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COAP IN 2011
Appropriateness of Percutaneous Coronary Interventions in
Washington State
Chris L. Bryson, MD, MS, COAP Medical Director
Steven M. Bradley, MD; Charles Maynard, PhD
VA Puget Sound Healthcare System and University of Washington
COAP IN 2011
The programs of the Foundation for Health Care Quality have been approved by the WA State Department of Health as
Coordinated Quality Improvement Programs (CQIP) under: RCW 43.70.51
“A CQIP… may share information and documents… with one or more other CQIPs or committees or boards…
and shall not be subject to the discovery process…”
Quality Improvement Protection:
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What Does COAP Do?
Collects data on all CABG, Valve and PCI procedures Analyzes data with feedback in the form of an annual risk-adjusted dashboard Distributes quarterly and annual descriptive reports Educates data managers Performs inter-rater reliability testing & audits Develops an ongoing QI plan dealing with participation status Improves quality of care in Washington State
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COAP is a quality improvement organization that is data driven
COAP Cardiac Quality measures are the most complete (all patients), most accurate (clinical data submitted by ‘tested’ abstractors, not billing data) and most timely (available within a few months after the close of a quarter, not a year later).
Outcomes are reported as a comparison with the rest of the state hospitals
Outcomes are expected to be within 2 SD of the mean
COAP data is reviewed as a yearly event as well trend outcomes over time
Sanctions occur if these outcomes are not met
COAP is responsive to regional activities - out of hospital arrest
COAP IN 2011
We use our data to identify best practices and rely on our practitioners to implement these best practices
Best Practices:Identify, document, replicate, and evaluate the implementation of best practices
Help to convene physician leaders and multidisciplinary teams with the goal of engaging them to develop sound QI approaches and promote widespread adoption.
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PCI: Appropriate Use
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Objectives
Reasons to measure PCI appropriateness
Appropriate Use Criteria for Coronary Revascularization
Appropriateness of PCI in Washington State
Future directions
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Background
PCI is critical tool in the management of CAD
In patients with ACS, PCI reduces mortality and recurrent MI
For stable coronary disease, PCI offers symptom relief in appropriate patients
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Pressures to Reduce Use of PCI
More than 1.2 million PCI are performed annually in the U.S. at $26 billion in cost
Volume- and cost-control efforts by payers have been amplified
Payer mechanisms are often intrusive, fail to improve quality, or optimal patient care
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Appropriate Use Criteria for Coronary Revascularization
Developed by the ACC in partnership with multiple professional organizations
National standard to quantify ‘appropriateness’ of PCI for clinical scenarios
Stewards of self-regulation and an opportunity to improve effective utilization
Patel MR, et al. JACC. 2009;53:530-553.
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Objectives Reasons to measure PCI appropriateness
Appropriate Use Criteria for Coronary Revascularization
Appropriateness of PCI in Washington State
Future directions
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Appropriateness Method
Adapted from Patel MR, et al. J Am Coll Cardiol. 2005;46:1606-13.
Literature review and synthesisof the evidence
List of clinicalscenarios
Expert panel rates the indications
1st Round – No interaction
2nd Round – Panel interaction
Appropriateness Score
(7-9) Appropriate(4-6) Uncertain(1-3) Inappropriate
Ap
pro
pri
ate
nes
s D
ete
rmin
atio
n
COAP IN 2011
Elements Defining Clinical Scenarios
Clinical presentation (e.g. ACS, stable angina)
Severity of angina (CCS classification)
Extent of ischemia on noninvasive testing and other prognostic factors (e.g. low EF, DM)
Extent of anti-anginal therapy
Extent of anatomic disease
Patel MR, et al. JACC. 2009;53:530-553.
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Definition of AppropriateCoronary Revascularization
“Coronary revascularization is appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the expected negative consequences of the procedure.”
Patel MR, et al. JACC. 2009;53:530-553.
COAP IN 2011
Example Ratings - ACS
Patel MR, et al. JACC. 2009;53:530-553.
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Example Ratings – Non-ACS
Patel MR, et al. JACC. 2009;53:530-553.
