for resources.
Given the current interest from policymakers to
develop a national quality improvement strategy and
use P4P programs to improve quality and outcomes
and reduce costs, it is important to understand what
tools and programs have shown effectiveness in
measuring, tracking and improving quality.
Consider the robust quality improvement model
developed for cath labs and interventional
cardiologists by the Society for Cardiovascular
Angiography and Interventions (SCAI) and
implemented in tandem with the American College
of Cardiology’s (ACC) National Cardiovascular Data
Registry (NCDR). While it is a work in progress, as any
continuous quality improvement program should be,
its scientific rigor and validity is earning the respect of
clinicians worldwide.
The Elements of a Continuous Quality
Improvement (CQI) Program in the Cath Lab
Improving quality in cath labs means routinely striving
to protect patient safety, improve outcomes and
carefully weigh the risks of the procedure against the
condition of the patient. This approach continuously
strives to enhance processes, efficiencies and
outcomes based on a fair physician-led review of
performance that objectively evaluates structure,
process and outcomes and takes the appropriate
corrective action when necessary.
6
That’s why we recommended CQI for all cath labs in
the 2005 PCI guideline update from the SCAI, ACC and
the American Heart Association (AHA);19 in addition,
we required CQI as a part of the new Accreditation
for Cardiovascular Excellence (ACE) program from
SCAI and ACC.20 ACE will offer objective, peer-review
evaluation of processes and assessment of outcomes
based on established benchmarks, tools and guidance
for improvement, and when necessary, help in
developing corrective action plans.
For cath labs, SCAI recommends five key elements as
part of a CQI program “blueprint”:
• Collecting data;
• Benchmarking data to find where improvement
is needed;
• Identifying quality indicators;
• Correcting deficiencies; and
• Reassessing the data to gauge the effect of the
corrective action.
A fundamental element for a CQI program, according
to SCAI, is to prospectively gather data about all of
a cath lab’s procedures and compare the outcomes
to national norms. To create those national norms,
SCAI encourages all interventional cardiologists
and cath labs to send their PCI data to the NCDR
CathPCI Registry. Registry data, which collect patient
demographics, clinical variables, and outcomes on
each procedure, are used to provide quarterly reports
with benchmarking and risk-adjusted outcomes. The
NCDR is the most comprehensive outcomes-based
quality improvement program in the U.S. with a suite
of data registries involving more than 2,400 hospitals
and more than 10.6 million patient records.21 The
evidence-based data are combined with process and
performance measures linked to current ACC/AHA/
SCAI clinical practice guidelines.22
To implement CQI, an independent committee
should be created with oversight over all aspects
of the CQI process to establish quality indicators,
track performance, and identify and correct
problems. Often directed by the cath lab director,
SCAI suggests the committee include among its
other voting members interventional cardiologists
and others associated with the cath labs as well as
non-interventional cardiologists, cardiac surgeons,
emergency room physicians and non-cardiologist
internists. Non-voting members may include
representatives of the hospital’s quality assurance
and cardiovascular administrations.
While protecting patient safety is the primary
purpose of the CQI committee, identifying
deficiencies in the program must be done openly and
with the involvement, as appropriate, of the hospital’s
risk management staff. The committee must operate
with equity and transparency to ensure fairness to
operators whose work they will review, quality for the
patient and credibility for the process.
One of the first tasks of the committee is to identify
quality indicators based on guidelines, accreditation
bodies, and local practice requirements. These
indicators often apply to processes and outcomes
within the cath lab, but may also include outside
factors affecting cath lab quality. For instance, in
a patient undergoing a heart attack, an important
quality indicator is how long it takes for the patient
to receive angioplasty after entering the Emergency
Room – the “door-to-balloon” time. The committee
regularly uses these quality indicators to evaluate the
cath lab’s performance.
Clinical practice guidelines and appropriateness
criteria are an essential part of the CQI process.
