From ACC/AHA Guidelines to Best Practice: Can "Acute MI Report Cards" Save Lives? Measuring Quality of Care for Patients With Cardiovascular Disease
Martha J. Radford, MDAssociate Professor of Medicine (Cardiology)
University of Connecticut School of Medicine
Farmington, CT
Quick Overview
Measuring Quality of Care: Pros and Cons
The concept of measuring quality of care is one that often makes physicians uneasy. There is concern that clinical subtleties will not be understood in measurements designed by nonphysicians. There is concern that making quantitative estimates of quality of care will lead to inappropriate ranking of providers based on measures whose precision is not well understood. There is concern that "cost of care" will be used as a surrogate for quality of care.Cardiovascular care is under particular scrutiny. Cardiovascular disease is common, and care is often "high tech" and expensive. Current clinical science supports a variety of approaches, and there are limitations with prescribed patterns of care ("cookbook medicine"). However, few would deny that it is important to develop quality measures based on firm scientific evidence that are meaningful to physicians and patients, likely to lead to improvements in the delivery and outcome of care, which can inform future clinical research questions and approaches.
The Cooperative Cardiovascular Project
The Cooperative Cardiovascular Project (CCP) is a landmark medical care quality improvement initiative in these regards. It is the first project undertaken by the Health Care Finance Administration (HCFA), which has fiscal and quality oversight for all care provided to Medicare beneficiaries, according to principles of quality improvement outlined in 1992. (1)An important aspect of the CCP is that input from the provider community was actively sought throughout the project. The Steering Committee consisted of representatives from all physician groups involved in the care of patients with coronary artery disease. The American College of Cardiology/American Heart Association guidelines for the care of patients with acute myocardial infarction (MI) (2) were used as the basis for designing the quality indicators. Physicians active in the care of patients were involved in designing the clinical logic, in verifying whether the logic correctly identified patients eligible for a given care process, and in analyzing and reporting patterns of care to physicians, hospitals, and the medical literature.
The CCP Pilot was carried out in four states-Alabama, Connecticut, Iowa, and Wisconsin-from 1992 through 1994. The principles underlying the CCP should reassure physicians:
- 1. Clinical information is important for judging quality of care.
Claims data are inadequate for process-of-care inquiries. In Connecticut,
more than 3,000 inpatient records for Medicare patients with acute MI during
1992 and 1993 were reviewed, and more than 750 clinical data elements were
abstracted for each record, including admission history and physical exam,
medications, test results, and complications.
- 2. Recommendations derived from well-designed clinical research (especially randomized controlled trials) are generalizable. For patients with acute MI, recommendations pertinent to administration of thrombolytic therapy, aspirin, beta blockers, ACE inhibitors, and withholding calcium channel blockers are considered well-grounded in the extensive clinical research. This research has contributed to the decline in mortality following acute MI that has been observed over the last two decades.
- 3. For a given intervention, a group of patients "ideal" to receive that intervention can be identified. This ideal group of patients, who have clear-cut indications for intervention and no contraindications, represents an "assay" for process of care. For patients not in the ideal group, who may have a relative contraindication to or an uncertain indication for a given care process, decision making is left up to the physician, with no judgment made about the quality of that decision.
.
The results of the CCP Pilot have been recently reported, (3) and show that even for patients considered ideal candidates for a given intervention, there is evidence of underutilization of accepted therapies (Table 1).
In addition, there is opportunity for improvement in the time to administration of thrombolytic therapy. Mean time between hospital arrival and administration was 1.2 hours; only 11% of patients received thrombolytic therapy within 30 minutes of arrival, the current national door-to-drug target.
As important as these insights to providers are, the CCP Pilot has also demonstrated to the "quality measurers" some important principles:
- 1. Cookbook medicine is not possible. The relatively small size of
the ideal candidate patient set for some therapies surprised many nonphysicians
but did not surprise physicians, who understand how commonly the clinical
characteristics of individual patients modulate care decisions, particularly
for the elderly. For patients who are not ideal candidates, therapy is left
up to physician judgment, as it should be.
- 2. It is easier to analyze patterns of care when the process is recommended for virtually all patients. Development of the ideal candidate methodology allowed for analysis of processes of care for generally applicable therapies. However, within a population-based sample such as the CCP records, quality of care for exceptional patients, eg, those with septal rupture after acute MI, cannot be measured in any meaningful way. Care of these far-from-average patients is an important-and as yet unmeasurable-component of the quality of care of a medical care system.
References
1. Jencks SF, Wilensky GR. The health care quality improvement initiative: a new approach to quality assurance in Medicare. JAMA. 1992;
268:900-903.
2. Gunnar RM, Bourdillon PDV, Dixon DW, et al. Guidelines for the early management of patients with acute myocardial infarction. J Am Coll Cardiol. 1990;6:249-292.
3. Ellerbeck EF, Jencks SF, Radford MJ, et al. Quality of care for Medicare patients with acute myocardial infarction. JAMA. 1995;273:1509-1514.
Return to Index of Articles for Clinician;
Volume 14.4
- Faculty Listing 3
- Introduction: Community Message in Acute Myocardial Ischemia 4
- Concept of Community Chest Pain Centers in Emergency Departments 5
- Reawakening Awareness of the Importance of Prodromal Symptoms in the Shifting Paradigm to Early Heart Attack Care (EHAC) 7
- The Role of Emergency Medicine in the Future of American Medical Care: A Summary of the Josiah Macy, Jr, Foundation Conference 12
- From ACC/AHA Guidelines to Best Practice: Can "Acute MI Report Cards" Save Lives?Measuring Quality of Care for Patients With Cardiovascular Disease 16
- Improving Lay Responses to Cardiovascular Emergencies and the Potential of Shifting the Paradigm to Early Heart Attack Care 18
- National Survey of Chest Pain Centers Rationale and Potential Results 21
- Outpatient Rule-Out Myocardial Infarction in Observation Units 22
- Reducing Time to Thrombolytic Treatment 24
- Intervention Programs to Reduce Patient Delays in Acute Myocardial Infarction 29
- Public Education Using the Early Heart Attack Care Program Shawnee Mission Medical Center 31
- School Component: Early Heart Attack Care Program Development and Evaluation 33
- Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction 36
- Precipitating Factors in Acute Cardiovascular Disease 41
- Use of Myocardial Perfusion Imaging in the Emergency Department for Risk Stratification 44
- The Evolution of Chest Pain Centers: The Impact of Technological Advances on the Evaluation of Patients With Possible Acute Ischemic Coronary Syndrome 47
- Critical Pathways for Triage and Treatment of Chest Pain Patients in the Emergency Department 53
- Chest Pain Centers: An Emerging Model for the Emergency Evaluation of Chest Pain and Treatment of Acute Myocardial Infarction 56
- The Key to Success in the Chest Pain Emergency Department: The Observational Role of theNurse 59
- Triage in Moderate Risk Patients With Chest Pain: The Emerging Role of Real-Time Continuous ECG Monitoring 61
- Diffusion of Innovations: The Introduction and Impact of the Chest Pain Emergency
- Department and its Comparison to the Coronary Care Unit Development 64
- Economics of Chest Pain Centers: What Really Matters? 68
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