Economic and clinical outcomes of a physician-led continuous quality improvement intervention in the delivery of percutaneous coronary intervention

OBJECTIVE

To compare clinical and economic outcomes associated with percutaneous coronary intervention (PCI) in cohorts before and after continuous quality improvement (CQI) was instituted.

STUDY DESIGN

Observational study.

METHODS

Clinical, angiographic, procedural, and outcome data on 1441 pre-CQI and 1760 post-CQI PCIs (performed in 1997 and 1998, respectively) were derived from an institutional PCI registry. Administrative data were used to estimate total procedural and postprocedural costs and length of stay (LOS). Logistic and generalized linear modeling was used to adjust in-hospital clinical and economic outcomes, respectively, for differences in patient characteristics.

RESULTS

The 2 cohorts were similar in terms of age, sex, and rate of diabetes. Post-CQI patients more often received intracoronary stents, had urgent PCIs, had a history of prior PCI, and received glycoprotein IIb/IIIa inhibitors. Procedural success without in-hospital complications occurred in 90% of both cohorts and did not differ statistically in adjusted analyses. Compared with patients treated pre-CQI, those treated post-CQI had a reduced adjusted odds ratio for in-hospital death or any myocardial infarction (odds ratio = 0.66; 95% confidence interval = 0.46, 0.95). Models predicted a mean postprocedural LOS difference of 0.8 days (2.8 days pre-CQI vs 2.0 days post-CQI; P <.001) and an average post-CQI cost savings of $5430 (P <.001).

CONCLUSION

Physician-led, multidisciplinary practice management efforts were successful at significantly reducing PCI-related costs in an era of rapid technological advances while maintaining and perhaps improving quality of care.

Implementation of a continuous quality improvement program for percutaneous coronary intervention and cardiac surgery at a large community hospital

BACKGROUND

Continuous quality improvement (CQI) is widely used in other industries and has been promoted as a method for quality control in medicine. The national databases developed by the American College of Cardiology and the Society of Thoracic Surgeons have greatly facilitated data collection for CQI. Hospitals can encounter barriers to CQI, however, which include creating the proper organizational infrastructure and engaging physicians and hospital administrators in the process. These barriers are particularly evident in large community hospitals.

METHODS

We describe the organizational infrastructure for CQI, including committee structure, methods of repeated data collection and feedback, and maintenance of data integrity and confidentiality. We report demographic data and clinical outcomes for patients undergoing percutaneous coronary intervention and coronary artery bypass surgery before and after implementation of our CQI program.

RESULTS

Since 1995, we have maintained a CQI process driven by repeated collection of valid, confidential, operator-specific data. We have observed sustained physician and administration participation and buy-in. During the follow-up period, patient complexity increased and observed outcomes improved, although the improvement was clearly multifactorial.

CONCLUSIONS

We describe the organization of a CQI program at a large complex community hospital. Our CQI program was successfully implemented, has been sustained, and is associated in observed improvement in patient outcomes. The program described here may be a useful model for other similar hospitals that are attempting to create a program to address quality improvement.

Kodak EDR2 film for patient skin dose assessment in cardiac catheterization procedures

Patient skin doses were measured using Kodak EDR2 film for 20 coronary angiography (CA) and 32 percutaneous transluminal coronary angioplasty (PTCA) procedures. For CA, all skin doses were well below 1 Gy. However, 23% of PTCA patients received skin doses of 1 Gy or more. Dose-area product (DAP) was also recorded and was found to be an inadequate indicator of maximum skin dose. Practical compliance with ICRP recommendations requires a robust method for skin dosimetry that is more accurate than DAP and is applicable over a wider dose range than EDR2 film.

Implementation of Guidelines Improves the Standard of Care

Background— The purpose of this study was to determine whether implementation of recent guidelines improves in-hospital mortality from acute ST-elevation myocardial infarction (STEMI) in a metropolitan area.