While guidelines are intended only as suggestions
based on scientific studies and cannot replace the
clinical judgment of the physician, it has been shown
that when overall guidelines are followed, clinical
outcomes improve.23
In 2009, several professional organizations,
including the ACC, SCAI, STS and the American
Association for Thoracic Surgery (AATS), conducted
an “appropriateness review” of common clinical
scenarios in which PCI is a possible treatment. These
scenarios included information on symptom status,
extent of medical therapy, risk level as assessed by
noninvasive testing, and coronary anatomy.
About 180 clinical scenarios were developed and
scored on a scale of 1 to 9. Scores of 7 to 9 indicate
that PCI was considered appropriate for the patient
and likely to improve health outcomes or survival;
often, these patients had heart attack, significant
heart disease symptoms and/or chest pain.24 In
contrast, scores of 1 to 3 indicate PCI was considered
inappropriate for the patient and unlikely to improve
health outcomes or survival; typically, these patients
did not have symptoms or were found to be of lowrisk by a noninvasive test. This appropriateness
rating system is expected to guide physician decision
making, patient education and future research.
While a cath lab does not have the workforce
to assess the appropriateness of each
procedure, random case reviews should evaluate
appropriateness, procedure documentation and
technique. Such reviews may identify cases in
which the operator prescribes PCI for low risk
patients who should have been treated only with
medication. Operators who frequently conflict with
guidelines or appropriateness criteria may prompt
the CQI committee to require a peer assessment
of performance.
We should not equate quality with lack of complications,
for to do so is to penalize physicians who take on complex
procedures and high-risk patients.
7
Data Collection and Benchmarking
Peer Review and Remediation
When a cath lab’s data vary significantly from quality
indicators, appropriateness criteria or from national
or regional norms, an internal peer-review process
should examine patient selection and outcomes.
Just as good drivers learn from “fender benders,”
good physicians learn from procedures that result
in complications. Sometimes, fender benders are
due to poor weather conditions, mechanical failure,
traffic, other drivers or operator error. Other times,
a pattern of fender benders suggests the driver is not
anticipating or responding to changing conditions, is
impaired or inattentive, or has some other issue that
needs remediation. Likewise, just as we need to go
beyond traffic reports to assess the quality of a driver,
we need to go beyond complication rates to assess
the quality of the physician.
Benchmarking against national standards enables
reviewers to compare an individual cath lab’s
outcomes to expected results as determined by
national registry data, which has been shown to be
effective in predicting outcomes.
By comparing a cath lab’s data to national
benchmarks, reviewers can detect worrisome
patterns. For instance, benchmarking may detect
a higher-than-average proportion of the cath lab’s
patients received PCI even though they may not have
been deemed an appropriate candidate based on
their condition.
At the same time, it is critical to understand when
a pattern is “worrisome” as opposed to when it
reflects a much more difficult and complex patient
base. We should not equate quality with lack of
complications, for to do so is to penalize physicians
who take on complex procedures and high-risk
patients. This could deny access to such patients as
the 65-year-old patient who has already had two
coronary bypass surgeries and now is in need of a
third or another procedure; many heart surgeons or
interventionalists would not take on such a high-risk
patient, especially if a less than optimal outcome
would damage their professional reputation. This is
why it is so critical to be sure that the data is riskadjusted so that the comparisons are fair, accurate
and relevant. That’s why all outcomes should be
adjusted to reflect the risk of the patient’s condition
as part of the process of determining if the
procedure was appropriate for that patient.
8
Evaluating an individual operator’s “quality” is
an integral part of a cath lab’s CQI process. The
clinical proficiency of each operator should be the
subject of an ongoing peer-review assessment that
includes random case review, identifies strengths
and weaknesses of the cath lab and the individual
operator, and compares individual and cath lab
outcomes against national standards and benchmark
databases. While operators may aspire to a high
standard of performance, they must also be required
to meet minimum standards to maintain their
privileges to operate in the cath lab.25
Once again, this peer-review process should be seen
as much about learning as it is about remediation.
