- Email: [email protected]
Physician Leadership for High-Quality Care
lation. The combination of OAC and antiplatelet therapy (the latter includes therapy with aspirin or thienopyridine agents) would only exacerbate the increased bleeding risks, especially in elderly patients with multiple comorbidities. Even though the sample size in the article by Le Tourneau et al4 is relatively small, the study demonstrates that ball-and-cage MVR is associated with a high thromboembolic complication rate. Although a wide (and high) therapeutic INR range was aimed for in this study (INR range, 2.0 to 4.5), patients with MVR still experienced thromboembolic events. Perhaps MVR patients do not warrant such a high level of anticoagulation. Whether the results of population studies would apply to individual cases is often debated. As an illustration, one published case report8 has described a patient who received a balland-cage MVR and a metallic aortic valve prosthesis who was free of thromboembolic complications for 30 years despite a history of AF and congestive heart failure, even in the absence of OAC with the patient receiving only high-dose aspirin therapy (4 to 12 325-mg tablets daily) for 30 years! This is clearly an extreme example, but, given the improved thrombogenic profile of new prosthetic valves, the current recommendations on target INR ranges for patients receiving prosthetic valves merit some attention. What should clinicians specifically do? Until evidence from large randomized, controlled trials is available, we should still defer to the published guidelines.3 However, associated comorbidities should be considered, given the delicate balance between the prevention of thrombosis and the risk of bleeding, and the need for the management of treatable risk factors (eg, hypertension) to be fully optimized. This is clearly the case for other conditions associated with thromboembolism, such as AF, in which the risk factors contributing to stroke are very well recognized (and greatly researched), and are cumulative in contributing to stroke risk.9,10 Perhaps, we need to turn greater attention to the risks of thrombosis and bleeding that are associated with anticoagulation in patients receiving prosthetic heart valves. Kok-Hoon Tay, MBBS Deirdre A. Lane, PhD Gregory Y. H. Lip, MD Birmingham, UK Affiliations: Drs. Tay, Lane, and Lip are affiliated with the University Department of Medicine, City Hospital. Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Gregory Y. H. Lip, MD, City Hospital, Haemostasis, Thrombosis, and Vascular Biology Unit, Dudley Rd, Birmingham, B18 7QH, UK; e-mail: [email protected] 1452
© 2009 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/ misc/reprints.xhtml). DOI: 10.1378/chest.09-1187
References 1 Edmunds LH Jr. Thrombotic and bleeding complications of prosthetic heart valves. Ann Thorac Surg 1987; 44:430 – 445 2 Edmunds LH Jr. Thromboembolic complications of current cardiac valvular prostheses. Ann Thorac Surg 1982; 34:96 –106 3 Salem DN, O’Gara PT, Madias C, et al. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133(suppl):593S– 629S 4 Le Tourneau T, Lim V, Inamo J, et al. Achieved anticoagulation versus prosthesis selection for mitral mechanical valve replacement: a population-based outcome study. Chest 2009; 136:1503–1513 5 Lane DA, Ponsford J, Shelley A, et al. Patient knowledge and perceptions of atrial fibrillation and anticoagulant therapy: effects of an educational intervention programme: the West Birmingham Atrial Fibrillation Project. Int J Cardiol 2006 28; 110:354 –358 6 Dahri K, Loewen P. The risk of bleeding with warfarin: a systematic review and performance analysis of clinical prediction rules. Thromb Haemost 2007; 98:980 –987 7 Tay KH, Lane DA, Lip GYH. Bleeding risks with combination of oral anticoagulation plus antiplatelet therapy: is clopidogrel any safer than aspirin when combined with warfarin? Thromb Haemost 2008; 100:955–957 8 Miller MM, Hipp R, Matsumura ME. Freedom from complications related to dual ball-and-cage mechanical valve prostheses despite thirty years without anticoagulation. Interact Cardiovasc Thorac Surg 2008; 7:1167–1169 9 Hughes M, Lip GY, Guideline Development Group, National Clinical Guideline for Management of Atrial Fibrillation in Primary and Secondary Care, National Institute for Health and Clinical Excellence. Stroke and thromboembolism in atrial fibrillation: a systematic review of stroke risk factors, risk stratification schema and cost effectiveness data. Thromb Haemost 2008; 99:295–304 10 McBane RD, Hodge DO, Wysokinski WE. Clinical and echocardiographic measures governing thromboembolism destination in atrial fibrillation. Thromb Haemost 2008; 99:951–955
Physician Leadership for High-Quality Care policymakers grapple with reforming the US A shealth-care system, a common theme is the urgent
need to assure that all Americans receive high-quality, affordable care. While specific details regarding how that goal will be achieved, and how rapidly we can get there, are the focus of extensive debate, it is clear that a focus on the public reporting of quality is likely to expand. In more recent years, strong collaborations between Medicare and the private sector now make it possible for the public to access information on quality within hospitals, nursing homes, home health care, and Editorials
