HCFA's Health Care Quality Improvement Program and the Cooperative Cardiovascular Project

Recording of quality indicators in the management of acute coronary syndromes: predictors of reperfusion times

BACKGROUND

There is wide variation in recording of reperfusion times in the management of ST segment elevation acute coronary syndromes (ACS). We investigated factors that could predict time to reperfusion.

METHODS

Single-centre, retrospective study of all consecutive patients admitted for primary PCI from June 2009 to October 2010. Door-to-artery (D2A) and Door-to-balloon (D2B) times were calculated from times noted by cathlab. nurses and compared with times from digital recordings of PCI procedures. Predictors of time to reperfusion were identified by logistic regression.

RESULTS

300 patients were included. Median (interquartile range) D2B time recorded by cathlab. nurses (D2B-CN) was 35.5 (24; 52) minutes, 32 (20; 51) min from PCI recordings (D2B-PCI). Average difference between D2B-CN and D2B-PCI was 6.2 min (P < 0.0001). Concordance of percent patients with a D2B time < 90 and < 45 min was mediocre, kappa coefficients 0.44 (95% CI: 0.10-0.79) and 0.68 (95% CI: 0.57-0.80) respectively. By multivariate analysis, older patients had longest D2A times (P = 0.04); patients with longest D2A and D2B times more frequently had elevated creatinine (P = 0.002 (D2A), P = 0.0003 (D2B). Organizational aspects did not influence reperfusion times.

CONCLUSION

Data regarding reperfusion times are unreliable when recorded by nurses. Age and creatinine levels are significantly associated with reperfusion times, whereas organizational aspects are not.

Reperfusion strategy in Europe: temporal trends in performance measures for reperfusion therapy in ST-elevation myocardial infarction

AIMS

The rate and type of reperfusion, as well as time delays to reperfusion are directly associated with mortality and are established as performance measures (PMs) in the treatment of ST elevation myocardial infarction (STEMI). To date, little information exists about PMs for reperfusion in clinical practice in Europe and their temporal changes.

METHODS AND RESULTS

Using the Euro Heart Survey ACS-III data set (2 years of inclusions between 2006 and 2008, 138 centres in 21 countries), we selected patients with STEMI eligible for reperfusion therapy. Recorded variables corresponded to the CARDS data set. The rate and type of reperfusion, as well as door to needle and door to artery times were assessed and compared between periods. Timely reperfusion was defined as a door to needle time < 30 min, or a door to artery time < 90 min. We assessed changes in PMs for reperfusion over the 2 years of recruitment. Among 19 205 patients included in the registry, 7655 had STEMI, and 6481 were admitted within the first 12 h and eligible for reperfusion. The rate of patients who underwent reperfusion increased from 77.2 to 81.3%, with an increase in the use of primary percutaneous coronary intervention (P-PCI). The door to needle and door to artery times decreased significantly during the study period, from 20 to 15 min (P = 0.0011) and from 60 to 45 min (P < 0.0001) respectively. As a result, the number of eligible patients receiving reperfusion therapy in a timely manner increased from 53.1 to 63.5% (P < 0.0001). In parallel, over the 2-year period, in-hospital mortality decreased from 8.1 to 6.6% (P = 0.047).

CONCLUSION

In centres participating in the Euro Heart Survey ACS III, PMs for reperfusion in STEMI improved significantly between 2006 and 2008, with greater use of PCI. Similarly, the rate of patients reperfused in a timely manner also increased, with a significant reduction in door to needle and door to artery times.

Examining guideline-concordant care for acute myocardial infarction (AMI): the case of hospitalized post-acute and long-term care (PAC/LTC) residents

BACKGROUND

Previous studies have examined differences in care for acute myocardial infarction (AMI) according to patient characteristics such as age, gender, or insurance, but little attention has been given to whether admission source is related to guideline adherence.