The CQI committee and the hospital’s quality
management department need to work closely
together to investigate reported events. Yet there are
many challenges to applying the CQI and peer-review
processes in a constructive and impartial manner.
For instance, close attention should be paid to
avoiding conflicts of interest in which the peer
reviewer may benefit from adjudicating adversely
on a physician’s care for political, financial or
personal reasons. Unfortunately, there have been
cases, albeit rare, in which physicians were unfairly
sanctioned.26 For example, complications can occur
in any circumstance, such as damage to an artery
during angioplasty; or unforeseen problems may be
discovered during a procedure. Peer reviewers must
strive to consider the context in which the procedure
was performed, and not judge a physician harshly
simply because the outcome did not measure up to
national norms. Conversely, reviewers must not close
ranks and protect physicians who are falling short of
expectations and are possibly in need of remediation
or sanction.
Concerns with operator performance may relate to
professional behavior, such as poor attitude or ethical
conduct; inadequacies in knowledge, judgment or
procedural skills; mental impairment or addictive
substance abuse; or a combination of any of the
above. To assure credibility, the peer-review process
must remain impartial, consistently applying review
criteria and establishing a random review mechanism
to avoid enabling operators to “game” the system.
Remediation often starts with a “neutral,” wellrespected individual in the cath lab assigned to
discuss the quality issue with the operator in
question using benchmarking data. Often this quiet,
though legally protected, discussion may be enough
to solve the performance problem. This process,
as defined in federal law, requires due process,
protects confidentiality and shields participants
from litigation.27 This is important, since if they are
not protected, these conversations and remediation
may be perceived as punitive; that may, in turn, be
an obstacle to the conversation and remediation,
thereby stifling quality improvement. When further
education or training is called for, it is typically
part of a non-punitive action plan that specifies
the required changes and includes appropriate,
constructive feedback. This corrective action
plan should include effectiveness measurements
and clearly state expected outcomes or targets.
Corrective actions should be reassessed on an
ongoing basis, and may prompt further steps, such
as additional education or mentoring.
When an internal resolution cannot be reached, the
case should be referred to the proper review body
within or outside the institution. Outside reviewers
should be impartial experts whose selection is subject
to the approval of all relevant parties.
A formal peer review of an individual physician’s
professional competence may or may not result in
punitive actions, such as suspension or revocation of
privileges, depending on the findings of the review.
Thoughtful consideration and clear deliberation on
physician remediation must be factored and weighted
against physician punishment. Since our society
has heavily invested in and depends on the skills
of our physicians, every effort should be made to
resolve quality problems through remediation. This
is especially true at a time when the physician supply
is already stressed due to a decreasing number of
physicians ready to replace those who are retiring and
rising demand for medical services due to our aging
population. Assessment and remediation programs
– such as the Physician Assessment and Clinical
Education Program at the University of California, San
Diego – can make a difference by sorting out those
physicians who are fully competent from those who
are not, and between those who could benefit from
additional training and those who should no longer
be practicing medicine.28
CQI must, by definition, identify program elements,
processes and operators in need of improvement. If it
is portrayed or viewed primarily as a way to identify,
investigate and punish outliers in the cath lab, its ability
to effect quality improvement in the cath lab will be
undermined because it likely will deter medical and
hospital personnel from raising problems.
9
Conclusion and Recommendations
There is a robust CQI process available for cath labs,
and while it is not perfect, it is the best there is for
delivering clear, measurable results. Improving quality
is ever a work in progress, and the interventional
cardiology community continues to seek
improvement and collaborate with other specialties,
such as anesthesiology and surgery.
However, spurred by health care reform and
increased payer and policymaker interest in quality
and cost, cath labs and interventional cardiologists
may face a much different approach to measuring
quality and performance. We believe there are
some critical elements that cath labs can implement
to safeguard and promote quality; and yet, we are
concerned that many of the existing approaches to
measuring quality and appropriateness (such as those
that rely solely on administrative data) not only fall
far short of the mark, but may also end up harming
patient care and access.
