ACC: Cards need to embrace quality metrics (Part One)
NEW ORLEANS—The cardiology profession seems to suffer from a collective case of magical thinking, offered Charles McKay, MD, of the University of California - Los Angeles. Symptoms include a sense that quality measurement is not real, an insistence that decision support is unnecessary and a belief that hospitals don’t care about quality. Researchers shared data from five outcome studies that addressed these sacred cows, during a presentation at the annual meeting of the American College of Cardiology (ACC). (The first three studies are profiled below. Read CVB Daily on April 12 for the final two.)
McKay confirmed the tremendous variations in performance and outcomes and emphasized that the specialty needs to address the situation. “Hospitals are going to be measured on administrative data [quality]. Cardiologists need to take responsibility for clinical data.”
PCIs and appropriate use
“There is substantial variation in the use of percutaneous coronary intervention (PCI) in the U.S. The underlying reasons are of great interest. One potential explanation is the appropriateness of angioplasties,” said Paul Chan, MD, of St. Luke's Mid America Heart Institute in Overland Park, Kan.
Appropriate use criteria (AUC) cover 198 clinical scenarios. Chan and colleagues undertook a study to determine the portion of PCIs categorized as appropriate, uncertain and inappropriate. The dataset was comprised of 500,000 patients over a 15-month period from 2009 to 2010.
Aggregate results showed that 84.6 percent of PCIs were appropriate, 11.2 percent were uncertain and 4.2 were inappropriate.
However, a subset analysis of non-acute elective procedures indicated that 50.4 percent were appropriate, 38.0 percent were uncertain and 11.6 percent were inappropriate.
The researchers found substantial variation among hospitals’ rates of inappropriate PCIs. Chan shared, “The next steps are to better understand the reasons for inappropriate PCIs at hospitals with high rates.”
Decision support and medication errors
Sylvia Oleck, MD, of the internal medicine program at the Ochsner Clinic Foundation in New Orleans, and colleagues hypothesized that computer-assisted decision support (CADS) could help reduce medication errors in acute coronary syndrome dialysis patients. Oleck cited earlier research showing that 22.3 percent of acute coronary syndrome dialysis patients had received a contradicted antithrombotic medication, which increased risk of bleeding and death.
The study examined 80 consecutive acute coronary syndrome patients requiring dialysis admitted to the hospital between 2009 and 2010. Physicians had the option of using a standard order set or CADS.
Oleck and colleagues found medication misuse in 17 percent of the standard order cohort and none in the CADS cohort. The standard order set cohort also had length of stay nearly double that of the CADS group, at 9.1 days vs. 4.8 days. The final finding, shared Oleck, was a nearly sixfold increase in in-hospital bleeding among the standard order group.
She concluded, “Use of CADS in acute coronary syndrome patients requiring dialysis reduces medication errors and results in reductions in bleeding and length of stay.”
Global antithrombotic guidelines compliance varies
RealiseAF is an international, large-scale, cross-sectional contemporary registry. Habib Gamra, MD, of the cardiology department at Fattouma Bourguiba University Hospital in Monastir, Tunisia, and colleagues leveraged the registry of 10,523 patients to determine adherence to antithrombotic guidelines.
The researcher found misuse in the 25 percent range, and reported that atrial fibrillation management deviates from guidelines with both overuse and underuse of antithrombotic treatment. In fact, oral anticoagulants were not prescribed to about half of patients with a CHADS2 score > 2.
“We need education to promote use of guidelines,” concluded Gamra.
McKay confirmed the tremendous variations in performance and outcomes and emphasized that the specialty needs to address the situation. “Hospitals are going to be measured on administrative data [quality]. Cardiologists need to take responsibility for clinical data.”
PCIs and appropriate use
“There is substantial variation in the use of percutaneous coronary intervention (PCI) in the U.S. The underlying reasons are of great interest. One potential explanation is the appropriateness of angioplasties,” said Paul Chan, MD, of St. Luke's Mid America Heart Institute in Overland Park, Kan.
Appropriate use criteria (AUC) cover 198 clinical scenarios. Chan and colleagues undertook a study to determine the portion of PCIs categorized as appropriate, uncertain and inappropriate. The dataset was comprised of 500,000 patients over a 15-month period from 2009 to 2010.
Aggregate results showed that 84.6 percent of PCIs were appropriate, 11.2 percent were uncertain and 4.2 were inappropriate.
However, a subset analysis of non-acute elective procedures indicated that 50.4 percent were appropriate, 38.0 percent were uncertain and 11.6 percent were inappropriate.
The researchers found substantial variation among hospitals’ rates of inappropriate PCIs. Chan shared, “The next steps are to better understand the reasons for inappropriate PCIs at hospitals with high rates.”
Decision support and medication errors
Sylvia Oleck, MD, of the internal medicine program at the Ochsner Clinic Foundation in New Orleans, and colleagues hypothesized that computer-assisted decision support (CADS) could help reduce medication errors in acute coronary syndrome dialysis patients. Oleck cited earlier research showing that 22.3 percent of acute coronary syndrome dialysis patients had received a contradicted antithrombotic medication, which increased risk of bleeding and death.
The study examined 80 consecutive acute coronary syndrome patients requiring dialysis admitted to the hospital between 2009 and 2010. Physicians had the option of using a standard order set or CADS.
Oleck and colleagues found medication misuse in 17 percent of the standard order cohort and none in the CADS cohort. The standard order set cohort also had length of stay nearly double that of the CADS group, at 9.1 days vs. 4.8 days. The final finding, shared Oleck, was a nearly sixfold increase in in-hospital bleeding among the standard order group.
She concluded, “Use of CADS in acute coronary syndrome patients requiring dialysis reduces medication errors and results in reductions in bleeding and length of stay.”
Global antithrombotic guidelines compliance varies
RealiseAF is an international, large-scale, cross-sectional contemporary registry. Habib Gamra, MD, of the cardiology department at Fattouma Bourguiba University Hospital in Monastir, Tunisia, and colleagues leveraged the registry of 10,523 patients to determine adherence to antithrombotic guidelines.
The researcher found misuse in the 25 percent range, and reported that atrial fibrillation management deviates from guidelines with both overuse and underuse of antithrombotic treatment. In fact, oral anticoagulants were not prescribed to about half of patients with a CHADS2 score > 2.
“We need education to promote use of guidelines,” concluded Gamra.