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Monitoring the Quality of Invasive Cardiac Services: The Unintended Consequences of Public Reporting Frederic S. Resnic, MD MSc, FACC Brigham and Women’s.

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Presentation on theme: "Monitoring the Quality of Invasive Cardiac Services: The Unintended Consequences of Public Reporting Frederic S. Resnic, MD MSc, FACC Brigham and Women’s."— Presentation transcript:

1 Monitoring the Quality of Invasive Cardiac Services: The Unintended Consequences of Public Reporting Frederic S. Resnic, MD MSc, FACC Brigham and Women’s Hospital and Harvard Medical School March, 2010

2 Brigham and Women’s Hospital Case Summary Mr. H. is an active 67 year old, with history of hypertension, coronary artery disease and dilated cardiomyopathy, who presented in acute pulmonary edema to an outside hospital. He had previously refused coronary angiography. On presentation, patient was profoundly hypotensive and dyspneic and required mechanical ventilation and support with multiple vas0-pressor agents Urgent catheterization revealed left main with severe three vessel CAD and a thrombotic (acute) lesion in right coronary artery. PCWP=38, pH=7.09 Underwent successful emergent PCI of RCA with IABP support. Echo demonstrated EF=15% with global hypokinesis and inferior AK.

3 Brigham and Women’s Hospital Echocardiogram

4 Brigham and Women’s Hospital Case Summary Transferred to BWH CCU for urgent consideration of CABG. Unable to wean IABP; continued pressor dependence, worsening O2 requirements, worsening renal function. Deemed not surgical candidate by two staff cardiac surgeons due to excessively high perioperative risk. Family sought “everything that can be done” Referred for high risk PCI of unprotected left main coronary artery, LAD and LCx to potentially allow wean from IABP and pressor support.

5 Brigham and Women’s Hospital

6 Brigham and Women’s Hospital

7 Brigham and Women’s Hospital Hospital Course Remained on pVAD support for 5 days with reduced vasopressor requirements. Myocardial function stabilized enough for pVAD to be removed; however continued pressor dependent and CVVH required for volume balance. Progressive multi-system organ failure with ARF, ARDS and progressive liver failure. No clear neurologic recovery despite weaning all sedation. Ultimately, patient made comfort measures only and expired peacefully on hospital day 20.

8 Issues Raised Brigham and Women’s Hospital When does therapy transition from compassionate high risk to futile care? What are the hidden costs of public reporting? –While no acute complication of either PCI procedure, patient’s ultimate death is associated with pVAD supported PCI at receiving hospital (LAD/LCX) for purposes of MA DPH reporting. Is risk adjusted mortality an adequate measure of cardiac quality for PCI? –Estimated mortality risk for this patient: ~ 40% per MA mortality prediction model.

9 Overview Brigham and Women’s Hospital Defining “Quality” in Cardiac Surgery and Angioplasty Benefits and risks of public release of individual quality monitoring results Evidence for unintended consequences Strategies for a more comprehensive approach to quality monitoring

10 Interpreting Mass-DAC Reports Brigham and Women’s Hospital Source: 2006 PCI in MA – Mass-DAC uses “Standardized Mortality Incidence Rates” (SMIR) to compare hospital risk adjusted in-hospital all-cause mortality as a measure of overall quality.

11 2008 No Shock and No STEMI Risk Model Brigham and Women’s Hospital Source: 2008 PCI in MA –

12 2008: No Shock and No STEMI Brigham and Women’s Hospital Source: 2008 PCI in MA – results indicate all centers performed within expectations.

13 2008 Shock or STEMI Risk Model Brigham and Women’s Hospital Source: 2008 PCI in MA –

14 2008 Results: Shock or STEMI Brigham and Women’s Hospital Source: 2008 PCI in MA – Again, no institutions identified as statistical outliers….

15 Cardiac Quality: The Big Picture Brigham and Women’s Hospital Clinical Outcomes Process Measures Appropriateness Access to Healthcare

16 Cardiac Quality: The Big Picture Brigham and Women’s Hospital Process Measures Appropriateness Access to Healthcare Clinical Outcomes

17 Benefits Risks Promotes Informed Consumer Choice Hawthorne Effect “Teeth” for Quality Monitoring Accelerates Adoption of Best Practices Transparency Brigham and Women’s Hospital Trade-Off’s in Public Reporting

18 Benefits Risks Promotes Informed Consumer Choice Hawthorne Effect “Teeth” for Quality Monitoring Accelerates Adoption of Best Practices Transparency Brigham and Women’s Hospital Trade-Off’s in Public Reporting

19 Outcomes Trends in MA Brigham and Women’s Hospital Adapted from cardiac surgery and PCI reports www.MassDac.org Unadjusted mortality has declined for both CABG and PCI treated patients in Massachusetts.

20 Volume and Mortality Trends Brigham and Women’s Hospital Source: 2007 PCI in MA – Statewide results indicate a 7.5% per year reduction in elective (non Shock or STEMI) volume since Continued reduction in mortality of high risk group may indicate growing risk aversion by PCI operators.