COAP IN 2011
PCI Appropriateness in NCDR More than 350,000 PCI performed nationally, 85%
appropriate and 4% inappropriate Acute indications 99% appropriate Non-acute indications 50% appropriate and 12%
inappropriate
Variation in PCI appropriateness by facility
NCDR beginning to provide feedback to participating facilities on PCI appropriateness
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Role of Appropriate Use Criteria Appropriate use criteria may identify appropriate
practice patterns and facilitate highly effective and efficient care
Similar appropriateness across practice settings is a reasonable goal; complete elimination of “inappropriate” use is not
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Interventionalist Perception of PCI Appropriateness
Survey of 85 interventionalists
84% agreement in the median appropriateness rating 94% (34 of 36) for appropriate indications 70% (7 of 10) for inappropriate indications
Non-agreement (>25% of respondents outside the median rating) common
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Rigorous Methodology Behind the Appropriate Use Criteria
Only 50% of technical panel members perform revascularization Balance of interventionalists and cardiac surgeons
Ensures agreement of ratings with best evidence
Emphasis on practice patterns of appropriateness
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Objectives Reasons to measure PCI appropriateness
Appropriate Use Criteria for Coronary Revascularization
Appropriateness of PCI in Washington State
Future directions
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Appropriateness of PCI in Washington State
Describe the appropriateness of all PCI performed in Washington State
Explore facility level variation in PCI appropriateness
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Washington State COAP Statewide QI program for coronary revascularization NCDR version 4 data elements
Mapping to the Appropriate Use Criteria Significant stenosis > 50% left main or > 70% other epicardial
coronary Maximal anti-ischemic medical therapy at least 2 classes of
therapy Mapping minimized influence of missing data
Methods
Patel MR, et al. JACC. 2009;53:530-553.
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Analysis
Appropriateness of PCI stratified by indication
Acute (acute myocardial infarction or unstable angina with high-risk features)
Non-acute (stable angina)
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9,924 PCI Mapped to Appropriate Use Criteria for Coronary Revascularization
3367 (25%) Not Mapped to the Appropriate Use CriteriaNo Appropriateness Rating in the Criteria, n=1054 (31%)
UA without High-Risk Features, n=902 (86%)Other, n=152 (14%)
Missing Necessary Data, n=2313 (69%)Missing non-invasive risk assessment, n=1906 (82%)Other missing data, n=407 (18%)
13,291 PCIs Performed at 32 Sitesin Washington State
Results: Patient Population
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Detailed results data embargoed; full manuscript under consideration
for publication.
Results:
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Acute Indications After Excluding UA without High-risk Features
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
AppropriateNot Classified
Percent PCI
Faci
lity
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Non-Acute Indications by Facility
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
InappropriateNot Classified
Percent PCI
Faci
lity
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Influence of Assumed Stress Test Results for Missing Data
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low-RiskHigh-Risk
Percent PCI
Faci
lity
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Summary
Of the >9000 PCI performed in Washington State that could be mapped to the Appropriate Use Criteria for Revascularization more than 85% were appropriate
Of PCI for non-acute indications, 10% were inappropriate even after assumptions to maximize appropriateness
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Summary
Challenges in the application of Appropriate Use Criteria for quality improvement
Missing data on non-invasive stress testing with wide variation by facility
CABG not assessed in current study
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Objectives Reasons to measure PCI appropriateness
Appropriate Use Criteria for Coronary Revascularization
Appropriateness of PCI in Washington State
Future directions
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Future Directions Incorporation of PCI appropriateness in dashboard
reports Inappropriate PCI for acute/non-acute indications Missing necessary data for classification
Incorporation of CABG appropriateness
Strategies to reduce variation in PCI appropriateness
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Conclusion
Application of appropriate use criteria may identify appropriate practice patterns and facilitate highly effective and efficient care
Similar appropriateness across practice settings is a reasonable goal; complete elimination of “inappropriate” use is not
COAP IN 2011
Thank you
Contact Us: Chris Bryson, MD, MS Kristin SitcovCOAP Medical Director COAP Program [email protected] [email protected] 206.682.2811, ext 23
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