- Email: [email protected]
Quality of Cardiac Care in Canada: Recommendations for Building a Sustainable Future
Canadian Journal of Cardiology
-
(2018) 1e4
Training/Practice Health Policy and Promotion
Quality of Cardiac Care in Canada: Recommendations for Building a Sustainable Future Courtney Young, MBA, MD, FRCPC,a Laurie Lambert, PhD,b James Abel, MSc, MD, FRCSC,c and Blair J. O’Neill, MD, FRCPCa a b
University of Alberta, Edmonton, Alberta, Canada
Institut national d’excellence en sante et en services sociaux, Que bec, Que bec, Canada c
University of British Columbia, Vancouver, British Columbia, Canada
ABSTRACT
RESUM E
Cardiovascular (CV) disease continues to present a significant disease and economic burden in Canada. To improve the quality of care and ensure sustainability of services, a national quality improvement initiative is required. The purpose of this analysis was to review the evidence for public reporting (PR) and external benchmarking (EB) to improve patient outcomes, and to recommend a strategy to improve CV care in Canada. To incorporate recent literature, the Canadian Cardiovascular Society (CCS) commissioned the Institute of Health Economics to provide a rapid update on the literature of PR and EB. The review showed that EB is more likely to promote positive effects, such as improved mortality, morbidity, and evidence-based clinical practice, and to limit negative effects, such as access restrictions or unintended provider behaviour associated with some forms of “topdown” PR. On the basis of these findings, this we recommend the following: (1) secure funding for the provincial collection of CV quality indicators and the creation of annual National CV Quality Reports; (2)
Les maladies cardiovasculaires (CV) constituent encore un important conomique au Canada. Pour ame liorer la qualite fardeau sanitaire et e des services, une initiative nationale des soins et assurer la viabilite lioration de la qualite est ne cessaire. La pre sente analyse passe d’ame es probantes sur l’e tablissement de rapports desen revue les donne s au public et l’e talonnage externe. Elle a e te effectue e dans tine liorer les re sultats des patients et de recommander l’optique d’ame gie axe e sur l’ame lioration des soins CV au Canada. Afin d’y une strate grer la documentation re cente, la Socie te canadienne de carinte à l’Institute of Health Economics le mandat de diologie (SCC) a confie che ance un bilan de la documentation touchant dresser à brève e tablissement de rapports destine s au public et l’e talonnage externe. l’e que l’e talonnage externe est La revue de la documentation a montre lioration plus susceptible de favoriser des effets positifs, tels que l’ame , de la morbidite et de la pratique clinique fonde es sur de la mortalite es probantes, et de limiter les effets ne gatifs, tels que les des donne
Cardiovascular (CV) disease places a huge burden on the Canadian health care system. As a leading cause of death and cause of hospitalization for Canadians, CV disease diagnosis and treatment consumes approximately $22.2 billion. In 2004, hospitalized patients in Canada had an adverse event rate of 7.5%-38%, many preventable (Supplemental References S1-S4). Because of the burden of CV disease and adverse events, national quality improvement initiatives are required to improve safety and quality of care. In this review we summarize the evidence for public reporting (PR) and
external benchmarking (EB) in improving patient outcomes and recommend a strategy to improve CV care in Canada. The difference between PR and EB is that EB is intended to promote improvement using comparative assessment as part of a broader, more comprehensive improvement plan. PR presents outcome data to the public for the purpose of comparisons of health care providers and or their programs. Historically, PR has led to punitive mechanisms for change,1 but organizations such as the National Health Service2 and Institute for Healthcare Improvement have emphasized the maxim: “Measurement is for improvement, not judgement.”3 EB is the process of assessing activities and comparing their outcomes across one or more organizations.4 By identifying top performers and describing the methods they used, best practices are shared so that organizations can strive to improve (Supplemental Reference S5). EB informs and promotes the development of new processes of care and measurement tools, driving improvement in outcomes.