OBJECTIVE

To investigate: (1) the use of aspirin and reperfusion in the care of post-acute/long-term care (PAC/LTC) patients who are hospitalized for AMI, and (2) 30-day mortality associated with these treatments.

DESIGN

Secondary examination of data from the Cooperative Cardiovascular Project (CCP) national baseline data.

SETTING

A total of 4013 U.S. hospitals.

SUBJECTS

Patients hospitalized with a confirmed AMI admitted from PAC/LTC (n = 8151) or community-dwelling (n = 120,032) settings.

MEASUREMENTS

Early administration of aspirin and reperfusion via either thrombolysis or percutaneous intervention.

RESULTS

PAC/LTC patients were less likely to receive treatment for AMI, even after adjustment for multiple variables associated with treatment choice. Differences persisted with additional econometric adjustment using seemingly-unrelated regression. Multivariable logistic regression results indicated that aspirin was related to improved 30-day survival for both PAC/LTC and community admissions (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.43-0.58 for PAC/LTC, and OR, 0.57; 95% CI, 0.54-0.60 for community). Reperfusion was associated with higher ORs for mortality for eligible patients admitted from community setting (OR, 1.24; 95% CI, 1.13-1.35), but ideally-eligible candidates had lower ORs for mortality (OR, 0.58; 95% CI, 0.35-0.95 for PAC/LTC, and OR, 0.74; 95% CI, 0.68-0.81 for community).

CONCLUSIONS

Patients transferred from PAC/LTC settings were less likely to receive early treatment for AMI than other patients. Future trials should inform which guidelines are applicable to PAC/LTC patients.

Using computerized medical databases to measure and to improve the quality of intensive care

This article reviews the potential for using computerized databases to measure the quality of care in the intensive care unit. There are 2 types of computerized databases used to assess quality of care: administrative databases used primarily for purposes other than medical care and electronic medical record databases collected specifically for clinical purposes. Quality of care is a difficult property to measure but is generally assessed along 3 domains: structure, process, and outcome. There are several problems with using computerized medical databases to measure and improve quality of care. Many factors known to be important to measuring the severity of illness and process of care in critically ill patients are not captured in routine administrative databases. The criteria for the ethical use of electronic medical record data for research, clinical care, and quality improvement are identical to those that should be applied to using paper medical records. Standardizing a minimal intensive care unit dataset, identifying and measuring optimal processes of care, and understanding the limits of risk adjusted outcomes are all important steps in the process of the optimal use of computerized databases to study and improve the quality of care in the intensive care unit.

Process of care and outcome after acute myocardial infarction for patients with mental illness in the VA health care system: are there disparities?

OBJECTIVE

To compare process of care and outcome after acute myocardial infarction, for patients with and without mental illness, cared for in the Veterans Health Administration (VA) health care system.

DATA SOURCES/SETTING

Primary clinical data from 81 VA hospitals.

STUDY DESIGN

This was a retrospective cohort study of 4,340 veterans discharged with clinically confirmed acute myocardial infarction. Of these, 859 (19.8 percent) met the definition of mental illness. Measures were age-adjusted in-hospital and 90-day cardiac procedure use; age-adjusted relative risks (RE) of use of thrombolytic therapy, beta-blockers, angiotensin converting enzyme (ACE) inhibitors, or aspirin at discharge; risk-adjusted 30-day and one-year mortality.

RESULTS

Patients with mental illness were marginally less likely than those without mental illness to undergo in-hospital angiography (age-adjusted RR 0.90 [95 percent confidence interval: 0.83, 0.98]), but there was no significant difference in the age-adjusted RR of coronary artery bypass graft surgery in the 90 days after admission (0.85 [0.69, 1.05]), or in the receipt of medications of known benefit. For example, ideal candidates with and without mental illness were equally likely to receive beta-blockers at the time of discharge (age-adjusted RR 0.92 [0.82, 1.02]). The risk-adjusted odds ratio (OR) for death in patients with mental illness versus those without mental illness within 30 days was 1.00 (0.75, 1.32), and for death within one year was 1.25 (1.00, 1.53).

