This post is authored by Gary Puckrein, PhD, president and chief executive officer of the National Minority Quality Forum.

Physicians and the medical community have reached a fork in the road: we need to document that quality and reduced costs are related. By doing so, we hope to offer policymakers a new framework in which to measure the value of medicine. The conjectures:

• An avoidable mortality index can be an indicator of unnecessary acute events (disease, hospitalizations, disability and death) in a population. Such an index may have utility in localizing the performance of our health care system, thus enabling the investigation of gaps in outcomes of care. 
• There are signals that avoidable acute events are non-random occurrences. There is a possibility that they manifest at predictable frequencies within clinical and geographic sub-populations, and are sentinels of health care and health status disparities.
• Unnecessary acute events have financial implications. At least one study found that 36% of diabetes-related hospitalizations were avoidable. If that percentage holds true for Medicare beneficiaries, the savings could well be over $10 billion per year.
• By reducing unnecessary acute events, we may be able to establish an association between improved quality and bending the cost curve, thereby offering a counterpoint to those who believe reducing provider reimbursements is a desirable cost savings device.
  

The American College of Cardiology, the National Minority Quality Forum (NMQF), and the American Association of Clinical Endocrinologists have joined forces to put our conjectures to the test and have formed the CardioMetabolic Health Alliance. The objective of the Alliance is to improve cardiometabolic risk factor control in diverse populations, including high blood pressure, elevated fasting blood sugar, dyslipidemia, abdominal obesity (waist circumference) and elevated triglycerides; and to provide more effective and coordinated care for people with established cardiometabolic disorders.

In pursuit of its mission, the Alliance will study the possibility that predictable patterns of unnecessary acute cardiac events occur in communities, and that these patterns are measurable and amenable within the context of current treatment modalities. By using the ACC’s PINNACLE Registry and CathPCI Registry, as well as NMQF’s Cardiovascular Disease Index and U.S. Diabetes Index, the Alliance will explore the possible correlation between cardiometabolic disease and unnecessary emergency room visits and hospitalizations; and how these findings can be used to design predictive models and quality improvement interventions targeted for providers and patients at high risk for an acute cardiovascular episode.

Members of the CardioMetabolic Health Alliance and ACC will be meeting at the 2012 Cardiometabolic Health Congress this week in Boston, Ma. Visit the Alliance’s website for more information www.cardiometabolicha.org. Also read more about CardioMetabolic Syndrome in an article in the July/August issue of Cardiology magazine.

By William J. Oetgen, MD, MBA, FACC, senior vice president of Science and Quality of the ACC.

The ACC’s NCDR® is comprised of six hospital-based registries and one ambulatory registry, known as the PINNACLE Registry®. These registries measure the application of clinical guidelines in the real world setting – which helps us target national opportunities for quality improvement.

The PINNACLE Registry currently has 5.3 million patient encounter records covering 1.5 million unique patients, submitted from over 550 office locations nationwide. Of those patients, nearly 320,000 have atrial fibrillation (AFib), which is the most common arrhythmia in clinical practice, and is responsible for 15-20 percent of all strokes. Due to the growing need for the understanding of treatments and practice patterns for AFib, last year we announced the expansion of the PINNACLE Registry to include a new platform focusing on AFib, and include the next generation of anticoagulants coming online.

As new treatments are introduced to the market, assessing shifts in care patterns – and the impact of these shifts on patients – is a top clinical and research priority. The Registry can provide a means to monitor practice pattern changes over time while we rigorously assess current practice patterns and provide feedback reports to help providers evaluate and improve adherence to established guidelines and performance measures. We are also interested to see if these new medications coming online change the way doctors think about stroke prevention, which will ultimately help us close a long-standing quality gap in anticoagulation.

PINNACLE-AF is already yielding powerful clinical insights, and a study published last year in the American Journal of Cardiology used the PINNACLE Registry to look at treatment rates with warfarin in outpatients with nonvalvular AFib who were at moderate to high risk for stroke, as well as the extent of patient- and practice- level variation in warfarin use. The investigators found that warfarin treatment in AFib was suboptimal, with large variations in treatment observed across practice, and noted that their findings suggest important opportunities for practice-level improvement in stroke prevention for outpatients with AFib and define a benchmark treatment rate before the introduction of newer anticoagulant agents.

