Author + information
- William A. Zoghbi, MD, FACC, ACC President⁎ ()
- ↵⁎Address correspondence to:
William A. Zoghbi, MD, FACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037
W. Edwards Deming, the father of modern quality control, promulgated an iterative 4-step method for continuously improving business processes and products. Known as PDSA, for Plan, Do, Study, and Act, it was based on the scientific method. The first step, Plan, entails deciding on the desired output and devising processes to achieve that end. Step 2, Do, is straightforward: implement the plan and collect data for step 3. Study is also straightforward, at least in concept: compare the actual against the expected results, and look for areas where the plan and its implementation diverged because of unforeseen realities. Analyzing the data makes it possible to determine how to take corrective action (or Act, step 4), to tweak the initial plan in hope of coming closer to the desired outcome. Other versions of this method have been proposed, with varying numbers of steps and varying acronyms, but the fundamental principle remains constant: it is an iterative approach.
The ACC's Approach to Quality Improvement
The American College of Cardiology (ACC) uses this same iterative approach in our own quality efforts as we strive to improve treatment utilization and outcomes, physician education, and patient health. The College's guidelines, performance measures, and appropriate use criteria (AUC) are the result of prior analyses and the foundation of our plans to achieve ever-better outcomes: they synthesize the latest scientific research into procedures that we can use to guide our decisions. The key to our collective ability to evaluate the efficacy of these guides is the suite of registries operating under the aegis of the National Cardiovascular Data Registry (NCDR®). These registries allow hospitals, and now practices, to measure their quality efforts and identify common trends, gaps in care, and areas where improvement is needed. Here, I want to describe some of the national quality initiatives the ACC has developed based on data from sources like NCDR or the Centers for Medicare and Medicaid Services (CMS), and then touch on areas that will require attention in the near future.
The Hospital to Home (H2H) Program
CMS data have revealed a wide disparity in overall hospital readmission rates, and the agency, as well as Congress, is focused on reducing these rates as a means to reduce skyrocketing health care costs while maintaining quality. The goal of H2H is to reduce 30-day hospital readmission rates for patients discharged with cardiac conditions by 20% by the end of 2012. To that end, H2H seeks to identify best practices in 3 main areas:
• post-discharge medication management;
• follow-up within 1 week of discharge; and
• patient recognition of signs and symptoms.
Program participants are challenged to focus on these areas and share best practices, resources, and tools.
Imaging in FOCUS
The thrust of initiative is to promulgate AUC at the point of care and help the referring health care professional in the appropriate utilization of imaging modalities in various clinical scenarios. There are currently 2 ways to participate in this national program: through a voluntary community or through a participating health plan.
Participants in the voluntary community can take advantage of a performance improvement module or other online data collection tools to track AUC use. These tools have proven especially useful over the last couple years, given the advent of new mandatory laboratory accreditation requirements and increasing maintenance of certification requirements. To date, participating practices have been able to reduce inappropriate ordering by close to 50% in 1 year (from 12% to 7%)—a true testament to quality in action.
Meanwhile, the health plan program is focused on ensuring appropriate patient selection through the use of AUC, point-of-order clinical decision support, and benchmarking to target education and quality improvement. Unlike radiology benefit managers, the health plan tool provides feedback on individual cases, reports on patterns of use over time, and provides an easy way for participants to engage in ACC-led quality improvement and education. This is already operational in Delaware and is being rolled out in other states. The same product will be offered directly to practices and hospitals later this year for direct use in patient care.
Door to Balloon (D2B)
The D2B Alliance was created to help providers meet the guideline-recommended D2B time of 90 min or less in the treatment of acute ST-segment elevation myocardial infarction (STEMI). This unique program has earned global attention for providing evidence-based strategies that led to success: a 2011 study found that heart attack patients are receiving lifesaving angioplasty just 64 min after arrival at the hospital—a mind-boggling 32 min faster than 5 years ago (1)!
The newest of the ACC's national quality efforts collects practice data in the outpatient setting using the PINNACLE Registry. These data are then used to help practices benchmark themselves against their peers and identify areas in which patient care can be improved. Relevant data are extracted electronically and seamlessly from the electronic health record (EHR). The registry also helps practices participate in federal quality improvement programs such as the Physician Quality Reporting System and the EHR Incentive Program.
Million Hearts and Choosing Wisely
The ACC is a part of both Million Hearts and Choosing Wisely—2 large-scale national programs designed to facilitate cooperation among health care providers, consumer groups, companies, and, importantly, patients. The goal of Million Hearts is to reduce the total number of heart attacks and strokes over the next 5 years by 1 million, through patient and provider education about healthy lifestyle choices, appropriate aspirin use, blood pressure and cholesterol management, and smoking cessation. Choosing Wisely, led by the American Board of Internal Medicine (ABIM) Foundation in collaboration with 8 other medical specialty societies, invites health care providers and patients to have a discussion about tests and procedures that are not beneficial or, in addition, may present risk. This campaign shares evidence-based guidelines for tests and procedures with both health care providers and patients. The ACC's list of “5 Things Physicians and Patients Should Question” recommends:
• Do not perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
• Do not perform annual stress cardiac imaging or advanced noninvasive imaging as part of routine follow-up in asymptomatic patients.
