The NCDR Has Made a Difference, but Experts See Room for Growth

The American College of Cardiology’s National Cardiovascular Data Registry (NCDR) plays a key role in letting centers know how they’re doing and where they can improve, but its impact could be even greater, experts say.

A new state-of-the-art review examining the integrity of the data within the NCDR’s collection of ten hospital-based and outpatient registries concludes that the “registry data are complete” and that the “accuracy is very good but variable,” according to authors led by David Malenka, MD (Dartmouth-Hitchcock Medical Center, Lebanon, NH), who has served as chair of the NCDR Data Quality Subcommittee of the NCDR Science and Quality Oversight Committee.

The review, now online, will be published in the May 3, 2022, issue of the Journal of the American College of Cardiology.

NCDR data are intended to support improvement in the quality and outcomes of cardiovascular care, evaluate new therapies, and fuel research, the authors note. Describing the strength of the overall registry, Malenka said most US centers that provide cardiovascular care participate in the relevant registry within NCDR, the quality of the collected data is generally high, and the information is used to improve how care is delivered.

“The NCDR has really taken a leadership position in saying that we as a profession need to understand what we’re doing to whom and what are the results,” Malenka told TCTMD. “There are numerous examples of how doing this has improved patient outcomes and decreased costs, which is bringing value to healthcare.”

He pointed to registry-derived efforts to reduce contrast-induced nephropathy in the cath lab, to understand which patients undergoing TAVI could safely undergo the procedure using conscious sedation versus general anesthesia, and to improve the use of guideline-recommended medications in patients undergoing PCI or receiving an implantable cardioverter-defibrillator.

But, Malenka and his co-authors acknowledge, “there is room for improvement.”

Agreeing was John Spertus, MD (Saint Luke’s Mid America Heart Institute/University of Missouri, Kansas City, MO), who co-authored a paper in the same issue of JACC, suggesting ways to enhance the NCDR’s value.

I don’t think the NCDR should go away. I think the NCDR needs to continue to evolve. David Malenka

“We ultimately think it’s a great asset. It forms the foundation not only for knowing how you are doing, but also for understanding whether or not there are racial or gender disparities in outcomes. It allows hospitals to figure out whether or not they need to really focus on a quality-improvement program to reduce complications of angioplasty, etc. There’s just so much value in it to the hospitals,” Spertus commented to TCTMD.

However, he said, “I don’t think it’s being optimally recognized or exploited. And the more hospitals perceive this as being really valuable to the way they do business, the more likely they are to be happy to participate and pay for the data collection that NCDR requires.”

If centers start dropping out to save on costs because the value of participation isn’t clear, “that would be very bad for the practice of high-quality cardiovascular care . . . and I ultimately think it would be bad for patient care,” Spertus said.

Boosting the NCDR’s Value

In their paper, Spertus, along with Michael Mack, MD (Baylor Scott & White Health, Plano, TX), and E. Magnus Ohman, MD (Duke University, Durham, NC), suggest ways to improve patient experience, realize gains in clinical outcomes, and lower the costs of participating in the NCDR.

To that last point, Spertus pointed out that hospitals operate on very thin margins. He said administrators might look to cut costs by stopping participation in the NCDR, for which data collection is expensive.

“What we are concerned about is that a tremendous national resource might lose its value because a lot of hospital CFOs don’t really appreciate the return on the investment they’re making,” Spertus said. “We are just trying to challenge the NCDR to be more explicit about how it is helping hospitals provide higher-value healthcare.”

Highlighting the changes he would most like to see, Spertus said the NCDR should continue to develop tools to improve care at the time it’s delivered, including risk models that can be deployed to tailor treatments according to an individual patient’s risk. Such tools could be used to lower the amount of contrast administered in patients at high risk of acute kidney injury, for example, or to preferentially use radial access or bivalirudin to lessen bleeding in patients at high risk for that procedural complication.

