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- S0735109717300153-9eefa9b06c88b5c7f73c084243a8b452A. Allen Seals, MD, FACC, Chair, ACC Board of Governors∗ ( and )
- S0735109717300153-e15838c04b5b56af30405e6a4fee74d2Richard A. Chazal, MD, FACC, President, American College of Cardiology
- ↵∗Address correspondence to:
A. Allen Seals, MD, FACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
The American College of Cardiology (ACC) was founded as an educational institution and has evolved to also encompass quality and advocacy as its cornerstones. The College operates on the premise that it has a fundamental responsibility to assist physicians and health care professionals with the delivery of evidence-based, quality care. This commitment to quality of patient care is reflected in the extensive breadth of ACC national quality campaigns that cover the spectrum of cardiovascular disease. In addition, with the advent of ACC state chapters in 1986, the College has encouraged the expansion of quality efforts at the local, state, and regional levels—resulting in greater innovation in methods of delivery of quality of cardiovascular care. For the ACC, this resolute dedication to quality of cardiovascular care is reflected clearly in the College’s mission statement: “to transform cardiovascular care and improve heart health.”
ACC National Quality Initiatives
Over the last decade, efforts focused on defining metrics and measurement of quality have led to the development of national initiatives that focus on improving identified gaps in care with proven, evidence-based strategies. The ACC’s Door-to-Balloon (D2B) Alliance, which celebrated its 10-year anniversary in November 2016, was 1 of the College’s early quality initiatives. More than 1,000 hospitals took part in a program that ultimately played a key role in changing the proportion of patients with D2B times <90 min to >75% by 2008, with even greater improvements thereafter (1). Since then, the College has launched several other quality campaigns, including the Hospital to Home heart failure program, the Patient Navigator Program, and the Surviving MI Program. These are all based on the successful D2B model and are intended to help cardiovascular professionals bridge gaps between science and practice to help ensure patient access to high-quality, appropriate, and cost-effective care.
The ACC has also played a role in facilitating hospital participation in the 10 National Cardiovascular Data Registry (NCDR) databases, as well as assisting hospitals that choose to publicly report NCDR quality measures. The “Find Your Heart a Home” site on CardioSmart.org helps patients to make more informed choices about their treatment options by learning if their hospital is participating in cardiac data registries and/or quality improvement programs. Plans to include whether a hospital is participating in 1 or more ACC Accreditation Services are also being discussed. With performance on quality measures becoming more closely tied to hospital and physician payments as a result of laws like the Patient Protection and Affordable Care Act of 2010 and the Medicare Access and CHIP Reauthorization Act of 2015, further evolution in how we measure, report, and pay for quality health care will continue in coming years. Most believe that the re-evaluation of the Affordable Care Act post-election will result in some changes in direction and implementation of health care reform, but that an ongoing move toward measurable cost-effective outcomes is inevitable. More on the effects of the presidential election are detailed in an all-member communication sent in December 2016, which is now available on ACC.org (2).
Challenge and opportunity abound. The need to help hospitals track quality of care to implement processes that ensure improved patient outcomes is essential. High-quality improvement processes that are cost-effective and strive to close gaps in guideline-based care are more important than ever. As such, developing a comprehensive health system strategy that best leverages the College's NCDR clinical data registries, accreditation programs, and quality campaigns is a major priority for the College.
The ACC has also taken a lead in participating in the Core Quality Measure Collaborative (CQMC), a major alliance between private payers and the Centers for Medicare and Medicaid Services (CMS), to establish a core set of quality measures that can be used for quality improvement, clinical decision making, and value-based payment and purchasing purposes. The College has long advocated on behalf of its members and their patients for alignment of quality measures among health plans and CMS, and this collaboration is a testament to these efforts. The goals of the CQMC include: 1) creating high-value, high-impact, evidence-based measures to promote improved outcomes; 2) removing low-impact metrics to ultimately reduce reporting burdens; and 3) harmonizing, refining, and aligning measures across payers.
The CQMC announced 6 core quality measures sets last February, 1 of which was for cardiology (3). Moving forward, the College is working with the other CQMC partners and with its members on how best to implement and evaluate the core set of cardiovascular measures, 8 of which are already included as part of ACC’s NCDR PINNACLE Registry reporting. Additionally, the College is working with members and payers where feasible to include ACC/American Heart Association (AHA) measures in payer contracts.
ACC State Chapter Quality Initiatives
In addition to ACC’s national quality campaigns, many ACC state chapters have taken on the task of developing cardiovascular quality of care initiatives for member physicians and care team members. It is the general consensus of the ACC Board of Governors that in the area of quality of cardiovascular care, the most clinically applicable innovations may be derived best from local- and state-level projects. Although not all of these local quality initiatives will fully realize their goals, the ACC Board of Governors feel that even projects that are not wholly successful will provide valuable insight into the processes surrounding implementation of such quality programs.
