ACC 2006 ANNUAL SESSION HIGHLIGHTS
Special Topics
Frederic S. Resnic, MD, MSc, FACC*,* and
JoAnne Foody, MD, FACC
* Division of Cardiology, Decision Systems Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
Cardiovascular Fellowship Program, Yale University School of Medicine, New Haven, Connecticut.
* Reprint requests and correspondence: Dr. Frederic S. Resnic, Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts 02115. (Email: fresnic{at}partners.org).
|
Abbreviations and Acronyms
| | ACC/AHA = American College of Cardiology/American Heart Association | | ACS = acute coronary syndrome | | CRUSADE Initiative = Can Rapid Risk Stratification of Unstable Angina Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines | | HF = heart failure | | MI = myocardial infarction | | NSTE = non–ST-segment elevation | | NSTEMI = non–ST-segment elevation myocardial infarction | | PCI = percutaneous coronary intervention | | PREMIER = Prospective Registry Evaluating Myocardial Infarction: Events and Recovery | | QI = quality improvement | | STEMI = ST-segment elevation myocardial infarction | | UFH = unfractionated heparin |
|
Within the ACC’s Annual Scientific Sessions, the Special Topics area encompasses a broad range of investigations covering subjects as diverse as assessing and improving cardiovascular health care quality to the measurement of the impact of cardiovascular informatics. More than 270 abstracts were submitted in the Special Topics area, and 88 were accepted for presentation at the Scientific Sessions. Despite the breadth of subjects explored, Special Topics investigations are united by their interdisciplinary nature and focus on identifying opportunities for improving cardiovascular care. In the following paper, we review some of the most important findings reported in the Special Topics sessions.
 |
Lessons learned from large clinical registries
|
|---|
Large-scale, multicenter, prospective clinical registries have been invaluable in exploring the many challenges faced in transforming clinical trial data into clinical practice. Several of these studies have focused on the status of guideline-based care in acute coronary syndromes (ACS) and heart failure (HF). Data from these registries demonstrate significant gaps between ideal clinical performance as defined by the ACC/American Heart Association (AHA) guidelines and the performance documented at the leading centers participating in these registries.
Investigators in the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER), a prospective multicenter study of 2,498 acute myocardial infarction (MI) survivors at 19 centers, explored a variety of health care topics ranging from the impact of insurance and socioeconomic status on clinical outcomes to long-term health status after ACS. Investigators found that after adjustment for other confounders, lack of health insurance at the time of initial hospitalization was associated with significantly lower usage of statin and beta-blocker therapy and a lower likelihood of having an identifiable health care provider at six months. All of these findings indicated poorer longitudinal treatment after acute MI (1).
Another study of the PREMIER registry investigated the relationship of socioeconomic status of the patients to clinical outcomes after acute MI. Patients in the lowest socioeconomic status strata had the highest rates of all-cause mortality and rehospitalization. After adjusting for clinical factors, insurance, and demographics, household income had a strong inverse association with mortality (2). Finally, another team of PREMIER investigators discovered that there was little difference in health status at one year between survivors of ST-segment elevation myocardial infarction (STEMI) versus non–ST-segment elevation myocardial infarction (NSTEMI), demonstrating the need to focus efforts on improving care and outcomes for the full range of ACS survivors (3).
Investigators from the large Can Rapid Risk Stratification of Unstable Angina Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE Initiative) provided ongoing information from this national registry. Launched in 2001, the CRUSADE Initiative is a national quality improvement initiative that is designed to increase the practice of evidence-based medicine for patients diagnosed with non–ST-segment elevation acute coronary syndromes (NSTE ACS) (i.e., unstable angina or NSTEMI). The ACC/AHA Guidelines for the Management of NSTE ACS are the "gold standard" by which appropriate care is defined. Through a continuous cycle of data collection, performance feedback (via site-specific reports), and quality improvement interventions, more than 140,000 cases have been submitted to the CRUSADE Initiative.
A key component of the CRUSADE Initiative is sharing the current state of care and acute outcomes for NSTE ACS patients with the cardiovascular community, through both scientific publications and presentations. At this year’s ACC sessions, investigators studied the performance of hospitals in the management of patients with ACS and identified that the involvement of a committed physician in the quality improvement (QI) process was a critical factor in achieving high rates of adherence to ACC/AHA class I quality indicators. Physician leadership in quality improvement initiatives was more predictive of high-quality care than financial resources, administrative support for QI efforts, or use of data feedback to the clinical services (4). Now that direct physician leadership in QI efforts has been identified as a key predictor of health care quality, cardiovascular leaders must rise to meet this challenge through active participation at their institutions, and institutions must recognize the importance of engaging the clinical community in QI efforts.
