1. NCDR Update Board of Governors Meeting September 16, 2007 John Brush, MD, FACC Chair, Quality Strategic Directions Committee ACC Governor, Virginia Chapter

2. 2 20 Years of Performance Measurement 198720071997 HCFA hospital mortality reports JCAHO “Agenda for Change” HCFA CCP Pilot HCFA National CCP NCQA HEDIS measures QPM to JCAHO IOM Rpt HCFA 6 Nat’l Conditions NQF JCAHO ORYX QPM to CMS Healthgrades NCQA websiteJCAHO Core Measures JCAHO Core Pilot Leapfrog HCFA HCQII IOM Rpt PQRI AQA CED HospitalsPhysicians

3. 3 QCARE ACC’s Commitment To You Continuous review of new science Evidence-based guidelines and standards Comprehensive education Data reporting and collection through registries (NCDR) National Quality Initiatives (D2B) Adoption and appropriate use of new technology Evaluation through self-assessment tools, performance testing and longitudinal studies

4. 4 PatientCenteredCare QCARE

5. 5 1997…..20042005200620072008beyond CathPCIRegistry ICDRegistry CARERegistry ACTIONRegistry IC3 CAD Office Imaging HF Registry PracMgt Registry PAD Registry EP Registry Ped. Registry CHD ICD Long

6. 6 Partners CathPCI Society for Cardiovascular Angiography and Intervention ICD Heart Rhythm Society CARE Society for Cardiovascular Angiography and Intervention Society for Interventional Radiology American Academy of Neurology American Academy of Neurosurgery Society of Vascular Medicine and Biology ACTION In discussion with American Heart Association

7. 7 Registry/QI >950 hospitals 6 million patient records Online data entry tool launch 4/07 Support D2B Alliance ARS States – MA, OH, WV, ?CT, ?NJ Payers – United, BCBSA, WellPoint Research and Publications DCRI analytic center 8* abstracts at AHA

8. 8 Registry 1450 enrolled 150,000 patient records Funding 2007 support from WellPoint $1,895/year ARS UHC added ICD Registry participation for sites with EP Labs Discussions underway with BCBSA Provide data to CMS for reimbursement Research ICD Longitudinal Study Performing analysis for FDA

9. 9 Registry 235 Participants Data entry tool $3195.00/year ARS CMS required Research Performing analysis for FDA Discussion with CAS makers re: PMS

10. 10 Registry 250+ participants No charge Funding provided by –Genentech –Bristol-Myers Squibb/Sanofi Partnership –Schering Plough Corporation ARS Early discussions with payers

12. 12 D2B

13. 13

14. 14

15. ACTION Registry™ (Acute Coronary Treatment and Intervention Outcomes Network) Initial Report 1st Quarter 2007 Results

16. 16 2006-07 Data Submission Summary Admission # of # of # of Timeframe Sites NSTEMI Records STEMI Records ACTION Jan. 1, 2007 – 227 6,917 4,259 Mar. 31, 2007 CRUSADE April 1, 2006 – 280 20,084 4,391 Dec. 31, 2006

17. 17 ACTION Registry 2007 Patient Enrollment Number of Patients enrolled

18. 18 NSTEMI Patient - Baseline Characteristics NSTEMIVariable (n = 26,902) Mean age ± SD (yrs)69 ± 14 Female 40% Diabetes mellitus 33% Prior MI 29% Prior CHF 16% Prior PCI 23% Prior CABG 19% ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n=26,902)

19. 19 In-Hospital Outcomes Variable NSTEMI (n = 26,902) Death 3.8% Re-infarction 1.5% CHF 6.8% Cardiogenic Shock 2.4% Stroke 0.7% RBC Transfusion* 8.9% *Excluding CABG patients ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n=26,902) *Excluding CABG patients ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n=26,902)

20. 20 NSTEMI Acute Medications ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007

21. 21 *LVEF < 40%, CHF, DM, HTN # Known hyperlipidemia,  TC,  LDL ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n= 26,902) NSTEMI Discharge Medications % Use

22. New Hospital-Based Registries

23. 23 Transcatheter device occlusion of CV malformations –Atrial Septal Defect –Ventricular Septal Defect –Patent Ductus Arteriosus –Fistula/Collateral Vessels—Blood Vessel Communication –Closure of Fontan Fenestration Transcatheter Balloon Dilation Transcatheter Stent Placement CathLab Congenital Heart Disease Registry

24. Pilot Study Evaluation of Appropriateness of SPECT MPI The American College of Cardiology The American Society of Nuclear Cardiology

