ACC NEWS
President’s Page: A Question of Quality: Why National Benchmarking?
Pamela S. Douglas, MD, FACC, President, American College of Cardiology* and
Ralph G. Brindis, MD, MPH, FACC, Chief Medical Officer, ACC-NCDR
* Address correspondence to: Dr. Pamela S. Douglas, American College of Cardiology, c/o Cathy Lora, 9111 Old Georgetown Road, Bethesda, Maryland 20814-1699.
When starting our medical careers, we invariably viewed our work as serving patients’ needs. Over the ensuing years, however, we increasingly have found ourselves responding to additional needs: payers, legislators, regulators, auditors, medical administrators, litigators, reformers, watchdogs, and even physicians from other disciplines. Most of these stakeholders want the same things we do: high-quality care that is accessible and affordable to all who need it. However, one important item has changed. Now we are being asked to "prove it."
The American College of Cardiology (ACC) finds itself at the hub of this evolving environment, and we are gearing up to provide cardiologists with tested tools to accurately measure and "prove" we deliver quality care. But measuring personal performance is just not enough. If all we ever did was use our own data as the basis for improvement, we would only be better than we used to be. National benchmarking sets the bar higher.
National benchmarking, in some form, has been around for many years, but it has not been until now that we are being asked—or forced in some cases—to compare our clinical practice and patient outcomes against our peers. Although this can be daunting and frightening, this is a step we must take. We no longer can rely simply on "physician’s prerogative" as the answer when there are clinical care discrepancies. The proof is in the data, reimbursement decision-makers are saying, and that data had better be good.
But, as we all know, not all benchmarking is created equal. For instance, if data collection is not standardized or audited, we are faced with a possible apples-to-oranges data incompatibility problem. It becomes imperative that data points are collected in a regulated manner, using identical elements that are input into a single electronic "home." The data are then independently analyzed in similar groupings to produce reliable results.
The ACC has wholeheartedly adopted this straightforward data evaluation approach with its landmark American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) (1). Although the original mission to develop a national benchmarking service to improve clinical quality in catheterization labs remains steadfast, the ACC-NCDR has begun to fulfill broader roles for the nation’s health care than its founders first envisioned.
In recent years, large payers, multi-system provider groups, federal agencies, and state regulators have greatly expanded the scope of the ACC-NCDR’s data to measure performance and utilization rates; replace and/or answer certificate-of-need questions; promote continuous quality improvement; conduct post-market drug and device surveillance; and track patient safety. Some of these bellwether stakeholders now mandate participation in the ACC-NCDR for their constituents and, only with the participating facility’s expressed agreement, receive either data exports or customized comparative reports of that lab’s ACC-NCDR aggregated data.
A new area of interest has included payer-sponsored "pay for performance" programs, where a local or regional payer has partnered with the ACC-NCDR and the state chapter to design and implement programs that use the registry to track and monitor catheterization lab performance measures against targeted performance goals.
The ACC-NCDR began in 1998 as a registry designed to standardize reporting of catheterization laboratory outcomes so that the data could be used to feed local hospital continuous quality improvement initiatives. Today, the ACC-NCDR has two registries with a third to be launched in March at ACC.06 in Atlanta, Georgia. The first registry, the CathPCI Registry, now counts almost 700 participating hospitals and more than 4.5 million documented diagnostic catheterization and percutaneous coronary intervention (PCI) procedures. More than 75 manuscripts and abstracts published from the CathPCI Registry aggregate data have offered opportunities for cardiologists, hospitals, and other cardiovascular professionals to better understand the risks, benefits, and effectiveness of present and emerging technologies employed in the cardiac catheterization laboratory (2–6).
In June 2005, the ACC-NCDR closely partnered with the Heart Rhythm Society (HRS) to launch the ICD Registry. This new registry meets an April 1, 2006, Centers for Medicare and Medicaid Services (CMS) mandate to specifically track activity in 1,300 electrophysiology laboratories nationwide for implantable cardioverter-defibrillators for the primary prevention of sudden death. The ICD Registry will address: 1) who is receiving the device; 2) who is implanting the device; 3) what brand of device is being implanted and how it is programmed; and 4) what are the in-hospital outcomes (7).
The history-making decision of the CMS speaks not only to the robust nature of the ACC-NCDR and its seven-year track record of delivery high-quality benchmarking, but also to the commitment of CMS as America’s largest purchaser of health care to evaluate patient outcomes to best assess and improve care of its Medicare population. It also reflects the power of partnership among physician societies focused on the same outcome: quality care for the ultimate evaluators—our patients. The HRS and the ACC worked side-by-side for more than nine months to effectuate this groundbreaking federal benchmarking mandate.
The current efforts of the ACC to develop a carotid stenting and endarterectomy registry are an excellent example of working collaboratively with the CMS and similarly situated physician societies. In March 2005, the CMS issued a coverage determination statement to reimburse selected carotid stenting procedures, but it stipulated that facilities must collect related data on patients receiving carotid stenting procedures. The ACC-NCDR catalyzed a national Carotid Artery Stenting Work Group that included representatives from the American Academy of Neurology (AAN), American Society of Neuroradiology (ASNR), Society for Vascular Surgery (SVS), Society for Vascular Medicine and Biology (SVMB), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Interventional Radiology (SIR), and ACC. As a result of this enlightening collaboration, the national carotid intervention registry will use a novel integrated data design suitable for all disciplines, including cardiology, neurology, radiology, and vascular surgery. Data elements are being especially selected to meet the CMS data collection requirements for coverage, while still incorporating all underlying ACC-NCDR data management processes.
