The Burden of Cardiovascular Disease: Challenges and Opportunities In the Middle East and Beyond Using Registries To Improve Care: Experience From The National Cardiovascular Data Registry (NCDR速) John Gordon Harold, MD President Elect, American College of Cardiology
SHA-ACC Joint Symposium February 2013
Presenter Disclosure Information for John Gordon Harold, MD MACC, MACP, FESC, FAHA Clinical Professor of Medicine David Geffen School of Medicine at UCLA and Cedars-Sinai Heart Institute Los Angeles, California No relationships to disclose
American College of Cardiology 64 Years of Quality and Education 1949-2012
Heart House, Washington D.C.
Unintended Variation and Waste in Healthcare Dr. Donald Berwick: “We basically have two economic health care optionsWe can cut care… Or we can improve care.” “The Triple Aim”
An International Strategy for Quality Improvement in Health Care’s
TRIPLE AIM
1 Better care 2 Population health 3 Affordable care
How Do We Improve Quality Of Care?
The Highest Quality Healthcare Is‌
Efficient
Effective Safe
Equitable Timely
PatientCentered
U.S. Institute of Medicine. Crossing the Quality Chasm: A New Healthcare System for the 21st Century National Academy Press 2001
Clinical Registries and The Cycle of Quality
Clinical Registries
Califf RM et al. Health Affairs, 26, no. 1 (2007): 62-74
At the Core of the ACC’s Strategy
Registry Registry Data Data
Why ACC invests in Registries: Registries Unique clinical information Enable performance measurement by physicians for physicians Support for novel scientific research production Scaled delivery of registrydriven quality improvement programs
What is the Role of Clinical Registries?
Bufalino VJ, Masoudi FA, et al. Circulation. 2011 Apr 11. [Epub ahead of print]
ACC’s Answer to the Triple Aim: Shift Focus from Volume to Quality of Care Leveraging increasing importance of measurement/tracking tools and initiatives like: National Cardiovascular Data Registry (NCDR Ž) FOCUS H2H Clinical Toolkits Clinical Documents SmartCare
NCDR速 Mission To improve the quality of cardiovascular patient care by providing information, knowledge and tools; implementing quality initiatives; and supporting research that improves patient care and outcomes.
National Cardiovascular Data Registry ACTION Registry® - GWTG™ CARE Registry® CathPCI Registry® ICD Registry™ IMPACT Registry™ PINNACLE Registry™ STS/ACC TVT Registry™ CathPCI Registry
ICD Registry
CARE Registry
Imaging Registry
ICD Long
IMPACT Registry PINNACLE ACTION Registry
AF Abl Registry PAD Registry Valve Registry
1998….. 2004 2005 2006 2007 2008 2012 and beyond "If you don't measure it, you can't manage it.” Peter Drucker
NCDR速 Clinical Registry Programs Data Elements and Definitions Clinical Data
Observational Database
Quality Assessment
Quality Improvement
Clinical Research
NCDR速 CathPCI Registry Adult Diagnostic Cath and PCI
The TheCathPCI CathPCIRegistry速 Registry速isisaapowerful powerful tool toolthat thatassesses assessesthe the characteristics, characteristics,treatments treatmentsand and outcomes outcomesof ofcardiac cardiacdisease diseasepatients patients who whoreceive receivediagnostic diagnostic catheterization catheterizationand/or and/orpercutaneous percutaneous coronary coronaryintervention intervention(PCI) (PCI) procedures. procedures. The TheCathPCI CathPCIRegistry Registrygives givesquality quality benchmarking benchmarkingdata datathat thatcompares compares lab labperformance performancewith withlike-sized like-sizedCath Cath labs labsand andthe thenational nationalaggregate. aggregate. Helps Helpsto toset setachievable achievableperformance performance goals goalsand andto todevelop developquality quality
NCDR® ICD Registry
Pediatric and Adult Lead and ICD Implants
80% submit all patients
•• The TheICD ICDRegistry™ Registry™is isaa nationwide nationwidequality qualityprogram programthat that helps helpsparticipating participatinghospitals hospitals measure measureand andimprove improvecare carefor for patients patientsreceiving receivingimplantable implantable cardioverter cardioverterdefibrillators defibrillators(ICDs). (ICDs). •• Government Governmentmandated mandateddata data repository repositoryfor forimplantable implantable cardioverter cardioverterdefibrillator defibrillator(ICD) (ICD) procedures. procedures. •• The The80 80percent percentof ofparticipating participating hospitals hospitalsthat thatreport reportdata dataon onall all implantations implantations— —regardless regardlessof of payer payeror orindication indication— —have havemade made the theregistry registryaapowerful powerfulquality quality benchmarking benchmarkingtool toolfor forany anyfacility facility involved involvedin inICD ICDimplantation, implantation, upgrade upgradeor orreplacement. replacement.
