News from the NCDR® Research Network at AHA 2013
The National Cardiovascular Data Registry (NCDR®) serves as the preeminent cardiovascular data repository. At the 2013 AHA Scientific Sessions, investigators presented a total of 16 papers/posters based on NCDR Research Network analyses. They shed light on current US cardiology practice and outcomes.
To watch exclusive interviews with presenters, visit youtube.cswnews.org.
Association of Electronic Health Record Use on AMI Care and Outcomes
The 2009 American Recovery and Reinvestment “Stimulus” Act appropriated $20 billion to increase the use of electronic health records (EHRs), among other health care initiatives. To date, most studies have indicated positive benefits for EHRs, but there is “likely a publication bias that exists favoring [positive] studies as opposed to those with neutral or negative findings,” said Jonathan Enriquez, MD, from the University of Missouri in Kansas City.
Using the NCDR’s ACTION Registry®-GWTG database and the American Hospital Association’s annual survey, Dr. Enriquez and colleagues studied the association between EHR use and acute MI (AMI) quality of care and outcomes. The primary endpoint, a composite performance metric of “defect-free care,” was calculated as the percentage of patients receiving all the appropriate AMI therapies for which that particular patient was eligible.
Between January 2007 and December 2010, 264,251 patients were enrolled in the ACTION registry. After excluding those with incomplete data or transferred for care, the cohort included 124,826 patients at 441 study sites.
Overall EHR use increased from 82.1% of ACTION sites in 2007 to 99.3% in 2010.
In hospitals with fully-implemented or partially-implemented EHR systems, EHR use was associated with (adjusted) significantly higher likelihood of provision of defect-free care compared to no EHR use.
Mortality and major bleeding were significantly lower for non-ST-elevation MI (NSTEMI) patients treated in hospitals with fully-implemented EHR systems, but in STEMI patients, the risk of mortality and major bleeding did not differ significantly by EHR status.
“A priori we hypothesized that this would be the case, finding no difference in STEMI outcomes, because STEMI outcomes are more likely to be influenced by timelines of revascularization, as well as procedural variables, which are already highly protocolized,” said Dr. Enriquez. “In comparison, non-STEMI care remains somewhat less protocolized and more susceptible to the individual provider and institution variation, thus leaving the opportunity for systems-level intervention like the electronic health record to potentially impact quality of care and outcomes.”
How Do Quality Improvement Systems and Quality Measures Impact PCI Case Mix?
Mandatory public reporting (MPR) of PCI outcomes appears to lead to the exclusion of high-risk patients who may benefit from PCI. Cross-institutional collaborative quality improvement (CQI) promotes accountability though sharing of information but does not include practitioner-level public reporting. Researchers led by Thomas Boyden, MD, University of Michigan, Ann Arbor, studied the states of New York, the pioneer in public reporting, and Michigan, a leader in CQI, to compare patient selection, quality of care, and PCI outcomes.
CathPCI Registry® data from January 2011 through September 2012 were used to compare baseline characteristics of PCI patients in New York (n = 51,983) and Michigan (n = 53,528).
At the time of PCI, patients in Michigan had a significantly greater burden of comorbidities and severity of illness as compared with New York PCI patients (e.g., more STEMI and NSTEMI, less stable angina and unstable angina). The Michigan patients also were more likely to have cardiogenic shock or cardiac arrest within 24 hours of PCI (p < 0.0001).
Predicted risk of all-cause mortality was higher in the Michigan CQI cohort compared with the New York MPR cohort. In a propensity-matched cohort, blood transfusion; urgent, emergent, or salvage CABG; and referral to cardiac rehabilitation were less likely in New York.
Unadjusted all-cause mortality was lower in New York versus Michigan (0.81% vs. 1.34%). The difference remained significant in the propensity-matched analysis, although the margin was smaller (0.84% vs. 1.17%). Dr. Boyden noted that the clinical relevance is unclear as the absolute difference in death was very small.
The researchers concluded that extremely high-risk patients were less likely to undergo PCI in New York compared with Michigan. Dr. Boyden noted, “Public reporting is associated with lower risk of mortality compared to CQI; however, we cannot explain that by case mix alone, as had been previously reported.” Further study is warranted.