Because global anticoagulation patterns, especially in emerging markets, are less understood, the ACC recently conducted a transnational survey of AFib patterns the U.S., U.K., Germany, Brazil, India, and China, in order to develop a broader understanding of the causes of gaps in anticoagulation. The October issue of CardioSource WorldNews details the results, so be on the lookout for your copy hitting newsstands in the coming weeks. As mentioned in a previous blog post, the College is currently in the early stages of developing a comprehensive initiative to address gaps in treatment and encourage compliance with guideline-recommended care.

The power of registries is immense, and we encourage the use of this quality improvement tool – all in the name of improving quality and outcomes for patients. Expect to see more data and research come to fruition in the coming months, especially in the topics related to kidney function and bleeding risk and events which are areas of clinical import with the next generation of anticoagulants.

This post is authored by Richard Kovacs, MD, FACC, chair of the Best Practices and Quality Improvement Subcommittee, a subcommittee of the College’s Clinical Quality Committee.

The ACC is leveraging AFib Awareness month to highlight the many ways the College has stayed on top of the clinical and practice needs and demands of CV professionals in what is truly an evolving landscape.

This month the ACC launched an Atrial Fibrillation (AFib) Toolkit to provide tools and strategies for the patient care team to support high-quality care for patients with AFib.  Rather than only defining high-quality AFib care as defined by clinical performance on National Quality Forum endorsed measures, the AFib Toolkit establishes clear goals for overall high-quality AFib care by identifying and filling gaps in the knowledge and behavior of the patient and the patient care team in meeting these goals.  

Included in the AFib Toolkit:

• Five tools focused on diagnosis and risk assessment
• Four tools, plus 23 individual drug monographs, for treatment and management of AFib
• Three tools focused on patient education

As noted in last week’s blog post, AFib is the most common arrhythmia in clinical practice, and is responsible for 15-20 percent of all strokes, which account for 1 in 17 deaths in the U.S. and rank third among all causes of death after heart disease and cancer. In addition to improving clinician adherence to National Quality Forum endorsed performance measures for AFib, the AFib Toolkit will increase patient awareness of the risks associated with AFib, and enhance patient engagement in their AFib care plan.  Provider understanding and inclusion of patient behavior, choices, and lifestyles in care planning is especially important with AFib because of the rapidly evolving landscape of AFib therapies.  The AFib Toolkit is an opportunity to identify approaches for supporting the patient-provider partnership in meeting care goals among considerable safety and efficacy concerns.

In addition to the AFib toolkit, the ACC provides innovative educational programs like A New ERA v 2.0, a free Performance Improvement-Continuing Medical Education activity designed to help physicians improve the care of their patients with atrial fibrillation. To track data of patients with AFib, last year the PINNACLE Registry launched a new platform, PINNACLE-AF, focusing on atrial fibrillation and including the next generation of anticoagulants. Currently a new national anticoagulation initiative, led by ACC, is under development to drive awareness of the efficacy and safety of new anticoagulation therapies.

In the end, whether we’re talking about AFib, or another area identified as ripe for improvement, ACC members need real-time, easy-to-use solutions that cross the spectrum of quality, advocacy and education and bring about real change. The efforts underway by a multi-disciplinary team of ACC members and staff are bringing these tools to life.

This blog post is part of a series of blog posts during AFib Awareness Month. Stay tuned in the coming weeks for more information from the College on AFib news, tools and initiatives. Also visit ACC’s Facebook page for additional information.

Hypertension, or high blood pressure, is a major and growing public health problem in the United States.  Approximately 72 million people in the U.S., or about 1 in 3 adults suffer from the disease, which if left untreated can increase risks for heart attack, stroke, and/or other health complications. Blood pressure management has been identified as a key component of the Million Hearts initiative, led by CMS and CDC with a goal to prevent one million heart attacks and strokes over the next five years by focusing on the “ABCS” (aspirin for high-risk patients, blood-pressure control, cholesterol management, and smoking cessation).

As part of “National High Blood Pressure Education Month,” the ACC throughout May is focused on reminding cardiovascular professionals about the tools and resources available to help not only improve care for patients with/or at risk of  hypertension, but also help educate patients about the importance of controlling their blood pressure and minimizing their cardiovascular risks.