Methods and Results— We organized a network that consisted of the Viennese Ambulance Systems, which is responsible for diagnosis and triage of patients with acute STEMI, and 5 high-volume interventional cardiology departments to expand the performance of primary percutaneous catheter intervention (PPCI) and to use the fastest available reperfusion strategy in STEMI of short duration (2 to 3 hours from onset of symptoms), either PPCI or thrombolytic therapy (TT; prehospital or in-hospital), respectively. Implementation of guidelines resulted in increased numbers of patients receiving 1 of the 2 reperfusion strategies (from 66% to 86.6%). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 34% to 13.4%, respectively. PPCI usage increased from 16% to almost 60%, whereas the use of TT decreased from 50.5% to 26.7% in the participating centers. As a consequence, in-hospital mortality decreased from 16% before establishment of the network to 9.5%, including patients not receiving reperfusion therapy. Whereas PPCI and TT demonstrated comparable in-hospital mortality rates when initiated within 2 to 3 hours from onset of symptoms, PPCI was more effective in acute STEMI of >3 but <12 hours’ duration.

Conclusions— Implementation of recent guidelines for the treatment of acute STEMI by the organization of a cooperating network within a large metropolitan area was associated with a significant improvement in clinical outcomes.

[Treatment of ST segment elevation myocardial infarctions according to the guidelines]

The guidelines "Akutes Koronarsyndrom" published by the German Society of Cardiology, "Management of acute myocardial infarction in patients presenting with ST-segment elevation", and "Guidelines for percutaneous coronary interventions" published by the European Society of Cardiology evaluate diagnostic tools and treatment strategies for ST segment elevation myocardial infarctions. These guidelines offer evidence-based recommendations and allow a standardized therapeutic approach thereby improving the patient's treatment and reducing the mortality. The optimal care for patients presenting with ST segment elevation myocardial infarctions consists of a prehospital phase where an immediate diagnosis should be reached by means of a twelve-channel ECG followed by basic medical treatment with administration of acetylsalicylic acid, heparin, beta-blocker, and nitrates by an emergency physician. The hospital phase can be optimized by integrated myocardial infarction networks with coronary care units offering primary percutaneous coronary interventions (PCIs) and adjuvant medical treatment including the administration of glycoprotein IIb/IIIa inhibitors. If the onset of symptoms is < 3 h and the transportation time to a coronary care unit > 90 min, the indication of primary fibrinolysis should be given by the emergency physician. If fibrinolysis fails, there is a clear indication for rescue PCI. Even with successful thrombolysis PCI should be performed within 24 h. A dual oral antithrombotic therapy starting immediately after diagnosis with a loading dose of 600 mg clopidogrel should be continued with 75 mg/d clopidogrel for 9-12 months on top of 100 mg/d acetylsalicylic acid.

[Comparative analysis of intimal hyperplasia after sirolimus-eluting stent and thin-strut bare-metal stent implantation in small coronary arteries]

OBJECTIVE

This study aimed at evaluating reduction in intimal hyperplasia volume following angioplasty using sirolimus-eluting stents (Cypher) compared with thin-strut bare-metal stents (Pixel) in patients with small vessels.

METHODS

Eighty patients with coronary artery disease were prospectively included in two consecutive series, the first using sirolimus-eluting stents (50) and the second using bare-metal stents (30).

RESULTS

The use of sirolimus-eluting stents reduced: in-stent net volume obstruction [5.0% (SE = 0.77) x 39.0% (SE = 4.72), p < 0.001], in-stent late loss [0.25 mm (SE = 0.03) x 1,11 mm (SE = 0.13), p < 0.001], in-segment late loss [0.30 mm (SE = 0.04) x 0.83 mm (SE = 0.11), p < 0.001], in-stent restenosis (0% x 33.3%, p < 0.001) and in-segment restenosis (4% x 36.7%, p < 0.001). The event-free survival rate was 96% in the sirolimus-eluting stent group versus 86.7% in the bare-metal stent group (BMS) (p = 0.190).

CONCLUSION

Sirolimus-eluting stents are superior to thin-strut bare-metal stents in reducing intimal hyperplasia (less in-stent obstruction and less late lumen loss) in patients with small vessels. The use of these stents significantly reduced angiographic restenosis at eight months.

Same-day transfer of patients with unstable angina and non-ST segment elevation myocardial infarction back to their referring hospital after angioplasty

BACKGROUND

Recent evidence has shown the advantages of an early invasive strategy for patients with high-risk unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI). However, the number of beds available for postangioplasty monitoring limits the use of this approach at the Centre hospitalier universitaire de Sherbrooke (Fleurimont, Quebec).

OBJECTIVES

To study the safety of a protocol allowing the same-day return of patients with UA or NSTEMI to their referring hospital after angioplasty at the Centre hospitalier universitaire de Sherbrooke.