Each year, ACC chapters share their successes and challenges from the year in the College’s annual “State of the States” report. The report compiles summaries from each chapter about the 4 key components of the ACC’s current strategic plan: member value and engagement, population health management, purposeful education, and transformation of care. From these reports, a brief summary of some notable ACC state chapter quality initiatives are summarized in the following text.
The Arkansas Chapter efforts at quality of care initiatives have focused on statewide ST-segment elevation myocardial infarction (STEMI) management. In collaboration with representatives of the American Heart Association, Arkansas State Health Department, and Arkansas Emergency Medical Services, leadership of the Arkansas Chapter developed a coalition of key stakeholders to help improve quality of statewide STEMI care. The Arkansas Chapter announced the formation of an Arkansas Advisory Council on STEMI Care, which will now collaborate with emergency medical systems (EMS) and hospitals throughout the state for standardization of STEMI management. The Advisory Council will utilize AHA Mission Lifeline as the principal data source from 18 participating interventional hospitals strategically positioned around the state. The goals of the Arkansas Chapter are to directly affect clinical outcomes, including a reduction in STEMI morbidity and mortality. The Chapter is also working with Surgeon General of Arkansas Gregory Bledsoe, MD, on additional approaches to implementing various ACC quality initiatives for improving the cardiovascular health of Arkansas residents.
The Florida Chapter organized their newest standing committee to focus on quality, and the committee is in the process of gaining an understanding of the current state of quality cardiovascular care in Florida. The Florida Chapter also established the Florida Quality Improvement in Cardiology program to highlight what chapter members are doing to improve quality cardiovascular care in Florida. These local quality improvement projects have connected members looking to improve quality metrics in their own practices, and these local single-practice projects are collated and shared with ACC leaders, as well as with other state and national stakeholders. Also in Florida, a major statewide quality initiative was launched in 2016. Funded by unrestricted grants, the Florida Cardiovascular Quality Network (FCQN) is a physician-driven quality initiative that will allow Florida cardiologists the opportunity to demonstrate the real application of clinical decision support tools to assist in providing high-quality cardiovascular care consistent with the best of evidence-based medicine, clinical guidelines, and appropriate use criteria. In a large population with stable ischemic cardiovascular disease, mobile tablets utilized at the point of care provide Florida clinicians with the Seattle Angina Questionnaire, ACC’s FOCUS tool, and CardioSmart resources, as well as have the potential to input patient specific information from NCDR’s CathPCI Registry and PINNACLE. A total of 20 Florida sites will enroll 4,000 patients in the first phase of this innovative quality demonstration project to directly improve clinical decisions and, thus, the overall quality and value of care.
The Louisiana Chapter continues to participate in the Blue Cross Blue Shield (BCBS) of Louisiana Cardiac Care Quality Metric project to review individual metrics related to cardiovascular medical conditions. Additionally, the Chapter signed an NCDR contract with the ACC that will enable the Chapter to collect the data and share with the membership starting in 2017 to identify gaps and plan programs for quality improvement. At the request of BCBS of Louisiana, a Chapter committee reviewed more than 150 clinical metrics related to cardiovascular care. The Chapter determined which metrics were important to track when assessing provider quality as related to appropriate use of laboratory tests and imaging in cardiovascular patients. The Chapter continues to work with BCBS in this ongoing review process. The approach by BCBS of Louisiana has fostered an improved communication between chapter members and the BCBS as it relates to prior authorization of certain tests and new pharmacological agents to treat coronary artery disease. The Chapter also collaborated with The Association of Black Cardiologists to examine how to improve health care access for minority and high-risk populations. The multimember roundtable consisted of physicians, nurses, and administrators from programs engaged in caring for at-risk populations. The attendees included the director of Louisiana Medicaid and senior representatives from CMS. A summary of recommendations outline is currently in preparation with the assistance of Inside Edge Consulting and will be submitted once approved by the roundtable committee and the Association of Black Cardiologists administration.
The State of Maryland has the first law that mandates external peer review for quality of care in patients receiving percutaneous coronary intervention (PCI). With the commitment of the Maryland Chapter leadership and members involved in the PCI review committees, extensive effort has been expended to make certain the law, as written, will apply fairly to large and small facilities, rural and urban locations, and private and academic practices alike. All Maryland hospitals performing PCI have now submitted 2 years (2015 to 2016) of PCI clinical cases and images for blinded external review. It is anticipated that this statewide quality initiative will not only yield useful information applicable to large health care systems, but also provide insight into case selection and procedural methods that will directly affect quality of PCI care for the individual interventional cardiologist. The Maryland Academic Consortium on PCI Appropriateness and Quality, the largest of the external peer review systems for the State of Maryland, has accepted the important role and responsibility of performing data analytics and announced plans to present and prepare a publication in 2017.
The Michigan Chapter worked closely with the national ACC organization on eReports, NCDR’s online business intelligence data report that assists in reviewing trends and comparing facility-level data, and assigned the Chapter’s Quality Minister the role of Program Relations Representative.
