NCDR: Physicians Leading the Effort To Quantify Quality


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  • This slide grows by highlighting components one by one. Note meaning of “ 2005Y2 ” = “2005Q2 and previous 3 quarters” to differentiate from “2005Q2” which would indicate just one quarter’s data. We’ve had quite a few questions about that. Emphasize “Best Practice” and note that “Leading” and “Lagging” are for values outside the 10 th and 90 th percentile.
  • Nice cars are no longer just for CV Surgeons! 3-vessel stent bought this cardiologist a very nice blood-red Beamer! With drug-eluting stents, he’ll soon be upgrading to the 7 series.
  • Overview of ACC efforts to achieve quality in imaging, coming from Duke/ACC Summit in 2006. Pamela Douglas and group led the effort to map this strategy. Well underway, follow up summit planned for October 8-10, 2007. ACR is an active participant in this effort.
  • NCDR: Physicians Leading the Effort To Quantify Quality

    1. 1. Ralph G. Brindis, MD, FACC Chief Medical Officer ACC-NCDR November 4, 2007 N ational C ardiovascular D ata R egistry NCDR: Physicians Leading the Effort To Quantify Quality CVS.42: Quality Improvement Initiatives in Cardiology
    2. 2. Disclosure Information NCDR: Physicians Leading the Effort To Quantify Quality Ralph Brindis, MD, MPH, FACC, FSACI Grant support (GS), consultant (C), speakers bureau (SB), stock options (SO), equity interest (EI): NONE Off label use of products will (not) be discussed in this presentation: NONE
    3. 3. Mission of the NCDR™ To improve the quality of cardiovascular patient care by providing information, knowledge and tools; implementing quality initiatives; and supporting research that improves patient care and outcomes.
    4. 4. NCDR is… N ational C ardioVascular D ata R egistry 1998….. 2004 2005 2006 2007 2008 beyond CathPCI Registry ICD Registry CARE Registry ACTION Registry IC3 CAD Imaging Registry HF Registry PracMgt Registry PAD Registry EP Registry Ped. Registry Congenital Registry Building a true… ICD Long Achieve
    5. 5. Registry Projects Registries QI Projects NCDR Management Board NCDR Operations Leadership Team Data Safety Monitoring Board Scientific Oversight Committee Research & Publications Clinical Support.Team Steering Committee CathPCI Registry CARE Registry ICD Registry Committee structure for each registry Includes 30day outcomes ACTION Registry IC 3 Program Steering Committee ACHIEVE Registry Steering Committee ICD Longitudinal Program Steering Committee Take ACTION Campaign Planning Work Group NCDR-D2B Project Managed by ACTION and CathPCI Steering Committees ambulatory longitudinal longitudinal QualityKIT/ CathKIT TBD QI Subcommittee Version 10/29/07 Advisory Council Industry Federal Health Plans Patients
    6. 6. Executive Summary Page
    7. 7. CathPCI™ Report: Executive Summary Median 75 Pctl 25 Pctl 90 Pctl 10 Pctl Your Hospital Best Practice Indicator Detail Line Number Rank percentile Rank Your Hospital
    8. 8. <ul><li>Registry/QI </li></ul><ul><li>>985 hospitals </li></ul><ul><li>6 million patient records </li></ul><ul><li>2 millions PCI records </li></ul><ul><li>Online data entry tool </li></ul><ul><li>Support D2B Alliance </li></ul><ul><li>Analytic Reporting Services </li></ul><ul><li>States – MA, OH, WV, ?CT, ?NJ </li></ul><ul><li>Payers – United, BCBSA, WellPoint </li></ul><ul><li>Research and Publications </li></ul><ul><li>DCRI analytic center </li></ul><ul><li>Over 100 publications </li></ul>
    9. 9. <ul><li>Registry </li></ul><ul><li>1425 enrolled </li></ul><ul><li>200,000 patient records </li></ul><ul><li>Analytic Reporting Services </li></ul><ul><li>UHC </li></ul><ul><li>Discussions with BCBSA </li></ul><ul><li>Provide data to CMS for reimbursement </li></ul><ul><li>Research </li></ul><ul><li>Abstracts at AHA </li></ul><ul><li>ICD Longitudinal Study </li></ul><ul><li>Performing analysis for FDA </li></ul>
