A consortium of professional organizations has developed new performance measures to benchmark and improve the quality of percutaneous coronary intervention (PCI) in the ambulatory and inpatient settings. The document was published online December 19, 2013, ahead of print in the Journal of the American College of Cardiology and Circulation.

The 11 measures, which focus on elective procedures and are the first to consider PCI appropriateness, were released by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society for Cardiovascular Angiography and Interventions, (SCAI) the AMA-Convened Physician Consortium for Performance Improvement (PCPI), and the National Committee for Quality Assurance (NCQA).

Writing committee co-chairs Brahmajee K. Nallamothu, MD, MPH, of the University of Michigan (Ann Arbor, MI), and Carl L. Tommaso, MD, of NorthShore University Health-System (Evanston, IL), and colleagues state that comprehensive documentation to determine the appropriateness of PCI and attention to care provided before, during, and after the procedure are critical to improving intervention quality. Procedural volume and whether institutions benchmark PCI by participating in registries are other important considerations. Hence, the measures include:

• Comprehensive documentation of the reasons for PCI

• An appropriate reason for elective PCI in nonacute settings, suggesting that procedure benefits outweigh risks

• A pre-procedure evaluation of the patient’s ability to tolerate and adhere to dual antiplatelet therapy

• The use of embolic protection devices in the treatment of saphenous vein bypass graft disease when feasible

• A pre-procedure renal function assessment, including glomerular filtration rate, and documentation of contrast volume used during the procedure

• Documentation of the radiation dose used during PCI

• The prescription of optimal medical therapy at discharge, including aspirin, P2Y12 inhibitors, and statins

• A referral to an outpatient cardiac rehabilitation program to reduce recurrent events

• Participation in a regional or national PCI registry to benchmark laboratory outcomes

• The average annual volume of PCIs performed by the physician during the last 2 calendar years

• The average annual volume of PCIs performed by the hospital during the last calendar year

Measures Developed to Close Gaps in Care

In a telephone interview with TCTMD, SCAI representative Peter L. Duffy, MD, of the Reid Heart Center (Pinehurst, NC), said the performance measures were created because well-established processes of patient care are not fully integrated into daily practice. “We want to identify these gaps and improve outcomes,” he said.

While cutting-edge research is critical to long-term outcomes, short-term results will improve when quality cath lab operators and staff are given the tools to evaluate their own practices, Dr. Duffy continued.

Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), told TCTMD in a telephone interview that the measures are reasonable and largely relevant to those who want to assess PCI quality or performance. Overall, the document will be practical for quality improvement initiatives, he said.

Procedure Appropriateness Critical

Based on the measures, providers need to evaluate individual patients to determine the best approach to care in the cath lab and consider where a procedure falls on a continuum of appropriateness, Dr. Duffy observed.

“PCI may seem very appropriate from an angiographic standpoint, but you need to consider other factors to determine whether the patient is going to get better because a stent was placed,” he said. For example, physicians need to evaluate kidney function before PCI and minimize contrast use and radiation exposure during the procedure, each of which tend to increase risk of morbidity, Dr. Duffy explained.

While established appropriate use criteria are a useful starting point when evaluating whether a particular patient will benefit from stent placement, using these criteria alone to determine the course of care has significant limitations, said Dr. Duffy.

The authors need to view appropriate use criteria as imperfect and only a tool for internal quality improvement, Dr. Kirtane said, adding that both underuse and potential for “gaming” are potential weaknesses of these criteria. The document endorses a more measured and generic approach to appropriateness, he commented.

Assess the Local Level First

In addition to not strictly adhering to appropriate use criteria, Dr. Duffy said he encourages cath labs to utilize local quality improvement teams to oversee their PCI processes because of nationwide and in-system variation. Whether this variation is appropriate needs to be assessed, he said, and outliers need to be “brought into the quality fold.” Once quality measures are implemented, then outcomes should be evaluated using a national registry, he continued.

Measures Not Included ‘Striking’

While the performance set is valuable, measures that were not included in the document are particularly “striking,” Dr. Kirtane said.

Specifically, the authors stated that they did not include 30-day mortality as a PCI performance measure because they did not want to duplicate efforts made by others. However, if 30-day mortality were truly a well-established performance measure, it would be relatively easy to incorporate, Dr. Kirtane said. The relationship between 30-day mortality and antecedent PCI is frequently not causal, he continued. Rather, the outcome may be due to patient comorbidities and selection.

Readmissions after PCI, for which the Centers for Medicare and Medicaid Services will not reimburse hospitals, also were not included as a performance measure, Dr. Kirtane noted. “The fact is that some of the metrics that are broadly used for PCI quality assessment in health care today just don’t make a lot of sense when assessing the performance and quality of PCI,” he said.

The hope is that payers or individuals trying to assess PCI quality pay more attention to these new performance measures and less to other metrics currently being used, including strict interpretations of appropriate use criteria, 30-day readmissions, and 30-day mortality, Dr. Kirtane concluded.

ACC/AHA/SCAI/AMA–Convened PCPI/NCQA 2013 performance measures for adults undergoing percutaneous coronary intervention: A report of the American College of Cardiology /American Heart Association task force on performance measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association–Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance. Circ Cardiovasc Qual Outcomes. 2013;Epub ahead of print.

Disclosures:

• Dr. Duffy reports no relevant conflicts of interest.

• Dr. Kirtane reports receiving institutional research funding from Acumed, Boston Scientific, Medtronic, and St. Jude Medical.

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