The Chapter has also worked on organizing Michigan STEMI care into regions that include emergency medical systems (EMS), PCI-performing (receiving) centers, and non-PCI (referring) centers, emphasizing EMS participation, patient-centered data collection/analysis, benchmarking EMS, and hospital performance, with a focus on utilization/cost reduction/readmission prevention and an eye toward CMS cardiac care bundles. The Chapter successfully advocated to jumpstart a Michigan Trauma Department STEMI Systems of Care Workgroup after several years of inactivity, and the president of the chapter now chairs the group. The workgroup is in the process of a survey that will provide information to map patient transport and care. Additionally, the Chapter is working to organize small groups via the Chapter’s Subspecialty Councilors to utilize eReports to assess and improve care focusing on disparities of care and outliers, with potential for meetings at the Chapter’s 2017 annual conference. Finally, the Chapter is writing administrative rules governing STEMI systems of care, and is assessing and finalizing the optimum data collection tool.
The Virginia Heart Attack Coalition, a statewide quality initiative to improve systems of care for the early recognition and treatment of all Virginia residents having heart attacks, now has all but 1 hospital in the Commonwealth participating in the NCDR’s ACTION Registry, allowing for robust statewide reporting of total numbers of STEMIs, D2B, and first contact to balloon. The Virginia Heart Attack Coalition is a collaborative partnership among the ACC’s Virginia Chapter, the AHA, the Virginia Office of Emergency Medical Services, the Virginia Hospital and Healthcare Association, the Virginia College of Emergency Physicians, the Virginia Department of Health Heart Disease, and the Stroke Prevention Project. Additionally, the Virginia Chapter has been invited by the Virginia Cardiac Services Quality Initiative (VCSQI)—the statewide collaboration between NCDR’s CathPCI Registry and Society for Thoracic Surgeons databases—to partner in changing its focus from measuring surgical outcomes to measuring overall quality. Virginia institutions that represent 70% of the total PCIs in the state are signed on and gearing up to report data. It is anticipated that analysis of the VCSQI data may give insight into methods to affect costs and insight into new payment models. The Center for Medicare and Medicaid Innovation has awarded VCSQI a grant to explore specific alternate payment models.
In partnership with the Florida Chapter, the Wisconsin Chapter is continuing work on Smarter Management and Resource use in Today’s Complex CV Care (SMARTCare). The 3-year quality improvement project, funded through a $15.8 million Health Care Innovations Round II Grant, implements a suite of tools and registries that engage clinicians and patients in shared decision making and decision support to help ensure that care meets ACC appropriate use criteria and guidelines consistent with the patient’s goals and values. At the time of this publication, the project is being used by more than 640 clinicians at 11 hospitals, and in over 124 locations, and it has affected the care of more than 20,000 patients. Sites continue to refine the clinical workflow utilized across all centers, and are now working diligently on a value-based payment framework that rewards the right care, at the right time, and at a level that maintains the ability to continue key care in all of our communities. Thus far, clinical cardiovascular teams have shown that the workflow may be replicated in multiple sites of various sizes and degree of information technology sophistication. The payment framework being considered is applicable to many clinical pathways in cardiology, and could be adapted for use in atrial fibrillation, structural heart disease, various stages of congestive heart failure, and even dizziness and syncope. The grant work is now in its last year, and is now exploring the potential for continuation of the SMARTCare system of care and potentially incorporating a sustainable alternate payment model.
ACC Past President Ralph Brindis, MD, MACC, summarized the importance of demonstration of quality in cardiovascular care:
“When we first become physicians we take the Hippocratic Oath, vowing to ‘apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.’ When we become members of the ACC, we further our commitment to quality cardiovascular care by promising to live its mission: to transform cardiovascular care and improve heart health, as well as its enduring purpose: to strive to improve cardiovascular health through education, research, quality care and health policy. The College will continue to provide its members with the education, tools and resources to help them provide the best, quality cardiovascular care to patients” (4).
Through their ongoing efforts and actions, the ACC national quality initiatives and state chapters have both demonstrated their tireless commitment to quality as a primary tenant of the College. As physicians committed to quality of care in our individual patients, as well as physicians committed to quality of care in populations of patients, we should actively support and actively seek to participate in these national and chapter-led quality initiatives.
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- ↵American College of Cardiology. Post-election response from ACC Leadership. December 1, 2016. Available at: http://www.acc.org/latest-in-cardiology/articles/2016/12/01/14/01/post-election-response-from-acc-leadership. Accessed January 3, 2017.
- ↵Centers for Medicare and Medicaid Services. Consensus core set: cardiovascular measures. Version 1.0. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/Cardiovascular-Measures.pdf. Accessed December 20, 2016.
- ↵Brindis RG. Striving to improve quality cardiovascular care. ACC in Touch Blog. Available at: http://blog.acc.org/post/striving-improve-quality-cardiovascular-care/. Accessed December 20, 2016.