NCDR Update Board of Governors Meeting September 16, 2007

NCDR UpdateNCDR Update

Board of GovernorsBoard of GovernorsMeetingMeeting

September 16, 2007September 16, 2007John Brush, MD, FACC

Chair, Quality Strategic Directions CommitteeACC Governor, Virginia Chapter

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20 Years of Performance Measurement1987 20071997

HCFA hospital mortality reports

JCAHO “Agenda for Change”

HCFA CCP Pilot

HCFA National CCP

NCQA HEDIS measures

QPM to JCAHO

IOM RptIOM Rpt

HCFA 6 Nat’l Conditions

NQF

JCAHOORYX

QPM to CMSHealthgrades

NCQA website JCAHO CoreMeasures

JCAHO Core Pilot

Leapfrog

HCFA HCQII IOM Rpt

PQRI

AQA

CED

Hospitals Physicians

3

QCAREACC’s Commitment To You• Continuous review of new science• Evidence-based guidelines and standards• Comprehensive education• Data reporting and collection through registries

(NCDR)• National Quality Initiatives (D2B)• Adoption and appropriate use of new technology• Evaluation through self-assessment tools,

performance testing and longitudinal studies

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Science

Technology

Evaluation

Standards

EducationReporting

Quality Initiatives

PatientPatientCenteredCentered

CareCare

QCARE

5

1997….. 2004 2005 2006 2007 2008 beyond

CathPCICathPCIRegistryRegistry

ICDICDRegistryRegistry

CARECARERegistryRegistry

ACTIONACTIONRegistryRegistry

IC3 CADOffice

Imaging

HFRegistry

PracMgtRegistry

PADRegistry

EPRegistry

Ped.Registry

CHD

ICD Long

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PartnersCathPCI• Society for Cardiovascular Angiography and InterventionICD• Heart Rhythm SocietyCARE• Society for Cardiovascular Angiography and Intervention• Society for Interventional Radiology• American Academy of Neurology• American Academy of Neurosurgery• Society of Vascular Medicine and BiologyACTION• In discussion with American Heart Association

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Registry/QI• >950 hospitals• 6 million patient records• Online data entry tool

launch 4/07• Support D2B AllianceARS• States – MA, OH, WV, ?CT,

?NJ• Payers – United, BCBSA,

WellPointResearch and Publications• DCRI analytic center• 8* abstracts at AHA

190272

321 362472

547658

825

1000

0

100

200

300

400

500

600

700

800

900

1000

Faci

litie

s

1999 2000 2001 2002 2003 2004 2005 2006 2007F

CathPCI Registry Enrollment

Participants

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Registry• 1450 enrolled• 150,000 patient recordsFunding• 2007 support from WellPoint• $1,895/yearARS• UHC added ICD Registry

participation for sites with EP Labs

• Discussions underway with BCBSA

• Provide data to CMS for reimbursement

Research• ICD Longitudinal Study• Performing analysis for FDA

110

325

746

11541206 1243

1324 1338 13501420 1438 1442 1450

0

200

400

600

800

1000

1200

1400

1600

Faci

litie

s

2/1/2006 4/1/2006 6/1/2006 8/1/2006 10/1/2006 12/1/2006 2/107

ICD Registry Enrollmennt

Participants

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Registry• 235 Participants• Data entry tool• $3195.00/yearARS• CMS requiredResearch• Performing analysis

for FDA• Discussion with CAS

makers re: PMS

8 13 2542 45 57

7487 98

154

198

235

0

50

100

150

200

250

Faci

litie

s

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

CARE Registry Participationt

Participants

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Registry• 250+ participants• No charge• Funding provided by

– Genentech– Bristol-Myers

Squibb/Sanofi Partnership

– Schering Plough Corporation

ARS• Early discussions with

payers0

50

100

150

200

250

Faci

litie

s

Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07

ACTION Registry Participationt

Participant

NCDR CathPCI% Patients with D2B Time

0%10%20%30%40%50%60%70%80%90%

100%

Timeframe

90 min 120 min 150 min

Data Source: NCDR CathPCI Database, 2004Q2 - 2006Q4

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Percentage of Primary PCI with D2B <= 90 minutesNCDR CathPCI v3

0%

10%

20%

30%

40%

50%

60%

70%

80%

Timeframe

Perc

enta

ge

D2B

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PCI Statins on Discharge

72.0%

74.0%

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

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ACTION Registry™ (Acute Coronary Treatment and Intervention

Outcomes Network)

Initial Report1st Quarter 2007 Results

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2006-07 Data Submission Summary

Admission # of # of # of Timeframe Sites NSTEMI Records STEMI Records

ACTION Jan. 1, 2007 – 227 6,917 4,259 Mar. 31, 2007

CRUSADE April 1, 2006 – 280 20,084 4,391 Dec. 31, 2006

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ACTION Registry 2007 Patient Enrollment

41693787

40044241 4154

0

1000

2000

3000

4000

5000

Jan-07 Feb-07 Mar-07 Apr-07 May-07

Num

ber o

f Pat

ient

s en

rolle

d

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NSTEMI Patient - Baseline Characteristics

NSTEMI Variable (n = 26,902)

Mean age ± SD (yrs) 69 ± 14Female 40%Diabetes mellitus 33%Prior MI 29%Prior CHF 16%Prior PCI 23%Prior CABG 19%

ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n=26,902)

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In-Hospital OutcomesVariable NSTEMI

(n = 26,902)

Death 3.8%Re-infarction 1.5%CHF 6.8%Cardiogenic Shock 2.4%Stroke 0.7%RBC Transfusion* 8.9%

*Excluding CABG patientsACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n=26,902)