25. 25 SPECT MPI Registry Objectives Evaluate appropriateness Promote awareness of appropriateness criteria in practice Provide feedback reports to improve both practice-level and individual physician- level adherence to the criteria Establish benchmarks to guide performance improvement

26. 26 NCDR QI National QI Programs –Implement guidelines recommendations –Improve physician adherence –Improve patient compliance Our Goal? –Reduce complications –Improve Structure and Process –Efficient Systems NCDR & D2B Take ACTION Field Consultants

27. 27 “Take ACTION” Campaign Nationwide QI Program –Increase awareness about relevant CPG recommended therapies for ACS and chronic stable coronary disease –Improve physician adherence and patient compliance Long-term Goal –Reduce secondary events post ACS –Measured incrementally through behavioral changes Multiple, overlapping Phases beginning ACC.07 –Phase I - What is the ACC doing to Take ACTION to improve care of patients with ACS? –Phase II - What are you doing as a physician to Take ACTION? –Phase III - What are you doing as patients to Take ACTION?

28. 28 Improving Continuous Cardiac Care

29. 29 Measuring the Continuum of CAD Care Patient with stable angina Onset of Acute Coronary Syndrome Post-Hospitalization: Risk factor modification Cardiac rehabilitation D/C PCI/CABG Admit AMI Care ACC- NCDR ACTIONIC 3 ACTION Follow-up

30. 30 The IC 3 Program First office-based registry designed to assess physician adherence to ACC/AHA Performance Measures. Provides a powerful tool to assess the current state of office-based clinical care for CAD and CHF patients.

31. 31 Philosophy of the IC 3 Program Make it easier for busy clinicians to do the right thing for the right patient at the right time –Track key performance measures for CAD/CHF Internal QI and P4P reporting at the practice level Performance measures for DM also captured –Make care more efficient A worksheet that readily identifies opportunities to apply CAD/ CHF guideline recommendations and performance measures –Coordinate care Create a visit summary to communicate with patients and other providers

32. 32 IC 3 Program: Incentives for Practices Develop tools to improve care –Provide real-time reporting of office-based quality indicators for CAD and CHF derived from clinical practice guidelines Create a trusted mechanism for measuring performance –Support evolving CMS outpatient quality measures and regulatory reporting initiatives –Support Pay-for-Performance programs with payers

33. 33 United (5) BCBS (9) Medicare (26) Medicaid (10) 40% 76% 100% Payer Perspective of my Performance Physician X’s Practice Physician X’s Overall Performance = 90%

34. 34 Partnering with Health Plans – Benefits to Plans… Health Plans get Better Picture of Practice Performance –Clinical data prospectively measured –More accurate assessment of practice performance from larger sample sizes than individual plans –Capture of complete ACC/AHA performance measures Plans need not develop their own

35. 35 Other IC 3 Program Goals Position the profession (ACC) to take a leadership role in quality assessment and improvement Support the evolution of quality assessment and improvement –Identify new opportunities to improve and coordinate CAD and CHF care Create a research agenda to improve care –Document the distribution of cardiac patients’ health status –Identify new performance measures –Support research of appropriateness

36. 36 Office Flow in IC 3 Pt presents for visit, reports med changes Vitals, health status assessed Physicia n Visit & Rx Data entered and Clinic Visit Form Generated Treatment plan Data entered Patient Letter & Visit Summary dispensed Visit Summary sent to other care providers Data Entered through NCDR IC 3

37. 37 Data Collection Types of data –Site Profile captured once –Patient History captured on entry –Treatment monitored longitudinally –Clinical event data captured longitudinally –Patient health status for CAD and CHF (optional) Data collection tools –Web-based data collection tool –Paper forms –Working on EMR integration for Decision Support

38. 38 Data Submission and Reporting Data will be subjected to completeness and consistency reviews –On-site audit to ensure accuracy (2009) Quarterly aggregate practice-level data reports and benchmark reports National benchmark performance Peer group benchmark performance Individual hospital performance Real-time QI reports generated for individual and practice-level data

39. 39 Release Enrollment begins October 1, 2007 Web-based data collection begins Jan 1, 2008 Training and roll-out for participants Client and contract support for participants Marketing and communications to broader physician community

40. 40 Participant Training and Education NCDR Online w ebsite Information packet/Welcome Kit Online training manual Annual User Group Meeting Workshops Special web casts On-line community development for collaborative learning and sharing

41. 41 For More Information… Visit: www.ncdr.com/ic3 Email: ncdr@acc.org