Quality Improvement in the Cath Lab Today and · PDF fileQuality Improvement in the Cath Lab...
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Quality Improvement in the Cath Lab Today and Tomorrow Sunil V. Rao MD The Duke Clinical Research Institute Duke University Medical Center
Transcript of Quality Improvement in the Cath Lab Today and · PDF fileQuality Improvement in the Cath Lab...
Quality Improvement in the CathLab Today and TomorrowSunil V. Rao MDThe Duke Clinical Research InstituteDuke University Medical Center
Disclosures
Consultant, Honoraria
ZOLL, BMS, The Medicines Company, Terumo Corporation, Eli Lilly/Daiichi-Sankyo, Terumo, Volcano
Research funding
Ikaria, sanofi-aventis
Off-label uses
May be discussed in this presentation
Cath Lab Quality - Agenda
Quality at the water cooler
Evolution in Quality Metrics
Current challenges
Facilitating quality assessment and improvement
Future directions
Summary
Cath Lab Quality - Agenda
Quality at the water cooler
Evolution in Quality Metrics
Current challenges
Facilitating quality assessment and improvement
Future directions
Summary
www.iom.edu
Association Between Hospital Guidelines Adherence Rates (Level I Recommendations)
and In-Hospital Mortality
7.61
5.514.76
4.27
6.31
5.04 4.724.15
0
1
2
3
4
5
6
7
8
9
Bottom 25% 25%-50% 50%-75% Top 25%
Hospital Composite Guideline Adherence Quartiles
% In
-Hos
pita
l Mor
talit
y
NSTEMI NSTE ACS
Peterson ED, JAMA 2006;295:1912-1920
In-Hospital Mortality by Age and Guidelines Adherence:
Observations from CRUSADE
3.13.55.2
6.7
8.710.4
17.6
0.611.8
2.73.5
10.7
6.5
02468
101214161820
0 1 2 3 4 5 6Number of Recommended Therapies
Perc
ent I
n-ho
spita
l Mor
talit
y
Age >=75 Age <75
- Boden et al, AHA 2005
Adj. OR: 0.71 (0.67-0.75) 0.79 (0.75-0.83)
Age Group
All Rights Reserved, Duke Medicine 2008
Cardiovascular Disease and the Baby Boom
• 10,000 people become Medicare eligible every day• Cardiovascular Care accounts for 43 cents of every Medicare Dollar• Successful Health Care systems will have to focus on heart care
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Spending & Revenues as a Share of GDP
Variation in rates of PCI
Source: Dartmouth Atlas
1.3 to 2.971.1 to < 1.30.9 to < 1.10.75 to < 0.90.35 to < 0.75Unpopulated
CHI: Unnecessary Stenting
1. Commonwealth of Kentucky, 27th Judicial Circuit , Laurel Circuit Court Division II, Civil Action No. 11CI00972
Slide courtesy of Manesh Patel MD
Implications
Utilization Review of all PCIs
(e.g., Oregon)
ReimbursementCuts for PCI
Pre-authorizationby insurers
RAC Audits
DOJInvestigatingDefibrillatorImplanters
Slide courtesy of Manesh Patel MD
All Rights Reserved, Duke Medicine 2008
The New Medical Dollar in the United States
All others must have pre-authorization for re-imbursement
Slide courtesy of Manesh Patel MD
Implications
Utilization Review of all PCIs
(e.g., Oregon)
ReimbursementCuts for PCI
Pre-authorizationby insurers
RAC Audits
DOJInvestigatingDefibrillatorImplanters
Slide courtesy of Manesh Patel MD
Cath Lab Quality - Agenda
Quality at the water cooler
Evolution in Quality Metrics
Current challenges
Facilitating quality assessment and improvement
Future directions
Summary
Defining Quality in the Cath Lab (old)
StructureCath lab equipment, appropriate certification/credentialing, radiation monitoring, QA committee, peer review process
Process Protocols, Treatment pathways, radiation safety,
OutcomesQuality of angiography, In-hospital mortality
Defining Quality in the Cath Lab (new)
StructureTools for physiological assessment, EHR
Process Documentation of procedure indication, AUC, CIN protocols, Bleeding avoidance strategies, “Heart team”
OutcomesIn-hospital mortality, 30-day mortality, Bleeding, 30-day readmission, CIN
Cath Lab Quality - Agenda
Quality at the water cooler
Evolution in Quality Metrics
Current challenges
Facilitating quality assessment and improvement
Future directions
Summary
AUC is not new
AUC for Coronary Revascularization
AUC under fire…
Achieving high quality cardiovascular procedures
Right Patient
Right Procedure Decision
Appropriate Use Criteria
Guidelines
Patient Preferences
Performance Measures
Quality Metrics
Public Reporting
Right Procedure Execution
Right Outcome
Ongoing trials and evidence
Strategy
Antman, Circulation 2009:119:1180-1185.