Just last year, the ACC Foundation, along with the American Heart Association and the American Medical Association – Physician Consortium for Performance Improvement, released truly ground-breaking performance measures designed to help clinicians treating adults with coronary artery disease (CAD) and hypertension (view the Performance Measures here). Unlike previous measures, these focused not just on treatment in the hospital setting, but on primary and secondary prevention as well. They also addressed whether important cardiac risk factors are being “controlled” to targeted goals vs. simply “treated” – a move that requires much greater patient involvement in treatment and care decisions. Finally, these performance measures emphasized patient-focused functional outcomes and stressed the need to not only assess patient angina and functional symptoms but also to develop treatment plans to improve these outcomes.

The ACC’s PINNACLE Registry takes these performance measures and puts them into action. Registry participants collect data on practice performance and then receive quarterly benchmark reports that can and should be used to identify areas for improvement. Participants in the registry also have access to the PINNACLE Network as a means of sharing best practices and encouraging quality improvement among registry users. PINNACLE is one of the primary ways the ACC is working on a national level with the Million Heart’s initiative.

The ACC’s CardioSmart^TM initiative is also a critical resource when it comes to hypertension. Cardiac care providers can download patient fact sheets in both English and Spanish, or send patients directly to CardioSmart.org to take advantage of the CardioSmart Health Tracker: Blood Pressure Tool. CardioSmart has set a goal of capturing 5,000 blood pressures through the month of May via the online tool and working with its partners at the grassroots level.

Sometimes the toughest problems have the easiest solutions. When it comes to taking down the number one cause of mortality worldwide, taking simple steps to manage conditions like blood pressure can go a long way.

In case you missed it, there’s only one day left to participate in the Office of the National Coordinator for Health Information Technology (ONC), Million Hearts and AHA “Beat Down Blood Pressure” video challenge: http://bloodpressure.challenge.gov/.

How are you helping your patients manage hypertension? Share your tips in the comment section below!

A recent article in Health Affairs examined the supply and distribution of the cardiology workforce across the country given “a sufficient cardiology workforce is necessary to ensure access to cardiovascular care. Specifically, access to cardiologists is important in the management and treatment of chronic cardiovascular disease.”  The paper was co-authored by Harlan Krumholz, MD, FACC, a member of the ACC Board of Trustees and professor of medicine and epidemiology and public health at Yale University School of Medicine.

The results showed that there has been a modest increase in the cardiology workforce over the past 12 years, whereas the primary care physician and entire physician workforce shortages are more pronounced. But there’s also a big disparity in the geographic distribution of cardiologists across the country, specifically in rural and socioeconomically disadvantaged areas.

As the U.S. “baby boomer” population becomes older, it is clear we will need to rely on team-based practice models to deal with the cardiovascular demands on the U.S. health care system that are certain to increase. A team-based model will enable delivery system and quality of care improvements as it offers solutions to the workforce shortage, and will expanded physician productivity, and improve job satisfaction by reducing workloads and preventing burnout.

According to the CDC, since 1950, age-adjusted death rates from cardiovascular disease have declined 60 percent, representing one of the most important public health achievements of the 20th century. Despite this huge reduction in morbidity and mortality, just imagine what we can accomplish when we work together in a team-based setting using NCDR^® and PINNACLE Registry^® data to systematically improve patient outcomes, and simultaneously improve efficiency and value.

We still have a long way to go in fighting the leading cause of death in the U.S., so let’s get to it!

Last night the Million Hearts initiative hosted a fantastic reception in Washington, DC, that was sponsored by the ACC, along with the American Heart Association and the Association of Black Cardiologists. The event not only provided us with an opportunity to highlight our commitment to help prevent 1 million heart attacks and strokes over the next five years, but also network with other public and private stakeholders around this shared goal.

The Million Hearts initiative was launched in September to directly address heart disease and stroke – two of the leading causes of death in the U.S. – by bringing “together communities, health systems, nonprofit organizations, federal agencies, and private-sector partners from across the country” (read a previous blog post about the initiative here). The program is jointly managed by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), with former ACC Senior Vice President for Science and Quality Janet Wright, MD, FACC, leading the charge.