CONCLUSIONS

Veterans Health Administration patients with mental illness were marginally less likely than those without mental illness to receive diagnostic angiography, and no less likely to receive revascularization or medications of known benefit after acute myocardial infarction. Mortality at one year may have been higher, although this finding did not reach statistical significance. These findings are consistent with other studies showing reduced health care disparities in the VA for other vulnerable groups, and suggest that an integrated health care system with few financial barriers to health care access may attenuate some health care disparities. Further work should address how health care organizational features might narrow disparities in health care for vulnerable groups.

Comparing performance of multinomial logistic regression and discriminant analysis for monitoring access to care for acute myocardial infarction

One way to monitor patient access to emergent health care services is to use patient characteristics to predict arrival time at the hospital after onset of symptoms. This predicted arrival time can then be compared with actual arrival time to allow monitoring of access to services. Predicted arrival time could also be used to estimate potential effects of changes in health care service availability, such as closure of an emergency department or an acute care hospital. Our goal was to determine the best statistical method for prediction of arrival intervals for patients with acute myocardial infarction (AMI) symptoms. We compared the performance of multinomial logistic regression (MLR) and discriminant analysis (DA) models. Models for MLR and DA were developed using a dataset of 3,566 male veterans hospitalized with AMI in 81 VA Medical Centers in 1994-1995 throughout the United States. The dataset was randomly divided into a training set (n = 1,846) and a test set (n = 1,720). Arrival times were grouped into three intervals on the basis of treatment considerations: <6 hours, 6-12 hours, and >12 hours. One model for MLR and two models for DA were developed using the training dataset. One DA model had equal prior probabilities, and one DA model had proportional prior probabilities. Predictive performance of the models was compared using the test (n = 1,720) dataset. Using the test dataset, the proportions of patients in the three arrival time groups were 60.9% for <6 hours, 10.3% for 6-12 hours, and 28.8% for >12 hours after symptom onset. Whereas the overall predictive performance by MLR and DA with proportional priors was higher, the DA models with equal priors performed much better in the smaller groups. Correct classifications were 62.6% by MLR, 62.4% by DA using proportional prior probabilities, and 48.1% using equal prior probabilities of the groups. The misclassifications by MLR for the three groups were 9.5%, 100.0%, 74.2% for each time interval, respectively. Misclassifications by DA models were 9.8%, 100.0%, and 74.4% for the model with proportional priors and 47.6%, 79.5%, and 51.0% for the model with equal priors. The choice of MLR or DA with proportional priors, or DA with equal priors for monitoring time intervals of predicted hospital arrival time for a population should depend on the consequences of misclassification errors.

Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction

OBJECTIVES

The goal of this study was to assess racial differences in process of care and outcome for acute myocardial infarction in the VA health care system.

DESIGN

Retrospective cohort study using clinical data.

SETTING

Eighty-one acute care VA hospitals.

PATIENTS

Four thousand seven hundred sixty veterans discharged with a confirmed diagnosis of acute myocardial infarction. The analysis was restricted to 606 black and 4005 white patients.

MAIN OUTCOME MEASURES

Comparison of use of guideline-based medications, invasive cardiac procedures, and all-cause mortality at 30 days, 1 year, and 3 years.

RESULTS

Black patients were equally likely to receive beta-blockers, more likely than white patients to receive aspirin (86.8% vs. 82.0%; P <0.05), and marginally more likely to receive angiotensin converting enzyme inhibitors (55.7% vs. 49.6%; P = 0.07) at the time of discharge. In contrast, black patients were less likely than white patients to receive thrombolytic therapy at the time of arrival (32.4% vs. 48.2%; P <0.01). There was no significant difference in refusal of angiography or percutaneous transluminal coronary angioplasty between black patients and white patients, or in crude rates of either of these procedures. There was also no difference overall in the percentage of patients who refused coronary artery bypass graft surgery. However, black patients were less likely than white patients to undergo bypass surgery (6.9% vs. 12.5% by 90 days; P <0.001). Black patients remained less likely to undergo bypass surgery even when high-risk specific coronary anatomy subgroups were examined. There was no difference in mortality in the two groups.