many other settings. Medicare demonstrations and private sector initiatives that attempt to align payment with quality rather than volume provide a foundation for future value-based purchasing initiatives. In this issue of CHEST (see page 1644), Metersky1 provides a clear summary of the Medicare physician quality reporting initiative (PQRI) for chest physicians. The article provides a cogent context for this initiative, and specific steps and advice that should enhance physicians’ ability to participate in this program. In addition to the PQRI, physicians can now receive additional incentive payments from Medicare for electronic prescribing (2%). The American Recovery and Reinvestment Act, passed in February 2009, also includes specific incentives for the “meaningful use” of health information technology, including the capacity to report quality measures electronically, for both Medicare and Medicaid starting in 2011. The pace of these developments represents an unprecedented opportunity for physician leadership. The article by Metersky1 accurately describes how important it is for physician practices to understand the specific details about the measures, and about data collection and submission. In anticipation of an increased focus on quality care, physicians should be thinking right now about how they can engage as individual practitioners as well as through their professional organizations.
Which Measures? The rate-limiting factor for all quality assessment efforts is the feasibility of collecting reliable data accurately and efficiently. Increased adoption of electronic health records and other applications of health information technology will dramatically alter this calculus, raising the following important question: which aspects of care are most important to measure? A key dimension of making care affordable as well as of high quality will be enhanced care coordination and transitions in care, raising the possibility of using measures that link the decisions of one physician with the actions of other physicians sharing the care of the same patient (eg, pathologists routinely include cancer stage on the pathology report, and oncologists then use that information to guide treatment). The PQRI now includes the possibility of reporting through patient registries. How might pulmonary specialists take advantage of this opportunity?
Health Information Technology The promise of more ubiquitous clinical electronic data for quality assessment is compelling and challenging. The majority of commercial products, which were developed for a system that rewards volume rather than www.chestjournal.org
quality, do not yet support easy data retrieval.2 This will change when the operational definition of “meaningful use” is established, but will also require physicians to work together to address issues that range from reconciling different values from different sources to the incorporation of standard data collection at the point of care. In addition to providing comments on the definition of “meaningful use” later this year, it is time to examine what aspects of daily practice will need to evolve to assure that collection data for patient care and quality reporting fit easily into the workflow. Getting to Improvement The annual National Healthcare Quality Report by the Agency for Healthcare Research and Quality has reflected steady, albeit modest, improvements across all settings and patient populations for the past 6 years.3 For the vast majority of clinical domains, there remains a substantial gap between the best possible care and that which is routinely delivered; that gap is larger still for members of racial and ethnic minorities, the poor, those with limited education, and others, as shown in the companion National Healthcare Disparities Report by the Agency for Healthcare Research and Quality.2 Transitioning from leisurely to rapid improvements will require timely feedback, clinical decision support, and broad engagement by practitioners and organizations to design systems and strategies that encourage and reinforce a culture of learning.4 Expanding the time-honored focus of seeing one patient at a time to one that incorporates a routine assessment of performance for patient groups has enormous implications for how we practice, how we educate future physicians, and how we collaborate with other stakeholders, including patients, to redesign our daily workflow. Don Berwick once observed,5 “In the end, only those who provide care can improve that care.” The article by Metersky1 clarifies the path for engaging the current PQRI. It is not too early for physicians to shift from reacting to specific programs to helping to shape them. Carolyn M. Clancy, MD Rockville, MD Affiliations: Dr. Clancy is Director, Agency for Healthcare Research and Quality. Financial/nonfinancial disclosures: The author has reported to the ACCP that no significant conflicts of interest exist with any conflicts/organizations whose products or services may be discussed in this article. Correspondence to: Carolyn M. Clancy, MD, Director, AHRQ, John M. Eisenberg Building, 540 Gaither Rd, Rockville, MD 20850; e-mail: [email protected] © 2009 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/ misc/reprints.xhtml). DOI: 10.1378/chest.09-1396 CHEST / 136 / 6 / DECEMBER, 2009