METHODS

From June 2001 to June 2003, of the 532 patients with UA and NSTEMI who underwent percutaneous coronary intervention with planned same-day transfer back to their referring hospital, 419 consecutive patients who were eligible to return the same day were prospectively followed for 24 h.

RESULTS

Stents were used in 94.7% of patients and platelet glycoprotein IIb/IIIa receptor antagonists were used in 34.8% of patients. For 85% of patients, the femoral artery was used as the access route for percutaneous coronary intervention. The mean time that patients stayed in the hospital after angioplasty before returning to their referring centres was 4.4 h. No deaths, life-threatening arrhythmias or urgent revascularizations were reported during the 24 h postangioplasty follow-up period, but one patient had a major bleeding complication. During the study period, the mean angioplasty waiting time decreased from 5.7 days to 2.1 days.

CONCLUSIONS

The protocol evaluated in the present article is safe. It frees more beds, thus reducing the waiting list and allowing patients with high-risk acute coronary syndromes without ST segment elevation from community hospitals to benefit from the advantages of an early invasive strategy.

Do operator volumes relate to clinical outcomes after percutaneous coronary intervention in the Canadian health care system?

BACKGROUND

Many US studies have documented an association between operator volume and outcomes after percutaneous coronary intervention (PCI). No study has assessed whether this relationship exists in Canada, where PCI is performed only at a limited number of regional centers and operator volumes are higher.

METHODS

All PCI procedures performed in the province of Ontario from 1995 to 2001 were analyzed using administrative databases. The outcomes of interest were coronary artery bypass graft during the same hospitalization, mortality at 30 days, or the combined end point.

RESULTS

A total of 38,561 PCI procedures were performed by 65 physicians at 8 centers. Over the study period, risk-adjusted coronary artery bypass graft rates fell from 2.0% in 1995 to 0.7% in 2000 (P < .0001) with no change in mortality. The median annual PCI volume was 132 (25th, 75th percentile: 81, 182) cases. After stratifying operators by average annual PCI volume into low (< 155 cases), intermediate (155-195 cases), and high (> 195 cases) volume, there were no significant linear relationships between risk-adjusted outcomes and operator terciles. No significant correlations were seen between individual PCI volume and risk-adjusted rates of mortality, bypass surgery, or the combined end point (P = .2, P = .35, and P = .95, respectively).

CONCLUSIONS

In contrast to US studies, there does not appear to be an association between PCI volume and outcomes in Ontario. These findings may be related to the high annual volumes of most operators and institutions within Ontario.

Achieving Rapid Door-To-Balloon Times

BACKGROUND

Fewer than half of patients with ST-elevation acute myocardial infarction (STEMI) are treated within guideline-recommended door-to-balloon times; however, little information is available about the approaches used by hospitals that have been successful in improving door-to-balloon times to meet guidelines. We sought to characterize experiences of hospitals with outstanding improvement in door-to-balloon time during 1999-2002.

METHODS AND RESULTS

We performed a qualitative study using in-depth interviews (n=122) with clinical and administrative staff at 11 hospitals that were participating with the National Registry of Myocardial Infarction and had median door-to-balloon times of < or =90 minutes during 2001-2002, representing substantial improvement since 1999. Data were organized with the use of NUD-IST 4 (Sage Publications Software) and were analyzed by the constant comparative method of qualitative data analysis. Eight themes characterized hospitals' experiences: commitment to an explicit goal to improve door-to-balloon time motivated by internal and external pressures; senior management support; innovative protocols; flexibility in refining standardized protocols; uncompromising individual clinical leaders; collaborative teams; data feedback to monitor progress and identify problems and successes; and an organizational culture that fostered resilience to challenges or setbacks in improvement efforts.

CONCLUSIONS

Several themes characterized the experiences of hospitals that had achieved notable improvements in their door-to-balloon times. By distilling the complex and diverse experiences of organizational change into its essential components, this study provides a foundation for future efforts to elevate clinical performance in the hospital setting.