Received for publication December 13, 2017. Accepted January 23, 2018. Corresponding author: Dr Blair J. O’Neill, University of Alberta, Edmonton, Alberta T6G 2B7, Canada. Tel.: þ1-780-342-2087; fax (780) 735-0850. E-mail: [email protected] See page 3 for disclosure information.
https://doi.org/10.1016/j.cjca.2018.01.025 0828-282X/Ó 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
2
Canadian Journal of Cardiology Volume - 2018
enhance the culture of using CV quality indicator data for continuous quality improvement and opportunities for national or regional EB and sharing best practices; and (3) implement ongoing evaluation and revision of CCS clinical practice guidelines incorporating key quality indicators. This is already under way to a limited extent by the CCS with its Quality Project, but intentional, sustained support needs to be secured to enhance this ongoing effort and improve the quality of CV care for all Canadians.
sirables de fournisseurs restrictions d’accès ou les comportements inde s à certaines formes « descendantes » d’e tablissement de associe s au public. Sur la base de ces constatations, nous rapports destine s d’inrecommandons de : 1) assurer le financement pour les releve en matière de soins CV à l’e chelle provinciale ainsi dicateurs de qualite daction de rapports annuels sur la qualite des soins CV à que la re chelle nationale; 2) promouvoir le recours syste mique aux indical’e en matière de soins CV aux fins d’ame lioration teurs de qualite , d’e talonnage externe à l’e chelle nationale ou continue de la qualite gionale et de mise en commun des pratiques exemplaires; 3) mettre re valuation et de re vision continues des lignes en place un processus d’e grant les principaux directrices de pratique clinique de la SCC inte . La SCC a d’ores et de jà amorce dans une cerindicateurs de qualite taine mesure la mise en œuvre de ces recommandations dans le cadre , mais un appui ferme et soutenu doit être de son Projet de qualite pour consolider la de marche en cours et ame liorer la qualite assure des soins CV au profit de tous les Canadiens.
Systematic Review In 2012, the Agency for Healthcare Research and Quality published a systematic review of studies between 1980 and 20115 on the outcomes of PR initiatives. The objective was to determine: (1) the effectiveness of PR as a quality improvement strategy; (2) whether PR leads to changes in health care delivery or in patients’ behaviours; and (3) whether the characteristics of reports and contextual factors influence the effect of PR. There was inconsistent evidence that PR is associated with reduced mortality, but consistent evidence that PR is associated with improvement in care processes and quality indicators (QIs). Negative consequences were unintended risk aversion for high-risk, complex patients or changing coding of procedures. As an update to this review, the Canadian Cardiovascular Society (CCS) commissioned the Institute of Health Economics to provide a rapid update on the literature on EB as well as PR (Supplemental Appendix S1). Nearly 1000 studies were filtered down to 28 studies of interest. The report showed mixed evidence for PR but consistent evidence for EB on positive CV outcomes. EB was not associated with any negative outcomes, but was correlated with improved mortality, morbidity, and evidence-based clinical practice. Thus, although both forms of comparative assessment have potential to drive quality improvement, recent evidence indicates EB is more likely to promote positive effects and limit negative effects.
