Door to Balloon Times:

Achieving 90 Minutes and

Less

Door to Balloon Times:

Achieving 90 Minutes and

Less

Quality Update from ACC

West Virginia Chapter3rd Annual Meeting

November 22, 2008

Quality Update from ACC

West Virginia Chapter3rd Annual Meeting

November 22, 2008

D2B Alliance D2B-Sustain the Gain Appropriateness Criteria App Use Criteria IC3 = Improving Continuous Cardiac Care

D2B Alliance D2B-Sustain the Gain Appropriateness Criteria App Use Criteria IC3 = Improving Continuous Cardiac Care

Janet Wright MD FACCSr VP of Science and Quality

020

40

60

80

100

120

Door-to

-balloon tim

e (m

inute

s)

Jan 99 Jul 00 Jan 02 Jul 03Month

Median Door-to-Balloon Time

McNamara et al., JACC, 2006

D2B Alliance GoalD2B Alliance Goal

Goal: –To achieve a door-to-balloon

time of ≤ 90 minutes for at least 75% of non-transfer primary PCI patients with STEMI.

Goal: –To achieve a door-to-balloon

time of ≤ 90 minutes for at least 75% of non-transfer primary PCI patients with STEMI.

Evidence-based Strategies that Reduce Treatment

Delays

Evidence-based Strategies that Reduce Treatment

Delays

1. ED physician activates the cath lab

2. One call activates the cath lab

3. Cath lab team ready in 20-30 minutes

4. Prompt data feedback

5. Senior management commitment

6. Team-based approach

*Optional: Pre-hospital ECG to activate the cath lab if feasible

1. ED physician activates the cath lab

2. One call activates the cath lab

3. Cath lab team ready in 20-30 minutes

4. Prompt data feedback

5. Senior management commitment

6. Team-based approach

*Optional: Pre-hospital ECG to activate the cath lab if feasible

D2B Alliance: TimelineD2B Alliance: Timeline

Krumholz HM et al. JACC-Cardiovascular Intervention 2008;1:97-104

More than 1,000 hospitalsjoined the effortMore than 1,000 hospitalsjoined the effort

ACC NCDR Cath-PCI Registry% D2B <90 minACC NCDR Cath-PCI Registry% D2B <90 min

62%

82%

71% 72%76% 79%

0%

20%

40%

60%

80%

100%

Q3 07 Q4 07 Q1 08 Q2 08

Goal Attained!!!ACTION Quarter Results -Non-Transfer Patients with DTB 90 mins

Non-transfer patients represent 67% of primary PCI population

Use of strategies in D2B Alliance hospitals changedUse of strategies in D2B Alliance hospitals changed

Recommended Strategy Baseline Follow-up

ED physician activates lab 52% 60%

Single call activates lab 31% 37%

Cath team in 20-30 minutes 81% 89%

Prompt data feedback 61% 79%

Team-based approach 64% 85%

PH ECG activates lab 33% 41%

Recommended Strategy Baseline Follow-up

ED physician activates lab 52% 60%

Single call activates lab 31% 37%

Cath team in 20-30 minutes 81% 89%

Prompt data feedback 61% 79%

Team-based approach 64% 85%

PH ECG activates lab 33% 41%

What is Next?What is Next?

The D2B-Sustain the Gain Program

Many hospitals – still actively implementing six strategies

ACC – will continue support – web pages, listserve support on bi-monthly webinars

MOC IV Certification Points available for QI activity Alignment with AHA’s Mission LIfeline

The D2B-Sustain the Gain Program

Many hospitals – still actively implementing six strategies

ACC – will continue support – web pages, listserve support on bi-monthly webinars

MOC IV Certification Points available for QI activity Alignment with AHA’s Mission LIfeline

Why ACCF Appropriate Use Criteria?Why ACCF Appropriate Use Criteria?

