NCDR Report Sheds Light on Cardiovascular Trends
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A report highlighting data from the ACC’s NCDR® provides a snapshot of the many unique ways clinical registry data can be used to assess quality of care and outcomes associated with broad populations of patients with cardiovascular disease.
The report, published Sept. 18 in the Journal of the American College of Cardiology, features highlights from five of the ACC’s hospital-based registries — ACTION Registry®-GWTG™; CathPCI Registry®; CARE Registry®; and ICD Registry™ — as well as its practice-based PINNACLE Registry®.
“The report provides a critical, national perspective on cardiac care and outcomes in both the in-patient and outpatient settings,” said NCDR Senior Medical Officer Frederick A. Masoudi, MD, MSPH, FACC. “In general, the report highlights the many improvements in quality of care that have occurred over the past three years, while also shedding light on areas where we can continue to improve.”
Among the success stories, data from both the CathPCI and ACTION registries show continued improvements in meeting guideline-recommended door-to-balloon (D2B) times of 90 minutes or less. Based on ACTION Registry data, the percentage of ST-segment elevation myocardial infarction (STEMI) patients (both non-transfer and transfer) receiving reperfusion in the guideline-recommended timeframe increased significantly between 2008 and 2011. D2B times for non-transfer patients increased from 81 percent in 2008 to 94.2 percent in 2011, while D2B times for transfer patients were even better, increasing from 18 percent in 2008 to 30.4 percent in 2011. Similarly, analysis of CathPCI data also indicates continued D2B success, with the percentage of non-transfer patients receiving immediate percutaneous coronary intervention (PCI) within 90 minutes growing from 85.8 percent in 2009 to 90.9 percent in 2011. For transfer patients, the percentage grew from 22.4 percent to 28.5 percent during that same period.
“This illustrates the success of quality improvement efforts like the ACC’s D2B Alliance,” Masoudi said. “Overall, the trend towards timely reperfusion is important for STEMI patients.”
The fact that medications are being prescribed consistently is another mark of quality improvement success, according to Masoudi. CathPCI data show prescription of aspirin and thienopyridine at discharge have remained relatively steady between 96 percent and 98 percent between 2009 and 2011. Prescription of lipid lowering agents rose from 89.7 percent in 2009 to 92.5 percent in 2011, while beta blocker prescriptions increased from 83.1 percent to 86.3 percent over the same period.
The ICD Registry is another success story. The registry contains data on 139,991 patients in 1,435 hospitals —nearly all hospitals performing implantable cardioverter defibrillator (ICD) implantation — and as such, can characterize trends ranging from device type to medication prescription patterns. According to the report, single chamber devices are least common ranging from 21.8 percent in 2007 to 19.3 percent in 2011. Dual chamber device implantations ranged from 39.1 percent in 2007 to 37.1 percent in 2011. There has been the most growth in cardiac resynchonication therapy defibrillator implants, from 39 percent in 2007 to 43.6 percent in 2011. In addition, the majority of ICD procedures (75.8 percent) are performed for primary prevention, rather than secondary prevention (24.2 percent). ICD Registry data also shows a slight continual increase (71.5 percent to 76.6 percent) in medications prescribed at discharge, whether it be ACE-1 or ARB for patients with left ventricular systolic dysfunction (LVSD) or beta blockers for patients with LVSD or prior myocardial infarction. That being said, Masoudi notes that almost 25 percent of ICD patients are not receiving optimal medical therapy.
Another promising trend is the number of patients undergoing PCI using the radial access site. According to CathPCI data, the percentage of patients undergoing PCI at the femoral access site between 2009 and 2011 decreased from 96.5 percent to 88.8 percent, while those patients undergoing PCI with radial access increased dramatically from 2.9 percent to 10.9 percent.
“For patients in whom it’s feasible, studies have shown lower bleeding rates and shorter recovery times with radial access,” Masoudi said. “These data indicate uptake in this approach and are reflective of greater physician comfort with the procedure.”
In terms of opportunities for improvement, the report indicates an opportunity to improve not only adherence to appropriate use criteria in patients without acute coronary syndrome (ACS), but potentially clarify areas of uncertainty. While a little more than half of patients without ACS (52.8 percent) were evaluated appropriately for PCI procedures, 37.3 percent fell into the uncertain category, whole nearly 10 percent were inappropriate. In contrast, patients with ACS were appropriately evaluated for PCI procedures 99.1 percent of the time. “If nothing else it’s an important opportunity to improve documentation to justify clearly the indication for procedures,” Masoudi said. “In an era of increasing health care costs this is an important are for introspection.”
Data from the PINNACLE Registry also suggest areas for improved care delivery. For example, when it comes to use of new oral anticoagulants, only 57.2 percent of atrial fibrillation patients are prescribed guideline-recommended anticoagulation therapy. “Clearly there is a need for increased education for patients and clinicians about new oral anticoagulants,” Masoudi said. “It will be interesting to watch these numbers as the College moves forward with its new Anticoagulation Initiative. We’ve identified an area for improvement and can now track our improvement over the next few years.”
Hypertension management is another possible growth area. While PINNACLE Registry data overwhelmingly shows providers regularly recording patient blood pressures (95.1 percent), only 34.5 percent of providers have indicated hypertension care plans. Finally, Masoudi notes that there is also room for improvement in follow up for patients undergoing carotid artery stenting or carotid endarterectomy. CARE Registry data showed follow-up performed within 30 days following a procedure is 60 percent among coronary artery stenting patients and only 38.7 among carotid endarterectomy patients.