pathway, where underperforming physicians suffering reputation loss, then improve (Supplemental References S6, S7). However, as shown in the reviews cited, the evidence for improvements through PR is inconsistent. Further, in the Canadian context, with its sparsely populated large land base and highly centralized health care, many individuals have only limited physicians or hospitals to choose from. Patients often have physicians and facilities selected for them, largely on the basis of their location. Therefore, improvement through the influences described is less likely to occur in Canada. Therefore, using PR to establish transparency and burning platforms for improvement, and EB to assess and compare health care outcomes might be more relevant to the Canadian context.4 However, large-scale change will only occur by engaging clinicians, measuring without judgement, and using EB to stimulate continuous quality improvement. There are examples within many jurisdictions in Canada where intraprovincial benchmarking has had an effect. Cardiac Services BC has annual quality meetings, which report key QIs among their cardiac centres. Sustained improvements in outcomes, such as mortality, evidence-based medications for secondary prevention, and annual reduction in blood product transfusion have been seen (Supplemental Appendix S2). In Alberta, a 1.5- to 2-fold difference in 30-day stroke mortality was identified and through establishment of key process indicators and learning collaboratives, stroke outcomes improved throughout rural Alberta (Supplemental Appendix S3). In Quebec, repeated province-wide benchmarking of care for patients with ST-elevation myocardial infarction across individual facilities has led to the mobilization of providers and decision-makers at many levels of the health care system and led to dramatic increases in the use of prehospital electrocardiograms, improved care pathways, and reductions in treatment delays (Supplemental Appendix S4). Information from benchmarking also contributed to the deliberation process for the new quality standards for ST-elevation myocardial infarction care in Quebec. Although noteworthy improvements have been achieved within provinces, national benchmarking gives the opportunity for coast-to-coast improvement. Because of the limited choices
Discussion To improve individual provider and facility outcomes, various jurisdictions have attempted to use PR to improve patient outcomes.5 In contrast to EB, PR is often perceived as a “top-down” approach, not associated with a deliberate plan for improving or changing the activities that generated the outcomes.1 Previously theorized pathways for PR to result in improvements were in the American context and included: (1) the selection pathway, where patients use public reports to choose better-performing physicians or facilities, thus motivating improvement; (2) the change pathway, whereby reported quality deficits spur improvement; and (3) the reputation
Young et al. Sustainable Quality Cardiac Care in Canada
patients have because of centralization of services, the system has a fiduciary responsibility to be the best it can. National EB with appropriate risk adjustment would ensure that Canadians have a robust, safe, and reliable CV national care system. Canadian CV care supported by QIs provides opportunities in which all health and disease care providers, individual as well as institutional, can share best practices with the attitude that everyone has something to teach, and everyone has something to learn. As a clinician-led national specialty society, the CCS has been a sought-after credible convener to bring together its clinicians, national agencies such as the Canadian Institutes for Health Information and the rich provincial registries to develop a common data dictionary and consensus on key QIs. Its goal has been to establish a national quality framework to allow measurement of care and share progress across provincial borders. Recommendations Recommendation 1. Secure funding for the provincial collection of CV QIs and the creation of annual National Quality Reports Having developed common QIs allowing national comparisons, the CCS, in collaboration with Canadian Institutes for Health Information has begun high-level PR (Supplemental References S8, S9). Sustained improvement and clinician engagement requires enhanced cross-country comparisons to measure, compare, and identify best practices. A major barrier to widespread EB is funding to collect and maintain the data, and to bring providers together. Further, EB is fundamental to the Canada Health Act’s pillar of accountability, and hence a requirement. CCS has presented that for only a modest investment of $2.5 million annually, a national system of EB could be established for revascularization, treatment of myocardial infarction, heart failure, and arrhythmias (Supplemental Reference S10). Recommendation 2. Enhance the culture of CV QI data collection and sharing and continuous improvement Measurement of key CV QIs should become the expectation and become included in Accreditation Canada’s selfassessment standards and survey instruments. Regional or national forums should be created to allow sharing of outcomes and best practices. The annual Canadian Cardiovascular Congress would be a natural national venue for subspecialty groups in CV care to come together to continuously improve care in Canada. Recommendation 3. Ongoing evaluation and revision of CCS clinical practice guidelines as a result of National Quality Reports National PR and EB will improve care on the basis of comparative assessment, and allow better CV disease management through standardized practice recommendations. Regular annual quality reports can engage clinicians, and facilitate local CV programs to observe trends and leading centres and provinces learning from their processes. More