Improve utilization of resource-intensive tests and procedures– Developed by physicians/providers– Literature-based (when possible) approach– Initial focus on advanced diagnostic cardiac imaging– Expansion to revascularization, potential for other

procedures

Focused reduction of procedures based on clinical value and practice patterns, not indiscriminant volume reduction

Facilitates continuous quality improvement though education and feedback

Preserves patient/provider relationship

Provides for continued patient access

Improve utilization of resource-intensive tests and procedures– Developed by physicians/providers– Literature-based (when possible) approach– Initial focus on advanced diagnostic cardiac imaging– Expansion to revascularization, potential for other

procedures

Focused reduction of procedures based on clinical value and practice patterns, not indiscriminant volume reduction

Facilitates continuous quality improvement though education and feedback

Preserves patient/provider relationship

Provides for continued patient access

The Appropriate Use Criteria QueueThe Appropriate Use Criteria Queue

√ Nuclear cardiology (SPECT MPI)October 2005

√ Cardiac CT/MR September 2006

√ Echocardiography (Transthoracic/Transesophageal)June 2007

√ Echocardiography (Stress)December 2007

Revascularization (PCI and CABG)December 2008 (In Press)

Revised SPECT Criteria (in preparation) CV imaging cross modality (efficiency) evaluation

√ Nuclear cardiology (SPECT MPI)October 2005

√ Cardiac CT/MR September 2006

√ Echocardiography (Transthoracic/Transesophageal)June 2007

√ Echocardiography (Stress)December 2007

Revascularization (PCI and CABG)December 2008 (In Press)

Revised SPECT Criteria (in preparation) CV imaging cross modality (efficiency) evaluation

Implementation and EvaluationImplementation and Evaluation

Development of methodology and publication of Criteria is not enough to ensure change in clinical practice

Formation of AUCIE (Appropriate Use Criteria Implementation and Evaluation) Working Group– Education/Communication (Kim Williams)– Implementation Tools (electronic) (Michael Mirro)– Databases and Registries (James Min)– CMS Demonstration Pilot Proposal (Eric Peterson)– Performance Measurement Development (Robert Hendel)

ACCF/United Healthcare SPECT Appropriateness Pilot

MIPPA mandate for Appropriateness Criteria Demo

Development of methodology and publication of Criteria is not enough to ensure change in clinical practice

Formation of AUCIE (Appropriate Use Criteria Implementation and Evaluation) Working Group– Education/Communication (Kim Williams)– Implementation Tools (electronic) (Michael Mirro)– Databases and Registries (James Min)– CMS Demonstration Pilot Proposal (Eric Peterson)– Performance Measurement Development (Robert Hendel)

ACCF/United Healthcare SPECT Appropriateness Pilot

MIPPA mandate for Appropriateness Criteria Demo

Evaluation of AppropriatenessEvaluation of Appropriateness

Appropriate Uncertain Inappropriate

Hendel, 2006 83% 6% 11%

Williams, 2006 78% 5% 8%

Ayyad, 2007 85% 5% 10%

Druz, 2007 57% 33% 10%

Gaztanega, 2007 55% 28% 17%

Al-Mallah, 2007 75% 12% 13%

Gibbons, 2008 64% 11% 14%

ACCF/ASNC & United Healthcare Partnership

Pilot Project GoalsACCF/ASNC & United Healthcare Partnership

Pilot Project Goals Quality Improvement

– Effective patient care– Efficient care

Assess Validity of Appropriateness Criteria– Provide data for revisions/updates– Determine threshold levels of performance

Assess Practice Patterns– Feedback to practice & individual physician– Identify areas for improvement

Analysis of Decision Making– Correlation of level of appropriateness and image findings/patient

outcome Alternative to Prior Notification/Prior Authorization

Quality Improvement– Effective patient care– Efficient care

Assess Validity of Appropriateness Criteria– Provide data for revisions/updates– Determine threshold levels of performance

Assess Practice Patterns– Feedback to practice & individual physician– Identify areas for improvement