All ACC-NCDR registries use standard data elements and definitions for patient demographics, clinical variables, and outcomes. Core to the ACC-NCDR are the following critical components:
- • Quarterly reports to each participating facility benchmarking its results, including risk-adjusted mortality, against national and peer groups;
- • Evidence-based data elements combined with process and performance measures that are linked to current ACC/American Heart Association (AHA) clinical practice guidelines;
- • Relationships with more than 18 certified software vendors that provide systems to collect data;
- • ACC technical and clinical support staff to provide expertise and training;
- • Access to Masters and/or PhD-level biostatisticians who conduct analysis and reporting; and
- • Rigorous methods to ensure data quality and accuracy, including an on-site audit program.
The ACC-NCDR appreciates our participants’ reports that the registries’ benchmarking has helped them to identify opportunities to improve clinical as well as financial performance. According to our ACC-NCDR facilities, they have actively used a supplementary product called ACC-CathKIT, a web-based quality catheterization laboratory tool kit developed by the ACC and the SCAI (8). Included in ACC-CathKIT are lessons in continuous quality improvement (CQI) methodology, examples of relevant CQI projects, such as management and avoidance of groin complications, and downloadable templates for catheterization laboratory protocols and PCI pathways.
The ACC-NCDR is guided in management and scientific oversight by a management board consisting of senior fellow ACC members with backgrounds in cardiovascular outcomes research and quality. Each ACC-NCDR registry is guided by a scientific work group that consists of fellow ACC members and relevant subspecialties and other society partners who have expertise in the particular registry.
Although national benchmarking of catheterization outcomes and performance measures may seem remote to the ACC members not involved in daily catheterization laboratory activities, overall performance measurement is definitely on the horizon. The ACC-NCDR has proved, unequivocally, that national benchmarking supports each of us as we strive to practice the right kind of medicine in an environment that supports our work. It also can forge friendly alliances among seemingly disparate groups that have an inherent interest in our practice.
There are many things we can do to support national benchmarking, even on a small scale. We can read more about benchmarking and the efforts of the ACC-NCDR. If our hospitals and facilities participate in the ACC-NCDR or any other registry, we can make certain that staff receive the support they need to be successful. We can become involved with our ACC state chapter and explore opportunities for collaborative benchmarking at a regional level.
Furthermore, as cardiologists we must become evangelists for our own hospitals’ quality initiatives through championing ACC-NCDR participation and identifying opportunities for local CQI initiatives. It is our obligation to step forward now, when others are seeking our guidance. Benchmarking undoubtedly will translate directly into dollars in a world of pay for performance. Against which measures should we be held accountable? Clean, unadulterated data should be collected, analyzed, and audited by our unbiased ACC rather than by some for-profit third-party vendor. We must—and can—be the masters of our own destiny.
 |
References
|
|---|
1. Brindis RG, Fitzgerald S, Anderson HV, Shaw RE, Weintraub WS, Williams JF. The American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)building a national clinical data repository. J Am Coll Cardiol 2001;37:2240-2245.[Free Full Text]2. Anderson HV, Shaw RE, Brindis RG, et al. A contemporary overview of percutaneous coronary interventions—the American College of Cardiology-National Cardiovascular Registry (ACC-NCDR) J Am Coll Cardiol 2002;39:1096-1103.[Abstract/Free Full Text] 3. Shaw RE, Anderson HV, Brindis RG, et al. Development of a risk adjustment mortality model using the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) experience1998–2000. J Am Coll Cardiol 2002;39:1104-1112.[Abstract/Free Full Text] 4. Anderson HV, Shaw RE, Brindis RG, et al. Relationship between procedure indications and outcomes of percutaneous coronary interventions by American College of Cardiology/American Heart Association Task Force guidelines Circulation 2005;112:2786-2791.[Abstract/Free Full Text] 5. Klein LW, Shaw RE, Krone RJ, et al. Mortality after emergent percutaneous coronary intervention in cardiogenic shock secondary to acute myocardial infarction and usefulness of a mortality prediction model—American College of Cardiology National Cardiovascular Data Registry Am J Cardiol 2005;96:35-41.[Web of Science][Medline] 6. Tavris DR, Gallauresi BA, Lin B, et al. Risk of local adverse events following cardiac catheterization by hemostasis device use and gender J Inv Card 2004;16:459-464. 7. Hammill SC, Phurrough S, Brindis R. The National ICD Registrynow and into the future. Heart Rhythm. 2006In Press.. 8. Dehmer GJ, Hirshfeld JW, Oetgen WJ, et al. CathKITimproving quality in the cardiac catheterization laboratory. J Am Coll Cardiol 2004;43:893-899.[Free Full Text]
|
Top
References