We are just trying to challenge the NCDR to be more explicit about how it is helping hospitals provide higher-value healthcare. John Spertus

A second big change that would up the value of the NCDR to participating centers, according to Spertus, is greater coordination with electronic medical record companies and organizations like the Society of Thoracic Surgeons, which also maintains a large national database, to ease the transfer of data from other sources into the NCDR and lessen the burden—and cost—of data collection for the centers.

Malenka, too, picked this out as an area ripe for improvement. “The data collection necessary to populate these registries is not insignificant and it takes up peoples’ time, it takes up resources,” he said. “So I think the NCDR has to evolve together with medicine in general to make better use of the electronic medical record, ensure interoperability, and work towards populating these registries by being smart about the use of the electronic medical records.”

And finally, Spertus said, an important advance would be to better leverage the NCDR to empower hospitals to gain greater insights into healthcare equity and eliminate disparities in care among women and minority groups.

Spertus told TCMTD that the leadership of the NCDR has a work group looking into how to address many of the issues he and his co-authors are raising. “NCDR’s a very important part of the identity of the American College of Cardiology, and I think they’re very vested in having it be as helpful to elevating practice as possible,” he noted.

A Real Impact on Patient Outcomes?

Asked whether the NCDR has had a positive impact on patient outcomes, Spertus replied that it has. He cited the improvement in the safety of angioplasty over time as an example, saying that the NCDR helped both put the spotlight on these issues and allow hospitals to learn how to improve their own processes. At his own center, Spertus said, implementation of bleeding and acute kidney injury models for patients heading to the cath lab, and development of protocols for higher-risk patients, has paid dividends in terms of procedural safety.

He also pointed to efforts by Amit Amin, MD (Dartmouth Hitchcock Medical Center, Lebanon, NH), when he was at Washington University in St. Louis, MO, to increase same-day discharge rates after PCI using a risk-based approach based on NCDR models, which also saved the health system millions of dollars.

Harlan Krumholz, MD (Yale School of Medicine, New Haven, CT), whose institution serves as a data analytic center for the NCDR, agreed that the effort has had a real impact on patient outcomes.

“Over the years, NCDR has pioneered the way for hospitals to work together to evaluate and act on real-world data,” Krumholz told TCTMD via email. “The Door-to-Balloon Alliance was just one example where these partnerships resulted in dramatic gains in quality of care and promoted better health outcomes.”

Looking to the Future

But Krumholz, too, indicated that the NCDR will have to evolve. “In an increasingly digital world, registries will be challenged to find ever more efficient ways to collect, process, and analyze data—and show how data can be used in timely ways to benefit patients. The days of labor-intensive, human-abstracted data are waning, and the need for contemporary approaches that reduce these costs and delays are growing,” he said. “Also, there is increasing pressure to engage patients and to collect new types of information, such as patient-reported outcomes.”

Taking a broader view of the NCDR in the past, present, and future, Krumholz said: “The most pivotal thing that NCDR did was to change the culture of medicine toward greater accountability and continuous improvement, with a spirit of hospitals and healthcare professionals helping each other to do better. This ethos remains critically important—even as the means of data collection and analysis is about to undergo major transformation.”

The most pivotal thing that NCDR did was to change the culture of medicine toward greater accountability and continuous improvement. Harlan Krumholz

Malenka said the NCDR has plenty of data, but that “we need to improve ready access to the information, ready feedback of that information to the facilities, and we need to promote the use of this information by clinicians to actively improve care.”

That is best done, he added, through regional collaboratives—like the Northern New England Cardiovascular Disease Study Group he leads and those funded by Blue Cross Blue Shield of Michigan—that get together to figure out how to implement actionable information from the registries to boost quality and lower costs. That, Malenka said, is the future of the NCDR.

“I think the NCDR has value, and I think it’s the right thing for every profession to actively engage in, measuring what they do and working to improve it,” he said. “I don’t think the NCDR should go away. I think the NCDR needs to continue to evolve, and that means being nimble enough to change data collection as new technologies evolve, and they’re doing that.”