Collaborative Maryland Initiative for Assuring Quality of Percutaneous

Coronary Intervention

Julie M. Miller, M.D., F.A.C.C., F.S.C.A.I.Associate Professor of Medicine, Johns Hopkins University

Director, Vascular Cardiology Program; Interventional Cardiology

On behalf of :

MARYLAND ACADEMIC CONSORTIUM FOR PERCUTANEOUS

CORONARY INTERVENTION APPROPRIATENESS AND QUALITY

(MACPAQ)A collaboration between the Divisions of Cardiology at

The Johns Hopkins University and The University of Maryland

MHCC and House Bill 1141 (2012 Chapter 418 MD Law)

• Directs MHCC to revise the State Health Plan regulatory oversight

• New plan will replace current process (CAG)• for establishing and maintaining PCI services• for on-going quality assurance

• Update to State Health Plan:

“ Regulations shall: include requirements for Peer or independent review, consistent with ACC/AHA guidelines..., of difficult or complicated cases and for randomly selected cases”

Peer Review

• Can be “Internal” or “External” • Internal: outcome based, difficult to remove bias• External: objective, can focus on both quality and

appropriateness

• External review – Constructive, expert, helps enhance knowledge for future decisions– Must be confidential, non-punitive, and unbiased

• Few models exist for collaborative, external review in PCI– Often expensive, limited long term value, do not engage

participants

Proposal: A Collaborative Maryland State-wide Quality Peer Review Initiative

Purpose• To perform independent external quality reviews for cath/PCI

with the goal of providing objective feedback to hospitals / physicians : case selection, performance, reporting

• To provide a data quality validation and risk adjustment

Methods• Apply established expertise of Maryland hospitals / physicians

• Physician Peer reviewers from all participating hospitals

• Cardiologists and cardiac surgeons

To achieve the “new standard” for the ongoing quality review

The MACPAQ Story

• The Maryland Academic Consortium for Percutaneous Coronary Intervention Appropriateness and Quality– Joint effort between JHU and UMD > 1 yr

• Combined resources• Organizational agreement, approved mission and goals• Incorporated into hospitals as quality assurance process

– Collaborative, physician external peer review• Meet needs of both health systems

• Physician lead blinded reviews of cath / PCI– Reduce same group / center bias– Expand educational and research missions

MACPAQ Review Initiative

• Independently review– “appropriateness” of PCI

• ACC/AHA guidelines• Standard clinical practice

– approach to revascularization (PCI/CABG)– coronary angiographic images

• Visual and selected computerized quantitative coronary angiography, intracoronary diagnostics

– Procedural outcome– Accuracy of reporting

• Cath report, NCDR data

MACPAQ: External Peer Review SystemParticipating UMD Hospitals

Source data/records/ Films

Results returned to Hospital/Cath Lab QA designee

Participating JHU/JHHS HospitalsSource data/records/ Films

Electronic

Results returned to Hospital/Cath Lab

QA designee

MACPAQ – Coordinating Center- Obtain necessary documentation- Ensure blinding of films/data- Distribute blinded data to reviewers (via web-based link)

Physician Peer review- Review of clinical records- Cath / PCI angiographic film*- PCI outcome review- “appropriateness” of Cath/PCI

MACPAQ – Coordinating Center- Summarized results- Identify disagreements for further review and group review- Summarize results quarterly

Results to Coord.

Ctr.

Individual Physicians

Core Lab- Angio review- Quantitative (QCA)-ACC “appropriateness”Current Members

Aversano T Brinker JGupta AMiller JMTexter J

Walford GZimrin D

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Structure Blinded cross-institutional physician-based

• All-inclusive, collaborative• All PCI hospitals/physicians represented• Goal : Objectively assess case selection,

performance, reporting • Clinical and angiograms

• Core Lab for quantitative analysis

Experience and Existing Infrastructure• Model (MACPAQ) currently running (JHH & UMD )

expanding to systems• Completed projects for health care system in PA

Proposal: State-Wide PCI Quality Review Initiative

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Value

• Provides a blinded independent peer review process

• Tailor to State/MHCC/CAG recommendations

• Evolution / flexible

• Validated quantification analysis use

• unique, for standardization

• High value to system at low cost

• Provides ability for data validation

• Maryland hospital and physician ownership

Proposed State-Wide PCI Quality Review Initiative

Physician Review Teams

Cardiology / Cardiac surgery Teams from all participating hospitals

Hospital APhysician 1,

2,3, etc.