CONCLUSIONS

In this integrated health care system, no significant racial disparities in use of noninterventional therapies, diagnostic coronary angiography, or short- or long-term mortality was found. Disparities in use of thrombolytic therapy and coronary artery bypass surgery existed, however, even after accounting for differences in clinical indications for treatment and patient refusals. Further work should assess the role of the medical interaction and physician behavior in racial disparities in use of health care.

Comparison of use of medications after acute myocardial infarction in the Veterans Health Administration and Medicare

BACKGROUND

There is concern that care provided in the Veterans Health Administration (VA) may be of poorer quality than non-VA health care. We compared use of medications after acute myocardial infarction in the VA with that in non-VA healthcare settings under fee-for-service (FFS) Medicare financing.

METHODS AND RESULTS

We used clinical data from 2486 VA and 29 249 FFS men >65 years old discharged with a confirmed diagnosis of acute myocardial infarction from 81 VA hospitals and 1530 non-VA hospitals. We reported odds ratios (ORs) for use of thrombolytics, beta-blockers, ACE inhibitors, or aspirin among ideal candidates adjusted for age, sample design (hospital academic affiliation, availability of cardiac procedures, and volume), and within-hospital clustering. Ideal VA candidates were more likely to undergo thrombolytic therapy at arrival (OR [VA relative to Medicare] 1.40 [1.05, 1.74]) or to receive ACE inhibitors (OR 1.67 [1.12, 2.45]) or aspirin (OR 2.32 [1.81, 3.01]) at discharge and equally likely to receive beta-blockers (OR 1.09 [1.03, 1.40]) at discharge.

CONCLUSIONS

Ideal candidates in VA were at least as likely as those in FFS to receive medical therapies of known benefit for acute myocardial infarction.

Cardiac surgery report cards: comprehensive review and statistical critique

Public report cards and confidential, collaborative peer education represent distinctly different approaches to cardiac surgery quality assessment and improvement. This review discusses the controversies regarding their methodology and relative effectiveness. Report cards have been the more commonly used approach, typically as a result of state legislation. They are based on the presumption that publication of outcomes effectively motivates providers, and that market forces will reward higher quality. Numerous studies have challenged the validity of these hypotheses. Furthermore, although states with report cards have reported significant decreases in risk-adjusted mortality, it is unclear whether this improvement resulted from public disclosure or, rather, from the development of internal quality programs by hospitals. An additional confounding factor is the nationwide decline in heart surgery mortality, including states without quality monitoring. Finally, report cards may engender negative behaviors such as high-risk case avoidance and "gaming" of the reporting system, especially if individual surgeon results are published. The alternative approach, continuous quality improvement, may provide an opportunity to enhance performance and reduce interprovider variability while avoiding the unintended negative consequences of report cards. This collaborative method, which uses exchange visits between programs and determination of best practice, has been highly effective in northern New England and in the Veterans Affairs Administration. However, despite their potential advantages, quality programs based solely on confidential continuous quality improvement do not address the issue of public accountability. For this reason, some states may continue to mandate report cards. In such instances, it is imperative that appropriate statistical techniques and report formats are used, and that professional organizations simultaneously implement continuous quality improvement programs. The statistical methodology underlying current report cards is flawed, and does not justify the degree of accuracy presented to the public. All existing risk-adjustment methods have substantial inherent imprecision, and this is compounded when the results of such patient-level models are aggregated and used inappropriately to assess provider performance. Specific problems include sample size differences, clustering of observations, multiple comparisons, and failure to account for the random component of interprovider variability. We advocate the use of hierarchical or multilevel statistical models to address these concerns, as well as report formats that emphasize the statistical uncertainty of the results.