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NSTEMI Acute Medications

ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007

97%93%

85%

53%60%

0%

20%

40%

60%

80%

100%

ASA BetaBlockers

Heparin(LMW+UHF)

GP llb-lllaInhibitors

Clopidogrel

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*LVEF < 40%, CHF, DM, HTN# Known hyperlipidemia, TC, LDL ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n= 26,902)

NSTEMI Discharge Medications96% 95%

73%

91%

74%

0%

20%

40%

60%

80%

100%

ASA B-Blocker ACE-I or ARB* Lipid LoweringAgent#

Clopidogrel

% U

se

New Hospital-Based Registries

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• Transcatheter device occlusion of CV malformations– Atrial Septal Defect– Ventricular Septal Defect– Patent Ductus Arteriosus– Fistula/Collateral Vessels—Blood Vessel

Communication– Closure of Fontan Fenestration

• Transcatheter Balloon Dilation• Transcatheter Stent Placement

CathLab Congenital Heart Disease

Registry

Pilot StudyEvaluation of

Appropriateness ofSPECT MPI

The American College of Cardiology The American Society of Nuclear Cardiology

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SPECT MPI Registry Objectives

• Evaluate appropriateness • Promote awareness of appropriateness

criteria in practice• Provide feedback reports to improve both

practice-level and individual physician-level adherence to the criteria

• Establish benchmarks to guide performance improvement

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NCDR QI

• National QI Programs– Implement guidelines

recommendations– Improve physician adherence– Improve patient compliance

• Our Goal? – Reduce complications– Improve Structure and Process– Efficient Systems

NCDR & D2BNCDR & D2BTake ACTIONTake ACTIONField Field ConsultantsConsultants

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“Take ACTION” Campaign• Nationwide QI Program

– Increase awareness about relevant CPG recommended therapies for ACS and chronic stable coronary disease

– Improve physician adherence and patient compliance

• Long-term Goal– Reduce secondary events post ACS– Measured incrementally through behavioral changes

• Multiple, overlapping Phases beginning ACC.07– Phase I  - What is the ACC doing to Take ACTION to improve care

of patients with ACS? – Phase II - What are you doing as a physician to Take ACTION? – Phase III - What are you doing as patients to Take ACTION?

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Improving Continuous Cardiac Care

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Measuring the Continuum of CAD Care

Patient withstable angina

Onset of AcuteCoronary Syndrome

Post-Hospitalization:Risk factor modificationCardiac rehabilitationD/C

PCI/CABGAdmit

AMI Care

ACC-NCDR

ACTION IC3IC3

ACTION Follow-up

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The IC3 Program• First office-based registry designed to

assess physician adherence to ACC/AHA Performance Measures.

• Provides a powerful tool to assess the current state of office-based clinical care for CAD and CHF patients.

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Philosophy of the IC3 Program• Make it easier for busy clinicians to do the right thing for

the right patient at the right time– Track key performance measures for CAD/CHF

• Internal QI and P4P reporting at the practice level• Performance measures for DM also captured

– Make care more efficient• A worksheet that readily identifies opportunities to

apply CAD/ CHF guideline recommendations and performance measures

– Coordinate care• Create a visit summary to communicate with patients

and other providers

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IC3 Program: Incentives for Practices

• Develop tools to improve care– Provide real-time reporting of office-based

quality indicators for CAD and CHF derived from clinical practice guidelines

• Create a trusted mechanism for measuring performance– Support evolving CMS outpatient quality

measures and regulatory reporting initiatives– Support Pay-for-Performance programs with

payers

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United (5)BCBS (9)Medicare (26)Medicaid (10)

40%76%100%

100%

Payer Perspective of

my Performance

Physician X’s Practice

Physician X’s Overall Performance = 90%

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Partnering with Health Plans –

Benefits to Plans…• Health Plans get Better Picture of Practice

Performance– Clinical data prospectively measured– More accurate assessment of practice

performance from larger sample sizes than individual plans

– Capture of complete ACC/AHA performance measures

• Plans need not develop their own

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Other IC3 Program Goals• Position the profession (ACC) to take a leadership

role in quality assessment and improvement• Support the evolution of quality assessment and

improvement– Identify new opportunities to improve and coordinate CAD

and CHF care• Create a research agenda to improve care

– Document the distribution of cardiac patients’ health status

– Identify new performance measures– Support research of appropriateness

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Office Flow in IC3

Pt presents for visit, reports

med changes

Vitals, health status

assessed

Physician Visit & Rx

Data entered

and Clinic Visit Form Generate

d

Treatment plan Data

entered

Patient Letter &

Visit Summary dispensed

Visit Summary

sent to other care

providers

Data Entered through

NCDR IC3

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Data Collection• Types of data

– Site Profile captured once – Patient History captured on entry– Treatment monitored longitudinally – Clinical event data captured longitudinally – Patient health status for CAD and CHF (optional)

• Data collection tools– Web-based data collection tool– Paper forms– Working on EMR integration for Decision

Support

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Data Submission and Reporting• Data will be subjected to completeness

and consistency reviews– On-site audit to ensure accuracy (2009)

• Quarterly aggregate practice-level data reports and benchmark reports

• National benchmark performance• Peer group benchmark performance• Individual hospital performance

• Real-time QI reports generated for individual and practice-level data

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Release• Enrollment begins October 1, 2007• Web-based data collection begins Jan

1, 2008 • Training and roll-out for participants• Client and contract support for

participants• Marketing and communications to

broader physician community

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Participant Training and Education

• NCDR Online website• Information packet/Welcome Kit• Online training manual• Annual User Group Meeting• Workshops• Special web casts• On-line community development for

collaborative learning and sharing

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For More Information…

Visit: www.ncdr.com/ic3Email: ncdr@acc.org