Image Sharing(Cath films)

Source clinical Medical

Information(NCDR data, Scanned

source documents, etc)

Blinded Peer-to- Peer Review

Appropriateness/Quality/ CABG vs PCI

Draft Peer Cath / PCI Quality Review

Quantitative Angiography Resource lab

(MACPAQ)

Sample of studies for objectivity ,

quantitative analysis, and peer training and

educationHospital x

Hospital y

Hospital BPhysician 1,

2,3, etc.

Hospital CPhysician 1,

2,3, etc.

Coordinating /Processing

Center

Blinding, Distribution /

Storage of data(MACPAQ)

Physician Reviewer

1

Physician Reviewer

2

electronic

- Review information - Peer Feedback to

Hospitals / Physician

Steering CommitteeChairman (rotating)

23 PCI Hospitals physician representatives MHCC, MHA,

MACPAQ representatives

External Peer Review

Administrative (Executive) Committee: Chairman, physicians, Financial,

Administration, others

ConsultantsAmerican College of

Cardiology, SCAI, MHCC, MHA

Armstrong Institute

Registry Data (NCDR) Review

Education / Feedback

Operations CommitteeData management, IT

Proposed Organizational Structure for State-Wide External Peer Review Process

Why Physicians Would Want to ParticipateEngage

Educate

EvaluatePerform- Uniform evaluation

standards- Unbiased - Self-study to apply guidelines

- Constructive, expert- Confidential, non-punitive- Educational (CME / MOC credits)

- Fundamentally educational

- Helps enhance knowledge for future decision making

- Dissemination of updates

- Helps identify areas of improvement- Helps confirm reporting (e.g. NDCR reporting)- Foster open communication /

consultation and support

Summary• Peer review is the cornerstone of quality

improvement & assurance of appropriateness• Physician-driven external peer review :

• Complementary to internal review• Improves quality, confidence

• The proposed all-inclusive, Maryland-based system will provide a robust and sustainable mechanism for cath/PCI quality improvement state-wide

1) A pre-determined algorithm for the percent of random cases per operator per institution to be established and used throughout the state

a) minimum number of cases per operator and hospital . # determined by the Steering Committee, in collaboration with the MHCC, MHA, and CAG.

b) In addition, the Steering committee may recommend additional triggers for case review

2) Random cases and selected cases will be identified for the review process by the Coordinating Center that meet the pre-specified criteria for review

3) Case-related documentation sent to Processing Center electronically

4) Documentation will be reviewed collated and patient, physician and hospital identifiers redacted (blinded)

5) Documentation and angiograms distributed to the reviewers electronically (projected 2 reviewers/case, third reviewer if disagreement).

Quality Review Initiative: Hypothetical Process: STEPSAll hospitals and their physicians participate

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6) Physicians who participate in the review process will be sent web-based links for reviewing a case, and an electronic report form for completion.

7) Cases will be reviewed for clinical appropriateness (based on published guidelines), angiographic appropriateness, approach, data accuracy and other parameters agreed to by the Steering committee.

7) Quantitative Coronary Angiographic (QCA) analysis will be performed separately to supplement the review process.

8) The Steering Committee will determine the processes for evaluating review differences between reviewers or disagreements.

9) The hospital will receive a summary report of each operator (blinded) and a hospital summary.

10) CAG will make recommendations as to other entities should receive blinded summary information, such as MHCC.

Quality Review Initiative: Hypothetical Process (cont)

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External Peer Review(e.g. MACPAQ)- Angio review- Angio appropriateness- Cath/PCI appropriateness- - Data audit and pt data validation

Internal ReviewPerformance and outcomesSelf-reportedRetrospective and ongoingComplicationsEquipment / drug utilization Hospital stay

Physician Decisions /

Performance External ReviewPeer-to-peerPeer communicationGuideline adherenceCath / PCI quality reviewAngiographic & clinical appropriatenessPCI vs CABG vs Medical RxRisk modelsValidate/audit data

Environment Assessment

(Hospital Process Review)Equipment/resourcesEnvironmental pressuresSocietal pressures

Knowledge Evolution

Training/ ExperienceOutside Peer GuidelinesKnowledge evolution

Quality Outcomes

NCDR(In-patient only, no

follow-up)

True Outcome Follow-up

(post discharge)

Internal Reviews

External Review