1453
References 1 Metersky M. The Medicare physician quality reporting initiative: what do chest physicians need to know? Chest 2009; 136:1644 –1649 2 Clancy CM, Anderson KM, White PJ. Investing in health information infrastructure: can it help achieve health reform? Health Aff (Millwood) 2009; 28:478 – 482
1454
3 Agency for Healthcare Research and Quality. National healthcare quality report 2008. Available at: www.ahrq.gov/ qual/qrdr08.htm. Accessed October 28, 2009 4 Conway PH, Clancy CM. Transformation of health care at the front line. JAMA 2009; 301:763–765 5 Berwick DM. Eleven worthy aims for clinical leadership of health system reform. JAMA 1994; 272:797– 802
Editorials
© 2009 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/ misc/reprints.xhtml). DOI: 10.1378/chest.09-1187
References 1 Edmunds LH Jr. Thrombotic and bleeding complications of prosthetic heart valves. Ann Thorac Surg 1987; 44:430 – 445 2 Edmunds LH Jr. Thromboembolic complications of current cardiac valvular prostheses. Ann Thorac Surg 1982; 34:96 –106 3 Salem DN, O’Gara PT, Madias C, et al. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133(suppl):593S– 629S 4 Le Tourneau T, Lim V, Inamo J, et al. Achieved anticoagulation versus prosthesis selection for mitral mechanical valve replacement: a population-based outcome study. Chest 2009; 136:1503–1513 5 Lane DA, Ponsford J, Shelley A, et al. Patient knowledge and perceptions of atrial fibrillation and anticoagulant therapy: effects of an educational intervention programme: the West Birmingham Atrial Fibrillation Project. Int J Cardiol 2006 28; 110:354 –358 6 Dahri K, Loewen P. The risk of bleeding with warfarin: a systematic review and performance analysis of clinical prediction rules. Thromb Haemost 2007; 98:980 –987 7 Tay KH, Lane DA, Lip GYH. Bleeding risks with combination of oral anticoagulation plus antiplatelet therapy: is clopidogrel any safer than aspirin when combined with warfarin? Thromb Haemost 2008; 100:955–957 8 Miller MM, Hipp R, Matsumura ME. Freedom from complications related to dual ball-and-cage mechanical valve prostheses despite thirty years without anticoagulation. Interact Cardiovasc Thorac Surg 2008; 7:1167–1169 9 Hughes M, Lip GY, Guideline Development Group, National Clinical Guideline for Management of Atrial Fibrillation in Primary and Secondary Care, National Institute for Health and Clinical Excellence. Stroke and thromboembolism in atrial fibrillation: a systematic review of stroke risk factors, risk stratification schema and cost effectiveness data. Thromb Haemost 2008; 99:295–304 10 McBane RD, Hodge DO, Wysokinski WE. Clinical and echocardiographic measures governing thromboembolism destination in atrial fibrillation. Thromb Haemost 2008; 99:951–955
Physician Leadership for High-Quality Care policymakers grapple with reforming the US A shealth-care system, a common theme is the urgent
need to assure that all Americans receive high-quality, affordable care. While specific details regarding how that goal will be achieved, and how rapidly we can get there, are the focus of extensive debate, it is clear that a focus on the public reporting of quality is likely to expand. In more recent years, strong collaborations between Medicare and the private sector now make it possible for the public to access information on quality within hospitals, nursing homes, home health care, and Editorials
many other settings. Medicare demonstrations and private sector initiatives that attempt to align payment with quality rather than volume provide a foundation for future value-based purchasing initiatives. In this issue of CHEST (see page 1644), Metersky1 provides a clear summary of the Medicare physician quality reporting initiative (PQRI) for chest physicians. The article provides a cogent context for this initiative, and specific steps and advice that should enhance physicians’ ability to participate in this program. In addition to the PQRI, physicians can now receive additional incentive payments from Medicare for electronic prescribing (2%). The American Recovery and Reinvestment Act, passed in February 2009, also includes specific incentives for the “meaningful use” of health information technology, including the capacity to report quality measures electronically, for both Medicare and Medicaid starting in 2011. The pace of these developments represents an unprecedented opportunity for physician leadership. The article by Metersky1 accurately describes how important it is for physician practices to understand the specific details about the measures, and about data collection and submission. In anticipation of an increased focus on quality care, physicians should be thinking right now about how they can engage as individual practitioners as well as through their professional organizations.