• Do not perform stress cardiac imaging or advanced noninvasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk noncardiac surgery.
• Do not perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
• Do not perform stenting of nonculprit lesions during percutaneous coronary intervention for uncomplicated hemodynamically stable STEMI.
The ACC's list was developed over several months of analysis and discussion, with the College asking its standing clinical councils to recommend between 3 and 5 procedures that should not be performed or should be performed less frequently and only under specific circumstances. The ACC staff took the councils' recommendations and compared them to the ACC's existing AUCs and guidelines, choosing items for the 5 scenarios that had the tightest inappropriate score in the AUCs and were also Class III recommendations in ACC/American Heart Association guidelines (not useful or harmful).
Obstacles in the Quest for Better Quality
Despite these innovative programs and documented improvements, the road to quality is not always smooth. The increasing amount of work and resources needed to identify, measure, and document quality indicators, rapid development of new technologies, controversies surrounding terminologies, and the current U.S. physician payment system are arguably among the biggest bumps—sometimes even yawning chasms—in the road.
Too Much, Too Fast
ACC past President David Holmes, Jr., MD, MACC, wrote a President's Page last year about the staggering amount of information now available to physicians and other care providers at the touch of a finger (2). The College is taking seriously the need to make our guidelines, AUC, performance measures, and other clinical documents relevant and useful in today's information-saturated digital environment. We are revamping our digital infrastructure and just had a retreat with experts in the field for this very purpose.
Related to this is the challenge of adopting EHRs. While the goal of universal adoption and interoperability between systems is laudable, how we get there is still very much up for debate, given the deep disparities between systems, their user-unfriendliness, and the high costs and lingering inefficiencies associated with their implementation.
Even technological advances sometimes lead to painful transitions. Each new device or therapy requires us, as well as CMS, the Food and Drug Administration, and others, to quickly provide guidance on training requirements, costs, and use. Transcatheter aortic valve replacement is a prime example of needing to be nimble, but thoughtful, with the rollout of a therapy that can transform the quality of care for patients with severe aortic stenosis who had no options before. Yet there is a veritable flood of new devices and therapies to be considered, and evaluation takes time—precious time for patients with no other options, but time that could nonetheless prevent tragic consequences. Somehow we must achieve a balance between the precautionary principle and the urgency constantly being urged on the FDA for ever-more-rapid approval.
Complex and Intertwined
Undoubtedly, delivery of health care is more complex than ever, for both the practitioner and the patient. Adding more work to the plate of the physician and health care team is understandably met with frustration and resentment. Definitions of “appropriate,” “inappropriate,” “public reporting,” “accountable care organization,” “comparative effectiveness,” “value,” and even “quality” are also a great source of controversy these days. Internally, College leaders are taking a close look at whether the appropriate, uncertain, and inappropriate terminology used in AUC should be modernized to better reflect the intent behind the designations and how they should be used. These debates are not “mere semantics;” go to any health policy meeting in Washington, DC, and the definitions of quality and value vary by speaker, making it extremely difficult to identify and implement solutions related to payment and recognition.
How to incentivize or reward quality remains a significant challenge but a laudable and important goal. There is truly no one-size-fits-all solution. Clearly, the solution to rising costs is not to squeeze healthcare teams even further. It is increasingly clear that the current payment system based on volume is not sustainable—particularly if one of the primary goals of health care reform is to reduce health care costs and eliminate waste in the system, while maintaining quality. We must also lead the way in having candid discussions about the real causes of the health crisis, and not just the healthcare crisis.
What Does the Future Hold?
Whether you see the situation as cause for more hope or despair is largely a matter of temperament, but in truth, none of these challenges are insurmountable. At the same time, we have to put the drive towards quality and its findings in context: the vast majority of physicians, and what they do, pass the quality metrics when applied. The aim here is to refine it further, and push the envelope towards the highest quality care realistically achievable, with the least variability—the underlying drive being improving patient health and outcome, and providing value.
We need to develop testable plans, implement them, fearlessly compare results, and figure out how to improve the next round. Our guidelines, AUC, and other clinical documents need to ultimately be more “living documents,” residing in cyberspace, that reflect the latest and best science, diagnostics, and therapies, and that can be readily updated. We have the opportunity to help transition these plans into usable tools that are integrated into our registries, EHR platforms, the ACC website, and even mobile applications. The NCDR offers countless opportunities to serve as platforms for clinical trials, post-market surveillance, and public physician-level reporting (once we agree on semantics). Each and every one of these opportunities can lead to significant improvements, some of which we likely cannot even imagine at this time.
In order to validate our guidelines and measures, however, we need ACC members to collaborate with us and take ownership, engage in verifying their own data that is being collected, help us to ask better questions, and further refine this process. Together we must commit ourselves to envisioning a better future, and we must have the courage to live in the space between what we see in the world and what we hope for.
Plan, do, study, act … it is an iterative process … and a proven path to progress.
- American College of Cardiology Foundation