3
deliberate engagement of its clinicians will allow the CCS to improve their published guidelines, develop best practice clinical protocols, and improve patient care at a national level. Conclusions The evidence suggests that combining PR and EB of CV outcomes is the best way for Canada to drive quality improvement. We call upon the federal government to support such an initiative. Canada lags behind most other jurisdictions in quality measurement and reporting. The CCS, made up of content experts in many fields of CV medicine, has used its clinician resources and credibility to lead a national initiative. Supported by the Public Health Agency of Canada, the CCS launched the Quality Project, and has facilitated creation of 37 QIs covering 6 priority areas of Canadian CV care (Supplemental Reference S11). These indicators were meant for measurement and reporting, as a first step in stimulating improvement. The first CCS National Quality Report was published in 2016, the National Quality Report: TAVI (Supplemental Reference S12) and was meant to help organizations compare and learn from each other. However, additional resources will allow the CCS to act as stewards of highest-quality CV care. Only as clinicians become immersed in measurement, QI, and techniques of EB, will progress be made. In 2018, providers, programs, and their patients need access to outcomes, benchmarked to other centres, and opportunities to compare best practices. This does require resources, champions, and a national vision. Acknowledgements The authors acknowledge the contributions of the following to the supplementary materials: Sean Hardiman and Carol Laberge of Cardiac Services BC, Anabèle Brière, Institut national d’excellence en sante et en services sociaux, the Cardiovascular Health and Stroke Strategic Clinical Network, Alberta Health Services, and the Institute for Health Economics, Edmonton, Alberta. Funding Sources Financial support for the systematic review provided by the CCS. Disclosures The authors have no conflicts of interest to disclose. References 1. Hannan EL, Cozzens K, King SB, Walford G, Shah NR. The New York State cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes. J Am Coll Cardiol 2012;59:2309-16. 2. NHS. NHS Improving Quality. Available at: https://nhsiq.wordpress.com/ 2014/02/07/measuring-for-improvement-not-for-judgement-how-nhssurgeons-are-leading-the-world-in-publishing-outcomes-data. Accessed December 5, 2017.
4
3. Berwick DM. Quality of health care. Part 5: Payment by capitation and the quality of care. N Engl J Med 1996;335:1227-31. 4. Brouwers C, Hooftman B, Vonk S, et al. Benchmarking the use of blood products in cardiac surgery to stimulate awareness of transfusion behaviour: results from a four-year longitudinal study. Neth Heart J 2017;25: 207-14. 5. Totten AM, Wagner J, Tiwari A, et al. Public reporting as a quality improvement strategy. Closing the quality gap: revisiting the state of the
Canadian Journal of Cardiology Volume - 2018 science (Vol. 5: Public reporting as a quality improvement strategy). Evid Rep Technol Assess 2012;208.5:1-645.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at https://doi.org/10. 1016/j.cjca.2018.01.025.
-
(2018) 1e4
Training/Practice Health Policy and Promotion
Quality of Cardiac Care in Canada: Recommendations for Building a Sustainable Future Courtney Young, MBA, MD, FRCPC,a Laurie Lambert, PhD,b James Abel, MSc, MD, FRCSC,c and Blair J. O’Neill, MD, FRCPCa a b
University of Alberta, Edmonton, Alberta, Canada
Institut national d’excellence en sante et en services sociaux, Que bec, Que bec, Canada c
University of British Columbia, Vancouver, British Columbia, Canada
ABSTRACT
RESUM E
Cardiovascular (CV) disease continues to present a significant disease and economic burden in Canada. To improve the quality of care and ensure sustainability of services, a national quality improvement initiative is required. The purpose of this analysis was to review the evidence for public reporting (PR) and external benchmarking (EB) to improve patient outcomes, and to recommend a strategy to improve CV care in Canada. To incorporate recent literature, the Canadian Cardiovascular Society (CCS) commissioned the Institute of Health Economics to provide a rapid update on the literature of PR and EB. The review showed that EB is more likely to promote positive effects, such as improved mortality, morbidity, and evidence-based clinical practice, and to limit negative effects, such as access restrictions or unintended provider behaviour associated with some forms of “topdown” PR. On the basis of these findings, this we recommend the following: (1) secure funding for the provincial collection of CV quality indicators and the creation of annual National CV Quality Reports; (2)