During the reception, ACC CEO Jack Lewin, MD, committed the College to educating both consumers and the entire cardiac care team about the best, evidence-based strategies for reducing cardiovascular disease. In particular, we are excited about the opportunity to help monitor progress toward the goals of the campaign and provide important feedback to providers through the ACC’s PINNACLE Registry^TM.  On the consumer front, the ACC’s CardioSmart^TM National Care Initiative will play an important role in educating consumers about the “ABCS” (Aspirin for high-risk patients, Blood-pressure control, Cholesterol management, and Smoking cessation) and everyday strategies for healthy living.

These and other strategies are also highlighted in a recent letter to Health and Human Services Secretary Kathleen Sebelius. I personally am very excited about the opportunity to partner with Million Hearts on this important venture that takes an important step towards dethroning heart disease as America’s #1 killer.

For more information on the Million Hearts initiative, including partner commitments, visit the Million Hearts website. Be on the lookout for an article about Million Hearts in the Nov./Dec. issue of Cardiology Magazine. For additional CardioSmart patient fact sheets or to view the fact sheets in Spanish, visit CardioSmart.org.

AFib is catching a lot of buzz lately. Two weeks ago, the PINNACLE Registry announced the expansion of its outpatient registry with a new platform focusing on atrial fibrillation that will include the next generation of anticoagulants and will be free for all cardiology practices. The new registry will help providers evaluate and improve adherence to established guidelines and performance measures and will strengthen future research and innovation. PINNACLE, part of NCDR, is the largest cardiovascular outpatient database in the country and currently has 2.1 million patient records representing valid patient encounters from hundreds of outpatient practices nationwide. Of the 2.1 million patients, more than 100,000 have AFib. Stay tuned for more developments as the registry becomes operational in 2012 and delves into collecting data that will improve patient care.

How do you use anticoagulants in your practice when dealing with AFib? Weigh in on the poll and see how others are thinking about new agents as well.

Results from the AFFIRM Trial (Atrial Fibrillation Follow-Up Investigation of Rhythm Management) were released last week. This trial explored how individual rhythm-control agents affect cardiovascular outcomes in patients with atrial fibrillation, looking at individual antiarrhythmic drug therapies compared with rate control with propensity score-matched analyses.  It turns out that rhythm-control agents had no effect on all-cause mortality, but were associated with an increased risk of cardiovascular hospitalizations.

This month’s featured article in the Atrial Fibrillation Community covers the clinical significance of silent stroke. According to the article, “[Recent] studies raise strong evidence that ‘ablation technology and energy source matters’ since non-irrigated multielectrode ablation resulted is a significantly higher silent stroke rate as compared to other ablation techniques. Thus, regarding the mechanism(s) leading to silent stroke it is very likely that most thromboembolic events are due to energy application, i.e. charring at the ablation catheter, rather than due to mobilization of pre-existing left atrial thrombi or air embolization.” So, should we be worried? Even though there is no current evidence that silent stroke impacts cognitive function, future studies are needed that explore the factors leading to their occurrence.

I invite you to visit the AFib Community which is a great resource to stay up-to-date on AFib developments and features articles, hot topics, news, case challenges and much more.

The prestigious Institute of Medicine (IOM) earlier this month opined concerned that most medical devices are cleared for sale without sufficient evidence that they are safe and effective -- even though we tend to delay approvals of devices far longer than the EU, Canada and most of the developed world. IOM’s assessment should give everyone pause -- particularly because they declared the current regulatory approach (related to the FDA 510K approval process) to be so messed up that we should scrap it and start over. FDA reacted immediately that they disagreed, stating they would instead work to fix the problems acknowledged in the 510K regulatory system.

The IOM committee found no major new horror stories related to existing devices on the market, but worried that FDA and the public have no good way to determine where risk may exist because there is virtually no good clinical data to rely on. Hello. The NCDR has the clinical data they seek; and if we could get the feds to offer incentives to help us diffuse the PINNACLE Registry across more outpatient practices, we could track post-approval performance and look for even low-signal adverse events incredibly effectively!

