Kim A Eagle MD

1
Quality of care, part 4 MI

• Kim A Eagle MD
• Albion Walter Hewlett Professor of Internal
  Medicine
• Chief, Clinical Cardiology
• Co-Director, Heart Care Program
• University of Michigan
• Ann Arbor, MI
• Dr Harlan Krumholz MD FACC
• Associate Professor of Medicine Epidemiology
  Public Health
• Yale University School of Medicine
• New Haven, CT

2
Quality of care
Making changes

• Quality of care has gotten a lot more important
  in this cost-cutting era.
• By evaluating what we do and making changes, we
  will get better value for the money.
• By identifying opportunities for improvement and
  making changes, we will be able to provide better
  care.

3
Care and outcomes
MI and AMI

• Clinical studies have identified several aspects
  of MI care that are closely linked to outcomes
  (use of aspirin, beta-blockers, reperfusion
  therapy).
• Quality of care for acute MI involves a much
  broader set of clinical skills the ability to
  detect whether or not an individual is actually
  having an AMI, the need for rapid triage, signs
  of decompensation, subtle murmurs, the need for
  surgery.

4
Indications of quality

• Several straightforward processes are relevant to
  the vast majority of patients the extent to
  which these are used can give us some indication
  of the quality of care that is being provided.
• For acute MI, as well as looking at processes,
  clinical decisions, and interventions, we have
  also looked at outcome, particularly mortality,
  and have been able to adjust for the severity of
  the AMI when comparing level of care across sites.

5
What to measure?
Proof of quality

• External partners eg, National Committee for
  Quality Assurance (NCQA), Health Plan Employer
  Data and Information Set (HEDIS), payers,
  insurers want some way to measure quality of
  care.
• The American College of Cardiology (ACC) and the
  American Heart Association (AHA) have put
  together a joint task force to develop
  performance measures for a variety of conditions,
  including AMI.
• Currently many of the measures of quality of AMI
  care used by external partners are similar to
  those we expect to see in the guidelines.
• These guidelines will help insurers and
  purchasers determine how good the care being
  delivered is.

6
Setting targets
LDL cholesterol levels

• An LDL cholesterol level of 130 mg/dL has been
  established as the target in patients with
  established coronary artery disease by the NCQA.
• Although many physicians believe that target LDL
  levels should be below 100 mg/dL in patients with
  established disease, the committee decided that
  130 mg/dL would be a reasonable first step
  towards instituting a cholesterol measure.

7
Setting targets
Choosing an acceptable level

• With a target of 130 mg/dL, care will be
  considered good if a patient reaches a level of
  105 mg/dL an additional medication will not be
  required to further lower LDL cholesterol.
• However, it would be very difficult for any
  clinician to argue that care is adequate when the
  LDL level is above 130 mg/dL.
• This measure provides managed care organizations
  with a way to systematically collect information
  and will give them some way to judge how
  successful they have been at lowering cholesterol
  in patients with coronary artery disease.
• Over time, this standard can be lowered, but the
  mere fact that a level has been established will
  lead to greater accountability.

8
Claims data
Using what is available

• The large sets of administrative data are being
  used to produce estimates of mortality for
  various groups, including hospitals.
• Because these sets of administrative data are
  available, they are being used.

9
Claims data
How good are they?

• Administrative billing codes correspond only very
  crudely with the actual clinical condition of an
  individual patient.
• When dealing with imprecise data and small sample
  sizes, performance of an individual physician,
  individual hospital, or even a region or
  healthcare system can be misrepresented.
• These data can be used for internal benchmarking,
  to generate hypotheses, and to look for ways to
  improve in our individual institutions.
• These data are not going to give consumers the
  information they need to make informed choices
  about where they should receive care.

10
Claims data
Risk-adjustment formulas

• The mathematical formulas we use to risk-adjust
  when we use claims data do not adequately account
  for the comorbidities that don't get entered in
  the claims database.
• Risk-adjustment formulas account for only 30 to
  40 of the variation in outcome.
• Outcome data can be used internally to give a
  physician an idea of how they're doing, but a
  particular outcome should not be used to rate a
  physicians performance because of the potential
  inaccuracy of those types of comparisons.

11
Commitment to quality
Physicians must take the lead

• Physicians need to look at their own practices
  and institute systems that will ensure that no
  patient misses out on interventions or
  medications that have been demonstrated to
  improve outcome.
• To do this, physicians need a specificity of
  purpose, a clearly defined aim, and the ability
  to measure performance.
• Physicians need to take the lead within the
  healthcare profession and show that such
  standards can be achieved.
• The abundance of evidence available on the care
  of AMI patients makes it the perfect testing
  ground.

12
Processes
Providing the basics

• These are the very basic treatments for which
  evidence has been available for 20 years, yet
  studies show that these have not been translated
  to the bedside for all patients who meet the
  criteria.
• on admission aspirin or beta-blockers
• on discharge aspirin, beta-blockers, or ACE
  inhibitors
• reperfusion therapy
• In time-sensitive therapies (eg, reperfusion
  therapy), time is being lost because of delays
  inherent in communications and decision-making
  systems.

13
Structure
Communication and integration

• Key structural components of a hospital are
  necessary to deliver the highest quality of care.
• integration of emergency medical services by the
  time the EMS arrives at the hospital, the
  emergency department should be prepared to
  deliver care immediately
• a reliable communication system the emergency
  department should be able to communicate quickly
  and easily with cardiologists and internists
• an efficient hospital set-up the hospital should
  be set up to allow the healthcare team to work as
  an integrative team measuring this will be
  difficult but better process will be the result

14
Process tools

• Tools are being developed that can be used to
  remind physicians of the critical elements that
  should be considered in every situation.
• These tools will help physicians become more
  systematic.
• The goal should be to translate the information
  we have to the bedside.
• Measuring quality of care can help us understand
  where we are and where we need to be.

15
The challenge

• One of the major challenges in this field is
  broadening the current focus on AMI to the area
  of acute coronary syndrome.
• It's been convenient to focus on AMI because we
  can create definitions for it some acute
  coronary syndromes are difficult to define.
• We must also be able to put into context the
  abundance of trials on different strategies (eg,
  LMWH, GP IIb/IIIa, interventional strategies,
  devices).
• Make sure the guideline process is implemented in
  a timely way, so that it helps assess performance
  to the benefit of patients.