This document summarizes the results of the initial site visits and reviews conducted as part of the Accreditation for Cardiovascular Excellence (ACE) accreditation process for 10 facilities. It found significant variation between facilities in completeness of documentation for variables related to quality assurance, risk adjustment, and appropriate use determination. Improvement is needed to ensure complete and consistent documentation across facilities in order to adequately assess quality and validate data used for public reporting, risk adjustment, and audits.

2. Accreditation for Cardiovascular
Excellence (ACE): The First
Experience with Process
Reviews
• Bonnie H. Weiner MD MSEC MBA, FSCAI FACC
– Accreditation for Cardiovascular Excellence
• Ralph G. Brindis MD MPH, FSCAI MACC
– Oakland Kaiser Medical Center
• Charles E. Chambers MD, FSCAI FACC
– Penn State Hershey Heart and Vascular Institute
• Gregory J. Dehmer MD, FSCAI FACC
– Scott & White Clinic
• Christopher J. White MD, FSCAI FACC
– Oschner Medical Center
• April W. Simon RN, MSN
– Cardiac Data Solutions, Inc.
• Kimberly Wright, RN
– Cardiac Data Solutions, Inc
• Mary E. Heisler RN
– Accreditation for Cardiovascular Excellence

3. Background
• Accreditation for Cardiovascular Excellence (ACE) is a non profit
organization performing accreditation services for invasive and
interventional cardiovascular procedures. This report is of the
reviews of the initial 10 facilities that have been site visited as
part of the process

4. Overview
of ACE
Process

5. Methods:
• Documents Reviewed
• All ACE Standard related policy and procedure documents
• Medical records
• History and Physical
• Office notes when available
• Prior hospitalizations
• Catheterization reports
• Reviewed for
• Completeness and
• Compliance with ACE standards
• All data are entered into an online case report form that populates
the database
• Exported directly from the database as individual records
• Analyzed in JMP® (version 10.0.0)
• Test for Homogeneity between facilities was performed
using Chi-Squared and Pearson Coefficient for
categorical variables
• All characteristics referred to in the ACE Standards
• Meeting the standard
• Partially meeting the standard
• Not meeting meeting the standard
• Variables for risk adjustment or appropriate use criteria (AUC) in
NCDR’s CathPCI.
• Recorded (validated against data submitted)
• Not Recorded (Information is not found anywhere in the
medical record)
• Does not Apply

6. Results: Quality Assurance Process (n=10 Facilities)
100%
10%
90% 20% 20% 20%
80% 40%
50%
70%
60%
50%
Does Not Meet
90%
40% 20% 80% 80% 80% Partially Meets
Meets ACE Criteria
30% 60%
20%
30%
10%
0%
Integrated Review for Major Individual Administration Quality
Quality Diagnostic Complication Operator Involvement Conference
Program Exists Accuracy and Reviews Complications
Quality Reviewed

7. RESULTS: Joint Commission (TJC) Variables
Diagnostic Cath/PCI PCI Only All Cases
Catheterization N=243 N=20 N=441
N=178 (39.3%) (55.8%) (4.8%) (100%)
Meets Reporting 169 (94.9%) 224 (92.2%) 18 (90.0%) 411 (93.2%)
Requirements (58.3-100%) (75-100%) (50-100%) (81.2-100%)
Documentation of 168 (92.1%) 235 (97.9%) 17 (100%) 419 (95.7%)
Complications (18.2-100%) (90.9-100%) (67.6-100%)
Any Radiation 150 (84.3%) 214 (89.5%) 16 (80.0%) 380 (87.0%)
Monitoring (8.3-100%) (8.3-100%) (0-100%) (7.1-100%)
Both Fluoro Time 132 (74.2%) 191 (80.3%) 15 (75.0%) 338 (77.5%)
and Air Kerma (14.3-100%) (9.5-100%) (0-100%) (3.6-100%)
recorded
There was significant variation between institutions in all parameters above for
all procedure types p<0.0001