Les maladies cardiovasculaires (CV) constituent encore un important conomique au Canada. Pour ame liorer la qualite fardeau sanitaire et e des services, une initiative nationale des soins et assurer la viabilite lioration de la qualite est ne cessaire. La pre sente analyse passe d’ame es probantes sur l’e tablissement de rapports desen revue les donne s au public et l’e talonnage externe. Elle a e te effectue e dans tine liorer les re sultats des patients et de recommander l’optique d’ame gie axe e sur l’ame lioration des soins CV au Canada. Afin d’y une strate grer la documentation re cente, la Socie te canadienne de carinte à l’Institute of Health Economics le mandat de diologie (SCC) a confie che ance un bilan de la documentation touchant dresser à brève e tablissement de rapports destine s au public et l’e talonnage externe. l’e que l’e talonnage externe est La revue de la documentation a montre lioration plus susceptible de favoriser des effets positifs, tels que l’ame , de la morbidite et de la pratique clinique fonde es sur de la mortalite es probantes, et de limiter les effets ne gatifs, tels que les des donne
Cardiovascular (CV) disease places a huge burden on the Canadian health care system. As a leading cause of death and cause of hospitalization for Canadians, CV disease diagnosis and treatment consumes approximately $22.2 billion. In 2004, hospitalized patients in Canada had an adverse event rate of 7.5%-38%, many preventable (Supplemental References S1-S4). Because of the burden of CV disease and adverse events, national quality improvement initiatives are required to improve safety and quality of care. In this review we summarize the evidence for public reporting (PR) and
external benchmarking (EB) in improving patient outcomes and recommend a strategy to improve CV care in Canada. The difference between PR and EB is that EB is intended to promote improvement using comparative assessment as part of a broader, more comprehensive improvement plan. PR presents outcome data to the public for the purpose of comparisons of health care providers and or their programs. Historically, PR has led to punitive mechanisms for change,1 but organizations such as the National Health Service2 and Institute for Healthcare Improvement have emphasized the maxim: “Measurement is for improvement, not judgement.”3 EB is the process of assessing activities and comparing their outcomes across one or more organizations.4 By identifying top performers and describing the methods they used, best practices are shared so that organizations can strive to improve (Supplemental Reference S5). EB informs and promotes the development of new processes of care and measurement tools, driving improvement in outcomes.
Received for publication December 13, 2017. Accepted January 23, 2018. Corresponding author: Dr Blair J. O’Neill, University of Alberta, Edmonton, Alberta T6G 2B7, Canada. Tel.: þ1-780-342-2087; fax (780) 735-0850. E-mail: [email protected] See page 3 for disclosure information.
https://doi.org/10.1016/j.cjca.2018.01.025 0828-282X/Ó 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
2
Canadian Journal of Cardiology Volume - 2018
enhance the culture of using CV quality indicator data for continuous quality improvement and opportunities for national or regional EB and sharing best practices; and (3) implement ongoing evaluation and revision of CCS clinical practice guidelines incorporating key quality indicators. This is already under way to a limited extent by the CCS with its Quality Project, but intentional, sustained support needs to be secured to enhance this ongoing effort and improve the quality of CV care for all Canadians.
sirables de fournisseurs restrictions d’accès ou les comportements inde s à certaines formes « descendantes » d’e tablissement de associe s au public. Sur la base de ces constatations, nous rapports destine s d’inrecommandons de : 1) assurer le financement pour les releve en matière de soins CV à l’e chelle provinciale ainsi dicateurs de qualite daction de rapports annuels sur la qualite des soins CV à que la re chelle nationale; 2) promouvoir le recours syste mique aux indical’e en matière de soins CV aux fins d’ame lioration teurs de qualite , d’e talonnage externe à l’e chelle nationale ou continue de la qualite gionale et de mise en commun des pratiques exemplaires; 3) mettre re valuation et de re vision continues des lignes en place un processus d’e grant les principaux directrices de pratique clinique de la SCC inte . La SCC a d’ores et de jà amorce dans une cerindicateurs de qualite taine mesure la mise en œuvre de ces recommandations dans le cadre , mais un appui ferme et soutenu doit être de son Projet de qualite pour consolider la de marche en cours et ame liorer la qualite assure des soins CV au profit de tous les Canadiens.