NCDR® CARE Registry CAS and CEA
•• NCDR® NCDR®CARE CARERegistry® Registry®--Data Data collection collectionfor forcarotid carotidartery artery stenting stenting(CAS) (CAS)and and endarterectomy endarterectomy(CEA) (CEA) procedures. procedures. •• AA"best "bestpractices practicesshowcase" showcase"for for all alldisciplines disciplinesinvolved involvedin intreating treating carotid carotidartery arterydisease disease-cardiology, cardiology,neurology, neurology,radiology, radiology, vascular vascularsurgery, surgery,neurosurgery, neurosurgery, and andinterventional interventional neuroradiology. neuroradiology.
NCDR® ACTION Registry-GWTG
STEMI and NSTEMI Upon Admission •• ACTION ACTIONRegistry®-GWTG™ Registry®-GWTG™isisaariskriskadjusted, adjusted,outcomes-based, outcomes-based,quality quality improvement improvementprogram programthat thatfocuses focuses exclusively exclusivelyon onhigh-risk high-riskSTEMI/NSTEMI STEMI/NSTEMI patients. patients. •• ItIthelps helpshospitals hospitalsapply applyACC/AHA ACC/AHAClinical Clinical Guidelines Guidelinesrecommendations recommendations inintheir their facilities, facilities,and andprovides providesinvaluable invaluabletools tools to toassist assistthem themininachieving achievingtheir theirgoal goalof of quality qualityimprovement. improvement. •• The Theregistry’s registry’sreal-time real-timequarterly quarterlyreports reports will willsupport supportefforts effortsto toreduce reduceprocedural procedural complications, complications,identify identifyareas areasof of excellence excellenceand andopportunities opportunitiesfor for improvement, improvement,and anddocument documentthe theresults results of ofQuality QualityImprovement Improvementefforts. efforts.
NCDR® PINNACLE Registry CAD, HF, HTN, AF More Morelarge large practices practices enrolling enrolling
•• PINNACLE PINNACLERegistry: Registry:For For coronary coronaryartery arterydisease, disease, hypertension, hypertension,heart heartfailure failure and andatrial atrialfibrillation fibrillationin inthe the outpatient outpatientsetting. setting. •• Nation's Nation'sLargest LargestAmbulatory Ambulatory Cardiovascular CardiovascularQuality Quality Improvement ImprovementRegistry. Registry. •• With Withmillions millionsof ofpatient patient records, records,the thePINNACLE PINNACLE Registry® Registry®isiscardiology's cardiology's largest largestoutpatient outpatientquality quality improvement improvementregistry. registry.
NCDR® IMPACT Registry
Pediatric and Adult Congenital Invasive Treatments •• The TheIMPACT IMPACTRegistry® Registry®assesses assessesthe the prevalence, prevalence,demographics, demographics, management managementand andoutcomes outcomesof of pediatric pediatricand andadult adultpatients patientswith with congenital congenitalheart heartdisease disease(CHD) (CHD)who who are areundergoing undergoingdiagnostic diagnostic catheterizations catheterizationsand andcathetercatheterbased basedinterventions. interventions. •• International InternationalInterest: Interest:Hospital Hospitalfor for Sick SickKids, Kids,Toronto Torontoand andRiyadh RiyadhSaudi Saudi Arabia ArabiaUS USNews Newsand andWorld WorldReport Report ––Best BestPediatric PediatricHospitals Hospitalsincludes includesaa measure measurefor forIMPACT IMPACTparticipation. participation.
NCDR® STS/ACC TVT Registry Transcatheter Valve Therapy
CMS Mandate
The TheTVT TVTRegistry™ Registry™isisaa benchmarking benchmarkingtool tooldeveloped developedto to track trackpatient patientsafety safetyand andreal-world real-world outcomes outcomesrelated relatedto tothe the transcatheter transcatheteraortic aorticvalve valve replacement replacement(TAVR) (TAVR)procedure. procedure. Created Createdby byThe TheSociety Societyof ofThoracic Thoracic Surgeons Surgeons(STS) (STS)and andthe theAmerican American College Collegeof ofCardiology Cardiology(ACC), (ACC),the the TVT TVTRegistry Registryisisdesigned designedto to monitor monitorthe thesafety safetyand andefficacy efficacyof of this thisnew newprocedure procedurefor forthe the treatment treatmentof ofaortic aorticstenosis. stenosis.