Specifically, there is an opportunity for interventional
cardiology to drive a grassroots initiative to connect
with local hospitals at the state level to ensure
quality standards are being met and the best in
quality improvement is implemented. State by state
demonstration of leadership on the physicians’ part
can only serve to extend the message of consistent
quality and continued focus on the best in patient
care regardless of hospital size or location.
Most importantly, establishing quality improvement
programs in the cath lab are critical. Other steps cath
labs can take to support the quality movement include:
• Following the successful model of the “cath lab
conference.” In regular multi-disciplinary cath lab
conferences, peers discuss significant cases in an
open forum. Such exercises are an important tool
to promote learning and improve quality.
10
• Reporting data to a national database. Insurance
databases document how many patients had a
particular diagnosis or procedure, while randomized clinical trials test therapies under tightly
controlled circumstances and in narrowly defined
groups of patients. The NCDR, for example, uses
direct clinical data from doctors and hospitals to
document the cardiovascular treatments average
patients receive every day, and how those treatments affect their health, helping doctors give
better cardiovascular care in daily practice. By
allowing hospitals and cardiologists to compare
their treatments and clinical outcomes against
those of similar volume and size across the nation, the NCDR also helps them to achieve the
highest quality of care.
• Seeking accreditation. Cath labs will benefit not
just from the process of achieving accreditation,
but from the continuing process of re-verification
that will further prompt cath labs to constantly
review their performances. Peer-reviewed studies have shown accreditation improves patient
outcomes and enhances patient safety.[i] ACE,
which requires CQI, provides guidance and tools
to help physicians and hospitals improve their
processes and outcomes, select patients according to established appropriateness criteria, and
report data, assure quality and peer review. Note
that accreditation for carotid stenting is now
required for all facilities performing these procedures by CMS – another indication that the federal government is focusing on quality and quality
improvement. While the first ACE project focuses
on carotid stenting, projects for cardiac catheterization, angiography and PCI are expected to be
operational by late 2010 or early 2011.[ii]
There is increasing focus on cath lab quality
from hospital administrators, insurers and other
payers, and regulators. So far, at least, the quality
improvement process for cath labs – including the
role that peer review plays in that process – has
been driven by interventional cardiologists and other
clinicians engaged with the patients, the procedure,
the science and the workings of the lab. But with the
growing focus on quality and P4P efforts from payers
to tie payments to quality outcomes, others less
familiar with cath labs are intensifying their interest in
cath lab quality.
As leaders in innovation and quality improvement,
interventional cardiologists believe it is the very act of
working with the patient, performing the procedures,
and conducting the follow up that helps us deliver
the best care for our patients. Not only do we see
first hand what works – we also see what needs to
be done better. We have the tools and programs
to improve quality, reduce variability, identify and
remediate performers who are less than optimal. We
owe it to our patients and to ourselves to meet and
build on our professional commitment to providing
the best possible care.
11
(Endnotes)
1 Kaiser Family Foundation, Summary of New Health Reform Law (Last Modified: March 26, 2010)
http://www.kff.org/healthreform/upload/8061.pdf
2 Kaiser Family Foundation, Health Reform Implementation Timeline, http://www.kff.org/healthreform/8060.cfm
3 Dehmer GJ. Pay for Quality – What Every Interventional Cardiologist Needs to Know. Catheterization and
Cardiovascular Interventions 68:169-172 (2006).
4 Osborne NH, et al. Do Popular Media and Internet-Based Hospital Quality Ratings Identify Hospitals with
Better Cardiovascular Surgery Outcomes? JACS Jan. 2010. 210; 1: 87-92.
5 Mulvey GK, et al. Mortality and Readmission for Patients With Heart Failure Among U.S. News & World
Report’s Top Heart Hospitals. Circulation: Cardiovascular Quality and Outcomes 2009;2:558-565.
6 Rothberg MB, et al. Choosing the Best Hospital: The Limitations Of Public Quality Reporting. Health Affairs
2008 27;6:1680-1687.
