Quality Improvement in the Cath Lab Today and Tomorrow. Sunil V. Rao MD The Duke Clinical Research Institute Duke University Medical Center
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1 Quality Improvement in the Cath Lab Today and Tomorrow Sunil V. Rao MD The Duke Clinical Research Institute Duke University Medical Center
2 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
3 Cath Lab Quality - Agenda Quality at the water cooler Evolution in Quality Metrics Current challenges Facilitating quality assessment and improvement Future directions Summary
4 Cath Lab Quality - Agenda Quality at the water cooler Evolution in Quality Metrics Current challenges Facilitating quality assessment and improvement Future directions Summary
5
6 Association Between Hospital Guidelines Adherence Rates (Level I Recommendations) and In-Hospital Mortality % In-Hospital Mortality Bottom 25% 25%-50% 50%-75% Top 25% Hospital Composite Guideline Adherence Quartiles NSTEMI NSTE ACS Peterson ED, JAMA 2006;295:
7 Percent In-hospital Mortality In-Hospital Mortality by Age and Guidelines Adherence: Observations from CRUSADE Age Group Age >=75 Age <75 Adj. OR: 0.71 ( ) 0.79 ( ) Number of Recommended Therapies Boden et al, AHA 2005
8 Cardiovascular Disease and the Baby Boom Spending & Revenues as a Share of GDP 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 8 All Rights Reserved, Duke Medicine 2008
9 Variation in rates of PCI 1.3 to to < to < to < to < 0.75 Unpopulated Source: Dartmouth Atlas
10 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
11 Implications Utilization Review of all PCIs (e.g., Oregon) RAC Audits Pre-authorization DOJ by insurers Investigating Defibrillator Implanters Reimbursement Cuts for PCI Slide courtesy of Manesh Patel MD
12 The New Medical Dollar in the United States All others must have preauthorization for re-imbursement Slide courtesy of Manesh Patel MD All Rights Reserved, Duke Medicine 2008
13 Implications Utilization Review of all PCIs (e.g., Oregon) RAC Audits Pre-authorization DOJ by insurersinvestigating Defibrillator Implanters Reimbursement Cuts for PCI Slide courtesy of Manesh Patel MD
14 Cath Lab Quality - Agenda Quality at the water cooler Evolution in Quality Metrics Current challenges Facilitating quality assessment and improvement Future directions Summary
15 Defining Quality in the Cath Lab (old) Structure Cath lab equipment, appropriate certification/credentialing, radiation monitoring, QA committee, peer review process Process Protocols, Treatment pathways, radiation safety, Outcomes Quality of angiography, In-hospital mortality
16 Defining Quality in the Cath Lab (new) Structure Tools for physiological assessment, EHR Process Documentation of procedure indication, AUC, CIN protocols, Bleeding avoidance strategies, Heart team Outcomes In-hospital mortality, 30-day mortality, Bleeding, 30- day readmission, CIN
17 Cath Lab Quality - Agenda Quality at the water cooler Evolution in Quality Metrics Current challenges Facilitating quality assessment and improvement Future directions Summary
18 AUC is not new
19 AUC for Coronary Revascularization
20 AUC under fire
21 Achieving high quality cardiovascular procedures Quality Metrics Patient Preferences Public Reporting Right Patient Right Procedure Decision Right Procedure Execution Right Outcome Appropriate Use Criteria Guidelines Ongoing trials and evidence Performance Measures
22 Strategy Antman, Circulation 2009:119:
23 Challenges Clinical care vs. documentation Missing data Incorrect abstraction Export to Registries Constantly evolving evidence base Constantly evolving AUC and performance measures Incentives/funding
24 Missing data & Documentation Bradley SM, Maynard C, Bryson CL. Circ Cardiovasc Qual Outcomes 2012
25 Missing data & Documentation Further emphasis on preprocedural risk stratification and documentation will be necessary to improve the relevance of appropriateness ratings in practice Bradley SM, Maynard C, Bryson CL. Circ Cardiovasc Qual Outcomes 2012
26 EHR keeping up with the mandates ACC certified vendors
27 UPLM PCI to Improve Survival (ACS) COR LOE IIa For UA/NSTEMI if not a CABG candidate IIa For STEMI when distal coronary flow is <TIMI grade 3 and PCI can be performed more rapidly and safely than CABG B C Hillis LD, et. al. JACC 2011
28 AUC for Diagnostic Cath
29 National Trends in 30-Day Readmission Rates, Joynt KE, Jha AK. N Engl J Med 2012;366:
30 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:
31
32 Mortality at 30 Days among All Hospitals, According to Pay-for- Performance Status, Jha AK et al. N Engl J Med 2012;366:
33 Mortality at 30 Days for Hospitals with Poor Performance at Baseline, According to Pay-for-Performance Status, Jha AK et al. N Engl J Med 2012;366:
34 Cath Lab Quality - Agenda Quality at the water cooler Evolution in Quality Metrics Current challenges Facilitating quality assessment and improvement Future directions Summary
35 Facilitating QA AUC SCAI AUC Tool ACC AUC Worksheet Risk adjustment 30-day mortality Bleeding
36 SCAI AUC Tool
37 30-day mortality after PCI ACC-NCDR linked with CMS Brennan JM, et. al. Circ Cardiovasc Qual Outcomes 2012
38 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, Mandeep Singh MD, Eric D. Peterson MD MPH on behalf of the National Cardiovascular Data Registry
39 Overall Model Discrimination 35% Overall 30% 25% C=0.777 Predicted Bleeding 20% 15% 10% 5% 0% % % % % 25% % Observed Bleeding
40 Cath Lab Quality - Agenda Quality at the water cooler Evolution in Quality Metrics Current challenges Facilitating quality assessment and improvement Future directions Summary
41
42 Coexistence of process and outcomes Bradley SM, et. al. Circ Cardiovasc Qual Outcomes 2012
43 TAVR Edwards-SAPIEN THV Retroflex 1 23mm and 26mm valve sizes 22F and 24F sheath sizes
44
45 SAFE-PCI for Women workflow Randomization Demographics Medical Hx Procedural data Autopopulate Analytic Unique pages for trial Database
46 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
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