CHICAGO – Researchers have identified seven specific hospital practices and procedures that are independently associated with very low 30-day risk-standardized mortality rates for percutaneous coronary interventions.
“Hospitals seeking to improve their outcomes may consider adopting one or more of these strategies if they haven’t done so already,” Dr. Jeptha P. Curtis said at the annual meeting of the American College of Cardiology.
He presented highlights of the Translating Outstanding Performance in Percutaneous Coronary Intervention (TOP PCI) study, a 5-year examination of hospital organizational strategies and enabling structures associated with lower 30-day risk-standardized rates for Medicare fee-for-service patients who underwent PCI in 2010-2012. The study included 398 randomly selected hospitals participating in the ACC’s National Cardiovascular Data Registry. The effort involved site visits and completion of a detailed 76-question survey by hospital officials.
The TOP PCI results have important practice implications.
“Despite improved technology and expansion of our evidence base, PCI carries a significant risk of adverse outcomes, including mortality. PCI outcomes are being considered for inclusion in public reporting and value-based purchasing programs, which reinforces the importance of trying to reduce mortality rates for hospitals,” observed Dr. Curtis of Yale University in New Haven, Conn.
Top among the findings that came as a surprise to him was that officials at 26% of hospitals reported that, at their institution, revenue and profits drove most decisions by senior management.
Another unexpected finding: “We asked if this hospital used data from the ACC CathPCI Registry or other sources to support specific quality improvement initiatives. I’m proud to say 84% did. I’m ashamed to say that 16% of hospitals that are making the investment to participate in this registry had not identified a single quality improvement project that was based off the data they were getting back,” Dr. Curtis said.
Many different hospital strategies and practices were looked at in TOP PCI, but in multivariate analysis, these seven stood out as having a significant association with lower 30-day risk-standardized mortality rates in PCI:
• Conducting regular reviews of PCI appropriateness by an interdisciplinary team including noninterventional cardiologists: 37% of hospitals reported doing so.
• Retaining and rewarding high-quality staff. Eight percent of hospitals were unable to do so, and they were at the high end of the 30-day mortality range.
• Using the radial approach to perform most or all PCIs. This was the practice at 22% of hospitals.
• Clinicians holding regular meetings with home health agencies to review the postdischarge care of cardiac patients. This was the practice at 24% of hospitals.
• Having PCI patients cared for by hospitalists only rarely or sometimes. At 22% of hospitals, hospitalists always cared for the PCI patients, and that practice was associated with higher 30-day mortality.
• Implementing hospital-initiated quality improvements aimed at reducing postdischarge mortality. Thirty percent of hospitals engaged in this approach.
• Use of the Plan-Do-Study-Act method of quality of improvement. This approach, widely accepted within the quality improvement field, was practiced routinely at 30% of hospitals.
Dr. Curtis noted that the nearly 400 hospitals participating in TOP PCI followed a bell-shaped curve in terms of the number of these successful strategies utilized. Some hospitals used none or one, a fewer number used five or six. None used all seven.
Discussant Spencer B. King III voiced skepticism about the TOP PCI effort.
“I know mortality is easy to measure, but in my view it does not assure quality of a PCI program by itself. I think one of the problems is that quality is kind of like pornography: Everybody knows it when they see it, but it’s hard to define. You’ve got to realize that the major mortality from interventions is patient related,” said Dr. King, who is president of the Heart and Vascular Institute at Saint Joseph’s Health System in Atlanta.
“This is a first step, it’s not the end of the story,” Dr. Curtis replied. “What this data set really represents is a unique snapshot of how at a very granular level hospitals are caring for their patients. That’s information we’ve really never had before. We can use it to look at differences in appropriateness, differences in discharge medications – any quality outcome you can come up with we can probably assess what strategies may or not be effective for those outcomes.”
Another audience critique was that, while each of the seven hospital strategies was associated with a statistically significant improvement in 30-day risk-stratified mortality, the absolute differences were quite small.
“Changing mortality is challenging. You’re really trying to change the direction of the Titanic,” Dr. Curtis responded. “It takes a long time, and it’s a matter of doing a bunch of small, subtle things. The issue is that we’ve never had any evidence to say what specific care and practices are effective. This is really the first toe in the water to say there are things you can do that actually make a difference at the end of the day.”