- Email: [email protected]
Improving Quality of Cardiac Care: A Global Mandate
Rev Esp Cardiol. 2015;68(11):924–927
Editorial
Improving Quality of Cardiac Care: A Global Mandate Mejorar la calidad de la asistencia cardiaca: un imperativo mundial ˜ a,c Robert Suter,d Louise Morgan,d Kathryn Taubert,d Sidney C. Smith, Jr.a,* Gregg C. Fonarow,b Ileana L. Pin Eduardo Sanchez,d and Elliott Antmane a
Heart and Vascular Center, University of North Carolina, Chapel Hill, North Carolina, United States Division of Cardiology, UCLA David Geffen School of Medicine, Los Angeles, California, United States Division of Cardiology, Albert Einstein College of Medicine, Bronx, New York, United States d American Heart Association, Dallas, Texas, United States e Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States b c
Article history: Available online 10 September 2015
Cardiovascular disease (CVD) is the leading cause of death in the world. It is estimated to have claimed the lives of 17.3 million people in 2008 and, if left unchecked, this figure expected to increase to more than 23.6 million deaths by 2030.1 The greatest increases in mortality from heart disease and stroke are expected to occur in low- and middle-income countries, which often have not implemented programs designed to curb this international epidemic. A number of therapies substantially reduce morbidity and mortality in patients with or at risk for CVD and stroke.2,3 Many of these evidence-based, guideline-directed therapies are readily available worldwide.4,5 However, studies in an array of settings have demonstrated that numerous patients still fail to receive effective, safe, high-value CVD and stroke treatments in a timely fashion.6,7 There are also substantial hospital and outpatient practice, regional, national, and global variations in the use of evidence-based care along with disparities in care, particularly among certain patient populations.6–8 One of the high impact strategies to respond to the global epidemic of CVD and stroke is to ensure more consistent implementation of evidence-based care. During the past 15 years, the American Heart Association/ American Stroke Association (AHA/ASA) has developed a group of evidence based quality improvement (QI) programs (eg, coronary artery disease/acute coronary syndromes, atrial fibrillation, heart failure, stroke, cardiac resuscitation), which can effectively reduce the morbidity and mortality associated with CVD. These QI programs are now being used in more than 2000 United States hospitals with the result that nearly 80% of patients are able to readily receive evidence-based, guideline-directed care for CVD. The result has been a dramatic reduction of 29.4% in 30-day mortality for myocardial infarction, 16.4% for heart failure, and 4.7% for stroke.9 If the countries of the world are to achieve similar results, QI programs and systems of care should be replicated by their health care delivery systems.
SEE RELATED ARTICLE: http://dx.doi.org/10.1016/j.rec.2015.07.003, Rev Esp Cardiol. 2015;68:976–95.e10.
* Corresponding author: Heart and Vascular Center, University of North Carolina, Chapel Hill, North Carolina, United States. E-mail address: [email protected] (S.C. Smith, Jr.).
The article published in Revista Espan˜ola de Cardiologı´a by Lo´pez-Sendo´n et al10 is a thoughtful consensus document focusing on the definition of quality standards and markers to properly assess overall performance. The Spanish Society of Cardiology (SEC), in collaboration with the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV), contend that these measures should be prepared by cardiac societies. Accordingly, they prepared their document to help define quality markers and metrics that can help evaluate the overall results of the clinical practice and outcomes in cardiology. The AHA is now collaborating with several international QI programs to improve outcomes for patients with CVD and has put forward the following discussion about improving quality of cardiac care to provide further information about the design and implementation of evidence based QI programs which have been successful in the United States. THE VALUE OF A FOCUS ON QUALITY OF CARE: QUALITY IMPROVEMENT PROCESSES AND PREDICTABLY AND MEASURABLY BETTER OUTCOMES The Institute of Medicine defines quality of care as: ‘‘The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’’.11 However, quality to a physician is very personal, ie, am I doing the right thing for my patients and are they better off for it? The Institute of Medicine definition is further elaborated by descriptions of care being timely, effective, safe, equitable, patient-centered, and cost effective. To enhance quality, clinical practice guidelines have been developed, not only in the United States but also in Europe, Canada, and other countries, to ‘‘guide’’ clinicians, using current evidence, to choose treatments for specific syndromes that are based on the risks and benefits studied in the literature. The use of guidelines should help with daily clinical decisions for treatment and decrease the heterogeneity of care. This promotes ‘‘best practices’’, allowing systems as well as payers and peers to define ‘‘quality’’. Guidelines, however, although essential, are insufficient to determine if quality care is being delivered. How can improvement
http://dx.doi.org/10.1016/j.rec.2015.08.002 ˜ ola de Cardiologı´a. Published by Elsevier Espan ˜ a, S.L.U. All rights reserved. 1885-5857/ß 2015 Sociedad Espan
S.C. Smith, Jr. et al. / Rev Esp Cardiol. 2015;68(11):924–927