    10. 10. <ul><li>Registry </li></ul><ul><li>235 Participants </li></ul><ul><li>> 3,000 patient records </li></ul><ul><li>Data entry tool </li></ul><ul><li>CMS data requirement </li></ul><ul><li>Research </li></ul><ul><li>Analysis for FDA </li></ul><ul><li>Discussion with industry - PMS </li></ul>
    11. 11. <ul><li>Registry </li></ul><ul><li>300 participants </li></ul><ul><li>Over 30,000 records by 9/07 </li></ul><ul><li>Funding provided by </li></ul><ul><ul><li>Genentech </li></ul></ul><ul><ul><li>Bristol-Myers Squibb/Sanofi Partnership </li></ul></ul><ul><ul><li>Schering Plough Corporation </li></ul></ul><ul><li>Analytic Reporting Services </li></ul><ul><li>Early discussions with payers </li></ul>
    12. 12. Concept Outcomes Clinical Trials Guidelines Performance Indicators Performance QUALITY NCDR: ICD, ACTION, CARE, CathPCI & STS The Cycle of Clinical Therapeutic Effectiveness
    13. 13. Benchmarking: Primary PCI % <90 Minutes
    14. 14. 2004 STEMI ACC/AHA Guideline Update & JCAHO Core Measure D2B Alliance Launch
    15. 15. ACC-Quality/CathKIT ™ CQI Tutorial Meeting Standards Reporting & Outcomes Implementing CQI
    16. 17. Hospital PCI Volume and In-Hospital Mortality ACC-NCDR ® 2001-2004 <ul><li>Hospital PCI STEMI Non-STEMI Elective </li></ul><ul><li>Volume (pts) n=90,256 pts n=94,587 pts n=482,960 pts </li></ul><ul><li>≤ 200 vs >800 0.99 (0.75,1.31) 0.64 (0.38,1.06) 1.17 (0.81,1.71) </li></ul><ul><li>201-400 vs >800 0.96 (0.83,1.12) 0.87 (0.68, 1.10) 1.12 (0.96, 1.31) </li></ul><ul><li>401-800 vs >800 0.95 (0.85,1.07) 0.96 (0.81,1.14) 1.10 (0.99,1.22) </li></ul><ul><li>Mortality 4.83% 2.09% 0.41% </li></ul>(Odds Ratio, 95% CI) Zhang et al Circulation 2005 Suppl II;112:792.
    17. 18. Performing Percutaneous Coronary Interventions at Facilities Without On-Site Cardiac Surgical Backup is Increasing A Report From The American College of Cardiology - National Cardiovascular Data Registry Dehmer GJ, Am J Cardiol 2007;99:329-332.
    18. 19. Proportion of Urgent PCIs with and without On-site Surgical Back-up Jan 2001 Dec 2004 Calendar Quarter
    19. 20. Proportion of Elective PCIs with and without On-site Surgical Backup Jan 2001 Dec 2004 Calendar Quarter
    20. 21. PCI With or Without Onsite Surgery Standby ACC-NCDR® 2001-2004 <ul><li>In-hospital Mortality : Offsite vs Onsite CVSx </li></ul><ul><li> Mortality Odds Ratio 95% CI P-value </li></ul><ul><li>No Acute MI (n=482,018) 0.54% vs 0.41% 1.04 (0.67,1.62) 0.87 </li></ul><ul><li>STEMI (n= 90,050) 4.65% vs 4.83% 0.96 (0.72,1.26) 0.75 </li></ul><ul><li>NSTEMI (n=94,347 ) 1.94% vs 2.09% 0.67 (0.40,1.11) 0.12 </li></ul>
    21. 22. PCI With or Without Onsite Surgery Standby ACC-NCDR®: January 2004 - March 2006 <ul><li>404 centers with Surgical Back-up </li></ul><ul><li>61 centers without Surgical Back-up </li></ul><ul><li>299,132 pts from centers with SOS </li></ul><ul><li>9,029 pts from centers without SOS </li></ul><ul><ul><li>13% of Registry PCI patients </li></ul></ul><ul><li>Data verified via Quality Initiative Query </li></ul>
    22. 23. PCI With or Without Onsite Surgery Standby ACC-NCDR® January 2004-March 2006 <ul><li>Unadjusted and Risk Adjusted Mortality </li></ul><ul><li>Emergency CABG rate and CABG Mortality </li></ul><ul><li>Elective and Emergent PCI </li></ul><ul><li>Procedural success </li></ul><ul><li>Door to Balloon times </li></ul><ul><li>Descriptors of care: </li></ul><ul><ul><li>PCI Volume, distance/time/mode of travel for off site Surgery, hospital characteristics, lesion risk, clinical variables for risk adjustment </li></ul></ul>
    23. 24. Improving Continuous Cardiac Care Office-Based Registry
    24. 25. Improving Continuous Cardiac Care – In the Office <ul><li>The first CAD office-based registry </li></ul><ul><ul><li>assess physician adherence to ACC/AHA clinical practice guidelines </li></ul></ul><ul><ul><li>includes patients with Hx of ACS, prior PCI and/or CABG. </li></ul></ul><ul><li>Powerful tool that allows MD/Payer to assess and improve current office-based clinical care. </li></ul>