Systematic Review In 2012, the Agency for Healthcare Research and Quality published a systematic review of studies between 1980 and 20115 on the outcomes of PR initiatives. The objective was to determine: (1) the effectiveness of PR as a quality improvement strategy; (2) whether PR leads to changes in health care delivery or in patients’ behaviours; and (3) whether the characteristics of reports and contextual factors influence the effect of PR. There was inconsistent evidence that PR is associated with reduced mortality, but consistent evidence that PR is associated with improvement in care processes and quality indicators (QIs). Negative consequences were unintended risk aversion for high-risk, complex patients or changing coding of procedures. As an update to this review, the Canadian Cardiovascular Society (CCS) commissioned the Institute of Health Economics to provide a rapid update on the literature on EB as well as PR (Supplemental Appendix S1). Nearly 1000 studies were filtered down to 28 studies of interest. The report showed mixed evidence for PR but consistent evidence for EB on positive CV outcomes. EB was not associated with any negative outcomes, but was correlated with improved mortality, morbidity, and evidence-based clinical practice. Thus, although both forms of comparative assessment have potential to drive quality improvement, recent evidence indicates EB is more likely to promote positive effects and limit negative effects.
pathway, where underperforming physicians suffering reputation loss, then improve (Supplemental References S6, S7). However, as shown in the reviews cited, the evidence for improvements through PR is inconsistent. Further, in the Canadian context, with its sparsely populated large land base and highly centralized health care, many individuals have only limited physicians or hospitals to choose from. Patients often have physicians and facilities selected for them, largely on the basis of their location. Therefore, improvement through the influences described is less likely to occur in Canada. Therefore, using PR to establish transparency and burning platforms for improvement, and EB to assess and compare health care outcomes might be more relevant to the Canadian context.4 However, large-scale change will only occur by engaging clinicians, measuring without judgement, and using EB to stimulate continuous quality improvement. There are examples within many jurisdictions in Canada where intraprovincial benchmarking has had an effect. Cardiac Services BC has annual quality meetings, which report key QIs among their cardiac centres. Sustained improvements in outcomes, such as mortality, evidence-based medications for secondary prevention, and annual reduction in blood product transfusion have been seen (Supplemental Appendix S2). In Alberta, a 1.5- to 2-fold difference in 30-day stroke mortality was identified and through establishment of key process indicators and learning collaboratives, stroke outcomes improved throughout rural Alberta (Supplemental Appendix S3). In Quebec, repeated province-wide benchmarking of care for patients with ST-elevation myocardial infarction across individual facilities has led to the mobilization of providers and decision-makers at many levels of the health care system and led to dramatic increases in the use of prehospital electrocardiograms, improved care pathways, and reductions in treatment delays (Supplemental Appendix S4). Information from benchmarking also contributed to the deliberation process for the new quality standards for ST-elevation myocardial infarction care in Quebec. Although noteworthy improvements have been achieved within provinces, national benchmarking gives the opportunity for coast-to-coast improvement. Because of the limited choices
Discussion To improve individual provider and facility outcomes, various jurisdictions have attempted to use PR to improve patient outcomes.5 In contrast to EB, PR is often perceived as a “top-down” approach, not associated with a deliberate plan for improving or changing the activities that generated the outcomes.1 Previously theorized pathways for PR to result in improvements were in the American context and included: (1) the selection pathway, where patients use public reports to choose better-performing physicians or facilities, thus motivating improvement; (2) the change pathway, whereby reported quality deficits spur improvement; and (3) the reputation
Young et al. Sustainable Quality Cardiac Care in Canada