Analysis of Decision Making– Correlation of level of appropriateness and image findings/patient

outcome Alternative to Prior Notification/Prior Authorization

Pilot Project MethodologyPilot Project Methodology

Sites– 7 participating sites– Cross-country geographic representation from Oregon to

Florida Data Collection

– Collected at imaging facility and feedback on practice patterns sent by sites to referring physicians

– ALL SPECT MPI patients at participating practices– Collected on paper form and entered online at practice site – Collect data to evaluate appropriate use and test result

Education and Feedback– Practice pattern reports– Change behavior at point of order with educ & tools

Sites– 7 participating sites– Cross-country geographic representation from Oregon to

Florida Data Collection

– Collected at imaging facility and feedback on practice patterns sent by sites to referring physicians

– ALL SPECT MPI patients at participating practices– Collected on paper form and entered online at practice site – Collect data to evaluate appropriate use and test result

Education and Feedback– Practice pattern reports– Change behavior at point of order with educ & tools

Data Collection FormData Collection Form

Front page– Patient

demographics– History & risk

factors– Prior procedures &

tests

Back page– Current study– Reference section

Designed to be completed in one minute or less

Front page– Patient

demographics– History & risk

factors– Prior procedures &

tests

Back page– Current study– Reference section

Designed to be completed in one minute or less

Most patients classified as to level of appropriateness Findings consistent with other studies

– Wide practice variation– Few indications account for majority of inappropriates– Greater frequency of inappropriate tests from outside of

lab Collection of test results

– Validate criteria – Potential to be used to track downstream utilization –

value of test (separate project - planning cohort study for CCTA)

Most patients classified as to level of appropriateness Findings consistent with other studies

– Wide practice variation– Few indications account for majority of inappropriates– Greater frequency of inappropriate tests from outside of

lab Collection of test results

– Validate criteria – Potential to be used to track downstream utilization –

value of test (separate project - planning cohort study for CCTA)

Preliminary FindingsPreliminary Findings

Preliminary DataPreliminary Data

Data collection from March 3 -July 31, 2008

6/7 sites entering data

3,035 studies

256 excluded– 173 for insufficient data

(64% from single practice)

– 82 for conflicting scores

Data collection from March 3 -July 31, 2008

6/7 sites entering data

3,035 studies

256 excluded– 173 for insufficient data

(64% from single practice)

– 82 for conflicting scores

18%

16% 66%

AppropriateUncertainInappropriate

n = 2,779

Pilot Site Specific ResultsPilot Site Specific Results

Site N Appropriate Uncertain Inappropriate Not classified

#1 157 55% 15% 22% 5%

#2 811 54% 8% 22% 14%

#3 728 60% 17% 17% 2%

#4 861 60% 21% 13% 3%

#5 291 79% 6% 11% 2%

#6 187 59% 19% 18% 2%

Most Common “Inappropriate” IndicationsMost Common “Inappropriate” Indications

INDICATION FREQUENCY PERCENT

Detection of CADAsymptomatic, low CHD risk

262 9%

Asymptomatic, post-revascularization< 2 years after PCI, symptoms before PCI

91 3%

Evaluation of chest pain, low probability ptInterpretable ECG and able to exercise

82 3%

Pre-operative assessmentLow risk surgery

21 1%

Asymptomatic or stable symptoms< 1 year after cath or abn prior SPECT

16 <1%

De-identified feedback to individual practitioners regarding their practice patterns in reference to benchmarks

Development and dissemination of list of top inappropriate indications

Internal education within cardiology practice regarding key inappropriate indications and ordering patterns

Support of joint attribution by a “non-threatening” letter to referring practitioners about inappropriate use and key targets

Decision support tools, via PDA, Internet, order-entry

De-identified feedback to individual practitioners regarding their practice patterns in reference to benchmarks

Development and dissemination of list of top inappropriate indications

Internal education within cardiology practice regarding key inappropriate indications and ordering patterns

Support of joint attribution by a “non-threatening” letter to referring practitioners about inappropriate use and key targets