    25. 26. Philosophy of the IC3 Program <ul><li>Make it easier for busy clinicians to do the right thing for the right patient at the right time </li></ul><ul><ul><li>Track key performance measures </li></ul></ul><ul><ul><ul><li>Internal QI and P4P reporting at the practice level </li></ul></ul></ul><ul><ul><li>Make care more efficient </li></ul></ul><ul><ul><ul><li>A worksheet that readily identifies opportunities to apply CAD guideline recommendations and performance measures </li></ul></ul></ul><ul><ul><li>Coordinate care </li></ul></ul><ul><ul><ul><li>Create a visit summary to communicate with patients and other providers </li></ul></ul></ul>
    26. 27. Measuring CAD Care Patient with stable angina Onset of Acute Coronary Syndrome Post-Hospitalization: Risk factor modification Cardiac rehabilitation D/C PCI/CABG Admit AMI Care NCDR ACTION Cath/PCI IC 3 IC 3 ACTION Follow-up
    27. 28. The IC 3 Registry Pt presents for visit, reports med changes Vitals, health status assessed Physician Visit & Rx Data entered and Clinic Visit Form Generated Treatment plan Data entered Patient Letter & Visit Summary dispensed Visit Summary sent to other care providers Data Entered through NCDR IC 3
    28. 29. IC3 Program Goals <ul><li>Provide QI tools designed for the entire office-based clinical care team </li></ul><ul><li>Create QI tools directed at patients to become active participants and advocates for their own healthcare </li></ul><ul><li>Explore strategies to support continuity of care among the multiple providers caring for an individual patient </li></ul><ul><li>Provide real-time reporting of office-based quality indicators derived from clinical practice guidelines recommendations </li></ul>
    29. 30. IC3 Program Goals <ul><li>Create a trusted mechanism for measuring performance </li></ul><ul><li>Serve as a valuable resource for research aimed at improving the treatment and outcomes of ACS/CAD patients in an ambulatory setting </li></ul><ul><li>Support evolving CMS outpatient quality measures and regulatory reporting initiatives </li></ul><ul><li>Support Pay-for-Performance programs </li></ul>
    30. 31. Sample QI Strategies <ul><li>Patient education resources </li></ul><ul><ul><li>Overview of ACS/CAD </li></ul></ul><ul><ul><li>Explanation of treatment recommendations </li></ul></ul><ul><li>Visit-based summaries of treatment plans </li></ul><ul><ul><li>Printable versions for patients </li></ul></ul><ul><ul><li>Encourage physician to physician communication </li></ul></ul><ul><li>Office identification and tracking systems </li></ul><ul><li>Dissemination of best practices Health status tools and reporting features </li></ul>
    31. 32. ACC’s Appropriateness Criteria: SPECT-MPI Cardiac CT Cardiac MRI Echo: TTE/TEE & Stress Coronary Revascularization: PCI/CABG
    32. 34. 64 Slice Coronary CT
    33. 35. Tools for Achieving Quality in Imaging ACC-Duke Think Tank 2006 JACC 2006 48: 2141 Registries Research Appropriateness criteria Benchmarking Provider education Lab accreditation Technologist cert. Lab accreditation Physician training Physician competency Key data elements Uniform structured reports Timeliness standards Patient Test selection Image acquisition Image interpretation Results communication Better patient care
    34. 36. Pilot Study: Evaluation of Appropriateness of SPECT MPI The American College of Cardiology The American Society of Nuclear Cardiology NCDR
    35. 37. Purpose of the Project <ul><li>Facilitate quality improvements </li></ul><ul><ul><li>Efficient, effective patient care </li></ul></ul><ul><li>Evaluate & promote awareness of appropriateness criteria in practice </li></ul><ul><li>Provide feedback reports to improve both practice-level and individual physician-level adherence to the criteria </li></ul><ul><li>Establish benchmarks to guide performance improvement </li></ul><ul><li>Provide an alternative to prior authorization </li></ul>
    36. 38. SPECT MPI Appropriateness Criteria Implementation Program <ul><li>Paper form and web-based portal for SPECT-MPI data collection, including indications for tests and test results </li></ul><ul><li>Analysis of practice patterns based on appropriateness criteria </li></ul><ul><li>Feedback of benchmarked practice patterns to physicians </li></ul>