Outcome of myocardial infarction in Veterans Health Administration patients as compared with medicare patients

BACKGROUND

Some have the opinion that patients cared for in Veterans Health Administration (VHA) hospitals receive care of poorer quality than those cared for in non-VHA institutions. To assess the quality of care in VHA hospitals, we compared the outcome of acute myocardial infarction among patients in VHA and non-VHA institutions while controlling for potential confounders, including coexisting conditions and severity of illness.

METHODS

We studied 2486 veterans discharged from 81 VHA hospitals and 29,249 Medicare patients discharged from 1530 non-VHA hospitals, restricting our samples to men at least 65 years of age who were discharged with confirmed acute myocardial infarction. We compared coexisting conditions, severity of illness, and 30-day and 1-year mortality in the two samples.

RESULTS

VHA patients were significantly more likely than Medicare patients to have a recorded history of hypertension (64.3 percent vs. 57.3 percent), chronic obstructive pulmonary disease or asthma (30.9 percent vs. 23.5 percent), diabetes (34.8 percent vs. 29.0 percent), stroke (20.4 percent vs. 14.2 percent), or dementia (7.2 percent vs. 4.8 percent) (P<0.001 for all comparisons). According to both multivariate logistic regression and an analysis using 2265 matched pairs of VHA and Medicare patients, there were no significant differences in 30-day or 1-year mortality. The matched-pairs analysis found that the difference in mortality at 30 days (the mortality rate among Medicare patients minus the mortality rate among VHA patients), averaged over the 5-year age groups, was -0.8 percent (95 percent confidence interval, -2.8 percent to 1.3 percent), and the difference in mortality at 1 year was -1.3 percent (95 percent confidence interval, -3.9 percent to 1.3 percent).

CONCLUSIONS

VHA patients had more coexisting conditions than Medicare patients. Nevertheless, we found no significant difference in mortality between VHA and Medicare patients, a result that suggests a similar quality of care for acute myocardial infarction.

Collection of process data after cardiac surgery: initial implementation with a Java-based intranet applet

BACKGROUND

Using a Java-based intranet program (applet), we collected postoperative process data after coronary artery bypass grafting.

METHODS

A Java-based applet was developed and deployed on a hospital intranet. Briefly, the nurse entered patient process data using a point and click interface. The applet generated a nursing note, and process data were saved in a Microsoft Access database. In 10 patients, this method was validated by comparison with a retrospective chart review. In 45 consecutive patients, weekly control charts were generated from the data. When aberrations from the pathway occurred, feedback was initiated to restore the goals of the critical pathway.

RESULTS

The intranet process data collection method was verified by a manual chart review with 98% sensitivity. The control charts for time to extubation, intensive care unit stay, and hospital stay showed a deviation from critical pathway goals after the first 20 patients. Feedback modulation was associated with a return to critical pathway goals.

CONCLUSIONS

Java-based applets are inexpensive and can collect accurate postoperative process data, identify critical pathway deviations, and allow timely feedback of process data.

Positive predictive value of the diagnosis of acute myocardial infarction in an administrative database

OBJECTIVE

To determine the positive predictive value of ICD-9-CM coding of acute myocardial infarction and cardiac procedures.

METHODS

Using chart-abstracted data as the standard, we examined administrative data from the Veterans Health Administration for a national random sample of 5,151 discharges.

MAIN RESULTS

The positive predictive value of acute myocardial infarction coding in the primary position was 96.9%. The sensitivity and specificity of coding were, respectively, 96% and 99% for catheterization, 95.7% and 100% for coronary artery bypass graft surgery, and 90.3% and 99. 7% for percutaneous transluminal coronary angioplasty.

CONCLUSIONS

The positive predictive value of acute myocardial infarction and related procedure coding is comparable to or better than previously reported observations of administrative databases.