Which Measures? The rate-limiting factor for all quality assessment efforts is the feasibility of collecting reliable data accurately and efficiently. Increased adoption of electronic health records and other applications of health information technology will dramatically alter this calculus, raising the following important question: which aspects of care are most important to measure? A key dimension of making care affordable as well as of high quality will be enhanced care coordination and transitions in care, raising the possibility of using measures that link the decisions of one physician with the actions of other physicians sharing the care of the same patient (eg, pathologists routinely include cancer stage on the pathology report, and oncologists then use that information to guide treatment). The PQRI now includes the possibility of reporting through patient registries. How might pulmonary specialists take advantage of this opportunity?
Health Information Technology The promise of more ubiquitous clinical electronic data for quality assessment is compelling and challenging. The majority of commercial products, which were developed for a system that rewards volume rather than www.chestjournal.org
quality, do not yet support easy data retrieval.2 This will change when the operational definition of “meaningful use” is established, but will also require physicians to work together to address issues that range from reconciling different values from different sources to the incorporation of standard data collection at the point of care. In addition to providing comments on the definition of “meaningful use” later this year, it is time to examine what aspects of daily practice will need to evolve to assure that collection data for patient care and quality reporting fit easily into the workflow. Getting to Improvement The annual National Healthcare Quality Report by the Agency for Healthcare Research and Quality has reflected steady, albeit modest, improvements across all settings and patient populations for the past 6 years.3 For the vast majority of clinical domains, there remains a substantial gap between the best possible care and that which is routinely delivered; that gap is larger still for members of racial and ethnic minorities, the poor, those with limited education, and others, as shown in the companion National Healthcare Disparities Report by the Agency for Healthcare Research and Quality.2 Transitioning from leisurely to rapid improvements will require timely feedback, clinical decision support, and broad engagement by practitioners and organizations to design systems and strategies that encourage and reinforce a culture of learning.4 Expanding the time-honored focus of seeing one patient at a time to one that incorporates a routine assessment of performance for patient groups has enormous implications for how we practice, how we educate future physicians, and how we collaborate with other stakeholders, including patients, to redesign our daily workflow. Don Berwick once observed,5 “In the end, only those who provide care can improve that care.” The article by Metersky1 clarifies the path for engaging the current PQRI. It is not too early for physicians to shift from reacting to specific programs to helping to shape them. Carolyn M. Clancy, MD Rockville, MD Affiliations: Dr. Clancy is Director, Agency for Healthcare Research and Quality. Financial/nonfinancial disclosures: The author has reported to the ACCP that no significant conflicts of interest exist with any conflicts/organizations whose products or services may be discussed in this article. Correspondence to: Carolyn M. Clancy, MD, Director, AHRQ, John M. Eisenberg Building, 540 Gaither Rd, Rockville, MD 20850; e-mail: [email protected] © 2009 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/ misc/reprints.xhtml). DOI: 10.1378/chest.09-1396 CHEST / 136 / 6 / DECEMBER, 2009
1453
References 1 Metersky M. The Medicare physician quality reporting initiative: what do chest physicians need to know? Chest 2009; 136:1644 –1649 2 Clancy CM, Anderson KM, White PJ. Investing in health information infrastructure: can it help achieve health reform? Health Aff (Millwood) 2009; 28:478 – 482
1454
3 Agency for Healthcare Research and Quality. National healthcare quality report 2008. Available at: www.ahrq.gov/ qual/qrdr08.htm. Accessed October 28, 2009 4 Conway PH, Clancy CM. Transformation of health care at the front line. JAMA 2009; 301:763–765 5 Berwick DM. Eleven worthy aims for clinical leadership of health system reform. JAMA 1994; 272:797– 802
Editorials