Hospital Ranking Based on Discharge Prescriptions After Acute Myocardial Infarction: A National Assessment over Three Consecutive Years

Transcription

1 Hospital Ranking Based on Discharge Prescriptions After Acute Myocardial Infarction: A National Assessment over Three Consecutive Years François Schiele 1, Frédéric Capuano 2, Geneviève Derumeaux 3, Nicolas Danchin 1, Christine Gardel 2, Melanie Couralet 2, Jean-François Thebaut 2, Armelle Desplanques-Leperre 2, Catherine Grenier 2, Raymond Le Moign 2 (1) French Society of Cardiology, Paris, France (2) Haute Autorité de Santé, Saint Denis, France (3) National Professional Board of Cardiology, Paris, France

2 Disclosures F Schiele reports receiving grant supports paid to his institution and travel support for scientific meetings from Astra Zeneca, Boehringer Ingelheim, Daiichi Sankyo, Lilly, Medtronic, Pfizer, Sanofi, Servier, Takeda. G Derumeaux reports receiving grant supports paid to her institution from: Astra Zeneca, Actelion, Bayer, Brahms, General Electrics, Medtronic, Pfizer, Servier, Toshiba, Trophos, and travel support for scientific meetings from: Actelion, Astra Zeneca, Boehringer Ingelheim, Medtronic, Pfizer, Sanofi, Servier. F. Capuano, P. Loirat, L Thebaut, A. Desplanques-Leperre, and C. Gardel have no conflict of interest to report.

3 Assessment of Quality of Care Evaluation of the quality of care provides key information for health authorities, health insurance providers, patients, the general public and physicians themselves. Measuring the actual process of care rather than merely outcomes is an alternative approach to assessing overall quality of care. Processes of care can be estimated by quality indicators (QIs) defined specifically for certain diseases. Acute myocardial infarction (AMI) is one such situation where QIs have been developed. In France, 3 campaigns to measure QIs for AMI at discharge have been implemented to date throughout the whole country, and in all centers admitting patients for chest pain. We report the results of these three consecutive campaigns of assessment of QIs in survivors after AMI, and discuss their interpretation, as well as the method used for public reporting.

4 Methods (1): Design National Authority for Health (Haute Autorité de Santé) launched a nationwide program of assessment of quality of care to evaluate management of AMI, benchmark performance and follow the evolution of AMI management from initial onset of symptoms up to 1 year after discharge. Specific QIs were defined for each situation. Periods of analysis: Three campaigns to measure QIs for AMI have been implemented to date, namely in 2008, 2009 and 2010, throughout the whole country, and in all 635 centres admitting patients for chest pain. Patient record selection: up to 80 patient files were randomly selected among those with discharge diagnosis of acute MI (ICD10). Data were recorded by an independent team after specific training in completion of the CRF.

5 Methods (2): QIs at discharge AP = prescription in the absence of contra-indication(ci) or non-prescription (NP) in case of documented CI Aspirin and Clopidogrel: CI= allergy, haemorrhagic process, uncontrolled gastric ulcer, pregnancy or lactation Beta-blockers : absolute or relative CI Absolute CI= uncontrolled heart failure, shock, bradycardia, severe COPD, hypersensitivity Relative CI = COPD, diabetes, asthma, AV block heart failure Assessment of LVEF and ACEI in patients with LVEF<0.40 CI= Intolerance or hypotension Statins regardless of cholesterol level CI= Intolerance Composite QI Composite indicator: aggregate of the 4 individual indicators using the All or None strategy (= 1 if all QI score 1, 0 if one or more QI score 0)

6 39776 patient records All Indicators Medical records (N) Aspirin AP (%) 38924(97.9) Justified NP/NP (%) 55.2 Clopidogrel AP (%) 37492(94.3) Justified NP/NP (%) 54.0 Beta Blockers AP (%) 35539(89.3) Justified NP/NP (%) 60.4 ACEI or ARB (LVEF<0.40) AP(%) 6455(89.4) Justified NP/NP (%) 52.6 Statins AP (%) 37119(93.3) Justified NP/NP (%) 41.8 Composite (All or None) Number (%) 28976(72.9)

7 QI Rates and Temporal trends

8 Composite Indicator According to Age, Gender, Type of Center and Year Typical patients with failure of composite indicator: Women, age>75, admitted in 2008 in a non-university centre at low activity volume

9 Hospital Ranking according to the Composite Indicator Composite indicator (95% CI) for each centre with >30 records, compared with national mean of the year and according to a threshold (80%) Theoretical threshold 80%

10 Hospital Ranking according to the Composite Indicator Results of the 3 campaigns: 2008, 2009 and campaign 2009 campaign 2010 campaign National mean vs theoretical threshold

11 Yearly Hospital Ranking: 3 categories according to the Composite Indicator

12 Public Reporting

13 Positive points: Discussion Driven by HAS => strong methodology (all centers, random selection of records), repeated over 3 years, total of 46,000 records. Construction of a composite indicator (all or none). Public reporting available on internet. Points of discussion: Suitable only for centres with > 30 AMI per year Analysis of the quality of prescription at discharge: relation between quality and age, gender, center categories and volume. No outcome indicator: adjusted mortality not included yet. Public reporting: Center classification but no benchmarking. Limited action for Class C and D Centers. Future actions: Evaluation extended to management of STEMI (pilot evaluation for reperfusion ongoing) and secondary prevention. Need for reassessment of the QIs, according to new guidelines and task forces.

14 Conclusions Feasibility of assessment of quality of care at a national level, repeated over 3 years, with public reporting in Trend towards better performance between 2008 and 2010, but 16% of centers present suboptimal performance: Class C. Extension of evaluation to other clinical situations would be easier with ESC defined Quality Indicators in Cardiovascular Situations and clear recommendations for assessment of the QI.