Author + information
- L. Kristin Newby, MD, MHS∗ ()
- Division of Cardiology, Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- ↵∗Reprint requests and correspondence:
Dr. L. Kristin Newby, Division of Cardiology, Duke Clinical Research Institute, PO Box 17969, Durham, North Carolina, 27715-7969.
Since the seminal description of the “cycle of quality” by Califf et al. (1) in 2002, in which the evidence established from randomized clinical trials and codified in practice guidelines was to be used to develop quality indicators and performance measures and adherence to which could be assessed in practice registries and fed back to providers in a loop of performance improvement, the relationship between performance and outcomes in acute cardiovascular care has been firmly established. The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative demonstrated that every 10% improvement in adherence to guidelines recommendations was associated with a 10% reduction in in-hospital mortality (odds ratio, 0.90 [95% confidence interval: 0.84 to 0.97]) (2). In addition, the important role of performance improvement programs and feedback to physicians and hospitals in improving adherence to guidelines has become clear. Not only have these programs improved adherence to guidelines recommendations (3), but they have also led to reductions in disparities in care (4). In fact, these programs have been so successful that a recent report from the National Cardiovascular Data Registry (NCDR) showed that performance based on key metrics of quality for acute and discharge treatment of patients with acute myocardial infarction (AMI) among hospitals participating in the NCDR ACTION (Acute Coronary Treatment and Intervention Outcomes Network)-GWTG (Get With The Guidelines) registry was so high and that the gap between leading (90th percentile) and lagging (10th percentile) centers had become so narrow that only limited room for incremental improvement remained in the arena of acute coronary care. For example, in 2011, the overall AMI performance composite scores at the 10th percentile of participating hospitals in the ACTION-GWTG registry were 84.3%, 94.4% at the 50th percentile, and 98.6% at the 90th percentile of hospitals (5). In 2011, in the CathPCI (Catheterization PCI) registry, discharge use of aspirin (97.9%), thienopyridines (97.3%), beta-blockers (86.3%), and lipid-lowering agents (92.5%) among eligible patients undergoing percutaneous coronary intervention (PCI) was also similarly high (5).
While these successes in improving the rates and consistency of in-hospital and discharge use of guideline-based treatments among patients with acute coronary disease and those treated with PCI should be celebrated, achieving such high levels of performance in secondary prevention have long been a challenge. In a single-center study of long-term adherence to secondary prevention treatment in 2002, the prevalence of aspirin use among coronary artery disease (CAD) patients was 83%, 61% for beta-blocker use, 63% for lipid-lowering therapy, and only 39% for use of all 3. Consistent use was below 50% for all agents except aspirin (6). A 2003 broad survey of the quality of health care for adults in the United States (7) found that of 37 quality indicators in coronary artery disease, the percentage of recommended care received was only 68.0% (64.2% to 71.8%); and a 2004 publication from the GRACE (Global Registry of Acute Coronary Events) registry noted that even among patients discharged on aspirin, beta-blocker, angiotensin-converting enzyme (ACE) inhibitor, or statin therapy, discontinuation rates at 6 months were 8% for aspirin, 12% for beta-blockers, 20% for ACE inhibitors, and 13% for statins (8).
A decade after these initial observations, the work by Maddox et al. (9) in this issue of the Journal highlights a persistent and disturbing failure to sustain the high levels of treatment observed in the acute and discharge settings in the 2011 NCDR registries into chronic secondary prevention for CAD in the outpatient setting. Using the NCDR PINNACLE (Practice INNovation And CLinical Excellence) registry created in 2008, which was designed specifically to measure the quality of cardiovascular care in the outpatient setting, Maddox et al. demonstrated that among 58 participating outpatient practices and a total of 156,145 CAD patients, the combination of beta-blockers, statins, and ACE inhibitors/angiotensin receptor blockers (ARBs) was prescribed as appropriate for eligible patients only 66.5% of the time at the first documented visit, which increased only slightly to 69.7% after accounting for all visits within a year of the initial encounter. Just as shown with acute and discharge care, which has been the focus of quality improvement in cardiovascular care over that past decade, there was wide variation in the rate of optimal prescription (from 28% to 100%; median: 73.5%) across the 58 practices and a 25% chance that similar patients treated at 2 different practices would receive different care. These data suggest substantial opportunities to improve quality of care through systematic application of provider feedback and best practices in process improvement. Importantly, preliminary data from 29 practices with pre- and post-PINNACLE participation data showed that sites were 14% more likely to prescribe the optimal combination of medications after initiating PINNACLE participation. However, length of participation in the PINNACLE registry was not associated with increased optimal prescription, suggesting that participation in a quality improvement registry is an important component for enhancing quality of care but insufficient to achieve a sustained trajectory of improvement and high rates of evidence-based secondary prevention medication use in the outpatient setting.
Unlike inpatient prescribing and discharge prescribing after an acute coronary syndrome, achieving high rates of outpatient secondary prevention treatment may be more challenging as the diversity of influences (some measured in the PINNACLE registry and others not) on measured performance will likely be greater in the outpatient setting. For example, to ensure optimal prescription of evidence-based secondary prevention medications, systematic approaches must include, and may be more dependent upon, efforts aimed at engaging a wider spectrum of providers, including not only cardiologists but also family practice physicians, internists, gynecologists, and advanced practice providers (nurse practitioners and physician assistants) who together, compared with acute inpatient care, may provide a larger portion of post-hospitalization care opportunities than cardiologists for patients with CAD post-MI or PCI, particularly as care becomes more temporally remote to the initial event. In this regard, it is of concern that diabetes was associated not only with lower prescription of optimal combination care but also lower prescription of ACE inhibitors or ARBs, for which clear renoprotective indications in diabetes also exist, suggesting that broader performance improvement initiatives may be needed.
Furthermore, care in the outpatient setting may be more geographically diffuse, with patients receiving PCI or treated for AMI at a given hospital dispersed among many primary providers and/or cardiology practices for follow-up care. Translating from the successes of integrated systems-based approaches to improving time to reperfusion in ST-segment elevation MI care may offer particular insights in this regard. Novel information technology solutions, including harnessing electronic health records systems and enabling integration of hospitals, outpatient practices, and pharmacies to ensure systematic information-based approaches to care, as well as integrating social media and other innovative approaches to educate, engage, and empower patients to participate in their own health care will almost certainly be necessary. In addition, despite the promise of the Affordable Care Act, consideration of costs of care at the point of care to ensure that all patients can obtain their prescribed medications and efforts to ensure the development and availability of tools and strategies to enhance patient compliance will remain factors in improving outcomes in secondary prevention.
In summary, the work of Maddox et al. (9) has once again called our attention to the substantial deficiencies in and challenges of attaining consistent, high-quality, evidence-based cardiovascular secondary prevention care in our outpatient practices. We must ensure that unlike previous reports, dating to more than a decade ago, this will be more than a shot across the bow and that we will collectively take action, embracing quality improvement initiatives like the PINNACLE registry and others, building on the past successes in acute cardiovascular care, and ensuring that the cycle of quality continues to turn.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Newby has received research grants through Duke University from Amylin, PCORI, NIH (NHLBI and NIDDK), Bristol-Myers Squibb, Merck and Company, and GlaxoSmithKline; and consulting honoraria from Genentech, GlaxoSmithKline, Roche Diagnostics, Daiichi Sankyo, Novartis, Janssen, AstraZeneca, Navigant, and DSI-Lilly.
- American College of Cardiology Foundation
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