occur, if measurement of baseline is unknown? How can healthcare organizations compare themselves among each other or peers and evaluate others against themselves? In 1999, the AHA convened a group of professionals as the First Scientific Forum on Assessment of Quality of Care and Outcomes Research in CVD and stroke. The areas of focus included myocardial infarction, stroke, heart failure, and methodology. The group clearly stated that quality measurement was no longer optional, but essential.12 The ultimate goal of any QI program is to reach the desired health outcomes of better health for a group or system. Measurement of quality is therefore an imperative. However, performance measures need to be distinguished from performance measurement and management. Performance measures are synthesized from clinical guidelines and can therefore be very disease specific and are meant to measure systems of care by operationalizing recommendations found in Guidelines. Performance measurement, on the other hand, is a process which includes the operations necessary to collect the data that are basic to using the performance measures. Obviously, one cannot exist without the other. However, choosing the right measures and deciding what outcomes should follow should precede the collection of such data. Hence performance management sets the goals of QI and uses the plan-do-study-act cycle to assess, improve, and reassess progress. Far too often data are collected without a goal being specified.13 The next 15 years of performance measurement brought a multitude of measures whose purpose was to improve care. The importance of measurement has not waned. However, its complexity has grown as organizations have looked to the public health agencies for confirmation or development of measures for a large group of conditions, very prominently, cardiac measures. In the complex world of organizations, health systems, and practices, the Agency for Healthcare Research and Quality convened a group of stakeholders to develop a taxonomy of healthcare systems that would allow comparisons across delivery to decide what is best for patients. One of the domains identified by this work, 15 years after the AHA forum, was ‘‘Care processes and infrastructure’’, which included performance measurement, public reporting, and QI.14 The Agency for Healthcare Research and Quality report provides some context for this suggested element as: 1. The extent to which the organization conducts regular measurement of performance with public reporting, feedback, and a systematic process of improvement. 2. Number of clinical performance measures assessed at least yearly. 3. Proportion of those measures with results reported to the public and those providing measured care. 4. Proportion of those measures with active action plans for improvement. Given these recommendations and the growing complexity of patient care added to extensive choices for treatment, true quality of care demands measurements, ie, proving that what we think we are doing, we are actually doing. The Institute of Medicine report also heralded the age of transparency. Today’s world economy also demands transparency with more scrutiny on public health and health systems practices, thereby demanding reporting of measurements and quality efforts. Government agencies use performance measures to add or remove resources if the data collected does not verify quality of care. Organizations use measures to monitor and compare practices and evaluate the need for additional resources to achieve their goals of care. Finally, clinicians use disease specific measures to selfregulate, compare and improve their delivery of care.
925
The plethora of measures in the last 15 years has not gone unnoticed by the Institute of Medicine. In their most recent report, ‘‘Vital signs: core metrics for health and health care progress’’, the group underscores the multitude of measures that have added complexity and confusion due to lack of focus, consistency, and organization.15 The report points out that similar measures have been developed by various groups with minor differences that impede comparisons within or among systems and providers. These limitations hinder the improvement of health systems. The report further advises that all stakeholders must notice which measures matter the most to focus on the health care of Americans. The report proposes a set of 15 measures covering the 4 domains of healthy people, care quality, lower cost, and engaged people. Such a set of measures could be conducive to a more focused health progress using the highest priority areas, ie, the 4 domains. The 15 measures are highlighted in the Figure. Pertinent to this commentary is number 10 or evidenced based care including: cardiovascular risk reduction, hypertension control, diabetes control composite, heart attack therapy protocol, stroke therapy protocol, and unnecessary care composite. The report describes this measure as ‘‘ensuring that patients receive care supported by scientific evidence for appropriateness and effectiveness is a central challenge for the health care system. Currently, an estimated one-third of United States health care expenditures do not contribute to improving health. Aggregating carefully selected and standardized clinical measures can provide a reliable composite index of system performance.’’ The mandates are clear: QI efforts can be effective when deployed with thoughtful measurement of performance by setting goals of outcomes as a priority and selection of measures that are poised to effectively measure true performance and allow comparisons among groups. At the same time, these measures should facilitate reporting to agencies that are responsible for payment and allocation of resources, eg, public health groups, insurers, and funding agencies. Selection of meaningful and targeted measures for QI should be a priority for providers, payers, and government agencies to promote the cardiovascular health of all its citizens.