NCDR速 Participants - Patient Records Manuscripts And Abstracts Registry Name
# of Participants
# of Patient Records
# of Manuscripts & Abstracts
CathPCI
1,580
15 million
80/164
ICD
1,710
950,000
24/34
ACTION-GWTG
825
500,000
32/50
CARE
180
25,000
5/16
IMPACT
70
20,000
1/3
TVT
180 2,000
3,800 7 million
PINNACLE
10/23
NCDR速 Collaborations
Expanding Role of Registries in 2013 • • • • • • •
Improve patient care Identify gaps in care Use in research Hospital report cards by health plans Platform for clinical trials Post-approval study performance Post-marketing surveillance
What Questions Should We Ask? Epidemiology Quality of care Patterns of care
Quality improvement Patient safety Personalized medicine Clinical trials
Door to Balloon Times Were Slow And Unchanging
20 10 0
Hospitals
30
40
D2B: Evidence Of Wide Variation In Performance
50
100 150 Door-to-balloon time (minutes)
200
Six Strategies Were Identified Among The Best Performing Hospitals
Bradley EH et al. N Engl J Med. 2006 Nov 30;355(22):2308-20
The American College of Cardiology Launched A National Campaign: D2B
More Than 1000 Hospitals Joined The Effort
There Was A Significant Increase In The D2B Strategies Used By Hospitals
Bradley EH et al. J Am Coll Cariol 2009; 54 (25): 2423–9
There Was A Significant Improvement In D2B Times Nationally
The D2B Alliance reached its goal of 75% of patients with STEMI having D2B times within 90 min by 2008.
Bradley EH et al. J Am Coll Cariol 2009; 54 (25): 2423–9
NCDR速 Quality Measurement Door to Balloon Time (DBT)
Appropriateness Definitions Used in NCDR® • Appropriate: generally acceptable and are a reasonable approach for the indication. • May be Appropriate Care (Uncertain): may be a reasonable approach for the indication. Does not mean Inappropriate and should be reimbursable. • Rarely Appropriate Care (Inappropriate): is not generally a reasonable approach for the indication. Does not mean fraud.
Executive Summary Test Metrics CathPCI Registry PCI Appropriate Use Criteria- NCDR Appropriate
Distribution of Hospital Performance
Proportion of PCI procedures that were appropriate.
10th percentile
My Hospital
All Hosp 50th Pctl
All Hosp 90th Pctl
94.0%
87.6%
98.6%
90 th percentile
Uncertain
Proportion of PCI procedures that were uncertain for appropriateness. My Hospital
All Hosp 50th Pctl
All Hosp 90th Pctl
3.0%
9.0%
0.0%
10th percentile
90 th percentile
Executive Summary Test Metrics CathPCI Registry PCI Appropriate Use Criteria- NCDR Distribution of Hospital Performance
Inappropriate
Proportion of PCI procedures classified as inappropriate . My Hospital All Hosp All Hosp 90th 2.7%
50th Pctl
Pctl
3.0
0.0%
Data Quality / Completeness
Proportion of PCI Procedures not classifiable My Hospital
All Hosp 50th Pctl
All Hosp 90th Pctl
23.9%
13.7%
1.9%
10th percentile
90 th percentile
10th percentile
90 th percentile
NCDR速 National Quality Measurement: In-Hospital Complications Of ICDs p<0.001
p<0.001
Peterson PN et al. Circulation 2009;119:1078-1084
NCDR速 National Quality Measurement: Processes Of Care Cardiac Performance Measures in Outpatients Beta blocker after MI
86%
Antiplatelet therapy
85%
Warfarin for Atrial Fibrillation (CHADS2 >2)
81%
Screening for Diabetes
13%
Peterson ED et al. Heart 2010;96:1798-1802 Chan PS et al. J. Am. Coll. Cardiol. 2010;56;8-14
2007-2009 383 sites
NCDR® Sample Benchmark Reports A hospital can see where it stands…
Sample excerpt from NCDR ICD quarterly outcomes report
… with respect to a national average…
… and against top performers
To Wrap Up…Participation in the NCDR® Registries Can Facilitate: • Better adherence to outpatient guidelines improves patient outcomes and reduces hospital readmissions • Measureable adherence to established clinical guidelines and performance measures • Comparison of practice and physician-level data to national benchmarks • Contribution to a growing collection of clinical research
NCDR速 Goes Global
NCDR速 International Registry Deployment Country/Site Enrolled
CathPCI
AR-G
Sheikh Khalifa Medical City
X
X
TotalCor, San Paulo Albert Einstein, San Paulo
X X
X X
IMPACT
CARE
PINNACLE
Abu Dhabi Brazil X
Canada Toronto Sick Kids Saudi Arabia King Abdulaziz Medical City, Riyadh India KEM Hospital, Mumbai
X X X
Science tells us what we can do; Guidelines what we should do; Registries what we are actually doing.
Invitation to San Francisco ACC.13
The Mission of the ACC
To Transform Cardiovascular Care and Improve Heart Health