ACE: The First Experience with Angiographic Reviews
Weiner scai 2013 poster final
2. Effect of ACE Catheterization Laboratory
Accreditation on Hospital NCDR CathPCI
Reports
• Bonnie H. Weiner MD MSEC MBA
• Ralph G. Brindis MD MPH
• Charles E. Chambers MD
• Gregory H. Dehmer, MD
• Christopher J. White, MD
• Mary E. Heisler, RN
3. Background
• Accreditation is an approach intended to improve
quality
– ACE has been accrediting cardiac catheterization
laboratories for 2 years
– The process includes both internal gap analysis and
external review to result in a comprehensive
corrective action plan
• The purpose of this analysis was to determine if the
accreditation process led to changes in quarterly
NCDR CathPCI Registry Reports
4. Methods
• All facilities submitted their most recent CathPCI Registry report as
part of the initial application (Baseline)
• Diagnostic Catheterization and PCI Patients (All Patients)
• PCI only (PCI Patients)
• Follow-up CathPCI Registry reports were obtained for this analysis
(Post)
• A minimum of 2 quarters following submission of the accreditation
application were required for inclusion in the analysis
• Data were abstracted from the detail section of the CathPCI
Registry reports by quarter
• Sixty-one variables were selected for analysis
• Based on importance as potential quality metrics or clinically
relevant characteristics
• Potential changes related to the accreditation process
• Comparisons between baseline and post accreditation were made using
JMP software (SAS, Version 10.0.2)
• Comparisons between sites were made using Chi Squared analysis
6. Results: All Patients
Canadian Cardiovascular Society Class II Angina
There was no difference in the
percentage of patients with No
Angina, Class I, III, or IV angina.
Few patients underwent
procedures with no angina or Class
I angina at either timepoint. The
percentage of patients with Class
III or IV angina was unchanged over
time. The reduction in Class II
angina suggests a more measured
approach to treatment of patients
with moderate angina
P=0.0326
7. Results: All Patients
Anti-anginal therapy in the past 2 weeks (not
ACS Patients)
The use of Anti-anginal therapy was
recorded more frequently following
accreditation than it was at baseline.
This was particularly true for the
non-ACS patients. A similar trend
(p=0.07) was seen in the ACS patients
but it did not reach statistical
significance. This is also consistent
with the reporting of less Class II
angina shown previously.
More patients had CHF reported
within the 2 weeks prior to
catheterization (p=0.0521) following
accreditation than occurred at
baseline.
p=0.0028
8. Results: All Patients
High Risk Stress Test
Consistent with the previous
findings, a higher percentage of
patients had high risk stress tests
at the later time point than did
earlier. There was no change in
the frequency of low or
intermediate risk stress tests
reported.
p=0.005
9. Results: PCI Patients
Canadian Cardiovascular Society Class II Angina
In PCI patients there was no
difference in the percentage of
patients with No Angina, Class I,
III, or IV angina. Few patients
underwent procedures with no
angina or Class I angina at either
timepoint.
The reduction in Class II angina
present at the time of PCI suggests
that fewer patients with less
severe angina are being treated by
PCI. This could indicate better
adherence to guideline
recommendations and the AUC
following accreditation
P=0.0396
10. Results: PCI Patients
FFR in Intermediate Lesions
FFR >0.75
FFR ≤ 0.75
A similar percent of elective patients
who underwent PCI had some type of
ischemic assessment (abnormal stress
tests or FFR ≤ .75) performed (59.9 ±
19.6% (baseline) vs. 64.4 ± 15.8%
(post))
The figure shows that the percent of
intermediate lesions (40-70% stenoses)
undergoing FFR assessment increased
following accreditation.
Note: for FFR findings to be
entered, PCI must be selected as a
procedure during data entry. Therefore
the increase in the frequency of FFRs >
0.75 does not reflect an increase in PCI
being performed on these lesions. It
more reflects higher utilization of the
technology for ischemia documentation
and in this case possibly deferring of PCI
p=0.0054
p<0.0001
11. Results: PCI AUC (not
ACS Patients
More patients were evaluable by
the AUC criteria after
accreditation than at baseline
(84.5 ± 7.3% vs. 91.0 ± 4.8%). This
again reflects improved
documentation including more
complete reporting of those
characteristics that contribute to
the AUC calculation.
Evaluable Patients
p=0.0005
12. Results: PCI AUC (not ACS Patients)
Appropriate Uncertain Inappropriate
Between the initial evaluation and the later timepoint, there was a change in the AUC criteria (2009 vs.
2012). Despite the improvement in documentation shown previously, the findings shown here may
represent change in those criteria, rather than a real change in the frequencies of appropriate and
inappropriate cases being performed or the documentation to support the characterization.
In ACS patients there was no difference in “Appropriate” or “Inappropriate” characterization. A small
number of cases were characterized as “Uncertain” and this frequency increased after accreditation (0.56
± 0.87% vs.. 1.92 ± 2.79%)
p=0.0271 p=0.0164NS
13. AUC conclusions
• A higher percentage of patients were evaluable by the AUC following
accreditation than were at baseline
– This is likely do to more complete documentation
• Documentation gaps were frequently identified during the
accreditation visit and corrective action plans were implemented to
address this issue
• Frequent recommendation for increased use of in lab assessment tools
• In ACS patients no change in “appropriate” or “inappropriate” classification
was seen
• In Non-ACS patients after accreditation compared to before:
– Lower percentage of Appropriate (48.1 ± 15.0% vs. 60.8 ± 21.5%)
– Higher Percentage of Inappropriate (16.8 ± 11.1% vs. 10.9±11.1%)
– No difference in Uncertain
14. Summary
• Overall changes in cath lab practices have occurred over the time
represented in this analysis
• A finding from our initial accreditations reviews demonstrated
gaps in documentation (SCAI 2012)
– These gaps were addressed as part of the corrective action
plan for each site
• Improved documentation is reflected in the current finding of
increased reporting of medication use, more high risk stress tests
and more evaluable patients by AUC
15. Summary
• The only change in ACS patients was an increase in the frequency of
“uncertain” categorization.
– Although documentation is improved as noted above, this finding
may primarily represent the difference between 2009 and 2012
AUC.
• In the Non-ACS patients, the reduction in the frequency of
appropriate categorization coupled with an increase in inappropriate
categorization is of concern particularly in light of the improved
documentation and increased use of FFR in intermediate lesions
– This may also represent the change in the AUC but since cases
were not reviewed from the sites for this analysis, a direct
comparison cannot be made