Modeling case mix adjustment of stroke rehabilitation outcomes

Case mix adjustment models for long-term stroke rehabilitation outcomes should be developed (1) to facilitate equitable comparisons of outcomes across treatment settings, thereby reducing disincentives for treating complex cases, (2) to improve triage into the most appropriate level of rehabilitative care after discharge from acute care, and (3) to confirm that case mix factors are equated in treatment effectiveness studies and by random assignment across conditions in clinical trials. Case mix adjustment is necessary for valid quality improvement processes. A conceptual model of case mix adjustment of long-term rehabilitation outcomes is presented that (1) is diagnosis-specific, (2) includes demographic variables as important case mix factors, (3) encompasses triage into rehabilitation as well as treatment processes as aspects of quality of rehabilitative care, (4) contains outcomes measuring functional status as well as mortality and morbidity, and (5) keys timing of outcomes to onset of conditions requiring rehabilitation rather than discharge from rehabilitation. The number of potential interactions among case mix indicators requires a sophisticated analytic framework. Random factors in the model illustrate that case mix adjustment can never be perfect. Nevertheless, it is essential. A brief review of the stroke literature on prediction of long-term outcomes suggests that additional work is needed to specify relevant case mix indicators.

The need for accurate risk-adjusted measures of outcome in surgery. Lessons learned through coronary artery bypass

OBJECTIVE

The authors review the Pennsylvania Health Care Cost Containment Council reports on coronary artery surgery and compare this reporting structure to others, including the Society for Thoracic Surgeons database, currently used by their own program. The authors review the growing likelihood of a need for outcome measures for all of the surgical subspecialties.

SUMMARY AND BACKGROUND DATA

Pressure from consumers and insurers will require surgical specialties to be graded by objective outcome measures. Practitioners must be prepared and become involved in the process.

METHODS

The authors reviewed the data, which grades all of Pennsylvania's hospitals at which coronary artery bypass is performed. Apparently, the major risk factors commonly employed in most other risk adjustment schemes for cardiac surgery have been deleted, and the practitioners might be judged unfairly. The Pennsylvania system appears to be insurance driven to reward low-cost providers who operate on patients with the lowest risk.

RESULTS

Review of data suggests that the Pennsylvania Health Care Cost Containment Council's annual publication, A Consumer's Guide for Coronary Artery Bypass Surgery, misrepresents fair risk adjustment in favor of lower-risk patients, thereby encouraging better score cards for those institutions with patients who are less ill. Data regarding charges for the procedure have not been risk adjusted or related to a regional economic index.

CONCLUSIONS

Surgeons must prepare to better understand relevant models that evaluate outcome. Cardiothoracic surgery is one of the first specialties to feel the pressures of mandated evaluations, and the lessons learned in Pennsylvania should be applicable to other states and their practitioners.

Participatory continuous improvement

There are a number of limitations to current models of risk-adjusted outcome, continuous quality improvement, the most important of which are the reliance on chart abstraction for data collection, the focus on a procedure rather than a disease with several treatment options, and the emphasis on outcomes--particularly the identification of care providers with high rates of adverse outcomes. In this article, I describe a paradigm that combines clinical information management with quality of care assessment and improvement and that emphasizes the participation of care providers. This participatory continuous improvement model is a synthesis of three existing concepts: (1) continuous quality improvement, (2) intellectually and altruistically motivated self-examination and self-improvement, and (3) a modern medical information system. Important design elements of the participatory continuous improvement model to overcome these limitations include (1) a patient population defined by a disease, or diseases, rather than by a treatment to allow for assessment of the appropriateness and access to care; (2) a database that includes all important patient-level risk, treatment (process), and outcome information; (3) data input by the care provider at the point of care; (4) timely information feedback to care providers in a nonadversarial environment; and (5) public accountability. I believe that participatory continuous improvement models can provide the framework for psychologically sound ways to positively influence practice behaviors, and that this will, in turn, result in improved access to care, quality of care, and cost-effectiveness of care.