21 Benefits Risks Promotes Informed Consumer Choice Hawthorne Effect “Teeth” for Quality Monitoring Accelerates Adoption of Best Practices Transparency Brigham and Women’s Hospital Trade-Off’s in Public Reporting Over-emphasis on MD Emphasis on Low Risk Cases Risk Avoidance of High Risk Cases Up-coding and Gaming Unmeasured Quality Parameters Ignored

22 NY State PCI Mortality Trends Brigham and Women’s Hospital Adapted from: Annual Angioplasty Quality Reports available from: In-hospital mortality declined by 29% between , but was accompanied by a 43% reduction in the PCI treatment of cardiogenic shock. NY PCI Mortality: PCI for Cardiogenic Shock

23 Survival with Cardiogenic Shock Brigham and Women’s Hospital Hochman J et al. The SHOCK Trial 1999 Immediate revascularization confers sustained survival benefit is similar whether PCI or CABG is used.

24 Risk Avoidance: Lessons from NY Brigham and Women’s Hospital Michigan, with no public reporting, was compared to NY State for PCI risk factors and outcomes. Adapted from: Moscucci et al. JACC 45(11). June MI Shock: 2.56% MA Shock: 2.28% NY Shock: 0.38% MI Shock: 2.56%

25 NY State in the SHOCK Trial Brigham and Women’s Hospital Apolito RA et al. Am Heart J February 2008 Investigators explored practice patterns of participating centers from NY State and all other U.S. enrolling centers in the SHOCK trial. NY State was only state mandating public release of risk adjusted outcomes. Provided a contemporaneous comparison with rigorous data collection and follow-up of high risk patient population in NY as compared with other regions.

26 NY State in the SHOCK Trial Brigham and Women’s Hospital Apolito RA et al. Am Heart J February 2008 After institution of public reporting, centers in NY demonstrated lower rates of emergent revascularization as compared to non-NY centers. Time to CABG: NY = hr Non-NY = 10.1hr

27 NY State in the SHOCK Trial Brigham and Women’s Hospital Apolito RA et al. Am Heart J February 2008 Selective utilization leads to decreased mortality for PCI and CABG in Shock patients….However, overall mortality is increased in NY as compared to other states.

28 NY State in the SHOCK Trial Brigham and Women’s Hospital Apolito RA et al. Am Heart J February 2008

29 Comparing NY and MA Brigham and Women’s Hospital Analysis based on data excerpted from public cardiac reports and U.S. census data Comparison of 2003 revascularization rates for cardiogenic shock demonstrate a 2-fold difference between the States. Cases of cardiogenic shock treated per 100,000 population 35.7 cases 71.3 cases

30 Risk Adjustment Specificity Brigham and Women’s Hospital Resnic FS and Welt FG Public Health Hazards of Risk Avoidance - JACC 2009 We reviewed over 5,000 consecutive PCI procedures at BWH to assess the adequacy of data collection systems and risk adjustment algorithms for predicting mortality post-PCI. Definite PCI Related Possible PCI Related NOT Procedure Related

31 MA Public Reporting: So What?

32 Outcomes Trends in MA Brigham and Women’s Hospital Adapted from cardiac surgery and PCI reports www.MassDac.org Unadjusted mortality has declined for both CABG and PCI treated patients in Massachusetts.

33 Decline of rate of revascularization in Cardiogenic Shock in Massachusetts Brigham and Women’s Hospital Source: Mass-DAC Data Review. November % 43% Between 2003 and 2005, the rates of revascularization in Massachusetts declined 37-43%

34 Cardiac Quality: The Big Picture Brigham and Women’s Hospital Clinical Outcomes Process Measures Appropriateness Access to Healthcare

35 Impact on Access to Care Brigham and Women’s Hospital Source: Werner RM, Asch DA and Polsky D. Circulation March 2005 Disparities in access to CABG increased in NY, relative to other states, after the release of report cards Reduced Access Improved Access

36 Operator Volume and PCI Outcomes Brigham and Women’s Hospital Source: Moscucci et al. JACC August 2005 Exploration of Michigan data revealed a consistent trend toward improved risk adjusted outcomes with increasing operator volumes.

37 Operator Volume and PCI Outcomes Brigham and Women’s Hospital Source: Moscucci et al. JACC August 2005 …. This trend was preserved within each expected risk quartile. Even in the lowest risk patients, low volume operators conferred twice the risk for death than high volume counterparts.

