Monitoring the Quality of Invasive Cardiac Services:

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Monitoring the Quality of Invasive Cardiac
Services The Unintended Consequences of
Public Reporting
November, 2007
Frederic S. Resnic, MD MSc, FACC Director
Cardiac Catheterization Laboratory Brigham and
Womens Hospital and Harvard Medical School
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Overview

• 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

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Cardiac Quality The Big Picture
Clinical Outcomes
Process Measures
Access to Healthcare
Appropriateness
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What is Cardiac Quality?

• Risk adjusted Outcomes
• mortality days, months, years?
• other outcomes symptoms, MI, function
• Process measures
• door to balloon time for Acute MI
• QA program, demonstrable QI efforts
• Access to care
• Uninsured, disadvantaged, sickest patients
• Appropriateness
• of procedures performed
• of procedures declined / deferred

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Current MA DPH Cardiac Quality Programs

• Risk-Adjusted Mortality Reports Mass-DAC
  Analysis of hospitals and operators
• Isolated CABG mortality through 30 days
• Angioplasty (PCI) mortality through discharge
• Public reporting of hospitals and CABG surgeons
  (Angioplasty operators to be public 2008)
• Special Project for Primary Angioplasty
• Community Elective Angioplasty Project
• Mass-COMM Study

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Cardiac Quality The Big Picture
Clinical Outcomes
Process Measures
Access to Healthcare
Appropriateness
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MA Cardiac Quality Report Card
Through Mass-DAC, the MA DPH publicly reports
risk adjusted in-hospital mortality for PCI
Source 2005 Adult CABG in MA www.massdac.org
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MA Cardiac Quality Report Card
Through Mass-DAC, the MA DPH publicly reports
risk adjusted in-hospital mortality for PCI
Source 2005 Percutaneous Coronary Intervention
in MA www.massdac.org
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MA Report Cards PCI for High Risk Cases
Source 2005 Percutaneous Coronary Intervention
in MA www.massdac.org
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Trade-Offs in Public Reporting

• Promotes Informed Consumer Choice
• Hawthorne Effect
• Teeth for Quality Monitoring
• Accelerates Adoption of Best Practices
• Transparency

Benefits
Risks
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Outcomes Trends in MA
Unadjusted mortality has declined for both CABG
and PCI treated patients in Massachusetts.
Adapted from www.MassDac.org cardiac surgery and
PCI reports 2002-2005
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Trade-Offs in Public Reporting

• Promotes Informed Consumer Choice
• Hawthorne Effect
• Teeth for Quality Monitoring
• Accelerates Adoption of Best Practices
• Transparency

• Over-emphasis on MD
• Emphasis on Low Risk Cases
• Risk Avoidance of High Risk Cases
• Up-coding and Gaming
• Unmeasured Quality Parameters Ignored

Benefits
Risks
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NY State PCI Mortality Trends
In-hospital mortality declined by 29 between
1998-2004, but was accompanied by a 43 reduction
in the PCI treatment of cardiogenic shock.
NY PCI Mortality 1998-2004
Adapted from Annual Angioplasty Quality Reports
1997-2004 available from
www.health.state.ny.us/statistics/diseases/cardiov
ascular/
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US Trends in AMI with Shock
The nationwide NRMI registry of over 290,000
patients presenting with AMI showed increasing
rates of shock and PCI for shock between 1995 and
2004.
Babaev et al. Trends in treatment of Cardiogenic
Shock in NRMI. JAMA 2005
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Risk Avoidance Lessons from NY
Michigan, with no public reporting, was compared
to NY State for PCI risk factors and outcomes.
MI Shock 2.56
MA Shock 2.28
NY Shock 0.38
Adapted from Moscucci et al. JACC 45(11). June
2005.
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Possible Changes in Referral Patterns
Observations of a change in the complexity
(predicted mortality) of patients referred from
NY State to Cleveland Clinic reinforce concerns
of risk-aversion in NY.
Predicted Mortality
Omoigui, N. A. et al. Circulation 19969327-33
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Pennsylvania Risk Avoidance
Surveys of cardiologists and cardiac surgeons
reinforce the concern that risk avoidance has
developed in other states.
Source Schneider EC and Epstein AM. NEJM
July 1996
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Comparing NY and MA
Comparison of 2003 revascularization rates for
cardiogenic shock demonstrate a 2-fold difference
between the States.
71.3 cases
35.7 cases
Cases of cardiogenic shock treated per 100,000
population
Preliminary Analysis based on data excerpted
from public cardiac reports and U.S. census data
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MA Public Reporting So What?
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Outcomes Trends in MA
Unadjusted mortality has declined for both CABG
and PCI treated patients in Massachusetts.
Adapted from www.MassDac.org cardiac surgery and
PCI reports 2002-2005
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Decline of rate of revascularization in
Cardiogenic Shock in Massachusetts
Between 2003 and 2005, the rates of
revascularization in Massachusetts declined 37-43
43
37
Source Mass-DAC Data Review. November 2007
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Cardiac Quality The Big Picture
Clinical Outcomes
Process Measures
Access to Healthcare
Appropriateness
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Impact on Access to Care
Disparities in access to CABG increased in NY,
relative to other states, after the release of
report cards
Source Werner RM, Asch DA and Polsky D.
Circulation March 2005
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Operator Volume and PCI Outcomes
Exploration of Michigan data revealed a
consistent trend toward improved risk adjusted
outcomes with increasing operator volumes.
Source Moscucci et al. JACC August 2005
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Cardiac Quality The Big Picture
Clinical Outcomes
Process Measures
Access to Healthcare
Appropriateness
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Appropriateness and Case Selection Creep
Patient Benefit
Acute Risk of Procedure
Incremental Patient Health Benefit
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Appropriateness and Case Selection Creep
Physician Preference
Patient Benefit
Acute Risk of Procedure
Incremental Patient Health Benefit
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Appropriateness and Case Selection Creep
Acute Risk of Procedure
Incremental Patient Health Benefit
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Appropriateness and Case Selection Creep
Acute Risk of Procedure
Incremental Patient Health Benefit
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Conclusions

• 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

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Recommendations

• 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.
• Develop a list of key performance indicators to
  evaluate process measures for both CABG and PCI
  care.
• ELIMINATE (immediately) public release of
  operator specific outcomes as this will amplify
  the risk-aversion behavior demonstrated in other
  states.
• PRESERVE rigorous physician level review as
  implemented by Mass-DAC and MA ACC.
• Initial experience with active support systems
  such as Impella LP, confirms that this technology
  represents a significant advance which allows the
  performance of the most complex high risk PCI.

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Comprehensive Cardiac Quality
Clinical Outcomes
Process Measures
Access to Healthcare
Appropriateness
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Thank You