Community engagement
Life expectancy Well-being
Individual engagement
Overweight and obesity
Population spending burden
Addictive behavior
Core metrics for health and health care progress
Personal spending burden
Unintended pregnancy
To achieve better health at lower cost, all stakeholders including health professionals, payers, policy makers, communities, and members of the public- must focus on what matters most. What are the core measures that will yield the clearest understanding of health and well-being in America? Vital Signs, a 2015 report from the Institute of Medicine, proposes a set of 15 core measures for health and health care. Explore the inforgraphic to see examples for each measure. match
Care with patient goals
Healthy communities
Evidencebased care
Preventive services Patient safety
Care access
Figure. The recommended Core Metrics 2015.15
S.C. Smith, Jr. et al. / Rev Esp Cardiol. 2015;68(11):924–927
HOW DIFFERENCES IN WHAT WORKS MAY BE DUE TO DIFFERENCES IN SYSTEM DESIGN AND LEGISLATION/ REGULATION/VOLUNTARY CERTIFICATION One challenge to global healthcare QI efforts is the need to use culturally and system specific tools that account for differences in data collection and the legal and regulatory environment unique to each country.16,17 The questions of whether participation in a specific QI program is mandatory or voluntary, and with or without achievement of special certification or recognition, are critical to the design of a successful program.18,19 Reportable metrics for accreditation vary widely between nations, potentially making the number of metrics within a specific QI tool either excessive or insufficient. In addition, variations in the degree that interdisciplinary care vs physician care drives the cultural adjustment needed in QI efforts and tools required.20,21 These sophisticated influences are reflected in the INCARDIO (Indicadores de Calidad en Unidades Asistenciales del A´rea del Corazo´n) approach in Spain.
CHOOSING, MEASURING, AND MONITORING THE RIGHT METRICS: THE AMERICAN HEART ASSOCIATION GUIDELINES AND GET WITH THE GUIDELINES EXPERIENCE The ACC/AHA (American College of Cardiology/American Heart Association) have developed clinical practice guidelines outlining diagnostic and therapeutic interventions for patients with and at risk for CVD. The evidence in favor of implementing certain recommendations is particularly strong, and provision of this care is thought to be critical in achieving optimal patient outcomes. Adherence to these suggested interventions may therefore serve as a marker of quality of care provided and form a foundation for QI. Performance measures have thus been developed to provide a mechanism through which the quality of medical care can be measured and improved. The ACC/AHA and other organizations developed processes and criteria to identify performance measures with validity, reliability, and feasibility.22 These performance measures are based on clinical practice guidelines, but are intended to be confined to those structural aspects or processes of care for which the evidence is so strong that the failure to perform them reduces the likelihood of optimal patient outcomes.22 To achieve the goal of serving as a vehicle for more rapidly translating the strongest clinical evidence into clinical practice, priority is placed on performance measures that have the strongest association to clinical outcomes and involve care with the largest gaps, variations, and disparities in routine practice. In conjunction with performance measures, a number of cardiovascular QI systems have been developed and deployed. The AHA launched the Get With The Guidelines program in 2000 to improve the quality of care and clinical outcomes of patients with CVD and stroke in the United States.23 Modules include coronary artery disease/acute coronary syndromes, heart failure, stroke, atrial fibrillation, cardiac resuscitation, along with outpatient primary and secondary prevention.23 The Get With The Guidelines program provides clinical decision support tools, real-time benchmarked performance feedback, conferences focused on QI, other educational materials, and opportunities for national recognition.23,24 The program also provides AHA field staff to assist clinicians, hospitals, and outpatient practices in deploying sophisticated QI strategies. By facilitating real access to benchmarked performance data, clinicians can compare their performance based on a large selection of performance measures, quality metrics, and patient subgroups. Participation in Get With The Guidelines has been demonstrated to be associated with rapid and sustained improvement in multiple care processes linked to improved clinical outcomes.23–25 This program resulted in
improvements in acute cardiovascular and stroke care and prevention guideline specific to the targeted performance measures, with improvements in care quality being sustained for more than a decade.23 Other programs have demonstrated significant improvements in care quality.26,27 For example, the GRACE registry27 demonstrated improvement in acute coronary syndrome care and outcomes among participating hospitals in Europe. Collectively, the findings with these programs suggest that the quality of care provided to patients with and at risk for CVD and stroke and clinical outcomes can be substantially enhanced by using data collection, performance feedback, clinical decision support tools, collaborative care models, and by concentrating on those processes of care that have been proved to improve outcomes.