Association of a Continuous Quality Improvement Initiative With Practice and Outcome Variations of Contemporary Percutaneous Coronary Interventions

BACKGROUND

The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline (January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention (January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10,287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case. Outcomes selected included emergency CABG, contrast nephropathy, myocardial infarction, stroke, transfusion, and in-hospital death. Compared with baseline and the control group, the intervention group at follow-up had higher use of preprocedural aspirin and glycoprotein IIb/IIIa blockers, lower use of postprocedural heparin, and a lower amount of contrast media per case (P<0.05). These changes were associated with lower rates of transfusions, vascular complications, contrast nephropathy, stroke, transient ischemic attack, and combined end points (all P<0.05).

CONCLUSIONS

Our nonrandomized, observational data suggest that implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI. A randomized clinical trial is needed to determine whether this is a "causal" or a "casual" relationship.

Patients enrolled in coronary intervention trials are not representative of patients in clinical practice: results from the Euro Heart Survey on Coronary Revascularization

AIMS

Revascularization in patients with coronary artery disease changed over the last two decades, favouring the number of patients treated by means of percutaneous coronary interventions (PCI) when compared with coronary artery bypass grafting (CABG). Many randomized controlled trials (RCTs) have been performed to compare these two competing revascularization techniques. Because of the strict enrolment criteria of RCTs in which highly selected patients are recruited, the applicability of the results may be limited in clinical practice. The current study evaluates to what extent patients in clinical practice were similar to those who participated in RCTs comparing PCI with CABG.

METHODS AND RESULTS

Clinical characteristics and 1-year outcome of 4713 patients enrolled in the Euro Heart Survey on Coronary Revascularization were compared with 8647 patients who participated in 14 major RCTs, comparing PCI with CABG. In addition, we analysed which proportion of survey patients would have disqualified for trial participation (n=3033, 64%), aiming at identifying differences between trial-eligible and trial-ineligible survey patients. In general, important differences were observed between trial participants and survey patients. Patients in clinical practice were older, more often had comorbid conditions, single-vessel disease, and left main stem stenosis when compared with trial participants. Almost identical differences were observed between trial-eligible and trial-ineligible survey patients. In clinical practice, PCI was the treatment of choice, even in patients who were trial-ineligible (46% PCI, 26% CABG, 28% medical). PCI remained the preferred treatment option in patients with multi-vessel disease (57% in trial-eligible and 40% in trial-ineligible patients, respectively, P<0.001); yet, the risk profile of patients treated by PCI was better than that for patients treated either by CABG or by medical therapy. In the RCTs, there was no mortality difference between PCI and CABG. In clinical practice, however, we observed 1-year unadjusted survival benefit for PCI vs. CABG (2.9 vs. 5.4%, P<0.001). Survival benefit was only observed in trial-ineligible patients (3.3 vs. 6.2%, P<0.001).

CONCLUSION

Many patients in clinical practice were not represented in RCTs. Moreover, only 36% of these patients were considered eligible for participating in a trial comparing PCI with CABG. We demonstrated that RCTs included younger patients with a better cardiovascular risk profile when compared with patients in everyday clinical practice. This study highlights the disparity between patients in clinical practice and patients in whom the studies that provide the evidence for treatment guidelines are performed.

Percutaneous coronary intervention: recommendations for good practice and training

Cardiologists undertaking percutaneous coronary intervention (PCI) are excited by the combination of patient and physician satisfaction and technological advance occurring on the background of the necessary manual dexterity. Progress and applicability of percutaneous techniques since their inception in 1977 have been remarkable; a sound evidence base coupled with the enthusiasm and ingenuity of the medical device industry has resulted in a sea change in the treatment of coronary heart disease (CHD), which continues to evolve at breakneck speed. This is the third set of guidelines produced by the British Cardiovascular Intervention Society and the British Cardiac Society. Following the last set of guidelines published in 2000, we have seen PCI activity in the UK increase from 33,652 to 62,780 (87% in four years) such that the PCI to coronary artery bypass grafting ratio has increased to 2.5:1. The impact of drug eluting stents has been profound, and the Department of Health is investigating the feasibility of primary PCI for acute myocardial infarction. Nevertheless, the changes in the structure of National Health Service funding are likely to focus our attention on cost effective treatments and will require physician engagement and sensitive handling if we are to continue the rapid and appropriate growth in our chosen field. It is important with this burgeoning development now occurring on a broad front (in both regional centres and district general hospitals) that we maintain our vigilance on audit and outcome measures so that standards are maintained for both operators and institutions alike. This set of guidelines includes new sections on training, informed consent, and a core evidence base, which we hope you will find useful and informative.