Door to Balloon Times: Achieving 90 Minutes and Less

Quality Update from ACC West Virginia Chapter 3 rd 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 FACC Sr VP of Science and Quality

Median Door-to-Balloon Time McNamara et al., JACC, 2006

D2B 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 1.ED physician activates the cath lab 2.One call activates the cath lab 3.Cath lab team ready in 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 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: Timeline Krumholz HM et al. JACC-Cardiovascular Intervention 2008;1:97-104

More than 1,000 hospitals joined the effort

ACC NCDR Cath-PCI Registry % D2B <90 min 62% 82%

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 changed Recommended Strategy Baseline Follow-up ED physician activates lab52%60% Single call activates lab31%37% Cath team in minutes81%89% Prompt data feedback61%79% Team-based approach 64%85% PH ECG activates lab33%41% Recommended Strategy Baseline Follow-up ED physician activates lab52%60% Single call activates lab31%37% Cath team in minutes81%89% Prompt data feedback61%79% Team-based approach 64%85% PH ECG activates lab33%41%

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 AHAs 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 AHAs Mission LIfeline

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 Queue Nuclear cardiology (SPECT MPI) Nuclear cardiology (SPECT MPI) October 2005 Cardiac CT/MR Cardiac CT/MR September 2006 Echocardiography (Transthoracic/Transesophageal) Echocardiography (Transthoracic/Transesophageal) June 2007 Echocardiography (Stress) 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) Nuclear cardiology (SPECT MPI) October 2005 Cardiac CT/MR Cardiac CT/MR September 2006 Echocardiography (Transthoracic/Transesophageal) Echocardiography (Transthoracic/Transesophageal) June 2007 Echocardiography (Stress) 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 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 Appropriateness AppropriateUncertainInappropriate Hendel, %6%11% Williams, %5%8% Ayyad, %5%10% Druz, %33%10% Gaztanega, %28%17% Al-Mallah, %12%13% Gibbons, %11%14%

ACCF/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 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 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 Findings

Preliminary 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 n = 2,779

Pilot Site Specific Results SiteNAppropriateUncertainInappropriate Not classified #115755%15%22%5% #281154%8%22%14% #372860%17%17%2% #486160%21%13%3% #529179%6%11%2% #618759%19%18%2%

Most Common Inappropriate Indications INDICATIONFREQUENCYPERCENT Detection of CAD Asymptomatic, low CHD risk 2629% Asymptomatic, post-revascularization < 2 years after PCI, symptoms before PCI 913% Evaluation of chest pain, low probability pt Interpretable ECG and able to exercise 823% Pre-operative assessment Low risk surgery 211% 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 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 IC 3 Program Quality Improvement in Practice In Every Office, Right Now

IC 3 Program at ACC Advocacy Chapters Science & Quality: NCDR & CQC Education IC3Program Informatics

The goal of the IC 3 Program is to help clinicians improve the quality of cardiovascular care and patient outcomes

IC 3 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

Study 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:

The goal of the IC 3 Program is to help clinicians... Documentation P4P Certification EHR …. Guideline-based Patient care survive

…improve the quality of cardiovascular care and patient outcomes Variation in Care Gaps in Care Poor Care Coordination

Outpatient Performance Measures CAD, Afib, HTN, Heart failure, Diabetes, Rehab ACC/AHA PCPI PQRI NQF

Community Building The IC 3 national network of practices dedicated to high quality CV care. Interactive communication. Best practices.

Education Educational programming. Clinical guideline updates. Selection of EHR vendors. Billing and coding.

Data Collection Office-based registry. Collect and use patient care data more effectively. Coordinate care. Benchmarking. Demonstrate quality of care.

Performance 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

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 HbA 1c (>9%) –LDL Control (<100) –BP Control (<140/80)

Recognition and Rewards Incentives. Recognition. ABIM MOC. Payers. Liability reduction. tipping points

Research New insights on care delivery. Impact of program. Practice-Based Research Network.

Rewards and Recognition PQRI as an example - CMS approval - 3 practices - Preparing for change from reporting to performance evaluation

IC 3 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, DMDecision 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 HITGuidance about selection and use of HIT Multiple mechanisms for data collection when readyMultiple mechanisms for data collection when ready Options for data reporting and benchmarkingOptions for data reporting and benchmarking Reporting for P4P and maintenance of certificationReporting for P4P and maintenance of certification ¤ Coordinate care across sites and settings ¤ Connect practices in a learning community committed to patient-centered care

IC 3 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 ¤ How-tos: 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 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 IC 3 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 IC 3 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