CRT-D Therapy and CV Mortality and Readmission in HF Patients
Cardiac resynchronization therapy defibrillators (CRT-D) reduce morbidity and mortality among selected heart failure (HF) patients in clinical trials, but its real-world effectiveness has not been well studied. Prateeti Khazanie, MD, Duke Medical Center, Durham, North Carolina, and colleagues conducted an effectiveness study using a cohort of 9,359 HF patients included in the ADHERE Registry and NCDR’s ICD Registry™. They used Cox proportional hazards models to compare outcomes with and without CRT-D after adjusting for demographics and clinical factors.
CRT recipients were younger, more likely to be male and white, and had more comorbidities compared to nonrecipients.
After multivariable adjustment, CRT-D was associated with lower 3-year risk of death (HR = 0.52; p < 0.0001) and cardiovascular readmission (HR = 0.60; p < 0.0001). This mortality benefit did not vary significantly among subgroups defined by age, sex, race, QRS duration, and optimal medical therapy.
Dr. Khazanie concluded that, in clinical practice, CRT-D was associated with a lower risk of mortality and cardiovascular readmission compared to medical therapy among HF patients, including those underrepresented in clinical trials.
TOP PCI: Translating Outstanding Performance for PCI
Thirty-day readmission rates differ more than two-fold among hospitals that perform PCI. Led by Jeptha P Curtis, MD, Yale School of Medicine, New Haven, Connecticut, researchers went to the source—paying particular attention to hospitals’ organizational strategies, their enabling structures, and internal environments associated with exemplary PCI care—to find out why.
Studying hospitals that ranked in the top and bottom 10% of risk-standardized readmission and 25% of risk-standardized mortality, Dr. Curtis and colleagues selected nine high- and four low-performing sites from a sample of 1,003 hospitals participating in the CathPCI Registry. They conducted nearly 200 interviews with varied personnel involved in PCI care.
High-performing hospitals identified themselves as ‘cardiac hospitals,’ had quality improvement instilled as a part of their culture, focused intently on external publicly reported measures, and were committed to caring for the underserved.
Top hospitals maintained more effective communication internally and with external organizations, both upstream (emergency services and referral hospitals) and downstream (engaging primary care physicians during transition).
High-performing hospitals were more willing to make necessary investments, “take a stand,” and move beyond the financials.
The best hospitals identified areas for improvement using NCDR reports, fostered a learning culture, and encouraged staff involvement and physician leadership.
Acknowledging that hospitals are very “complex” organizations, Dr. Curtis said, “Changing processes are hard, changing culture is probably harder, but what we have identified is that high-performing hospitals create an environment that promotes excellence through organization, cooperation, and physician components.”
Reperfusion Times and Outcomes in Patients with Isolated Posterior MI
An isolated posterior MI (PMI) is associated with significant morbidity and mortality, possibly approaching that seen with an anterior MI. Prompt reperfusion is critical, but physicians fail to recognize the typical electrocardiographic features of a typical isolated PMI in >50% of cases, resulting in subsequent delays in revascularization. Stephen Waldo, MD, University of California, San Francisco, and colleagues used ACTION Registry-GWTG data from 2007 to 2012 to study reperfusion times and in-hospital outcomes among patients with isolated PMI. Among 117,739 registry participants with STEMI, 824 (0.7%) had an isolated PMI based on their ECGs on presentation.
Compared to those with non-PMI STEMI, isolated PMI patients were older, had more comorbidities, and were more likely to present with cardiac arrest, cardiogenic shock, and signs of congestive HF.
The median time from arrival ECG to PCI or thrombolysis was significantly longer among subjects with a PMI, such that significantly fewer patients were reperfused within guideline-recommended times.
While rates of in-hospital cardiac arrest and cardiogenic shock were higher in the PMI group, no differences were seen in length of stay, HF, or major bleeding.
Unadjusted in-hospital mortality was greater for those with isolated PMI (OR = 1.76; p < 0.01). However, after multivariate adjustment, this difference was no longer seen (aOR = 1.11, p = 0.48).
“This is the first study to describe the reperfusion times and in-hospital outcomes in patients with an isolated posterior MI in a national dataset,” said Dr. Waldo. While the true incidence is of PMI is difficult to ascertain—ranging from 4–7% in previous research utilizing ECG adjudication and at 0.7% in this study—the variation in incidence is likely related to diagnostic challenges. “The decreased incidence in this national data set likely represents poor recognition and potential misclassification of patients,” said Dr. Waldo. “Ongoing educational initiatives to increase recognition of a posterior infarct are needed to improve the reperfusion times and outcomes associated with this condition.”
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