Transcript Utilizing Registries and Guidelines in CV Care: Have They Improved

Utilizing Registries and
Guidelines in CV Care: Have
They Improved Outcomes &
Decreased Cost?
Amy Simone, PA-C
Emory University Hospital
Structural Heart and Valve Program
DISCLOSURES
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Edwards Lifesciences
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Consultant Fees/Honoraria
WHY IS THIS RELEVANT?
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We all share common goals as practitioners
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To provide patients with the best clinical practice
implementing the most current therapies
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To achieve the best possible clinical outcomes
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To do so in a financially responsible way to ultimately
decrease overall expenditure to the health care system
Utilizing
and
are the key!
OBJECTIVES
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Multiple CV registries are collecting data utilized to
promote best clinical practices which improves
clinical outcomes
The STS database is the flagship surgical registry
and this data is instrumental in guideline
formulation
Financial impact of registry data is institution
specific as there is no inherent cost element within
national registries
Through examination of both national and
institutional data, Emory University implemented
the Minimalist Approach to TAVR with a proven
cost benefit
ACC NCDR
REGISTRIES
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National Cardiovascular Data Registry
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Developed in 1997 by ACC
Quality initiative to improve CV care through
application of data
Multiple registries capture reliable data  drives
quality at level of both provider and institution
Various dedicated & specific registries
This data prompts guideline formation which
improves patient care worldwide
Guidelines update and enforce best clinical practices
and standards of care according to evidence based
medicine
ACC NCDR
REGISTRIES
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Hospital registries for the in-patient setting
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ACTION Registry®-GWTG™
CathPCI Registry®
ICD Registry™
IMPACT Registry®
PVI Registry™
STS/ACC TVT Registry™
Outpatient registries for the ambulatory care
setting
Diabetes Collaborative Registry™
 PINNACLE Registry®
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SIX HOSPITAL BASED REGISTRIES
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ACTION Registry–GWTG
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CathPCI Registry
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LE peripheral vascular, carotid revascularization and endarterectomy
procedures
IMPACT Registry
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Implantable defibrillator procedures
PVI Registry
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Diagnostic LHC and PCI
ICD Registry
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Acute MI treatment
Pediatric and adult congenital treatment procedures
STS/ACC TVT Registry
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Transcatheter valve therapy (TAVR, MitraClip)
Importance of documentation!
EXAMPLES OF CV IMPACT
IMPLEMENT
BEST
CLINICAL
PRACICES
THE FLAGSHIP OF ALL REGISTRIES…
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One of the oldest
Robust
High levels of compliance
Spans states & institutions
Independent audits to
maintain integrity of data
A LITTLE HISTORY LESSON ABOUT
STS DATABASE…
Formed in 1989 as a quality initiative
 The website states 94% of adult cardiac surgery
centers are participating
 In the year 2014 there were 94 publications
which utilized data from the STS database.
 These publications have impacted clinical care by
removing variables – i.e. experience of the
surgeon, case acuity of the hospital, number of
surgeries performed at the institution annually,
etc.
 The STS is…
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AVERAGE COMPARIBLE DATA
i.e. STS risk stratification score
LIMITATIONS OF STS DATABASE
 Short
term data
 30 days of data only
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Includes immediate post operative data but not long
term…
TVT…infancy…but promising!
o Just starting out…formed 12/2011, mandatory 5/2012
by National Coverage Decision
o Purpose: safety & efficacy of new devices
o Frequent additions and updates, constant evolution
o Period of data collection is one year
o Can query CMS
o Lessons learned…
HOW DO REGISTRIES IMPACT
GUIDELINES?
The STS Workforce on Evidence Based Surgery 
Creates Guidelines
Areas of responsibility will include the development of
patient management protocols and guidelines, and
enhancement of the dissemination and implementation of
STS practice guidelines.
REGISTRIES AND COST…
 National
registries do not report a national cost
element
Data only!
 No relationship with CMS (*other than TVT)
 No national cost averages are known
within registries themselves
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$ IS INSTITUTION SPECIFIC
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No financial link between registry data and CMS*
unless requested by an institution
The relationship between implementing guideline
directed therapy and cost reduction is institution
specific
Real
World!
THE ELEPHANT IN THE ROOM…
$ Cost of Device, Complications, Procedure, Recovery…
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How can we make TAVR more cost effective while preserving
superior clinical outcomes and protecting patients?
Which costs are fixed and which are variable?
THE WAY IT HAD ALWAYS BEEN
DONE…
Eligibility confirmed by the Heart Team
Access determined
All cases done in Hybrid OR
*This was the plan of care for ALL
patients, no matter what the access
or patient status*
“We had used MAC in the OR a few
times…Could this be transitioned to
the Cath Lab?”
General Anesthesia
GOALS:
Transesophageal echo
ICU admission post TAVR
minimize the
procedure
minimize the
cost
COLLABORATIVE CARE MODEL
Anesthesia
VCC
Cath Lab
Staff
Nursing
Staff
Radiology
Echo
Staff
Social
Services
Administrators
OR Staff
PT/OT &
Nutrition
THE MOVE TO THE MINIMALIST
APPROACH AT EMORY UNIVERSITY
A true collaborative effort between all members
of the Heart Team
 Illustrating the value of non-physician members
of The Heart Team
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Valve Clinic Coordinator  patient screening and
selection
Nursing Staff  care of this nuanced & tenuous
population
Echo, Cath Lab staff intraprocedure logistics
Administrators  institution “buy in”
PT/OT/SS  patient recovery, early discharge
planning
CLOSE TO MY HEART…
PROCEDURE DETAILS
Minimalist
Approach
Standard
Approach
N=70
N=72
P value
Procedure Success
70 (100)
69 (96)
0.24
Procedure Mortality
0 (0)
3 (4)
0.24
2nd Valve Implanted
4 (6)
2 (3)
0.43
Concomitant PCI
Coronary obstruction
5 (7)
0 (0)
1 (1)
0 (0)
0.11
--
Characteristic
OUTCOMES
Outcome
In-hospital
Mortality
Hospital Stay –
days*
Hospital Stay
Procedure to
discharge – days*
30 day Mortality
Minimalist
Approach
Standard
Approach
N=70
N=72
P value
0 (0)
3 (4.2)
0.24
4 (3-7)
6 (4-9)
0.01
3 (2-4)
5 (3-6.5)
<0.001
0 (0)
4 (6)
0.12
* Median (Interquartile range)
COST SAVING WITH MINIMALIST
APPROACH
$55,377±22,587
$45,485 ± 14,397
TRANSITION TO MINIMALIST TF
TAVR
Sept 2007
May 2012
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Decrease the number of people in the room
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Simplify procedure
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Maintain superior outcomes, short and long term
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Decrease resource utilization and cost
SALIENT POINTS
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The data placed into registries promotes best
clinical practice and is instrumental in improving
outcomes within multiple aspects of CV care
The STS database is the flagship surgical registry
from which guidelines and standards of care are
formed
Financial impact of registry data is institution
specific
Data exploration prompted the implementation of
the Minimalist Approach at Emory University and
has decreased cost to the health care system
Thank you!
[email protected]