CV Quality Corner

Clinical data registry programs like ACC’s NCDR “provide unique opportunities to advance the understanding of the clinical characteristics, care and outcomes of patients with cardiovascular disease,” according to the recent “Trends in U.S. Cardiovascular Care” report.

The report, published in the Journal of the American College of Cardiology (JACC), provides insights based on 2014 data into the patient populations, participating centers and patterns of care from four of the 10 NCDR registries – CathPCI Registry, ICD Registry, ACTION Registry-GWTG and IMPACT Registry. These registry programs focus on PCI interventions, implantable cardioverter-defibrillator (ICD) implantation, acute coronary treatment and outcomes and pediatric and adult congenital heart disease.

Key findings from each registry include:

CathPCI Registry

Of the 667,424 patients undergoing PCI in 2014, 35.3 percent of PCIs were performed for elective indications, compared with 64.7 percent performed for non-elective indications.

Between 2011 and 2014, the use of femoral access declined from 88.4 percent to 74.5 percent, while the use of radial access increased from 10.9 percent to 25.2 percent.

Use of evidence-based therapies, including aspirin, P2Y12 inhibitors and statins for eligible patients, continue to remain high at 93.3 percent.

Median door-to-balloon time for primary PCI for STEMI also remains strong at 59 minutes for patients receiving PCI at the presenting hospital and 105 minutes for transfer patients.

Cardiology

ICD Registry

Of the 158,649 patients receiving ICD therapy in 2014, 120,228 received a device for primary prevention reasons, compared with 38,421 who received a device for secondary prevention indications. Of all ICD implants in 2014, 25 percent involved single-chamber devices, 32 percent involved dual-chamber devices and 43 percent involved cardiac resynchronization therapy-defibrillator devices (CRT-D), compared with 19 percent, 37 percent and 44 percent, respectively, in 2011. While use of evidence-based therapies are generally high, performance on a composite medication metric, including use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers for patients with left ventricular systolic dysfunction (LVSD) and beta-blockers for patients with LVSD, could be a target for quality improvement efforts. Between 2011 and 2014, the composite rate of use grew from 76.7 percent to 80.3 percent, with room for continued improvement.

Cardiology

ACTION Registry-GWTG

Of the 182,903 patients with acute myocardial infarction in 2014, 71,368 had STEMI, while 111,535 had NSTEMI.

There is room for improvement in the areas of overall defect-free care (78.4 percent); P2Y12 inhibitor use in eligible patients (56.7 percent); and use of aldosterone antagonists in patients with LVSD and either diabetes or heart failure (12.8 percent).

Compared with NSTEMI patients, STEMI patients were more likely to experience certain adverse events during hospitalization, including death (6.4 percent vs. 3.4 percent); cardiogenic shock (4.4 percent vs. 1.6 percent), or bleeding (8.5 percent vs. 5.5 percent).

Of the STEMI patients, 95.8 percent underwent coronary angiography and 90.7 percent underwent PCI, compared with NSTEMI patients of whom 81.9 percent underwent coronary angiography and 52.4 percent underwent PCI.

Cardiology

IMPACT Registry

Of the 20,169 patients with congenital heart disease undergoing cardiac catheterization or a catheter-based intervention, 86.0 percent were under the age of 18 and 24.6 percent were under a year old.

Procedures such as atrial septal defect (ASD) closure, patent ductus arteriosus (PDA) closure, aortic coarctation stenting and pulmonary valvuloplasty had success rates exceeding 84 percent. Aortic coarctation balloon angioplasty was less successful at 55.1 percent.

Device embolization was reported in 1.2 percent of ASD closure procedures and 1.1 percent of PDA closure procedures. A clinically significant increase in aortic regurgitation following valvuloplasty was noted in 10.6 percent of cases.

Cardiology

Cardiology“NCDR data provide a unique, clinically rich national perspective on the care and outcomes of high-impact cardiovascular conditions and procedures that are not available elsewhere,” said Frederick A. Masoudi, MD, MSPH, FACC, chair of the NCDR Management Board, et al., in a corresponding Executive Summary also published in JACC. He and his colleagues note that the report is “intended to provide a national perspective on the quality of cardiovascular care for common procedures and inform clinical practice and healthy policy.”

“In some cases, hospitals are consistently providing excellent care; the registries, however, allow us to identify those aspects of care where the cardiovascular clinical community can improve,” adds Masoudi. “The value of these data will increase as reimbursement for medical care in the U.S. changes from ‘payment for quantity’ to ‘payment for quality.’ Hospitals and systems who know how they care for patients and have objective national benchmarks for performance, will be better positioned to adapt to the marked changes occurring in health care.”

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