8. PCI Variables used by NCDR for Procedure Risk Adjustment
Variables Recorded Not Recorded P Value for
between facility
Coded on variability
Admission
Age 252 (98.4%) 4 (1.6%) NS
(90-100%) (0-9.5%)
BMI 208 (81.6%) 47 (18.4%) <0.0001
(66.7-100%) (0-33.3%)
Cardiogenic Shock on 18 (7.0%) 239 (93.0%) <0.0001
Admission (0-56.3%) (37.5-100%)
History of CHF 37(15.5%) 218 (84.5%) 0.0004
(9.5-100%) (14.3-100%)
Previous Valve 9 (9.3%) 244 (90.7%) <0.0001
Surgery (0-37.5%) (43.8-100%)
Cerebrovascular 18 (8.6%) 235 (91.4%) <0.0001
Disease (0-37.5%) (43.8-100%)
Peripheral Vascular 27 (12.0%) 231 (88.0%) <0.0001
Disease (0-43.8%) (56.3-100%)
Diabetes 96 (37.2%) 162 (62.8%) 0.0189
(24.4-62.5%) (31.2-75.6%)
Chronic Lung Disease 27 (10.4%) 332 (89.6%) <0.0001
(0-31.2%) (68.8-96.8%)
Prior PCI 104 (40.3%) 154 (59.7%) 0.0104
(20-87.5%) (12.5-72.7%)
GFR 222 (85.4%) 38 (14.6%) 0.0014
(53.3-100%) (0-46.7%)
Dialysis 4 (1.5%) 255 (98.5%) <0.0001
(0-6.2%) (93.9-100%)
NYHA Classification 54 (21.8%) 205 (79.2%) <0.0001
(0—100%) (0-100%)
Elevated Biomarkers 115 (44.9%) 141 (55.1%) 0.0004
(13.8-73.9%) (33.3-86.1%)

9. RESULTS: NCDR Risk Variables for PCI Procedures
Procedural Recorded Not Recorded P Value for between
facility variability
Variables
Pre Procedure IABP 17 (6.5%) 243 (93.5%) <0.0001
(0-75%) (25-100%)
Ejection Fraction 204 (79.1%) 54 (21.9%) 0.025
(56.2-95.4%) (4.6-43.8%)
PCI Status Elective: 125(48.4%) 18 (7.0%) <0.0001
Emergent: 31 (12.0%) (0-29%)
Urgent: 82 (31.8%)
Salvage:2 (0.58%)
Lesion≥50% and subacute 63 (24.5%) 194 (75.5%) <0.0001
thrombosis (0-55.6%) (44.4-100%)
Pre Procedure TIMI Flow 145(56.0%) 114 (44.0%) <0.0001
(0-97.2%) (2.8-100%)
Highest Risk Lesion 48 (18.6%) 210 (81.4%) <0.0001
(0-67.7%) (32.3-100%)
Lesion Location 252 (98.0%) 5 (2.0%) NS
(93.2-100%) (0-6.8%)

10. RESULTS: Selected Appropriate Use Determination
Variables for Non-Emergent Procedures (n=144)
100% 95% 94%
91%
90%
83%
80%
70%
61% 61%
60% 50%
50% 49%
50%
38%
40% Yes
28% 29% No
30%
Not Available
20% 15%
11% Unknown
10% 8% 10% 9% 7% 6%
5%
1%
0%

11. Other Outcome Characteristics: All
PCI Patients (n=258)
100.0% 92.3%
87.1% 89.2%
90.0%
80.0%
70.0%
60.0%
50.0% Yes
40.0% No
Data Unavailable
30.0%
20.0% 9.7%
10.2%
7.4%
10.0% 2.7% 1.2% 0.4%
0.0%
Attributable 30 Day 30 Day CIN
Re-Admission Mortality
There was significant variation between institutions in these parameters
p<0.0001

12. Summary:
• ACE Process Findings:
– Documentation of critical information required for risk adjustment
and appropriate use determination are frequently missing.
– There is a high degree of variability among facilities in the
completeness of their documentation.

13. Conclusions
• Improvement in facility level documentation is necessary to
adequately validate data used for risk stratification and
appropriate use determination.
• Facility-based quality improvement teams and cath lab personnel
including physicians, must assure completeness of data collection
to reduce variability.
• Process improvement at the facility level will improve the quality
of the data used for public reporting and also protect the facility
from external regulatory and fiscal audits.