1. The IC 3 (Improving Continuous Cardiac Care) - PINNACLE Program: A Report of the first 14,000+ Patients Paul S. Chan, MD MScWilliam J. Oetgen, MD Donna Buchanan, PhDKristi Mitchell MPH Fran F. Fiocchi, MPHFengming Tang, MS Philip G. Jones, MSDuane Thrutchley, RN Tracie Breeding, RN BSNJohn S. Rumsfeld, MD PhD John A. Spertus, MD MPH

2. Disclosures Funding for IC 3 /PINNACLE: -American College of Cardiology - Bristol-Myers Sanofi

3. Overview of Performance Measurement Performance measures represent a subset of the Guidelines – What must be done in care… Much improvement in inpatient care has emerged from performance measurement While numerous outpatient performance measures exist… –These have not been systematically collected –Current performance is unknown –Until measured, QI can not occur

4. Current ACC/AHA Performance Measures CAD Performance Measures BP Measurement Symptom & Activity Assessment Smoking Assessment –Counseled to quit Anti-platelet Therapy Lipid Profile Use of Lipid Therapy  -blocker post-MI ACE/ARB in  EF & DM Screening for Diabetes CHF Performance Measures 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

5. Current ACC/AHA Performance Measures A Fib Performance Measures 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 PMs Referral to a Rehab Program –Within 12 months of ACS PCI CABG Valve Surgery Transplant –Stable Angina

6. Challenges with the Current Quality Model Consensus on Optimal Performance Measures –Payers often use their own measures Accurately Capturing Performance Measures –Administrative data often used Reporting Performance to Payers –Administratively cumbersome to practices, especially with different measures for different payers

7. What is IC 3 /PINNACLE? Prospective collection of outpatient clinical data Use of that data to assist in the office visit Use of that data to coordinate/communicate care Use of that data to generate performance reports –Physician-level reports for QI –Practice-level reports for QI and P4P Programs

8. Implementation Modes of data collection –Existing EMRs Specifications provided to EMR Vendors Quarterly transmission to ACC for Benchmarking reports –Paper forms For practices without an EMR

9. IC 3 Program: Incentives for Practices To improve care –Provide measurement of quality indicators from guidelines and performance measures –Frequent assessment of performance so that improvements can be made and monitored Trusted mechanism for reporting performance –Support evolving CMS PQRI initiatives –Support Pay-for-Performance programs with payers –Collect once, report to all

10. Objectives of this Study Descriptive report of first 14,000+ outpatients Focus on 11 CAD performance measures (PMs) Definition of CAD: 1.prior MI 2.prior coronary revascularization 3.known coronary stenosis >70%

11. Methods Primary Outcome: Compliance with PMs # patients (or visits) which met a PM # of eligible patients (or visits) for that PM Denominator exclusions –medical (e.g., allergies) –personal (e.g., cost, refusal) reasons Patients could be excluded for some, but included in other, CAD PMs

12. RESULTS

13. Enrollment Period: July 2008 to June 2009 Study Sample 18,021 encounters among 14,464 patients from 26 practices Of these, 10,337 encounters among 8132 CAD patients

15. Limitations First report of 14,000+ patients from 26 practices - small practice numbers - practices highly-motivated No way of determining whether data on some cardiac patients were excluded from submission  however, this would preclude use of data for P4P and PQRI Clinicians could ‘game’ the system by assigning exclusions for patients who are otherwise not compliant with a particular PM  still found gaps in compliance with various PMs

16. Next Steps Examine PM adherence in other cardiac diseases (HF, A Fib) Examine whether PM adherence differs by gender, race Examine if participation in IC 3 (quarterly reports, benchmarking) improves PM adherence over time Develop real-time decision support to improve adherence

17. Conclusions Compliance rates for CAD among outpatients enrolled in IC3 varied substantially, ranging from 13% to 94% These results highlight important gaps in the quality of outpatient CAD care and provide a valuable benchmark for future improvement