Transcript Dosage of enalapril for congestive heart failure in USA

Quality of care,
part 4: MI
Kim A Eagle MD
Albion Walter Hewlett Professor of
Internal Medicine
Chief, Clinical Cardiology
Co-Director, Heart Care Program
University of Michigan
Ann Arbor, MI
Dr Harlan Krumholz MD FACC
Associate Professor of Medicine &
Epidemiology & Public Health
Yale University School of Medicine
New Haven, CT
Quality of care
Making changes
Quality of care has gotten a lot more
important in this cost-cutting era.
By evaluating what we do and making
changes, we will get better value for the
money.
By identifying opportunities for improvement
and making changes, we will be able to
provide better care.
Care and outcomes
MI and AMI
Clinical studies have identified several aspects
of MI care that are closely linked to outcomes
(use of aspirin, beta-blockers, reperfusion
therapy).
Quality of care for acute MI involves a much
broader set of clinical skills: the ability to
detect whether or not an individual is actually
having an AMI, the need for rapid triage, signs
of decompensation, subtle murmurs, the need
for surgery.
Indications of quality
Several straightforward processes are relevant
to the vast majority of patients; the extent to
which these are used can give us some
indication of the quality of care that is being
provided.
For acute MI, as well as looking at processes,
clinical decisions, and interventions, we have
also looked at outcome, particularly mortality,
and have been able to adjust for the severity
of the AMI when comparing level of care
across sites.
What to measure?
Proof of quality
External partners — eg, National Committee for
Quality Assurance (NCQA), Health Plan Employer Data
and Information Set (HEDIS), payers, insurers — want
some way to measure quality of care.
The American College of Cardiology (ACC) and the
American Heart Association (AHA) have put together a
joint task force to develop performance measures for a
variety of conditions, including AMI.
Currently many of the measures of quality of AMI care
used by external partners are similar to those we
expect to see in the guidelines.
These guidelines will help insurers and purchasers
determine how good the care being delivered is.
Setting targets
LDL cholesterol levels
An LDL cholesterol level of 130 mg/dL has been
established as the target in patients with
established coronary artery disease by the
NCQA.
Although many physicians believe that target
LDL levels should be below 100 mg/dL in
patients with established disease, the
committee decided that 130 mg/dL would be a
reasonable first step towards instituting a
cholesterol measure.
Setting targets
Choosing an acceptable level
With a target of 130 mg/dL, care will be considered good
if a patient reaches a level of 105 mg/dL; an additional
medication will not be required to further lower LDL
cholesterol.
However, it would be very difficult for any clinician to
argue that care is adequate when the LDL level is above
130 mg/dL.
This measure provides managed care organizations with
a way to systematically collect information and will give
them some way to judge how successful they have been
at lowering cholesterol in patients with coronary artery
disease.
Over time, this standard can be lowered, but the mere
fact that a level has been established will lead to greater
accountability.
Claims data
Using what is available
The large sets of administrative data are
being used to produce estimates of
mortality for various groups, including
hospitals.
Because these sets of administrative data
are available, they are being used.
Claims data
How good are they?
Administrative billing codes correspond only very
crudely with the actual clinical condition of an
individual patient.
When dealing with imprecise data and small
sample sizes, performance of an individual
physician, individual hospital, or even a region or
healthcare system can be misrepresented.
These data can be used for internal benchmarking,
to generate hypotheses, and to look for ways to
improve in our individual institutions.
These data are not going to give consumers the
information they need to make informed choices
about where they should receive care.
Claims data
Risk-adjustment formulas
The mathematical formulas we use to risk-adjust
when we use claims data do not adequately
account for the comorbidities that don't get
entered in the claims database.
Risk-adjustment formulas account for only 30% to
40% of the variation in outcome.
Outcome data can be used internally to give a
physician an idea of how they're doing, but a
particular outcome should not be used to rate a
physician’s performance because of the potential
inaccuracy of those types of comparisons.
Commitment to quality
Physicians must take the lead
Physicians need to look at their own practices and
institute systems that will ensure that no patient
misses out on interventions or medications that
have been demonstrated to improve outcome.
To do this, physicians need a specificity of purpose,
a clearly defined aim, and the ability to measure
performance.
Physicians need to take the lead within the
healthcare profession and show that such standards
can be achieved.
The abundance of evidence available on the care of
AMI patients makes it the perfect testing ground.
Processes
Providing the basics
These are the very basic treatments for which
evidence has been available for 20 years, yet
studies show that these have not been translated
to the bedside for all patients who meet the
criteria.
 on admission: aspirin or beta-blockers
 on discharge: aspirin, beta-blockers, or ACE
inhibitors
 reperfusion therapy
In time-sensitive therapies (eg, reperfusion
therapy), time is being lost because of delays
inherent in communications and decision-making
systems.
Structure
Communication and integration
Key structural components of a hospital are
necessary to deliver the highest quality of care.
 integration of emergency medical services: by
the time the EMS arrives at the hospital, the
emergency department should be prepared to
deliver care immediately
 a reliable communication system: the
emergency department should be able to
communicate quickly and easily with
cardiologists and internists
 an efficient hospital set-up: the hospital should
be set up to allow the healthcare team to work
as an integrative team; measuring this will be
difficult but better process will be the result
Process tools
Tools are being developed that can be used to
remind physicians of the critical elements that
should be considered in every situation.
These tools will help physicians become more
systematic.
The goal should be to translate the
information we have to the bedside.
Measuring quality of care can help us
understand where we are and where we need
to be.
The challenge
One of the major challenges in this field is
broadening the current focus on AMI to the area of
acute coronary syndrome.
It's been convenient to focus on AMI because we
can create definitions for it; some acute coronary
syndromes are difficult to define.
We must also be able to put into context the
abundance of trials on different strategies (eg,
LMWH, GP IIb/IIIa, interventional strategies,
devices).
Make sure the guideline process is implemented in
a timely way, so that it helps assess performance
to the benefit of patients.