    37. 39. Appropriateness Based on Physician Ordering
    38. 40. Anderson et al. Circulation 2005; 112:2786 Indications Relationship between Procedure Indications & Outcomes of PCI: ACC/AHA Guidelines ACC-NCDR
    39. 41. Relationship between Procedure Indications and Outcomes of PCI by ACC/AHA Guidelines Anderson et al. Circulation 2005; 112:2786 Adverse Events ACC-NCDR
    40. 42. Special Efforts in PCI Outcomes Evaluation: DES/BMS Dual Antiplatelet Therapy <ul><li>NCDR Strengths: </li></ul><ul><ul><li>Consecutive patients </li></ul></ul><ul><ul><li>Audited data </li></ul></ul><ul><ul><li>Widespread participation > 1 million/year vs 15k clinical trial </li></ul></ul><ul><ul><li>“ Real life” patients (co-morbid conditions, older) </li></ul></ul><ul><ul><li>“ Real life” physicians (ask Rob Califf) </li></ul></ul><ul><ul><li>Successful FDA – NCDR Groin closure study </li></ul></ul><ul><ul><li>Analytical centers/CV outcomes experts </li></ul></ul>
    41. 43. Special Efforts and DES/DAP going Forward <ul><li>Missing Elements/Challenges </li></ul><ul><ul><li>Longitudinal Projects/Registries difficult to launch </li></ul></ul><ul><ul><ul><li>Patient, Hospital, MD, Industry incentives </li></ul></ul></ul><ul><ul><ul><li>Burden of longitudinal data collection- varying models </li></ul></ul></ul><ul><ul><ul><li>HIPAA issues- unique patient identifiers </li></ul></ul></ul><ul><ul><ul><li>IRB approval - not required for “In hospital” QI Registries but would most likely required for longitudinal f/u </li></ul></ul></ul><ul><ul><ul><li>Funding, funding, funding, funding </li></ul></ul></ul><ul><ul><li>Registries- good for QI, safety, and measuring and benchmarking many outcomes but not ideal/challenging for use in clinical trials </li></ul></ul>
    42. 44. NCDR Data Merging Partnerships <ul><li>AHRQ- DEcIDE Collaborative with DCRI </li></ul><ul><ul><li>NCDR patients </li></ul></ul><ul><ul><ul><li>600 sites, 2002-2006- 900,000 PCI’s of which 712,000 DES </li></ul></ul></ul><ul><ul><li>Linkage of NCDR with complete Medicare files </li></ul></ul><ul><ul><ul><li>Creating a longitudinal database </li></ul></ul></ul><ul><ul><li>Linkage with HMORN </li></ul></ul><ul><ul><ul><li>Kaiser patient data-pharmacy, costs, and longitudinal results </li></ul></ul></ul><ul><ul><li>Real world outcomes assessment tracking </li></ul></ul><ul><ul><li>DES use/outcomes </li></ul></ul>
    43. 45. AHRQ- DEcIDE Collaborative with DCRI <ul><li>Linkage procedure via probabilistic matching </li></ul><ul><ul><li>Provider #, record #(unique encrypted identifier), DOB, sex, admit/discharge dates </li></ul></ul><ul><ul><li>Match with CMS with very high degree of accuracy </li></ul></ul><ul><ul><li>HIPAA compliant- “limited dataset” without patient direct identifiers (no name or SSN) </li></ul></ul><ul><ul><li>Longitudinal records: f/u hospitalizations, death </li></ul></ul>
    44. 46. AHRQ- DEcIDE Collaborative with DCRI <ul><li>Goals </li></ul><ul><ul><li>Describe temporal trends of DES/BMS </li></ul></ul><ul><ul><li>Analyze downstream DES/BMS patient outcomes </li></ul></ul><ul><ul><ul><li>readmissions, MI’s, repeat revascularizations, and death </li></ul></ul></ul><ul><ul><ul><li>Role of DAT- length of use post implantation </li></ul></ul></ul><ul><ul><li>Create conceptual model of stent decision making </li></ul></ul><ul><ul><li>Feedback to clinicians-outcomes, workshops, publications, education tools, etc </li></ul></ul>
    45. 47. AHRQ- DEcIDE Collaborative with DCRI <ul><li>Advantages of NCDR large patient base </li></ul><ul><ul><li>Assess low frequency adverse events </li></ul></ul><ul><ul><li>Subgroup patients of interest: </li></ul></ul><ul><ul><ul><li>Women </li></ul></ul></ul><ul><ul><ul><li>Minorities </li></ul></ul></ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul><ul><ul><ul><li>Acute coronary syndromes </li></ul></ul></ul><ul><ul><ul><li>Very elderly (>80years) </li></ul></ul></ul><ul><ul><ul><li>Renal failure </li></ul></ul></ul>