Quality of care, part 4: MI Kim A Eagle MD Albion Walter Hewlett Professor of Internal Medicine Chief, Clinical Cardiology Co-Director, Heart Care Program University of Michigan Ann Arbor, MI Dr Harlan Krumholz MD FACC Associate Professor of Medicine & Epidemiology & Public Health Yale University School of Medicine New Haven, CT

Quality of care has gotten a lot more important in this cost-cutting era. By evaluating what we do and making changes, we will get better value for the money. By identifying opportunities for improvement and making changes, we will be able to provide better care. Quality of care Making changes

Care and outcomes Clinical studies have identified several aspects of MI care that are closely linked to outcomes (use of aspirin, beta-blockers, reperfusion therapy). Quality of care for acute MI involves a much broader set of clinical skills: the ability to detect whether or not an individual is actually having an AMI, the need for rapid triage, signs of decompensation, subtle murmurs, the need for surgery. MI and AMI

Indications of quality Several straightforward processes are relevant to the vast majority of patients; the extent to which these are used can give us some indication of the quality of care that is being provided. For acute MI, as well as looking at processes, clinical decisions, and interventions, we have also looked at outcome, particularly mortality, and have been able to adjust for the severity of the AMI when comparing level of care across sites.

What to measure? External partners — eg, National Committee for Quality Assurance (NCQA), Health Plan Employer Data and Information Set (HEDIS), payers, insurers — want some way to measure quality of care. The American College of Cardiology (ACC) and the American Heart Association (AHA) have put together a joint task force to develop performance measures for a variety of conditions, including AMI. Currently many of the measures of quality of AMI care used by external partners are similar to those we expect to see in the guidelines. These guidelines will help insurers and purchasers determine how good the care being delivered is. Proof of quality

Setting targets An LDL cholesterol level of 130 mg/dL has been established as the target in patients with established coronary artery disease by the NCQA. Although many physicians believe that target LDL levels should be below 100 mg/dL in patients with established disease, the committee decided that 130 mg/dL would be a reasonable first step towards instituting a cholesterol measure. LDL cholesterol levels

Setting targets With a target of 130 mg/dL, care will be considered good if a patient reaches a level of 105 mg/dL; an additional medication will not be required to further lower LDL cholesterol. However, it would be very difficult for any clinician to argue that care is adequate when the LDL level is above 130 mg/dL. This measure provides managed care organizations with a way to systematically collect information and will give them some way to judge how successful they have been at lowering cholesterol in patients with coronary artery disease. Over time, this standard can be lowered, but the mere fact that a level has been established will lead to greater accountability. Choosing an acceptable level

Claims data The large sets of administrative data are being used to produce estimates of mortality for various groups, including hospitals. Because these sets of administrative data are available, they are being used. Using what is available

Claims data Administrative billing codes correspond only very crudely with the actual clinical condition of an individual patient. When dealing with imprecise data and small sample sizes, performance of an individual physician, individual hospital, or even a region or healthcare system can be misrepresented. These data can be used for internal benchmarking, to generate hypotheses, and to look for ways to improve in our individual institutions. These data are not going to give consumers the information they need to make informed choices about where they should receive care. How good are they?

Claims data The mathematical formulas we use to risk-adjust when we use claims data do not adequately account for the comorbidities that don't get entered in the claims database. Risk-adjustment formulas account for only 30% to 40% of the variation in outcome. Outcome data can be used internally to give a physician an idea of how they're doing, but a particular outcome should not be used to rate a physician’s performance because of the potential inaccuracy of those types of comparisons. Risk-adjustment formulas

Commitment to quality Physicians need to look at their own practices and institute systems that will ensure that no patient misses out on interventions or medications that have been demonstrated to improve outcome. To do this, physicians need a specificity of purpose, a clearly defined aim, and the ability to measure performance. Physicians need to take the lead within the healthcare profession and show that such standards can be achieved. The abundance of evidence available on the care of AMI patients makes it the perfect testing ground. Physicians must take the lead

Processes These are the very basic treatments for which evidence has been available for 20 years, yet studies show that these have not been translated to the bedside for all patients who meet the criteria.  on admission: aspirin or beta-blockers  on discharge: aspirin, beta-blockers, or ACE inhibitors  reperfusion therapy In time-sensitive therapies (eg, reperfusion therapy), time is being lost because of delays inherent in communications and decision-making systems. Providing the basics

Structure Key structural components of a hospital are necessary to deliver the highest quality of care.  integration of emergency medical services: by the time the EMS arrives at the hospital, the emergency department should be prepared to deliver care immediately  a reliable communication system: the emergency department should be able to communicate quickly and easily with cardiologists and internists  an efficient hospital set-up: the hospital should be set up to allow the healthcare team to work as an integrative team; measuring this will be difficult but better process will be the result Communication and integration

Process tools Tools are being developed that can be used to remind physicians of the critical elements that should be considered in every situation. These tools will help physicians become more systematic. The goal should be to translate the information we have to the bedside. Measuring quality of care can help us understand where we are and where we need to be.

The challenge One of the major challenges in this field is broadening the current focus on AMI to the area of acute coronary syndrome. It's been convenient to focus on AMI because we can create definitions for it; some acute coronary syndromes are difficult to define. We must also be able to put into context the abundance of trials on different strategies (eg, LMWH, GP IIb/IIIa, interventional strategies, devices). Make sure the guideline process is implemented in a timely way, so that it helps assess performance to the benefit of patients.