QUALITY OF CARE ACROSS THE CONTINUUM–PRIMARY CARE/ SPECIALTY CARE/DIAGNOSTICS/HOSPITAL CARE/POST-ACUTE AND POST-HOSPITAL CARE The hospital and specialty focused approach of INCARDIO mirrors that of current efforts in most countries including the United States.23 The global challenge for QI efforts going forward is to improve cardiovascular care across the continuum of care by all providers of care, not just specialists.4,28 Some procedural interventions are limited to specialists, but other diagnostic and therapeutic care may be provided by others including primary care and nonphysician providers such as nurses. In addition, there are marked global and regional variations in settings for care delivery.29 Depending on the system, a specific intervention may occur in the hospital, clinic, emergency department, or a postacute setting.30 National QI efforts must evolve to address this reality, and it is important to note that INCARDIO is providing leadership by beginning to incorporate this spectrum with its inclusion of cardiac rehabilitation measures.10 CONCLUSIONS As the global healthcare community engages in the transition from the Millennium Development Goals to Sustainable Development Goals, it is critical that we establish metrics for assessing the quality of clinical care. Given the burden of CVD worldwide, it is appropriate that leading national cardiac societies identify QI indicators and put in place procedures for tracking progress toward desired objectives. Thus, the collaborative work of the SEC, SECTCV, and ESC is an especially welcome contribution. As we illustrate in this commentary, lessons learned from the experience in the United States may be helpful for formulating programs in other countries. The Leadership Council of the Sustainable Development Solutions Network envisions that national monitoring plans and thematic monitoring plans (that span national boundaries) are part of a rich integrated network that informs regional and global monitoring plans. The path is now clear–if we wish to impact the future of CVD around the world, we must take action now–starting with national imperatives. Felicitaciones a nuestros colegas espan˜oles! !
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CONFLICTS OF INTEREST None declared. REFERENCES 1. Cardiovascular disease [accessed 2015 Jul 2]. Geneva: World Health Organization; 2013. Available at: http://www.who.int/cardiovascular_diseases/ about_cvd/en/
S.C. Smith, Jr. et al. / Rev Esp Cardiol. 2015;68(11):924–927 2. O’Gara PT, Kushner FG, Ascheim DD, Casey Jr DE, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:529–55. 3. Jauch EC, Saver JL, Adams Jr HP, Bruno A, Connors JJ, Demaerschalk BM, et al.; American Heart Association Stroke Council, Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2013;44:870–947. 4. Puymirat E, Battler A, Birkhead J, Bueno H, Clemmensen P, Cottin Y, et al. Euro Heart Survey 2009 Snapshot: regional variations in presentation and management of patients with AMI in 47 countries. Eur Heart J Acute Cardiovasc Care. 2013;2:359–70. 5. Wang M, Moran AE, Liu J, Coxson PG, Heidenreich PA, Gu D, et al. Costeffectiveness of optimal use of acute myocardial infarction treatments and impact on coronary heart disease mortality in China. Circ Cardiovasc Qual Outcomes. 2014;7:78–85. 6. Krumholz HM, Radford MJ, Ellerbeck EF, Hennen J, Meehan TP, Petrillo M, et al. Aspirin in the treatment of acute myocardial infarction in elderly Medicare beneficiaries. Patterns of use and outcomes. Circulation. 1995;92:2841–7. 7. Ellerbeck EF, Jencks SF, Radford MJ, Kresowik TF, Craig AS, Gold JA, et al. Quality of care for Medicare patients with acute myocardial infarction. A four-state pilot study from the Cooperative Cardiovascular Project. JAMA. 1995;273:1509–14. 8. Sonel AF, Good CB, Mulgund J, Roe MT, Gibler WB, Smith Jr SC, et al.; CRUSADE Investigators. Racial variations in treatment and outcomes of black and white patients with high-risk non –ST-elevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?) Circulation. 2005;111:1225–32. 9. Krumholz HM, Normand SL, Wang Y. Trends in Hospitalizations and Outcomes for Acute Cardiovascular Disease and Stroke, 1999-2011. Circulation. 2014;130:966–75. 10. Lo´pez-Sendo´n J, Gonza´ lez-Juanatey JR, Pinto F, Cuenca Castillo J, Badimo´n L, Dalmau R, et al. Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del A´rea del Corazo´n): A SEC/SECTCV Consensus Position Paper. Rev Esp Cardiol. 2015;68:976–95.e10. 11. Lohr KN, editor. Medicare: a strategy for quality assurance, Vol1. Washington: National Academy Press; 1990. 12. Quality of Care and Outcomes Research in CVD and Stroke Working Groups. In: Measuring and Improving Quality of care: a Report From the American Heart Association/American College of Cardiology First Scientific Forum on Assessment of Healthcare Quality in Cardiovascular Disease and Stroke. Circulation. 2000;101:1483–93. 13. Performance Management and Measurement. Washington, DC: Health Resources and Services Administration: U.S. Department of Health and Human Services; 2011. ˜ a IL, Cohen PD, Larson DB, Marion LN, Sills MR, Solberg LI, et al. A framework 14. Pin for describing health care delivery organizations and systems. Am J Public Health. 2015;105:670–9.