Challenges
Clinical care vs. documentation
Missing data
Incorrect abstraction
Export to Registries
Constantly evolving evidence base
Constantly evolving AUC and performance measures
Incentives/funding
Missing data & Documentation
Bradley SM, Maynard C, Bryson CL. Circ Cardiovasc Qual Outcomes 2012
Missing data & Documentation
Bradley SM, Maynard C, Bryson CL. Circ Cardiovasc Qual Outcomes 2012
“Further emphasis on preprocedural risk stratification and documentation
will be necessary to improve the relevance of appropriateness ratings in
practice”
EHR – keeping up with the mandatesACC certified vendors
www.ncdr.com
UPLM PCI to Improve Survival (ACS)
COR LOE
IIa⎯For UA/NSTEMI if not a CABG candidate B
IIa⎯For STEMI when distal coronary flow is <TIMI grade 3 and PCI can be performed more rapidly and safely than CABG
C
Hillis LD, et. al. JACC 2011
AUC for Diagnostic Cath
National Trends in 30-Day Readmission Rates, 2002–2009.
Joynt KE, Jha AK. N Engl J Med 2012;366:1366-1369.
Amount of Variance across HRRs in Readmission Rates after Index Hospitalization for Congestive Heart Failure or Pneumonia Explained by Different Predictors.
Epstein AM et al. N Engl J Med 2011;365:2287-2295.
Mortality at 30 Days among All Hospitals, According to Pay-for-Performance Status, 2002–2009.
Jha AK et al. N Engl J Med 2012;366:1606-1615.
Mortality at 30 Days for Hospitals with Poor Performance at Baseline, According to Pay-for-Performance Status, 2002–2009.
Jha AK et al. N Engl J Med 2012;366:1606-1615.
Cath Lab Quality - Agenda
Quality at the water cooler
Evolution in Quality Metrics
Current challenges
Facilitating quality assessment and improvement
Future directions
Summary
Facilitating QA
AUC
SCAI AUC Tool
ACC AUC Worksheet
Risk adjustment
30-day mortality
Bleeding
SCAI AUC Tool
30-day mortality after PCIACC-NCDR linked with CMS
Brennan JM, et. al. Circ Cardiovasc Qual Outcomes 2012
Contemporary Predictors of Post-Procedural Bleeding Complications Among Patients
Undergoing Percutaneous Coronary Intervention (PCI): Results from the NCDR®
• Sunil V. Rao MD, Lisa Kaltenbach MS, John Spertus MD MPH, Ronald Krone MD, MandeepSingh MD, Eric D. Peterson MD MPH on behalf of the National Cardiovascular Data Registry
Overall Model Discrimination
‐5%
0%
5%
10%
15%
20%
25%
30%
35%
0.00 5.00 10.00 15.00 20.00 25.00
Pred
icted Bleeding
Observed Bleeding
Overall
C=0.777
0 5% 10% 15% 20% 25%
Cath Lab Quality - Agenda
Quality at the water cooler
Evolution in Quality Metrics
Current challenges
Facilitating quality assessment and improvement
Future directions
Summary
Coexistence of process and outcomes
Bradley SM, et. al. Circ Cardiovasc Qual Outcomes 2012
TAVR
Retroflex 1Edwards-SAPIEN THV
23mm and 26mmvalve sizes
22F and 24Fsheath sizes
SAFE-PCI for Women workflow
Demographics
Medical Hx
Procedural data
Autopopulate
Analytic
Database
Unique pages for trial
Randomization
Quality Improvement - Summary
“Quality” has evolved from the shadows, to a “buzzword,” to arguably the most important issue in cardiovascular medicine
It’s the right thing to do…The registries need to be prepared
Technology needs to be catch up
Data entry needs to be consistent and validated
Need to integrate all of this into the daily workflow
The future of QI is to be proactive as technology evolves
