SCAI Launches Nationwide Cath Lab Quality Improvement Effort

 In part to prevent future occurrences such as the recent incident at a Maryland hospital characterized by overuse of stenting, the Society for Cardiovascular Angiography and Interventions (SCAI) unveiled a multi-pronged program aimed at improving the care delivered by cath labs nationwide. The announcement came May 5, 2011, during a press conference at the SCAI 2011 Scientific Sessions in Baltimore, MD.

“Cardiology has been under attack from multiple different areas with questions that all revolve around quality and appropriateness of utilization,” incoming SCAI president Christopher J. White, MD, of the Ochsner Clinic Foundation (New Orleans, LA), told TCTMD in a telephone interview. “Who’s watching the store? Who’s keeping patients safe? Doctors care about quality, and if somebody is going to tell us we could do this better, it should be us.”

Providing the Tools

The program consists of several key elements, the first of which involves a “toolkit” or series of measures that can be implemented and customized to individual hospitals. These include educational material regarding:

• Guidelines
• Peer review conferences
• Random case selection
• National database participation
• Pre-procedure checklists
• Data collection
• Inventory management 

“We’d like to have these broadly distributed in a grassroots effort so that every cath lab would be expected to have a quality improvement program in place,” Dr. White said. “We’re preaching that this is the way we’re going to do things from now on. We’re going to hold weekly peer review conferences, we’re going to have monthly audits of random records, we’re going to do checklisting every time somebody comes into the cath lab. We don’t expect people to make these [processes] up, we’ve said: Here, this is what works, feel free to adopt ours.”

Another key component was detailed in a position paper released by SCAI advocating changes in how PCI outcomes are measured and reported. The organization proposed risk-adjusted quality measures based on clinical data from a patient’s medical chart, as opposed to claims information intended for billing purposes, which are used by many programs. Other features of quality PCI outcome reporting should include:

• Validated risk-adjustment models for mortality and major complications
• 30-day mortality, to follow patients after they leave the hospital
• Data collected in a nationally or regionally benchmarked database

Measuring PCI Appropriateness

The position paper also calls for a method to assess the clinical appropriateness of PCI procedures, recommending that such a measure accurately capture 30-day mortality outcomes post PCI using a risk-adjusted model that accounts for all major complications directly related to PCI. By contrast, all-cause mortality is not always associated with a patient’s PCI procedure, and therefore does not always represent an accurate correlate of outcomes. In addition, results on a program-wide basis should be measured against those in national databases such as the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) CathPCI Registry to identify best practices and standards of care.

“There are benchmarks, there are minimums, there are things we’d like to know that our hospitals are doing, and appropriateness of utilization is certainly one of those elements,” Dr. White said.

New Accreditation Agency

The last key piece of the quality initiative involves independent accreditation of cath labs. At the annual SCAI meeting, it was announced that the cardiac cath and angioplasty/stenting program at Bon Secours St. Francis Health System (Greenville, SC) was the first to receive accreditation from the Accreditation for Cardiovascular Excellence (ACE) program. ACE is an organization jointly founded by ACC and SCAI, but which operates independent of both societies.

ACE reviews facilities that perform invasive cardiac and endovascular procedures, accrediting those that achieve predetermined benchmarks for quality care. According to ACE chief medical officer and chair of ACE’s board of directors Bonnie Weiner, MD, MBA, of Saint Vincent Hospital (Worcester, MA), 6 more hospitals are in the process of applying for ACE accreditation.

“We see this as a way to raise the quality of care throughout the country,” Dr. Weiner said during the press conference. “It’s an important piece to reestablishing and perpetuating the patient’s trust in the health care they’re receiving.”

Maryland’s ‘Perfect Storm’

Patient trust became an issue after allegations were raised against Mark G. Midei, MD, formerly chief of the cath lab at St. Joseph Medical Center (Towson, MD), for unnecessary stent implantation, as many as 30 in a single day according to 1 report.

“It’s a real perfect storm for someone to be able to get away with those kinds of things. It’s not easy to hide that kind of stuff,” Dr. White said. “It’s very rare and it gives us a huge black eye. One of the purposes of doing this multipronged program is for the community and our patients to understand that we own quality.”

While he stressed that such circumstances are “bizarre” and uncommon, Dr. White noted that the new quality initiative should make them less frequent. “If the question is whether it is less likely that the Maryland thing could ever happen again, the answer is, I think it’s a lot less likely,” he said.

An Answer to Legislation

Both Drs. White and Weiner emphasized that the new program represents a continuous cycle, and not a “quick fix.”

“It’s not a one-stop shop,” said Dr. Weiner, a past president of SCAI. “You don’t get your stamp and move on. This is an ongoing process.”

Dr. White added that the SCAI initiative also may be seen as a way to implement potential legislative mandates to assure cath lab quality. “Maryland seriously considered requiring accreditation for every hospital performing stent implantation in the state. They ended up not doing that, but I think that’s coming,” he said. “We understand if the legislature feels like it has to respond by saying, Okay, we’re going to mandate accreditation. But who’s doing to do that? We’re now stepping up to the plate to offer perhaps the answer to some of these mandates.”

1. Society for Cardiovascular Angiography and Interventions. The quality imperative: Lessons from the cath lab protecting patients, meeting reform goals and assessing performance with accuracy and fairness [position paper]. May 5, 2011.
2. Klein L, Uretsky B, Chambers C, et al. Quality assessment and improvement in interventional cardiology, part 1: A position statement of the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2011.Epub ahead of print.

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• ACC, SCAI Propose Independent Oversight to Ensure Appropriate Stent Use