Investigators of the Portuguese Registry of Acute Coronary Syndromes studied the compliance with guidelines regarding the medical therapy for the treatment of NSTEMI and unstable angina. In reviewing the in-hospital outcomes of more than 7,500 patients, the investigators found that complete compliance with medical therapy recommendations was associated with a 70% lower risk of in-hospital mortality. This study confirms the findings of previous investigators who have found compliance with ACC/AHA guidelines in the treatment of ACS to be a critical determinant of clinical outcome (5). Separately, investigators from Case Western Reserve University studied the relationship between medical center volume of acute MI cases treated and adherence to guideline-based care, by examining the 3,712 centers included in the Centers for Medicare and Medicaid Services Hospital Compare database. They found a significant and continuous improvement in adherence rate across all studied measures as acute MI volumes increased, confirming the adage that "practice makes perfect" (6).
|
Improving the quality of cardiovascular care
|
|---|
Continuing with the theme of optimizing acute MI care, investigators from University of Michigan and Yale University undertook a novel exploration of the feasibility of access to primary percutaneous coronary intervention (PCI) for STEMI, by assessing the driving distances and times for the U.S. population to hospitals with the capabilities for performing PCI. The investigators studied U.S. census tract data and integrated it with driving times and distances to PCI and non-PCI hospitals using a nationwide road network database. The investigators found that 79% of U.S. adults lived within a 60-min prehospital time period that would make transfer to a PCI hospital feasible in the setting of STEMI (Fig. 1), which is within the targeted door-to-balloon time guidelines. This finding supports the feasibility of targeting primary PCI as the therapy of choice for STEMI for most U.S. regions, if it can be provided at an experienced center within the recommended door-to-balloon time guidelines (7).
View larger version (98K):
[in this window]
[in a new window]
|
Figure. 1 Pre-hospital time periods in the U. S. Green indicates 60 min or less; yellow indicates >60 min. Reprinted with permission (7).
|
|
Another provocative study, from the University of California system (Los Angeles and Irvine campuses), explored the impact of a variety of organizational strategies to improve quality of care. The investigators studied 9,746 patients with diabetes from 57 provider groups and assessed the impact of organizational incentives and processes on cardiovascular outcomes. The authors found that higher-intensity use of clinical information systems was associated with 45% fewer admissions for congestive HF. Of importance, the investigators also determined that alignment of financial incentives for physicians with quality targets significantly increased guideline adherence for lipid-lowering therapy and was independently associated with 59% fewer congestive HF admissions. Conversely, increasing a physician’s gate-keeping functional role was associated with worse adherence to guideline therapies and a 55% increase in congestive HF admissions (8).
|
Identifying risks in cardiovascular care
|
|---|
Another theme in the Special Topics area is the identification of gaps or risks in the quality of cardiovascular care provided to patients. To that end, a series of studies explored the risks and consequences of medication noncompliance as well as health care system barriers that may increase this risk. Investigators from the University of Pennsylvania probed the impact of pill burden on medication compliance by studying the proportion of days covered for antihypertensive and lipid-lowering therapy in a retrospective cohort of 8,406 patients. The investigators found that pill burden had the greatest negative impact on medication adherence in patients taking the fewest medications and was a significant independent predictor of adherence to cardiovascular medication therapy (9).
A separate investigation from the Department of Veterans Affairs and Kaiser Permanente studied the impact of medication non-adherence on hospitalization and mortality among patients with diabetes. This retrospective study of 11,532 patients with diabetes identified that 21.3% of patients were nonadherent to medical prescriptions (defined as <80% proportion of days covered for filled prescriptions). Nonadherent patients were younger and had fewer comorbidities. In a multivariate analysis, medication nonadherence was associated with a 36% increase in all-cause hospitalization and a 72% increase in the relative risk of all-cause mortality. The authors recommended assessment of medication adherence in routine clinical practice as a mechanism for identifying these patients with a significantly increased risk of adverse events (10).
Barriers to obtaining medically appropriate medications were identified as a significant risk for adverse events in two independent studies. Researchers from the University of Michigan explored the records of more than 93,000 statin users to estimate the relationship between co-payments for medication and adherence to medication. They determined that higher co-payments were independently associated with a 25% reduction in the rates of adherence to statin prescriptions. Of importance, higher rates of statin adherence were associated with fewer cardiovascular hospitalizations and emergency room visits (11).
A second study from the University of Montreal explored the impact of restrictive access for the distribution of clopidogrel following PCI on 13,663 patients not previously taking the medication. The investigators found that 20.1% of patients had their prescription for clopidogrel delayed by at least one day as compared with the prescription filling of other cardiac medications (12). In this subset of delayed or unfilled prescriptions, the risk-adjusted mortality was 47% higher at 12 months than in the medically compliant group. This analysis highlights the critical importance of the attention health care delivery systems must pay toward access to needed medications.
|
Cardiovascular informatics
|
|---|
The increasing use and sophistication of computer applications within cardiovascular medicine has opened new opportunities for novel research in ways to identify risks to quality of care as well as develop tools to improve delivery of cardiovascular care. Several notable examples of cardiovascular informatics research were presented at the Scientific Sessions. Researchers at Harvard Medical School studied the patterns of alerts associated with administration of unfractionated heparin (UFH) from a computerized order entry system at Brigham and Women’s Hospital. A total of 501 alerts were triggered in 3,674 patients who received UFH, of which 50% were related to suspected overdosing. Peak error times for UFH administration, as evidenced by changes in programmed dosing following alerts, correlated with nursing shift times. Smart infusion pump technology reduced errors in the administration of UFH (13).
