US_Cardio_Rumsfeld_Cardiology_book_temp 26/10/2009 12:09 Page 14
Editor’s Choice
Table 2: Future Directions for the National Cardiovascular
• In a study utilizing CathPCI registry data, Kutcher et al. compared
Data Registry
hospitals performing PCI with and without on-site cardiothoracic
surgery, a topic of considerable debate with regard to quality of care
Point-of-care reporting and clinical decision support.
and patient outcomes, yet lacking in evidence
.8
This study found that
Data collection integrated with routine clinical care.
PCI centers with off-site cardiac surgery had similar procedure
Longitudinal care and patient outcomes.
success, complications, emergency cardiac surgery rates, and risk-
Use of National Cardiovascular Data Registry data for performance improvement.
adjusted mortality. These data support the safety of PCI at facilities
Use of National Cardiovascular Data Registry data to satisfy regulatory and other
reporting requirements, including quality of care incentive programs.
without cardiac surgery but only at facilities where “rigorous clinical,
Expansion of multistakeholder partnerships in the registry programs.
operator, and institutional criteria are in place and where data are
Utilizing the National Cardiovascular Data Registry network for comparative
submitted and reviewed in a comprehensive multicenter registry
effectiveness research, patient safety surveillance, and efficient clinical trials. such as NCDR.” This study therefore relates to the effectiveness and
International collaboration and participation. safety domains of quality as described by the IOM.
True ‘patient-centered’ registries.
• In a study utilizing ICD Registry data, Curtis et al. compared the
outcomes of patients who received an ICD implantation by an
With regard to quality improvement tools, the NCDR developed CathKIT, electrophysiologist or non-electrophysiologist.
9
They found that
to guide local evaluation, and ‘Plan–Do–Study–Act’ interventions, to non-electrophysiologists currently implant about 30% of ICDs in the
improve the quality of care in the cardiac catheterization laboratory.
6
In US; however, implantation by a non-electrophysiologist was associated
addition, the NCDR now partners with leading regional percutaneous with a significantly higher risk for peri-procedural complications.
coronary intervention (PCI) quality programs, including the Blue Cross Moreover, these patients were less likely to receive cardiac
Blue Shield of Michigan Cardiovascular Consortium (BMC2) and Northern resynchronization therapy when it was indicated. It is very unlikely that
New England Cardiovascular Study Group (NNE). BMC2 and NNE a question such as this would be evaluated in a randomized clinical
both implement and evaluate quality improvement interventions (e.g. trial, and thus these data provide critical evidence regarding the
an intervention to reduce vascular complications). Where successful, importance of sub-specialty certification and the IOM quality domains
these interventions can then be disseminated nationally via the NCDR. of effectiveness and safety with regard to ICD implantation.
• In a study utilizing data from the ACTION Registry, Diercks et al.
Education evaluated the proportion of patients with ST-segment elevation
The NCDR also promotes quality of care through education in several ways. MI who receive a pre-hospital electrocardiogram (ECG), as
First, the NCDR Annual Meeting is a conference of NCDR participants with recommended in a Scientific Statement from the AHA.
10
They found
an agenda focused on data quality and quality improvement. Experts in that just over one-quarter of patients transported by emergency
data collection and quality improvement lead interactive workshops and medical services receive a pre-hospital ECG, yet patients who did
presentations such as ‘How to use your data for QI.’ Second, the American receive a pre-hospital ECG were more likely to receive reperfusion
Board of Internal Medicine offers Maintenance of Certification (MOC) credit therapy and had shorter door to reperfusion times, and there was a
linked to participation in NCDR registries, as well as participation in trend toward lower in-hospital mortality. These findings shed light on
the D2B alliance, as part of its performance improvement modules the timeliness and effectiveness of a key, modifiable process of care
(www.abim.org/pims/choose/specialty/cardiovascular-disease.aspx). With in relation to patient outcomes.
these modules, cardiovascular specialists can use the NCDR to measure • In a study funded by the US Food and Drug Administration (FDA), a
their quality of care (e.g. their CathPCI metrics), plan and execute a local subset of hospitals participating in the CathPCI registry participated
performance improvement intervention (e.g. to improve door to balloon in a detailed investigation of bleeding complications associated with
time), and document results of the intervention as reflected in their various groin closure devices.
11
This study revealed that one device,
hospital’s NCDR quality metrics (e.g. whether or not their NCDR door to VasoSeal, was associated with a significantly higher rate of vascular
balloon time measure improved). Finally, the ACC as well as other NCDR complications. The results of this study led to the removal of the
partners offers a wide range of educational resources, such as those device from the market. Thus, this study had a direct impact on
available at www.cardiosource.com for cardiovascular professionals and patient safety and also addresses the IOM domain of equity, as the
www.cardiosmart.com for patients. complication risk was found to be particularly high in women.
Outcomes Research Future Directions
A key aspect of the NCDR mission is to leverage the clinical registry data Looking ahead, the role of NCDR in quality improvement will significantly
for health outcomes research. The Institute of Medicine (IOM) has expand, paralleling advances in health information technology and the
proposed six domains of high-quality healthcare, namely care that is rapidly changing healthcare environment in the US (see Table 2). First,
effective, equitable, efficient, safe, timely, and patient-centered.
3
Health point-of-care reporting is currently being implemented, whereby
outcomes research is focused on the study of these six domains of quality participants can generate instant local reports based on their NCDR data
in order to improve healthcare delivery and patient outcomes.
7
The NCDR as a complement to their quarterly outcomes reports that include
thereby views outcomes research as an essential tool to provide new formal regional and national benchmarking. Such reporting capability
knowledge on quality of care and the determinants of patient outcomes, enhances local quality assessment and improvement efforts. Moreover,
learning from the collective practice of NCDR hospitals and practices. NCDR is moving to offer clinical decision support tools in several registry
Examples of outcomes research from the NCDR best illustrate this point: programs. An example is a pre-catheterization risk estimator for
14 US CARDIOLOGY