The IC3 (Improving Continuous Cardiac Care) - PINNACLE

Program: A Report of the first 14,000+ Patients

Paul S. Chan, MD MSc William J. Oetgen, MD Donna Buchanan, PhD Kristi Mitchell MPHFran F. Fiocchi, MPH Fengming Tang, MSPhilip G. Jones, MS Duane Thrutchley, RNTracie Breeding, RN BSN John S. Rumsfeld, MD PhDJohn A. Spertus, MD MPH

Paul S. Chan, MD MSc William J. Oetgen, MD Donna Buchanan, PhD Kristi Mitchell MPHFran F. Fiocchi, MPH Fengming Tang, MSPhilip G. Jones, MS Duane Thrutchley, RNTracie Breeding, RN BSN John S. Rumsfeld, MD PhDJohn A. Spertus, MD MPH

Disclosures

• Funding for IC3/PINNACLE:

- American College of Cardiology

- Bristol-Myers Sanofi

• Funding for IC3/PINNACLE:

- American College of Cardiology

- Bristol-Myers Sanofi

Overview of Performance Measurement• Performance measures represent a subset

of the Guidelines – What must be done in care…

• Much improvement in inpatient care has emerged from performance measurement

• While numerous outpatient performance measures exist…– These have not been systematically collected– Current performance is unknown– Until measured, QI can not occur

Current ACC/AHA Performance Measures

CAD Performance Measures

• BP Measurement• Symptom & Activity

Assessment• Smoking Assessment

– Counseled to quit• Anti-platelet Therapy• Lipid Profile• Use of Lipid Therapy -blocker post-MI• ACE/ARB in EF & DM• Screening for Diabetes

CHF Performance Measures

• LVEF Assessment• Weight Measurements• BP Measurements• Clinical Symptom

Assessment• Activity Assessment• Signs of Volume Overload• Patient Education -blocker in EF • ACE/ARB in EF• Warfarin for Afib• Initial Lab Tests

Current ACC/AHA Performance Measures

A Fib Performance Measures• Thromboembolic Risk

– Prior CVA/TIA– Age ≥75– Hypertension– Diabetes– Heart failure or EF

• Warfarin use in High-risk pts• Monthly INR in pts on warfarin

Cardiac Rehabilitation PMs• Referral to a Rehab Program

– Within 12 months of• ACS• PCI• CABG• Valve Surgery• Transplant

– Stable Angina

Challenges with the Current Quality Model

• Consensus on Optimal Performance Measures

– Payers often use their own measures

• Accurately Capturing Performance Measures

– Administrative data often used

• Reporting Performance to Payers

– Administratively cumbersome to practices, especially with different measures for different payers

What is IC3/PINNACLE?

• Prospective collection of outpatient clinical data

• Use of that data to assist in the office visit

• Use of that data to coordinate/communicate care

• Use of that data to generate performance reports– Physician-level reports for QI

– Practice-level reports for QI and P4P Programs

Implementation

• Modes of data collection– Existing EMRs

• Specifications provided to EMR Vendors

• Quarterly transmission to ACC for Benchmarking reports

– Paper forms

• For practices without an EMR

IC3 Program: Incentives for Practices

• To improve care– Provide measurement of quality indicators from

guidelines and performance measures– Frequent assessment of performance so that

improvements can be made and monitored

• Trusted mechanism for reporting performance– Support evolving CMS PQRI initiatives– Support Pay-for-Performance programs with payers– Collect once, report to all

Objectives of this Study

• Descriptive report of first 14,000+ outpatients

• Focus on 11 CAD performance measures (PMs)

• Definition of CAD: 1.prior MI2.prior coronary revascularization3.known coronary stenosis >70%

Methods

• Primary Outcome: Compliance with PMs

# patients (or visits) which met a PM # of eligible patients (or visits) for that PM

• Denominator exclusions– medical (e.g., allergies)– personal (e.g., cost, refusal) reasons

• Patients could be excluded for some, but included in other, CAD PMs

RESULTS

Enrollment Period: July 2008 to June 2009

Study Sample

• 18,021 encounters among 14,464 patients from 26 practices

• Of these, 10,337 encounters among 8132 CAD patients

Enrollment Period: July 2008 to June 2009

Study Sample

• 18,021 encounters among 14,464 patients from 26 practices

• Of these, 10,337 encounters among 8132 CAD patients

CompliancePerformance Measure Denominator Numerator RateBeta-Blocker Therapy after MI 1782 1540 86.4%Blood Pressure Measurement 7698 7235 94.0%Antiplatelet Therapy 7944 6742 84.9%Screening for Diabetes 6199 822 13.3%Smoking Query 8132 6812 83.8%Smoking Cessation 500 356 71.2%Symptom & Activity Assessment 8132 6981 85.8%ACE-I or ARB Therapy 4623 3349 72.4%Annual Lipid Profile 8132 6044 74.3%Lipid Lowering Therapy 1607 1355 84.3%Cardiac Rehabilitation Referral 1108 200 18.1%

Clopidogrel Post DES 397 325 81.9%

Limitations• First report of 14,000+ patients from 26

practices- small practice numbers- practices highly-motivated

• No way of determining whether data on some cardiac patients were excluded from submission however, this would preclude use of data for P4P and PQRI

• Clinicians could ‘game’ the system by assigning exclusions for patients who are otherwise not compliant with a particular PM still found gaps in compliance with various PMs

Next Steps

• Examine PM adherence in other cardiac diseases (HF, A Fib)

• Examine whether PM adherence differs by gender, race

• Examine if participation in IC3 (quarterly reports, benchmarking) improves PM adherence over time

• Develop real-time decision support to improve adherence

Conclusions

• Compliance rates for CAD among outpatients enrolled in IC3 varied substantially, ranging from 13% to 94%

• These results highlight important gaps in the quality of outpatient CAD care and provide a valuable benchmark for future improvement