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15. Institute of Medicine. Vital signs: core metrics for health and health care progress [accessed 2015 Jul 26]. Washington: National Academies Press; 2015. Available at: http://www.iom.edu/coremetrics 16. Burgers JS, Grol R, Klazinga NS, Makela M, Zaat J; AGREE Collaboration. Towards Evidence-based Clinical practice: an International Survey of 18 Clinical Guideline Programs. Int J Qual Health Care. 2003;15:31–45. 17. Ollenschla¨ger G, Marshall C, Qureshi S, Rosenbrand K, Burgers J, Ma¨kela¨ M, et al. Improving the quality of health care: using international collaboration to inform guideline programmes by founding the Guidelines International Network. Qual Saf Health Care. 2004;13:455–60. 18. Murray CJ, Frenk J. A Framework for Assessing the Performance of Health Care Systems. Bull World Health Org. 2000;78:717–31. 19. Rooney AL, van Ostenberg PR. Licensure, Accreditation, and Certification: Approaches to Health Services Quality. Bethesda:, MD, United States: USAID; 1999. 20. Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On The Front Lines Of Care: Primary Care Doctors’ Office Systems, Experiences, And Views In Seven Countries. Health Aff. 2006;25:555–71. 21. Schmitt MH. Collaboration improves the quality of care: methodological challenges and evidence from US health care research. J Interprof Care. 2001;15:47–66. 22. Spertus JA, Eagle KA, Krumholz HM, Mitchell KR, Normand SL; American College of Cardiology/American Heart Association Task Force on Performance Measures. American College of Cardiology and American Heart Association methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. J Am Coll Cardiol. 2005;45:1147–56. 23. Ellrodt AG, Fonarow GC, Schwamm LH, Albert N, Bhatt DL, Cannon CP, et al. Synthesizing lessons learned from get with the guidelines: the value of diseasebased registries in improving quality and outcomes. Circulation. 2013;128: 2447–60. 24. Lewis WR, Peterson ED, Cannon CP, Super DM, LaBresh KA, Quealy K, et al. An organized approach to improvement in guideline adherence for acute myocardial infarction: results with the Get With The Guidelines quality improvement program. Arch Intern Med. 2008;168:1813–9. 25. Schwamm LH, Fonarow GC, Reeves MJ, Pan W, Frankel MR, Smith EE, et al. Get With The Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009;119:107–15. 26. Alexander KP, Roe MT, Chen AY, Lytle BL, Pollack Jr CV, Foody JM, et al. Evolution in cardiovascular care for elderly patients with non—ST-segment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative. J Am Coll Cardiol. 2005;46:1479–87. 27. Fox KA, Steg PG, Eagle KA, Goodman SG, Anderson Jr FA, Granger CB, et al.; GRACE Investigators. Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006. JAMA. 2007;297:1892–900. 28. Jollis JG, DeLong ER, Peterson ED, Muhlbaier LH, Fortin DF, Califf RM, et al. Outcome of Acute Myocardial Infarction According to the Specialty of the Admitting Physician. NEJM. 1996;335:1880–7. 29. Joshi R, Jan S, Wu Y, MacMahon S. Global inequalities in access to cardiovascular health care: our greatest challenge. J Am Coll Cardiol. 2008;52:1817–25. 30. Evans A, Perez I, Harraf F, Melbourn A, Steadman J, Donaldson N, et al. Can differences in management processes explain different outcomes between stroke unit and stroke-team care? Lancet. 2001;358:1586–92.
Editorial
Improving Quality of Cardiac Care: A Global Mandate Mejorar la calidad de la asistencia cardiaca: un imperativo mundial ˜ a,c Robert Suter,d Louise Morgan,d Kathryn Taubert,d Sidney C. Smith, Jr.a,* Gregg C. Fonarow,b Ileana L. Pin Eduardo Sanchez,d and Elliott Antmane a
Heart and Vascular Center, University of North Carolina, Chapel Hill, North Carolina, United States Division of Cardiology, UCLA David Geffen School of Medicine, Los Angeles, California, United States Division of Cardiology, Albert Einstein College of Medicine, Bronx, New York, United States d American Heart Association, Dallas, Texas, United States e Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States b c
Article history: Available online 10 September 2015
Cardiovascular disease (CVD) is the leading cause of death in the world. It is estimated to have claimed the lives of 17.3 million people in 2008 and, if left unchecked, this figure expected to increase to more than 23.6 million deaths by 2030.1 The greatest increases in mortality from heart disease and stroke are expected to occur in low- and middle-income countries, which often have not implemented programs designed to curb this international epidemic. A number of therapies substantially reduce morbidity and mortality in patients with or at risk for CVD and stroke.2,3 Many of these evidence-based, guideline-directed therapies are readily available worldwide.4,5 However, studies in an array of settings have demonstrated that numerous patients still fail to receive effective, safe, high-value CVD and stroke treatments in a timely fashion.6,7 There are also substantial hospital and outpatient practice, regional, national, and global variations in the use of evidence-based care along with disparities in care, particularly among certain patient populations.6–8 One of the high impact strategies to respond to the global epidemic of CVD and stroke is to ensure more consistent implementation of evidence-based care. During the past 15 years, the American Heart Association/ American Stroke Association (AHA/ASA) has developed a group of evidence based quality improvement (QI) programs (eg, coronary artery disease/acute coronary syndromes, atrial fibrillation, heart failure, stroke, cardiac resuscitation), which can effectively reduce the morbidity and mortality associated with CVD. These QI programs are now being used in more than 2000 United States hospitals with the result that nearly 80% of patients are able to readily receive evidence-based, guideline-directed care for CVD. The result has been a dramatic reduction of 29.4% in 30-day mortality for myocardial infarction, 16.4% for heart failure, and 4.7% for stroke.9 If the countries of the world are to achieve similar results, QI programs and systems of care should be replicated by their health care delivery systems.