The IOM committee commented specifically on what they termed "highest-risk" CV devices, such as implantable defibrillators and replacement heart valves. They noted that clinical trials with relatively few enrolled patients are used to demonstrate safety and effectiveness of such devices, deeming that they afford only a “moderate risk,” based on having the manufacturer show that they are “substantially equivalent” to devices previously cleared. The added concern is that those devices in turn may have been cleared because they were “substantially equivalent” to earlier devices that may no longer be in use -- a ‘house of cards’ process.

IOM deserves credit for spotlighting the issues. But, not only the FDA objected to IOM’s recommendations: the device industry, already frustrated with the cumbersomeness of the 35-year old 510K process, are yet even more worried about and opposed to completely scrapping the process. They want to see it streamlined instead. What we need to do is show FDA, IOM and industry what the broad use of registries could do to carefully track ALL patients who are device recipients. That’s what needs to happen! Upcoming FDA hearings on the IOM recommendations and the future of the 510K process will give us an opportunity to promote this potential of using our registries to provide more rigorous and effective surveillance of CV devices after they are on the market.

The Centers for Medicare & Medicaid Services (CMS) last week issued a report that highlights significant trends in the growth of two “pay-for-reporting" programs: the ePrescribing Incentive Program and Physician Quality Reporting System (PQRS...formerly known as the Physician Quality Reporting Initiative or PQRI). According to the report, 2009 Physician Quality Reporting System and ePrescribing Experience Report, 119,804 physicians/eligible professionals in 12,647 practices received incentive payments under PQRS totaling more than $234 million—well above the $36 million paid in 2007, the first year of the program. Under the ePrescribing Program, CMS paid $148 million to 48,354 physicians/eligible professionals in 2009. Results show that participation in PQRS has grown at about 50 percent every year, on average, since the program began.

On average, 2009 bonus payments for satisfactory reporters in PQRS were $1,956 per eligible professional, but $18,525 per practice that participated. Eligible professionals received even more from the ePrescribing Program in 2009: the average bonus payment was just over $3,000 per eligible professional and $14,501 per practice.

The report also shows health care professionals report complying more often with evidence-based care practices. Based on reported data on the 55 measures that have been a part of the PQRI/PQRS program since it began in 2007, providers have improved the frequency for which they deliver recommended care by about 3.1 percent on average. Similarly, of the 99 measures that were part of the System in 2008 and 2009, performance improved at about 10.6 percent on average. In some cases, gains have been even more dramatic. More about the report is available on the CMS website.

The incentives are still trivially small to really move the system. At least our PINNACLE Registry users got fully reimbursed with no hassles through the PQRS program. For 2009, 172 providers from 14 practices used the PINNACLE Registry to report --100% successfully--with an average payment of $8,352 per provider. But the CMS incentives need to be made much more significant if we want these programs to work and to significantly improve quality systematically.

Today I met briefly with the NCDR and the Society of Thoracic Surgeons database leadership team. The NCDR (National Cardiovascular Data Registry) continues to be the most comprehensive, outcomes-based quality improvement program in the U.S. NCDR over the last couple of years has grown exponentially, to offer not only several hospital-based registries (covering ACS, carotid artery resvacs and endarterectomy procedures, diagnostic cath and PCI, and ICDs) but also the first-ever CV practice-based registry, PINNACLE. PINNACLE collects data on practice performance on CAD, hypertension, HF and AFib, and then provides practices with quarterly benchmark reports that can help them to improve performance.

ACC’s newest registry actually launched officially just last week. The IMPACT Registry will assess the prevalence, demographics, management and outcomes of pediatric and adult patients with congenital heart disease who are undergoing diagnostic catheterizations and catheter-based interventions. This registry is groundbreaking – to date, no single registry has collected sufficient national quality-focused data in this area. Its data will provide significant contributions to the knowledge base and outcomes associated with congenital heart disease.

Today’s meeting confirms what everyone who works with NCDR knows: because NCDR collects real-world data, it is uniquely positioned to help participating facilities and medical professionals identify and close gaps in quality of care, reduce wasteful and inefficient care variations and implement effective, continuous quality improvement processes.

Registry data is the future of measurement. For every trial that relies on error-fraught claims data, we need to replace it with the outcomes-based data that NCDR provides. This will help us understand what is actually happening in CV care.

AHA will feature a record number of abstracts with NCDR data. You should check them out if you’re interested in seeing how the data can be applied. Here’s a PDF listing of times and locations.