Ensuring Quality in the Cardiac Cath Lab

Who defines quality in the cardiac cath lab?

Let’s first look at the definition of “quality.” Quality, according to Merriam-Webster’s dictionary, is the standard of something as measured against other things of a similar kind; the degree of excellence of something. Quality is hard to define because it depends on one’s perspective. It is a singular judgment for all of our customers: patients, expert clinicians, administrators, payers, cardiac cath lab (CCL) team members, patients, and their family and loved ones. Expert clinicians say quality is measured by outcomes, but success is often a matter of perspective. Administrators equate quality to return on investment (ROI) and payers look to metrics like Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to benchmark against national averages, possibly measuring against faulty data. A CCL team might judge quality through specific metrics and standards such as the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) database. Finally, a patient’s family might judge quality based on how well the staff kept the family informed. As a patient, quality could be perceived by the staff caring for you as an individual.

The determination of successfully meeting quality metrics in the CCL is complicated and ever changing. In a pay-for-performance health care model, the insistence of transparency of process and third-party validation is an unequivocal reality. Noting that systems of care are increasingly complex, Dr. Babb states, “…it becomes a challenge for all of us to practice at the highest level while keeping up with expert opinion and evidence-based guidelines.”

Why is quality important in the cardiac cath lab?

With cardiovascular disease being the number-one killer¹, cardiovascular care is one of the largest consumers of healthcare dollars. Because of the high cost of health care and its impact on government budgets, cardiovascular care will continue to be scrutinized. Approximately 600,000 people die of heart disease in the United States every year, which equates to one in every four deaths.² Coronary heart disease alone costs the United States $108.9 billion each year.³ We know that on a daily basis, interventional cardiologists perform thousands of cases that save lives. We also know there is room for improvement due to continued variation in practice (Figures 1-2). Standardization of care based on best practice to ensure optimal outcomes is required. To deliver cost effective, optimal cardiovascular care for every patient, it is imperative to secure the very best outcomes for every procedure. Quality cardiovascular patient care should ensure that the right patient has the right procedure with the right execution, resulting in the right outcome as benchmarked by the NCDR (Figure 3). Additionally, quality cardiovascular care should include random case peer review to ensure these key components are met.

The ACC/American Heart Association/Society for Cardiovascular Angiography and Interventions 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures defines quality in PCI: “[It] includes selecting appropriate patients for the procedure, achieving risk-adjusted outcomes that are comparable to national benchmark standards (in terms of procedural success and adverse event rates), using reasonable resources, achieving quality procedure execution (including the use of evidence-based medical therapies) and providing an acceptable patient experience. To achieve optimal quality and outcomes in PCI, including acceptable angiographic, procedural, and clinical success rates, it is necessary that operators and the supporting institution be appropriately skilled and experienced, collect data to allow quality analysis, and have established appropriate systems of care.”⁴

Research to support proactive peer review

Peter C. Block, MD, FSCAI, Professor of Medicine and Cardiology, Emory University, Atlanta, Georgia, emphasizes the importance of expert, external review. Noting that protection for the patient, hospital and physician is the purpose of peer review, Dr. Block stated that the process improves documentation and “…that documentation relates to better patient care, including improving physician thought processes, clarifying patient issues, and clearly documenting the outcomes.”

The writing committee for the Clinical Competence Statement on Coronary Artery Interventional Procedures supports the recommendation⁴ that every PCI program should operate a quality improvement program that routinely:

• Reviews quality and outcomes of the entire program. 
• Emphasizes clinical documentation.
• Reviews results of individual operators.
• Includes risk adjustment. 
• Provides peer review of difficult or complicated cases.
• Performs random case reviews.

Each institution that provides PCI services must establish an ongoing mechanism for valid and continuous peer review of its quality and outcomes. Every CCL professional should know their lab’s NCDR data, and it should be reviewed and discussed at every team meeting, while looking for ways to improve. Many organizations collect the data, but are they verifying their data and using their data to improve their cardiovascular services? Payers reference this data and reimburse for performance based on your data; it is important to be effective users of your data.

Proactive peer review is preventive medicine for the health of your cardiovascular program

One of the ways to ensure quality in the CCL is to employ external, expert, random case peer review. Based on the expert consensus document⁴, measurable outcomes maintain quality as an objective achievement. Therefore, proactive peer review can ensure quality and help you identify any opportunities for improvement. 

A credible resource is the Accreditation for Cardiovascular Excellence (ACE) Quality Review. ACE, sponsored by the Society for Cardiovascular Angiography and Interventions (SCAI) and the ACC, specializes in cardiology and delivers a physician-led consultative perspective. Engagement with clinical staff and physicians provides successful outcomes for hospitals, patients, payers and providers alike. Quality Review is a system of peer review that relies on standardization and determines quality on angiographic case review utilizing Appropriate Use Criteria (AUC) from the most recent published guidelines. ACE’s expert clinician teams provide specific, customized direction to prove appropriate use. “Accreditation for Cardiovascular Excellence offers the option for external peer review, providing opportunities to look at the CCL for specific issues that need to be addressed,” emphasized Charles E. Chambers, MD, FSCAI, Penn State Hershey Medical Center, during the 2013 SCAI Scientific Sessions.

Cath labs benefit from the ACE Quality Review program by developing an integrated quality program and mandating a thorough review of diagnostic accuracy and quality. “Being proactive really sits well with external reviewers,” stated Ralph G. Brindis, MD, FSCAI, Clinical Professor of Medicine, University of California, San Francisco. ACE cardiology peer review experts utilize a process that is performed, discussed, and implemented at all levels and amongst all disciplines within the cardiovascular program. The most objective method for validating a peer review program is to partner with an organization that includes cardiology expertise such as the ACE Quality Review program. We hope you have already started a proactive peer review program in your lab. If not, why not?

Hear what the experts have to say about the ACE Quality Review program at https://www.cvexcel.org/ace-video-series/

About Accreditation for Cardiovascular Excellence

ACE, an independent organization sponsored by the Society for Cardiovascular Angiography and Interventions (SCAI) and the American College of Cardiology Foundation (ACCF), offers independent evaluation and monitoring of facilities that provide cardiovascular care. By reviewing facility and operator performance and comparing clinical decision-making to nationally accepted best practices, ACE peer review and accreditation services plays a critical role in continuous quality improvement programs. Learn more at https://www.cvexcel.org

References 

1. World Health Organization. The Top Ten Causes of Death. Available online at https://www.who.int/mediacentre/factsheets/fs310/en/index2.html. Accessed December 18, 2013.
2. Kochanek KD, Xu JQ, Murphy SL, Miniño AM, Kung HC. Deaths: final data for 2009. National vital statistics reports. 2011; 60(3): 1-117. Available online at https://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_03.pdf. Accessed February 12, 2014.
3. Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011 Mar 1; 123(8): 933-944. doi: 10.1161/CIR.0b013e31820a55f5.
4. Harold JG, Bass TA, Bashore TM, Brindis RG, Brush JE Jr, Burke JA, Dehmer GJ, Deychak YA, Jneid H, Jollis JG, Landzberg JS, Levine GN, McClurken JB, Messenger JC, Moussa ID, Muhlestein JB, Pomerantz RM, Sanborn TA, Sivaram CA, White CJ, Williams ES. ACCF/AHA/SCAI 2013 update of the clinical competence statement on coronary artery interventional procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (Writing Committee to Revise the 2007 Clinical Competence Statement on Cardiac Interventional Procedures). J Am Coll Cardiol. 2013 Jul 23; 62(4): 357-396. doi: 10.1016/j.jacc.2013.05.002.