patients have because of centralization of services, the system has a fiduciary responsibility to be the best it can. National EB with appropriate risk adjustment would ensure that Canadians have a robust, safe, and reliable CV national care system. Canadian CV care supported by QIs provides opportunities in which all health and disease care providers, individual as well as institutional, can share best practices with the attitude that everyone has something to teach, and everyone has something to learn. As a clinician-led national specialty society, the CCS has been a sought-after credible convener to bring together its clinicians, national agencies such as the Canadian Institutes for Health Information and the rich provincial registries to develop a common data dictionary and consensus on key QIs. Its goal has been to establish a national quality framework to allow measurement of care and share progress across provincial borders. Recommendations Recommendation 1. Secure funding for the provincial collection of CV QIs and the creation of annual National Quality Reports Having developed common QIs allowing national comparisons, the CCS, in collaboration with Canadian Institutes for Health Information has begun high-level PR (Supplemental References S8, S9). Sustained improvement and clinician engagement requires enhanced cross-country comparisons to measure, compare, and identify best practices. A major barrier to widespread EB is funding to collect and maintain the data, and to bring providers together. Further, EB is fundamental to the Canada Health Act’s pillar of accountability, and hence a requirement. CCS has presented that for only a modest investment of $2.5 million annually, a national system of EB could be established for revascularization, treatment of myocardial infarction, heart failure, and arrhythmias (Supplemental Reference S10). Recommendation 2. Enhance the culture of CV QI data collection and sharing and continuous improvement Measurement of key CV QIs should become the expectation and become included in Accreditation Canada’s selfassessment standards and survey instruments. Regional or national forums should be created to allow sharing of outcomes and best practices. The annual Canadian Cardiovascular Congress would be a natural national venue for subspecialty groups in CV care to come together to continuously improve care in Canada. Recommendation 3. Ongoing evaluation and revision of CCS clinical practice guidelines as a result of National Quality Reports National PR and EB will improve care on the basis of comparative assessment, and allow better CV disease management through standardized practice recommendations. Regular annual quality reports can engage clinicians, and facilitate local CV programs to observe trends and leading centres and provinces learning from their processes. More
3
deliberate engagement of its clinicians will allow the CCS to improve their published guidelines, develop best practice clinical protocols, and improve patient care at a national level. Conclusions The evidence suggests that combining PR and EB of CV outcomes is the best way for Canada to drive quality improvement. We call upon the federal government to support such an initiative. Canada lags behind most other jurisdictions in quality measurement and reporting. The CCS, made up of content experts in many fields of CV medicine, has used its clinician resources and credibility to lead a national initiative. Supported by the Public Health Agency of Canada, the CCS launched the Quality Project, and has facilitated creation of 37 QIs covering 6 priority areas of Canadian CV care (Supplemental Reference S11). These indicators were meant for measurement and reporting, as a first step in stimulating improvement. The first CCS National Quality Report was published in 2016, the National Quality Report: TAVI (Supplemental Reference S12) and was meant to help organizations compare and learn from each other. However, additional resources will allow the CCS to act as stewards of highest-quality CV care. Only as clinicians become immersed in measurement, QI, and techniques of EB, will progress be made. In 2018, providers, programs, and their patients need access to outcomes, benchmarked to other centres, and opportunities to compare best practices. This does require resources, champions, and a national vision. Acknowledgements The authors acknowledge the contributions of the following to the supplementary materials: Sean Hardiman and Carol Laberge of Cardiac Services BC, Anabèle Brière, Institut national d’excellence en sante et en services sociaux, the Cardiovascular Health and Stroke Strategic Clinical Network, Alberta Health Services, and the Institute for Health Economics, Edmonton, Alberta. Funding Sources Financial support for the systematic review provided by the CCS. Disclosures The authors have no conflicts of interest to disclose. References 1. Hannan EL, Cozzens K, King SB, Walford G, Shah NR. The New York State cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes. J Am Coll Cardiol 2012;59:2309-16. 2. NHS. NHS Improving Quality. Available at: https://nhsiq.wordpress.com/ 2014/02/07/measuring-for-improvement-not-for-judgement-how-nhssurgeons-are-leading-the-world-in-publishing-outcomes-data. Accessed December 5, 2017.
4
3. Berwick DM. Quality of health care. Part 5: Payment by capitation and the quality of care. N Engl J Med 1996;335:1227-31. 4. Brouwers C, Hooftman B, Vonk S, et al. Benchmarking the use of blood products in cardiac surgery to stimulate awareness of transfusion behaviour: results from a four-year longitudinal study. Neth Heart J 2017;25: 207-14. 5. Totten AM, Wagner J, Tiwari A, et al. Public reporting as a quality improvement strategy. Closing the quality gap: revisiting the state of the
Canadian Journal of Cardiology Volume - 2018 science (Vol. 5: Public reporting as a quality improvement strategy). Evid Rep Technol Assess 2012;208.5:1-645.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at https://doi.org/10. 1016/j.cjca.2018.01.025.