PCI Performance Feedback Faces Disinterest, Disengagement, and Distrust

Despite using quality measures to benchmark their practice and compare themselves with others in their field, interventional cardiologists do not necessarily feel that the information helps them improve their practice, according to a new survey.

“We heard over and over that people would look at these reports, but then the question became, what next? How do I learn to be better? How do I find out other ways of doing things and how do I improve my performance on these quality measures?” said the survey’s senior author Jacob A. Doll, MD (VA Puget Sound Health Care System, Seattle, WA). “We also found that some of our respondents don't use the quality measures at all and said they didn't trust them to really assess their practice.”

Doll emphasized to TCTMD that the majority of respondents were supportive of quality measures in general, and all indicated that PCI performance at their institution was assessed by a variety of benchmarks, including mortality, readmission, radiation utilization, bleeding rates, and arterial access- site rates, among others.

“We were fortunate enough to recruit people at all different phases in their practice, and I will say that the early-career people seemed to be much more engaged and actively seeking out feedback,” he added. “Often these junior members felt that some of the senior members of their groups were not interested in receiving feedback from them.”

Several experienced operators, Doll noted, “said outright that they don't want feedback from some young, new operator who hasn't done 10,000 PCIs.” Another quote included in the paper backs up that sense of distrust that some operators feel, with the individual saying: “I personally think probably 80% of the people I’m surrounded by are not qualified to give feedback, because we have a lot of very, very low-volume, low-acuity, part-time operators.”

Praise for Case-Based Discussions

The survey, published online ahead of print in the American Heart Journal, with lead author Krishna M. Prabhu, MD (University of Washington, Seattle), included 20 interventional cardiologists who had been in practice for an average of 5 years or more, ranging from 1 to 35 years. They were mostly male (85%) and practiced in private, academic, or Veterans Affairs settings; all reported performing at least 60 PCIs per year. Four respondents were in leadership positions in their cath lab or hospital.

One thing that the survey respondents reported as being important to them in terms of feedback was the source and context. Some said in-person discussions about performance measures with leadership, senior colleagues, or their full clinical group were more impactful than the reporting of feedback alone, especially when they were linked to improvement goals for the group. Others were critical of their hospitals’ systems for quality measurement and reporting.

It really has to be an intentional and group-based effort. Jacob Doll

According to Doll, those who took the survey frequently expressed that the culture and leadership of an institution are important when it comes to motivating operators to improve and to stay patient-focused, as well as to promoting respectful feedback and avoiding situations where staff might become defensive.

“We have individuals who describe structures within their cath lab that really encourage people to collaborate; things like case conferences, heart team conferences, morbidity and mortality conferences that are attended by everyone, and everyone presents their own cases and takes feedback from everybody,” he explained.

At least one respondent admitted that while that type of collaboration sounded great, setting it up seemed like “an intangible” that was out of reach. Doll said responses like that give some clues about how to improve things moving forward. One approach might be setting up regional or national consortia where operators can share experiences, post cases, and get feedback on their cases from others outside of their institution.

“In fact, for some people who may be an independent operator and have a very small group, or who may be the only one who does the procedure in their hospital, there may not be an obvious person for them to get feedback from, so creating these larger communities could be really valuable,” he added. “One of the main points of this paper, and why we wanted to do the study, is to raise awareness that these things are important. It's not just about presenting quality measures in a spreadsheet once a quarter and then seeing what happens. It really has to be an intentional and group-based effort.”