ACC NEWS
President's Page: Meeting the Challenges of Outcome Measures
Alfred A. Bove, MD, PhD, FACC, ACC President* and
John A. Spertus, MD, Chair, Task Force on Public Reporting of Hospital Level Cardiovascular Outcomes
* Address correspondence to: Alfred A. Bove, MD, PhD, FACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037
The most important mission of the American College of Cardiology is to advocate for quality cardiovascular care. Efforts to measure and improve the quality of care are ultimately directed at optimizing our patients' outcomes. One step toward this goal is the public reporting of hospitals', surgeons', and cardiologists' performance, an activity that is becoming increasingly common in the emerging era of accountability. While conceptually admirable, a critical challenge is to exclude the variability in outcomes due to the complexity of individual patients so that the comparisons are fair and independent of the "sickness" of treated patients (1). Among the greatest challenges in creating clinically valid risk models to compare providers' outcomes is acquiring the relevant and prognostically important clinical data, especially when administrative data is the easiest and most common source of outcomes estimates. Without high-quality clinical data, a number of alternate approaches have been, and are being, conducted. For example, individual states have been reporting outcome measures for years. Pennsylvania annually reports on hospital mortality for a number of disorders and periodically reports the morbidity and mortality for cardiothoracic surgeons. New York reports similar statistics, and the federal government reports on outcomes for a number of diseases for individual hospitals. The value of these reports is uncertain. Although a few programs have been improved when confronted with suboptimal performance data, public perceptions rarely have changed the practice of individual surgeons, while some have been reluctant to operate on high-risk patients because of concerns for adverse reporting from imperfect risk adjustment models (2).
We are experiencing an accelerating trend toward measuring quality of care and, when costs are included, efficiency. Much of this effort is being led by the National Quality Forum (NQF), a nonprofit organization that aims to improve the quality of health care by setting priorities and goals for performance improvement, by endorsing standards for measuring and publicly reporting on performance, and by promoting the attainment of national goals through education and outreach programs. The NQF is supported by a large consortium of stakeholders, including the American College of Cardiology (ACC), and is working on a broad spectrum of quality metrics. These include care coordination, composite measures for quality, imaging efficiency, medication management measures, patient outcome measures, and many more.
A key focus of the NQF's efforts is cardiovascular disease. To improve the scientific validity of their efforts, they have consulted the ACC for assistance in developing outcomes measures for a number of cardiovascular conditions. To best accomplish this, the ACC has proposed that its National Cardiovascular Data Registry database, which is rich in clinically important details, be used as one method for improving the accuracy of outcomes measurement. Topics being considered by the NQF and the ACC include acute myocardial infarction, heart failure, atrial fibrillation, and ischemic heart disease. Recently, at the request of the Centers for Medicare and Medicaid Services, the ACC has worked to develop a new outcome measure for readmission after percutaneous coronary intervention (PCI), an extension of previous efforts that have focused only on mortality. By taking the lead in this process, the ACC has the opportunity to accomplish a number of important goals: first, we can specify the measures that are clinically coherent with the practice of cardiology; second, we can demonstrate a profound professional commitment to quality; and third, we will have quality measures to put forth for new reimbursement methods when the opportunity arises.
These efforts are congruent with a long-standing investment of the College in elevating the quality of cardiovascular care. The foundation of all of our efforts is the synthesis of clinical evidence into guidelines, an activity that the College and the American Heart Association have led for over 25 years. From these, the ACC has led the development of performance measures and appropriate use criteria, which can improve both the practice of evidence-based medicine and the selection of patients most likely to benefit from cardiovascular care. Beyond merely setting theoretical goals for care, the National Cardiovascular Data Registry has also created an opportunity to prospectively collect data in the setting of PCI, angiography, acute coronary syndromes, implantable cardioverter-defibrillator implantation, and carotid revascularization so that the quality of care can be assessed and improved. All of these efforts represent a monumental commitment to ensure that our patients benefit from the care that we deliver.
As the ACC steps forward with its partner organizations to create a robust infrastructure for quality assessment, however, several important conceptual points need to be emphasized. Using the rich clinical data from our registries can improve the methodological rigor for assessing clinical outcomes. In the setting of PCI, for example, knowing the severity of patients' coronary disease and their clinical comorbidities can markedly improve the accuracy of risk-adjustment models that control for the illness severity of treated patients. Moreover, by proactively collaborating with Medicare, we can make the outcomes being assessed more clinically relevant and accurate. For example, excluding staged revascularization procedures from the readmission outcome measures that are being developed allows efforts to improve the safety of the procedure to not be counted as adverse outcomes. Yet, as the ACC works to develop outcome-based measures that focus upon a procedure, such as PCI, there may be an inclination to hold the operator for that procedure accountable for any adverse outcomes. This is problematic. For example, in an outcome-based measure that seeks to compare 30-day readmission rates after PCI, it is clear that many of these admissions are not necessarily due to the PCI procedure itself, but rather to the numerous co-morbidities found in patients with coronary disease. In such an example, accountability lies not with the interventionalist, but with the entire team that provides care for that patient and those who organize the transition of care from the inpatient to the outpatient setting. This creates a challenge for our community. If the Centers for Medicare and Medicaid Services is going to use a sentinel procedure, such as PCI, to compare subsequent readmission rates, we need to educate our membership, their colleagues, and their hospitals to recognize that such outcomes require a collective effort by all to improve patient care. Accordingly, the ACC is committed to working with our members to educate, develop novel treatment strategies, and disseminate best practices so that our profession can continue to lead organized medicine in how best to optimize the quality of care. This will require us all to work diligently in the upcoming years to collaboratively improve the foundation of cardiovascular care and to improve our patients' outcomes.
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1. Krumholz HM, Brindis RG, Brush JE, et al. Standards for statistical models used for public reporting of health outcomes: an American Heart Association Scientific Statement from the Quality of Care and Outcomes Research Interdisciplinary Writing Group: cosponsored by the Council on Epidemiology and Prevention and the Stroke Council Circulation 2006;113:456-462.[Abstract/Free Full Text]2. Omoigui NA, Miller DP, Brown KJ, et al. Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes Circulation 1996;93:27-33.[Abstract/Free Full Text]
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