SEE RELATED ARTICLE: http://dx.doi.org/10.1016/j.rec.2015.07.003, Rev Esp Cardiol. 2015;68:976–95.e10.
* Corresponding author: Heart and Vascular Center, University of North Carolina, Chapel Hill, North Carolina, United States. E-mail address: [email protected] (S.C. Smith, Jr.).
The article published in Revista Espan˜ola de Cardiologı´a by Lo´pez-Sendo´n et al10 is a thoughtful consensus document focusing on the definition of quality standards and markers to properly assess overall performance. The Spanish Society of Cardiology (SEC), in collaboration with the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV), contend that these measures should be prepared by cardiac societies. Accordingly, they prepared their document to help define quality markers and metrics that can help evaluate the overall results of the clinical practice and outcomes in cardiology. The AHA is now collaborating with several international QI programs to improve outcomes for patients with CVD and has put forward the following discussion about improving quality of cardiac care to provide further information about the design and implementation of evidence based QI programs which have been successful in the United States. THE VALUE OF A FOCUS ON QUALITY OF CARE: QUALITY IMPROVEMENT PROCESSES AND PREDICTABLY AND MEASURABLY BETTER OUTCOMES The Institute of Medicine defines quality of care as: ‘‘The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’’.11 However, quality to a physician is very personal, ie, am I doing the right thing for my patients and are they better off for it? The Institute of Medicine definition is further elaborated by descriptions of care being timely, effective, safe, equitable, patient-centered, and cost effective. To enhance quality, clinical practice guidelines have been developed, not only in the United States but also in Europe, Canada, and other countries, to ‘‘guide’’ clinicians, using current evidence, to choose treatments for specific syndromes that are based on the risks and benefits studied in the literature. The use of guidelines should help with daily clinical decisions for treatment and decrease the heterogeneity of care. This promotes ‘‘best practices’’, allowing systems as well as payers and peers to define ‘‘quality’’. Guidelines, however, although essential, are insufficient to determine if quality care is being delivered. How can improvement
http://dx.doi.org/10.1016/j.rec.2015.08.002 ˜ ola de Cardiologı´a. Published by Elsevier Espan ˜ a, S.L.U. All rights reserved. 1885-5857/ß 2015 Sociedad Espan
S.C. Smith, Jr. et al. / Rev Esp Cardiol. 2015;68(11):924–927
occur, if measurement of baseline is unknown? How can healthcare organizations compare themselves among each other or peers and evaluate others against themselves? In 1999, the AHA convened a group of professionals as the First Scientific Forum on Assessment of Quality of Care and Outcomes Research in CVD and stroke. The areas of focus included myocardial infarction, stroke, heart failure, and methodology. The group clearly stated that quality measurement was no longer optional, but essential.12 The ultimate goal of any QI program is to reach the desired health outcomes of better health for a group or system. Measurement of quality is therefore an imperative. However, performance measures need to be distinguished from performance measurement and management. Performance measures are synthesized from clinical guidelines and can therefore be very disease specific and are meant to measure systems of care by operationalizing recommendations found in Guidelines. Performance measurement, on the other hand, is a process which includes the operations necessary to collect the data that are basic to using the performance measures. Obviously, one cannot exist without the other. However, choosing the right measures and deciding what outcomes should follow should precede the collection of such data. Hence performance management sets the goals of QI and uses the plan-do-study-act cycle to assess, improve, and reassess progress. Far too often data are collected without a goal being specified.13 The next 15 years of performance measurement brought a multitude of measures whose purpose was to improve care. The importance of measurement has not waned. However, its complexity has grown as organizations have looked to the public health agencies for confirmation or development of measures for a large group of conditions, very prominently, cardiac measures. In the complex world of organizations, health systems, and practices, the Agency for Healthcare Research and Quality convened a group of stakeholders to develop a taxonomy of healthcare systems that would allow comparisons across delivery to decide what is best for patients. One of the domains identified by this work, 15 years after the AHA forum, was ‘‘Care processes and infrastructure’’, which included performance measurement, public reporting, and QI.14 The Agency for Healthcare Research and Quality report provides some context for this suggested element as: 1. The extent to which the organization conducts regular measurement of performance with public reporting, feedback, and a systematic process of improvement. 2. Number of clinical performance measures assessed at least yearly. 3. Proportion of those measures with results reported to the public and those providing measured care. 4. Proportion of those measures with active action plans for improvement. Given these recommendations and the growing complexity of patient care added to extensive choices for treatment, true quality of care demands measurements, ie, proving that what we think we are doing, we are actually doing. The Institute of Medicine report also heralded the age of transparency. Today’s world economy also demands transparency with more scrutiny on public health and health systems practices, thereby demanding reporting of measurements and quality efforts. Government agencies use performance measures to add or remove resources if the data collected does not verify quality of care. Organizations use measures to monitor and compare practices and evaluate the need for additional resources to achieve their goals of care. Finally, clinicians use disease specific measures to selfregulate, compare and improve their delivery of care.