Decision support tools, via PDA, Internet, order-entry

Quality Improvement and Educational InitiativesQuality Improvement and Educational Initiatives

ConclusionsConclusions Appropriate use evaluation tool

– Rapid, easy to use, and provides feedback Transparent methods accepted by physicians and

payer Potentially superior method to RBMs’

indiscriminant volume reduction Potential to understand the value of imaging test

results and their impact on downstream utilization Important collaboration between physicians/

medical societies and health plans for ongoing quality improvement for cardiovascular imaging

Appropriate use evaluation tool– Rapid, easy to use, and provides feedback

Transparent methods accepted by physicians and payer

Potentially superior method to RBMs’ indiscriminant volume reduction

Potential to understand the value of imaging test results and their impact on downstream utilization

Important collaboration between physicians/ medical societies and health plans for ongoing quality improvement for cardiovascular imaging

The IC3 ProgramQuality Improvement in Practice

In Every Office, Right Now

The IC3 ProgramQuality Improvement in Practice

In Every Office, Right Now

IC3 Program at ACCIC3 Program at ACC

Advocacy

Chapters

Science & Quality: NCDR & CQC

Education IC3 Program

Informatics

The goal of the IC3 Program is to help clinicians improve the quality of cardiovascular care

and patient outcomes

The goal of the IC3 Program is to help clinicians improve the quality of cardiovascular care

and patient outcomes

IC3 Program Context: The ACC ‘We Believes’IC3 Program Context: The ACC ‘We Believes’

Performance-based reimbursement is your future– Measurement, the given– Improvement, the opportunity

You must invest in and use health IT Your practice pattern is or will soon be public It takes a team to deliver quality care

– Preventive, acute, chronic, and palliative care Your patients trust you; you can build on that trust

Performance-based reimbursement is your future– Measurement, the given– Improvement, the opportunity

You must invest in and use health IT Your practice pattern is or will soon be public It takes a team to deliver quality care

– Preventive, acute, chronic, and palliative care Your patients trust you; you can build on that trust

Study last week in the LancetStudy last week in the Lancet

• “Best practice interventions would reduce overall coronary heart disease deaths by 57%, and the difference in deaths by socioeconomic groups by 69%.”

• Such interventions include, “reduction of systolic blood pressure by 10 mmHg, of cholesterol by 2 mmol/L, and of blood glucose by 1 mmol/L in pre-diabetic people, and quitting smoking.”

Kivimaki et al. Lancet 2008;372:1648-54

The goal of the IC3 Program is to help clinicians ...The goal of the IC3 Program is to help clinicians ...

DocumentationP4P

CertificationEHR….

Guideline-basedPatient care

survive

…improve the quality of cardiovascular care and patient outcomes

…improve the quality of cardiovascular care and patient outcomes

Variation in CareGaps in Care

Poor Care Coordination

Outpatient Performance MeasuresOutpatient Performance Measures

CAD, Afib, HTN,Heart failure,

Diabetes, Rehab-----------

ACC/AHAPCPIPQRINQF

Community BuildingCommunity Building

The IC3 national network of practices

dedicated to high quality CV care.

Interactive communication.Best practices.

EducationEducation

Educational programming.

Clinical guideline updates.

Selection of EHR vendors.

Billing and coding.

Data CollectionData Collection

Office-based registry.

Collect and use patient care data more effectively.Coordinate care.Benchmarking.Demonstrate

quality of care.

Performance ImprovementPerformance Improvement

Practice assessment.

QI tools.Decision support

(CardioPATH).

