ACE: The First Experience with Process Reviews
- 2. Accreditation for Cardiovascular Excellence (ACE): The First Experience with Process Reviews • Bonnie H. Weiner MD MSEC MBA, FSCAI FACC – Accreditation for Cardiovascular Excellence • Ralph G. Brindis MD MPH, FSCAI MACC – Oakland Kaiser Medical Center • Charles E. Chambers MD, FSCAI FACC – Penn State Hershey Heart and Vascular Institute • Gregory J. Dehmer MD, FSCAI FACC – Scott & White Clinic • Christopher J. White MD, FSCAI FACC – Oschner Medical Center • April W. Simon RN, MSN – Cardiac Data Solutions, Inc. • Kimberly Wright, RN – Cardiac Data Solutions, Inc • Mary E. Heisler RN – Accreditation for Cardiovascular Excellence
- 3. Background • Accreditation for Cardiovascular Excellence (ACE) is a non profit organization performing accreditation services for invasive and interventional cardiovascular procedures. This report is of the reviews of the initial 10 facilities that have been site visited as part of the process
- 5. Methods: • Documents Reviewed • All ACE Standard related policy and procedure documents • Medical records • History and Physical • Office notes when available • Prior hospitalizations • Catheterization reports • Reviewed for • Completeness and • Compliance with ACE standards • All data are entered into an online case report form that populates the database • Exported directly from the database as individual records • Analyzed in JMP® (version 10.0.0) • Test for Homogeneity between facilities was performed using Chi-Squared and Pearson Coefficient for categorical variables • All characteristics referred to in the ACE Standards • Meeting the standard • Partially meeting the standard • Not meeting meeting the standard • Variables for risk adjustment or appropriate use criteria (AUC) in NCDR’s CathPCI. • Recorded (validated against data submitted) • Not Recorded (Information is not found anywhere in the medical record) • Does not Apply
- 6. Results: Quality Assurance Process (n=10 Facilities) 100% 10% 90% 20% 20% 20% 80% 40% 50% 70% 60% 50% Does Not Meet 90% 40% 20% 80% 80% 80% Partially Meets Meets ACE Criteria 30% 60% 20% 30% 10% 0% Integrated Review for Major Individual Administration Quality Quality Diagnostic Complication Operator Involvement Conference Program Exists Accuracy and Reviews Complications Quality Reviewed
- 7. RESULTS: Joint Commission (TJC) Variables Diagnostic Cath/PCI PCI Only All Cases Catheterization N=243 N=20 N=441 N=178 (39.3%) (55.8%) (4.8%) (100%) Meets Reporting 169 (94.9%) 224 (92.2%) 18 (90.0%) 411 (93.2%) Requirements (58.3-100%) (75-100%) (50-100%) (81.2-100%) Documentation of 168 (92.1%) 235 (97.9%) 17 (100%) 419 (95.7%) Complications (18.2-100%) (90.9-100%) (67.6-100%) Any Radiation 150 (84.3%) 214 (89.5%) 16 (80.0%) 380 (87.0%) Monitoring (8.3-100%) (8.3-100%) (0-100%) (7.1-100%) Both Fluoro Time 132 (74.2%) 191 (80.3%) 15 (75.0%) 338 (77.5%) and Air Kerma (14.3-100%) (9.5-100%) (0-100%) (3.6-100%) recorded There was significant variation between institutions in all parameters above for all procedure types p<0.0001
- 8. PCI Variables used by NCDR for Procedure Risk Adjustment Variables Recorded Not Recorded P Value for between facility Coded on variability Admission Age 252 (98.4%) 4 (1.6%) NS (90-100%) (0-9.5%) BMI 208 (81.6%) 47 (18.4%) <0.0001 (66.7-100%) (0-33.3%) Cardiogenic Shock on 18 (7.0%) 239 (93.0%) <0.0001 Admission (0-56.3%) (37.5-100%) History of CHF 37(15.5%) 218 (84.5%) 0.0004 (9.5-100%) (14.3-100%) Previous Valve 9 (9.3%) 244 (90.7%) <0.0001 Surgery (0-37.5%) (43.8-100%) Cerebrovascular 18 (8.6%) 235 (91.4%) <0.0001 Disease (0-37.5%) (43.8-100%) Peripheral Vascular 27 (12.0%) 231 (88.0%) <0.0001 Disease (0-43.8%) (56.3-100%) Diabetes 96 (37.2%) 162 (62.8%) 0.0189 (24.4-62.5%) (31.2-75.6%) Chronic Lung Disease 27 (10.4%) 332 (89.6%) <0.0001 (0-31.2%) (68.8-96.8%) Prior PCI 104 (40.3%) 154 (59.7%) 0.0104 (20-87.5%) (12.5-72.7%) GFR 222 (85.4%) 38 (14.6%) 0.0014 (53.3-100%) (0-46.7%) Dialysis 4 (1.5%) 255 (98.5%) <0.0001 (0-6.2%) (93.9-100%) NYHA Classification 54 (21.8%) 205 (79.2%) <0.0001 (0—100%) (0-100%) Elevated Biomarkers 115 (44.9%) 141 (55.1%) 0.0004 (13.8-73.9%) (33.3-86.1%)
- 9. RESULTS: NCDR Risk Variables for PCI Procedures Procedural Recorded Not Recorded P Value for between facility variability Variables Pre Procedure IABP 17 (6.5%) 243 (93.5%) <0.0001 (0-75%) (25-100%) Ejection Fraction 204 (79.1%) 54 (21.9%) 0.025 (56.2-95.4%) (4.6-43.8%) PCI Status Elective: 125(48.4%) 18 (7.0%) <0.0001 Emergent: 31 (12.0%) (0-29%) Urgent: 82 (31.8%) Salvage:2 (0.58%) Lesion≥50% and subacute 63 (24.5%) 194 (75.5%) <0.0001 thrombosis (0-55.6%) (44.4-100%) Pre Procedure TIMI Flow 145(56.0%) 114 (44.0%) <0.0001 (0-97.2%) (2.8-100%) Highest Risk Lesion 48 (18.6%) 210 (81.4%) <0.0001 (0-67.7%) (32.3-100%) Lesion Location 252 (98.0%) 5 (2.0%) NS (93.2-100%) (0-6.8%)
- 10. RESULTS: Selected Appropriate Use Determination Variables for Non-Emergent Procedures (n=144) 100% 95% 94% 91% 90% 83% 80% 70% 61% 61% 60% 50% 50% 49% 50% 38% 40% Yes 28% 29% No 30% Not Available 20% 15% 11% Unknown 10% 8% 10% 9% 7% 6% 5% 1% 0%
- 11. Other Outcome Characteristics: All PCI Patients (n=258) 100.0% 92.3% 87.1% 89.2% 90.0% 80.0% 70.0% 60.0% 50.0% Yes 40.0% No Data Unavailable 30.0% 20.0% 9.7% 10.2% 7.4% 10.0% 2.7% 1.2% 0.4% 0.0% Attributable 30 Day 30 Day CIN Re-Admission Mortality There was significant variation between institutions in these parameters p<0.0001
- 12. Summary: • ACE Process Findings: – Documentation of critical information required for risk adjustment and appropriate use determination are frequently missing. – There is a high degree of variability among facilities in the completeness of their documentation.
- 13. Conclusions • Improvement in facility level documentation is necessary to adequately validate data used for risk stratification and appropriate use determination. • Facility-based quality improvement teams and cath lab personnel including physicians, must assure completeness of data collection to reduce variability. • Process improvement at the facility level will improve the quality of the data used for public reporting and also protect the facility from external regulatory and fiscal audits.