In a very different study, researchers from the National Cardiovascular Centre Research Institute in Suita-City, Japan, evaluated a closed-loop automated drug delivery system to optimize the management of left atrial pressure, cardiac output, and systemic arterial pressure in a decompensated congestive HF canine model. The system was able to rapidly achieve optimized hemodynamic parameters that stabilized within 30 min of initiation of the system in 12 dogs, thereby avoiding the frequent adjustments of drug infusion rates (14). Investigations such as this one may soon lead to closed-loop automated dose titration systems for human trials, thereby potentially reducing human error in dosing of critical cardiovascular medications.
|
Summary
|
|---|
The highlights reviewed here represent only a small sample of the novel investigations presented at the Annual Scientific Sessions regarding the assessment of quality of care, identification of risks to effective treatment, and new horizons in the use of computerized systems to support delivery of cardiovascular care. Through assessments of the quality of cardiovascular care delivered in practice, the entire cardiovascular community gains critical insight into the requirements for most effectively treating our patients.
|
References
|
|---|
- Georgakis A, Spertus J, Reid KJ, et al. The relationship between health insurance and long-term health status among acute myocardial infarction survivorsresults from the PREMIER registry. (abstr) J Am Coll Cardiol 2006;47(Suppl A):256A.
- Bernheim SM, Spertus JA, Reid KJ, et al. Cardiovascular Outcomes Research Consortium The impact of inpatient quality of care on socioeconomic disparities in outcomes from acute myocardial infarction(abstr) J Am Coll Cardiol 2006;47(Suppl A):257A.
- Khanal S, Bazari R, Tucciarone M, et al. Health status and clinical outcomes after myocardial infarction at one-yeara comparison between patients hospitalized with ST-elevation versus non–ST-elevation myocardial infarction. (abstr) J Am Coll Cardiol 2006;47(Suppl A):256A.
- Lytle BL, Frauio ES, Neelon BH, et al. What aspects of hospital culture influence quality(abstr) J Am Coll Cardiol 2006;47(Suppl A):257A.
- Aguiar CT, Ferreira JS. Compliance with contemporary guidelines for non–ST-elevation acute coronary syndromesinfluence on outcome and interaction with risk stratification. (abstr) J Am Coll Cardiol 2006;47(Suppl A):257A.
- Lewis WR, Sorof SA, Super DM. Practice makes perfectACC/AHA guideline adherence is higher in hospitals with high acute myocardial infarction volume. (abstr) J Am Coll Cardiol 2006;47(Suppl A):255A.
- Nallamothu BK, Bates ER, Polavarapu V, et al. Driving times and distances to hospitals with percutaneous coronary intervention in the U.Simplications for pre-hospital triage of patients with ST-elevation myocardial infarction. (abstr) J Am Coll Cardiol 2006;47(Suppl A):256A.
- Malik S, Ettner S, Selby J, et al. Effect of physician financial incentives and clinical information systems on medication use and congestive heart failure admissions(abstr) J Am Coll Cardiol 2006;47(Suppl A):264A.
- Benner JS, Petrilla AA, Schwarts JS, et al. Patients’ pill burden predicts adherence to antihypertensive and lipid-lowering therapy(abstr) J Am Coll Cardiol 2006;47(Suppl A):263A.
- Ho PM, Runsfeld JS, Masoudi FA, et al. The impact of medication non-adherence on hospitalization and mortality among patients with diabetes(abstr) J Am Coll Cardiol 2006;47(Suppl A):264A.
- Gibson TB, Mark TL, Axelsen K, et al. The effects of statin co-payments and statin adherence on medical care utilization and expenditures(abstr) J Am Coll Cardiol 2006;47(Suppl A):263A.
- Sheehy O, LeLorier J, Rinfret S. Impact of restrictive access to clopidogrel following coronary stent implantation on patient health outcomes(abstr) J Am Coll Cardiol 2006;47(Suppl A):257A.
- Fanikos J, Silverman J, Saniuk C, Luppi C, Goldhaber SZ. Patient safety suffers at nursing shift changeserror rate peaks for intravenous unfractionated heparin administration. (abstr) J Am Coll Cardiol 2006;47(Suppl A):255A.
- Kamiya A, Uemura K, Shimizu S, et al. Closed-loop automated drug delivery to optimize systemic arterial pressure, cardiac output and left heart filling pressure in decompensated heart failure(abstr) J Am Coll Cardiol 2006;47(Suppl A):265A.
Top
Lessons learned from large...
Improving the quality of...