Coronary Artery Disease

• BP Measurement• Symptom & Activity

Assessment• Smoking Assessment• Anti-platelet Therapy

• Lipid Profile• Use of Lipid Therapy

• -blocker post-MI• ACE/ARB in EF & DM

• Screening for Diabetes

Heart Failure• LVEF Assessment

• Weight Measurements• BP Measurements• Clinical Symptom

Assessment• Activity Assessment

• Signs of Volume Overload• Patient Education• -blocker in EF • ACE/ARB in EF• Warfarin for Afib• Initial Lab Tests

Current ACC/AHA Performance Measures

Current ACC/AHA Performance MeasuresCurrent ACC/AHA Performance Measures

Atrial Fibrillation Thromboembolic Risk

– Prior CVA/TIA– Age ≥75– Hypertension– Diabetes– Heart failure or EF

Warfarin use in High-risk pts Monthly INR in pts on warfarin

Atrial Fibrillation Thromboembolic Risk

– Prior CVA/TIA– Age ≥75– Hypertension– Diabetes– Heart failure or EF

Warfarin use in High-risk pts Monthly INR in pts on warfarin

Cardiac Rehabilitation• Referral to a Rehab

Program– Within 12 months of

• ACS• PCI

• CABG• Valve Surgery

• Transplant– Stable Angina

Diabetes– Poor HbA1c (>9%)

– LDL Control (<100)– BP Control (<140/80)

Recognition and RewardsRecognition and Rewards

Incentives.Recognition.ABIM MOC.

Payers.Liability

reduction.tipping points

ResearchResearch

New insights on care delivery.

Impact of program.

Practice-Based Research Network.

Rewards and RecognitionRewards and Recognition

PQRI as an example-CMS approval

- 3 practices-Preparing for change from

reporting to performance evaluation

PQRI as an example-CMS approval

- 3 practices-Preparing for change from

reporting to performance evaluation

Current status

233 offices385 more have signed intent

to enroll46 states

Current status

233 offices385 more have signed intent

to enroll46 states

IC3 Program AimsIC3 Program Aims

Prepare clinicians to thrive in a performance-based healthcare system • Decision support to ensure consistent practice of evidence-

based medicine: CAD, HF, Afib, Htn, DM Provide the road map and vehicle for QI

• Guidance about selection and use of HIT• Multiple mechanisms for data collection when ready• Options for data reporting and benchmarking• Reporting for P4P and maintenance of certification

Coordinate care across sites and settings Connect practices in a learning community

committed to patient-centered care

Prepare clinicians to thrive in a performance-based healthcare system • Decision support to ensure consistent practice of evidence-

based medicine: CAD, HF, Afib, Htn, DM Provide the road map and vehicle for QI

• Guidance about selection and use of HIT• Multiple mechanisms for data collection when ready• Options for data reporting and benchmarking• Reporting for P4P and maintenance of certification

Coordinate care across sites and settings Connect practices in a learning community

committed to patient-centered care

IC3 Program PackageIC3 Program Package

Practice Readiness Assessment

Series of Webinars Guideline Derivatives Periodic newsletter MAHI Help Desk Practice Certificate Data submission to

payers; “collect once, report to all”

Practice Readiness Assessment

Series of Webinars Guideline Derivatives Periodic newsletter MAHI Help Desk Practice Certificate Data submission to

payers; “collect once, report to all”

How-to’s: EMR selection, PQRI participation, ABIM Maintenance of Cert, Team-based Care

Workflow design tips Medication adherence aids Community access for best

practice sharing and problem-solving

Liability reduction

How-to’s: EMR selection, PQRI participation, ABIM Maintenance of Cert, Team-based Care

Workflow design tips Medication adherence aids Community access for best

practice sharing and problem-solving

Liability reduction

How to JoinHow to Join

Review the levels of participation at improvingcardiaccare.org and choose yours based on practice readiness and resources

Not ready to collect or submit data?– Sign the IC3 Program Participant Agreement to

gain access to all activities and support

Data collection and submission-worthy?– Sign the contract so that protected health

information can be transmitted

Review the levels of participation at improvingcardiaccare.org and choose yours based on practice readiness and resources

Not ready to collect or submit data?– Sign the IC3 Program Participant Agreement to

gain access to all activities and support

Data collection and submission-worthy?– Sign the contract so that protected health

information can be transmitted