925
The plethora of measures in the last 15 years has not gone unnoticed by the Institute of Medicine. In their most recent report, ‘‘Vital signs: core metrics for health and health care progress’’, the group underscores the multitude of measures that have added complexity and confusion due to lack of focus, consistency, and organization.15 The report points out that similar measures have been developed by various groups with minor differences that impede comparisons within or among systems and providers. These limitations hinder the improvement of health systems. The report further advises that all stakeholders must notice which measures matter the most to focus on the health care of Americans. The report proposes a set of 15 measures covering the 4 domains of healthy people, care quality, lower cost, and engaged people. Such a set of measures could be conducive to a more focused health progress using the highest priority areas, ie, the 4 domains. The 15 measures are highlighted in the Figure. Pertinent to this commentary is number 10 or evidenced based care including: cardiovascular risk reduction, hypertension control, diabetes control composite, heart attack therapy protocol, stroke therapy protocol, and unnecessary care composite. The report describes this measure as ‘‘ensuring that patients receive care supported by scientific evidence for appropriateness and effectiveness is a central challenge for the health care system. Currently, an estimated one-third of United States health care expenditures do not contribute to improving health. Aggregating carefully selected and standardized clinical measures can provide a reliable composite index of system performance.’’ The mandates are clear: QI efforts can be effective when deployed with thoughtful measurement of performance by setting goals of outcomes as a priority and selection of measures that are poised to effectively measure true performance and allow comparisons among groups. At the same time, these measures should facilitate reporting to agencies that are responsible for payment and allocation of resources, eg, public health groups, insurers, and funding agencies. Selection of meaningful and targeted measures for QI should be a priority for providers, payers, and government agencies to promote the cardiovascular health of all its citizens.
Community engagement
Life expectancy Well-being
Individual engagement
Overweight and obesity
Population spending burden
Addictive behavior
Core metrics for health and health care progress
Personal spending burden
Unintended pregnancy
To achieve better health at lower cost, all stakeholders including health professionals, payers, policy makers, communities, and members of the public- must focus on what matters most. What are the core measures that will yield the clearest understanding of health and well-being in America? Vital Signs, a 2015 report from the Institute of Medicine, proposes a set of 15 core measures for health and health care. Explore the inforgraphic to see examples for each measure. match
Care with patient goals
Healthy communities
Evidencebased care
Preventive services Patient safety
Care access
Figure. The recommended Core Metrics 2015.15
S.C. Smith, Jr. et al. / Rev Esp Cardiol. 2015;68(11):924–927
HOW DIFFERENCES IN WHAT WORKS MAY BE DUE TO DIFFERENCES IN SYSTEM DESIGN AND LEGISLATION/ REGULATION/VOLUNTARY CERTIFICATION One challenge to global healthcare QI efforts is the need to use culturally and system specific tools that account for differences in data collection and the legal and regulatory environment unique to each country.16,17 The questions of whether participation in a specific QI program is mandatory or voluntary, and with or without achievement of special certification or recognition, are critical to the design of a successful program.18,19 Reportable metrics for accreditation vary widely between nations, potentially making the number of metrics within a specific QI tool either excessive or insufficient. In addition, variations in the degree that interdisciplinary care vs physician care drives the cultural adjustment needed in QI efforts and tools required.20,21 These sophisticated influences are reflected in the INCARDIO (Indicadores de Calidad en Unidades Asistenciales del A´rea del Corazo´n) approach in Spain.