38 Cardiac Quality: The Big Picture Brigham and Women’s Hospital Clinical Outcomes Process Measures Appropriateness Access to Healthcare

39 Incremental Patient Health Benefit ↑ Patient Benefit ↑ Survival ↓ Patient Benefit ↓ Survival ↑ Patient Benefit ↓ Survival ↓ Patient Benefit ↑ Survival Physician Preference Patient Benefit Appropriateness and Case Selection Creep Brigham and Women’s Hospital Acute Risk of Procedure

40 Brigham and Women’s Hospital Incremental Patient Health Benefit Acute Risk of Procedure Appropriateness and Case Selection Creep

41 50yo STEMI in Shock Focal CAD w/ Angina Focal CAD w/o Angina 65yo with Ant. STEMI 55yo with NSTEMI 75yo STEMI in Shock 75yo ST Δ’s w/ Sepsis Unstable Angina Brigham and Women’s Hospital Minimal CAD w/o Ischemia Incremental Patient Health Benefit Acute Risk of Procedure Appropriateness and Case Selection Creep

42 50yo STEMI in Shock Focal CAD w/ Angina Focal CAD w/o Angina 65yo with Ant. STEMI 55yo with NSTEMI 75yo STEMI in Shock 75yo ST Δ’s w/ Sepsis Unstable Angina Brigham and Women’s Hospital Minimal CAD w/o Ischemia Incremental Patient Health Benefit Acute Risk of Procedure Appropriateness and Case Selection Creep Public Reporting can promote a Perverse Incentive

43 Acute Risk of Procedure ↑ Patient Benefit ↓ Survival ↓ Patient Benefit ↑ Survival Brigham and Women’s Hospital Incremental Patient Health Benefit Appropriateness and Case Selection Creep

44

45 Improving Risk Adjustment Brigham and Women’s Hospital Based on physician input, beginning in 2006, Mass- DAC began prospectively collecting compassionate use classification information for all PCI cases. Compassionate Use Prospectively Defined by any of: –Coma on presentation (Glasgow Coma score < 7) –Requirement for percutaneous assist support or percutaneous bypass (since amended to high anatomic risk with or without ventricular support) –CPR at start of procedure. 100% adjudication for all compassionate use cases by trained interventional cardiologists. Appeal process implemented to challenge adjudication decisions

46 Decline of prevalence of Cardiogenic Shock in PCI and CABG in MA Brigham and Women’s Hospital Source: Mass-DAC Data Review. November 2008 Between 2003 and 2005, the rates of revascularization in Massachusetts declined 37-43%..... Intro Comp Use Criteria

47 Outcomes of CU Admissions Brigham and Women’s Hospital Source: Mass-DAC October 2009

48 Improvement in Mortality Prediction Model (Shock/STEMI) Brigham and Women’s Hospital Source: Mass-DAC October 2009

49 Improvement in Mortality Prediction Model (Shock/STEMI) Brigham and Women’s Hospital Source: Mass-DAC October 2009

50 Brigham and Women’s Hospital Improvement in Mortality Prediction Model (Shock/STEMI) ROC Area: No CU: 0.87 w. CU: 0.90 P<0.01

51 Why? Reclassification of Cases Brigham and Women’s Hospital Source: Mass-DAC October 2009

52 Brigham and Women’s Hospital Reclassification of Cases with CU Source: Mass-DAC October 2009

53 Decline of rate of revascularization in Cardiogenic Shock in Massachusetts Brigham and Women’s Hospital Source: Mass-DAC Data Review. November 2008 Between 2003 and 2005, the rates of revascularization in Massachusetts declined 37-43%..... Intro Comp Use Criteria

54 Additional Physician Input Brigham and Women’s Hospital Based on MA-ACC Quality Oversight Committee recommendation, DPH and Mass-DAC have agreed to incorporate an additional covariate of “Extraordinary Risk” to account for unmodeled covariates in current models. Extraordinary risk cases will include: –Cases meeting appropriateness criteria for PCI –Likelihood of benefit to patient –Coexisting condition not currently in model that would substantially increase risk of in-hospital death –100% review and adjudication by multidisciplinary committee to include interventional cardiologist, clinical cardiologist, patient representative, DPH representative and medical ethicist. Culmination of 3 year effort by MA Chapter ACC.

55 Outcomes Trends in MA Brigham and Women’s Hospital Adapted from cardiac surgery and PCI reports www.MassDac.org Unadjusted mortality has declined for both CABG and PCI treated patients in Massachusetts.

56 Recommendations Brigham and Women’s Hospital Implement processes to monitor both appropriateness and access to care –Appropriateness: focus on sampling and review of low risk procedures and random reviews of high risk cases avoided by institutions –Access to care: monitor treatments according to indices of: sickest patients, poorest, racial mix for geography served by institution, age. Incorporate clinical perspective in improving risk assessment through active participation of physicians. Avoid public release of operator specific outcomes as this will amplify the risk-aversion. Report ONLY non shock cases at the institution level publicly. Preserve internal (DPH) rigorous operator level quality review to identify outliers requiring additional investigation.

57 Conclusions Brigham and Women’s Hospital Monitoring the quality of cardiac procedures is essential, given the cost and consequences of these services. –Historical failure of physicians to adequately police the process MA has the most statistically rigorous methods to evaluate risk-adjusted mortality, and is viewed as a model by other states Rigorous review of high quality risk-adjusted mortality data is necessary, but not sufficient, to assess the quality of cardiac care delivered in Massachusetts. Beyond risk-adjusted mortality, quality must also account for appropriateness of care, access to care, additional health related outcomes of care, and evaluate key processes of care delivered

58 Comprehensive Cardiac Quality Brigham and Women’s Hospital Clinical Outcomes Process Measures Appropriateness Access to Healthcare


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