7 Heupler FA Jr, Chambers CE, Dear WA, Angello DE, Helaler M and members of the Laboratory Performance
Standards Committee of the Society for Cardiac Angiography and Interventions. Guidelines for internal peer
review in the cardiac catheterization laboratory. Cathet Cardiovasc Diag 1997; 40:21-32.
8 Burack JH, et al. Public reporting of surgical mortality: a survey of New York State cardiothoracic surgeons.
Ann Thorac Surg. 1999 Oct;68(4):1195-200.
9 Omoigui NA, et al., “Outmigration for Coronary Bypass Surgery in an Era of Public Dissemination of Clinical
Outcomes,” Circulation 93, no. 1 (1996): 27–33
10 Dranove D, et al. Is More Information Better? The Effects Of “Report Cards” On Health Care Providers. The
Journal of Political Economy (June 2003) 111;3: 555-588.
11 Ibid.
12 Ibid.
13 TH Lee, et al. A middle ground on public accountability. N Engl J Med. (June 3, 2004) 350;23:2409-12.
14 Sternberg S. Premier hospital, high angioplasty death rate. USA Today Feb. 10, 2009.
15 Stulberg JJ, et al. Adherence to Surgical Care Improvement Project Measures and the Association With
Postoperative Infections. JAMA (June 23/30, 2010) 303;24:2479-2485.
16 Werner RM, et al. Relationship Between Medicare’s Hospital Compare Performance Measures and Mortality
Rates. JAMA (Dec. 13, 2006) 296; 22: 2694-2702.
17 Ibid.
18 Moscucci M, et al. Association of a continuous quality improvement initiative with practice and outcomes
variations of contemporary percutaneous coronary interventions. Circulation 2006;113:814-822.
19 Smith SC, Jr, Feldman TE, Hirshfeld JW, Jr, et al. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous
Coronary Intervention—summary article: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001
Guidelines for Percutaneous Coronary Intervention). Circulation. 2006;113(1):156-175.
20 Smith SC Jr, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous intervention: A report of the
American College of Cardiology Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001
Guidelines for Percutaneous Coronary intervention). J Am Coll Cardiol. Available at: http://www.acc.org/
clinical/guidelines/percutaneous/update/index.pdf
21 ACC’s NCDR Analysis Reveals Positive Trends in Heart Attack Care, July 12, 2010. http://www.cardiosource.
org/News-Media/Media-Center/JACC-Releases/2010/07/NCDR-positive-trends-in-heart-attack-care.aspx
12
22 Brindis RG, Dehmer GJ. Continuous quality improvement in the cardiac catheterization laboratory. Are the
benefits worth the effort? Circulation 2006; 113: 767 – 770.
23 Anderson HV, Shaw RE, Brindis RG, et al. Relationship between procedure indications and outcomes of
percutaneous coronary interventions by American College of Cardiology/American Heart Association task
force guidelines. Circulation 2005; 112: 2786 – 2791.
24 Patel MR, et al. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary
Revascularization. Catheterization and Cardiovascular Interventions 73:E1–E24 (2009).
25 Ibid.
26 Parmley WW. Clinical peer review or competitive hatchet job? J Am Coll Cardiol 2000; 36: 2347.
27 Heupler FA Jr, Chambers CE, Dear WA, Angello DE, Helaler M and members of the Laboratory Performance
Standards Committee of the Society for Cardiac Angiography and Interventions. Guidelines for internal peer
review in the cardiac catheterization laboratory. Cathet Cardiovasc Diag 1997; 40:21-32.
28 Landro L. A Cure for Troubled Doctors: A University of California program combines data and gut instincts to
determine if – and when – physicians who have been disciplined can start practicing again. The Wall Street
Journal, April 13, 2010.
29 Longo DR, et al. Hospital Patient Safety: Characteristics of Best-Performing Hospitals. Journal of Healthcare
Management, May 1, 2007.
30 Accreditation for Cardiovascular Excellence, Accreditation and Ongoing QA of Cardiac Catheterization and
Percutaneous Coronary Intervention Programs.
13