CHOOSING, MEASURING, AND MONITORING THE RIGHT METRICS: THE AMERICAN HEART ASSOCIATION GUIDELINES AND GET WITH THE GUIDELINES EXPERIENCE The ACC/AHA (American College of Cardiology/American Heart Association) have developed clinical practice guidelines outlining diagnostic and therapeutic interventions for patients with and at risk for CVD. The evidence in favor of implementing certain recommendations is particularly strong, and provision of this care is thought to be critical in achieving optimal patient outcomes. Adherence to these suggested interventions may therefore serve as a marker of quality of care provided and form a foundation for QI. Performance measures have thus been developed to provide a mechanism through which the quality of medical care can be measured and improved. The ACC/AHA and other organizations developed processes and criteria to identify performance measures with validity, reliability, and feasibility.22 These performance measures are based on clinical practice guidelines, but are intended to be confined to those structural aspects or processes of care for which the evidence is so strong that the failure to perform them reduces the likelihood of optimal patient outcomes.22 To achieve the goal of serving as a vehicle for more rapidly translating the strongest clinical evidence into clinical practice, priority is placed on performance measures that have the strongest association to clinical outcomes and involve care with the largest gaps, variations, and disparities in routine practice. In conjunction with performance measures, a number of cardiovascular QI systems have been developed and deployed. The AHA launched the Get With The Guidelines program in 2000 to improve the quality of care and clinical outcomes of patients with CVD and stroke in the United States.23 Modules include coronary artery disease/acute coronary syndromes, heart failure, stroke, atrial fibrillation, cardiac resuscitation, along with outpatient primary and secondary prevention.23 The Get With The Guidelines program provides clinical decision support tools, real-time benchmarked performance feedback, conferences focused on QI, other educational materials, and opportunities for national recognition.23,24 The program also provides AHA field staff to assist clinicians, hospitals, and outpatient practices in deploying sophisticated QI strategies. By facilitating real access to benchmarked performance data, clinicians can compare their performance based on a large selection of performance measures, quality metrics, and patient subgroups. Participation in Get With The Guidelines has been demonstrated to be associated with rapid and sustained improvement in multiple care processes linked to improved clinical outcomes.23–25 This program resulted in
improvements in acute cardiovascular and stroke care and prevention guideline specific to the targeted performance measures, with improvements in care quality being sustained for more than a decade.23 Other programs have demonstrated significant improvements in care quality.26,27 For example, the GRACE registry27 demonstrated improvement in acute coronary syndrome care and outcomes among participating hospitals in Europe. Collectively, the findings with these programs suggest that the quality of care provided to patients with and at risk for CVD and stroke and clinical outcomes can be substantially enhanced by using data collection, performance feedback, clinical decision support tools, collaborative care models, and by concentrating on those processes of care that have been proved to improve outcomes.
QUALITY OF CARE ACROSS THE CONTINUUM–PRIMARY CARE/ SPECIALTY CARE/DIAGNOSTICS/HOSPITAL CARE/POST-ACUTE AND POST-HOSPITAL CARE The hospital and specialty focused approach of INCARDIO mirrors that of current efforts in most countries including the United States.23 The global challenge for QI efforts going forward is to improve cardiovascular care across the continuum of care by all providers of care, not just specialists.4,28 Some procedural interventions are limited to specialists, but other diagnostic and therapeutic care may be provided by others including primary care and nonphysician providers such as nurses. In addition, there are marked global and regional variations in settings for care delivery.29 Depending on the system, a specific intervention may occur in the hospital, clinic, emergency department, or a postacute setting.30 National QI efforts must evolve to address this reality, and it is important to note that INCARDIO is providing leadership by beginning to incorporate this spectrum with its inclusion of cardiac rehabilitation measures.10 CONCLUSIONS As the global healthcare community engages in the transition from the Millennium Development Goals to Sustainable Development Goals, it is critical that we establish metrics for assessing the quality of clinical care. Given the burden of CVD worldwide, it is appropriate that leading national cardiac societies identify QI indicators and put in place procedures for tracking progress toward desired objectives. Thus, the collaborative work of the SEC, SECTCV, and ESC is an especially welcome contribution. As we illustrate in this commentary, lessons learned from the experience in the United States may be helpful for formulating programs in other countries. The Leadership Council of the Sustainable Development Solutions Network envisions that national monitoring plans and thematic monitoring plans (that span national boundaries) are part of a rich integrated network that informs regional and global monitoring plans. The path is now clear–if we wish to impact the future of CVD around the world, we must take action now–starting with national imperatives. Felicitaciones a nuestros colegas espan˜oles! !
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CONFLICTS OF INTEREST None declared. REFERENCES 1. Cardiovascular disease [accessed 2015 Jul 2]. Geneva: World Health Organization; 2013. Available at: http://www.who.int/cardiovascular_diseases/ about_cvd/en/
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