Weiner scai 2013 poster final


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Weiner scai 2013 poster final

  1. 1. Effect of ACE Catheterization LaboratoryAccreditation on Hospital NCDR CathPCIReports• 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
  2. 2. Background• Accreditation is an approach intended to improvequality– ACE has been accrediting cardiac catheterizationlaboratories for 2 years– The process includes both internal gap analysis andexternal review to result in a comprehensivecorrective action plan• The purpose of this analysis was to determine if theaccreditation process led to changes in quarterlyNCDR CathPCI Registry Reports
  3. 3. Methods• All facilities submitted their most recent CathPCI Registry report aspart 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 accreditationapplication were required for inclusion in the analysis• Data were abstracted from the detail section of the CathPCIRegistry reports by quarter• Sixty-one variables were selected for analysis• Based on importance as potential quality metrics or clinicallyrelevant characteristics• Potential changes related to the accreditation process• Comparisons between baseline and post accreditation were made usingJMP software (SAS, Version 10.0.2)• Comparisons between sites were made using Chi Squared analysis
  4. 4. Results
  5. 5. Results: All PatientsCanadian Cardiovascular Society Class II AnginaThere was no difference in thepercentage of patients with NoAngina, Class I, III, or IV angina.Few patients underwentprocedures with no angina or ClassI angina at either timepoint. Thepercentage of patients with ClassIII or IV angina was unchanged overtime. The reduction in Class IIangina suggests a more measuredapproach to treatment of patientswith moderate anginaP=0.0326
  6. 6. Results: All PatientsAnti-anginal therapy in the past 2 weeks (notACS Patients)The use of Anti-anginal therapy wasrecorded more frequently followingaccreditation than it was at baseline.This was particularly true for thenon-ACS patients. A similar trend(p=0.07) was seen in the ACS patientsbut it did not reach statisticalsignificance. This is also consistentwith the reporting of less Class IIangina shown previously.More patients had CHF reportedwithin the 2 weeks prior tocatheterization (p=0.0521) followingaccreditation than occurred atbaseline.p=0.0028
  7. 7. Results: All PatientsHigh Risk Stress TestConsistent with the previousfindings, a higher percentage ofpatients had high risk stress testsat the later time point than didearlier. There was no change inthe frequency of low orintermediate risk stress testsreported.p=0.005
  8. 8. Results: PCI PatientsCanadian Cardiovascular Society Class II AnginaIn PCI patients there was nodifference in the percentage ofpatients with No Angina, Class I,III, or IV angina. Few patientsunderwent procedures with noangina or Class I angina at eithertimepoint.The reduction in Class II anginapresent at the time of PCI suggeststhat fewer patients with lesssevere angina are being treated byPCI. This could indicate betteradherence to guidelinerecommendations and the AUCfollowing accreditationP=0.0396
  9. 9. Results: PCI PatientsFFR in Intermediate LesionsFFR >0.75FFR ≤ 0.75A similar percent of elective patientswho underwent PCI had some type ofischemic assessment (abnormal stresstests or FFR ≤ .75) performed (59.9 ±19.6% (baseline) vs. 64.4 ± 15.8%(post))The figure shows that the percent ofintermediate lesions (40-70% stenoses)undergoing FFR assessment increasedfollowing accreditation.Note: for FFR findings to beentered, PCI must be selected as aprocedure during data entry. Thereforethe increase in the frequency of FFRs >0.75 does not reflect an increase in PCIbeing performed on these lesions. Itmore reflects higher utilization of thetechnology for ischemia documentationand in this case possibly deferring of PCIp=0.0054p<0.0001
  10. 10. Results: PCI AUC (notACS PatientsMore patients were evaluable bythe AUC criteria afteraccreditation than at baseline(84.5 ± 7.3% vs. 91.0 ± 4.8%). Thisagain reflects improveddocumentation including morecomplete reporting of thosecharacteristics that contribute tothe AUC calculation.Evaluable Patientsp=0.0005
  11. 11. Results: PCI AUC (not ACS Patients)Appropriate Uncertain InappropriateBetween 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 mayrepresent change in those criteria, rather than a real change in the frequencies of appropriate andinappropriate cases being performed or the documentation to support the characterization.In ACS patients there was no difference in “Appropriate” or “Inappropriate” characterization. A smallnumber 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
  12. 12. AUC conclusions• A higher percentage of patients were evaluable by the AUC followingaccreditation than were at baseline– This is likely do to more complete documentation• Documentation gaps were frequently identified during theaccreditation visit and corrective action plans were implemented toaddress this issue• Frequent recommendation for increased use of in lab assessment tools• In ACS patients no change in “appropriate” or “inappropriate” classificationwas 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
  13. 13. Summary• Overall changes in cath lab practices have occurred over the timerepresented in this analysis• A finding from our initial accreditations reviews demonstratedgaps in documentation (SCAI 2012)– These gaps were addressed as part of the corrective actionplan for each site• Improved documentation is reflected in the current finding ofincreased reporting of medication use, more high risk stress testsand more evaluable patients by AUC
  14. 14. Summary• The only change in ACS patients was an increase in the frequency of“uncertain” categorization.– Although documentation is improved as noted above, this findingmay primarily represent the difference between 2009 and 2012AUC.• In the Non-ACS patients, the reduction in the frequency ofappropriate categorization coupled with an increase in inappropriatecategorization is of concern particularly in light of the improveddocumentation and increased use of FFR in intermediate lesions– This may also represent the change in the AUC but since caseswere not reviewed from the sites for this analysis, a directcomparison cannot be made