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The overall quality of hospital care received by cardiovascular patients across the United States is high and improving, according to a report from the National Cardiovascular Data Registry (NCDR) registry program. However, the data, published online September 18, 2013, ahead of print in the Journal of the American College of Cardiology, also highlight some areas where current practice falls short. 

A team led by Frederick A. Masoudi, MD, MSPH, of the University of Colorado Anschutz Medical Campus (Aurora, CO), gathered data from 5 of the NCDR’s 7 registries covering distinct quality measurement and improvement programs for which comprehensive data were available for the year 2011:

• ACTION-GWTG: 119,967 patients at 567 hospitals
• CathPCI: 632,557 patients at 1,337 hospitals
• CARE: 4,934 patients at 130 hospitals
• ICD:139,991 patients at 1,435 hospitals
• PINNACLE: 249,198 outpatients at 74 practices involving 1,222 providers 

“This report provides a relatively rare insight into the global quality landscape with respect to a broad range of patients with cardiovascular disease,” Dr. Masoudi told TCTMD in a telephone interview.

It is also useful for identifying both longer-term and new trends in therapy, observed Sorin J. Brener, MD, of Weil Cornell Medical College (New York, NY). The data are strengthened by the fact that NCDR registries use well-defined reporting criteria, represent all-comers, and cover a large proportion of US cardiovascular patients, he told TCTMD in a telephone interview. 

“In terms of providing evidence-based care, the findings suggest that things either have been improving or have gotten to the point where a substantial majority of patients are receiving this care,” Dr. Masoudi said, adding, “Of course, there’s room for improvement in some areas.” 

ACTION Registry-GWTG: AMI Care

In a key STEMI metric, the proportion of patients with door-to-balloon (D2B) times within the guideline-recommended 90 minutes increased over 3 years, while the median delay to PCI decreased, both for those who presented to a PCI-capable hospital and those who were transferred to such a center (table 1).

Table 1. Trends in Timely Primary PCI

Despite these improvements, the adjusted mortality rate remained essentially unchanged (5.32% in 2009 and 5.9% in 2011). Together with similar recent findings reported in the New England Journal of Medicine, these data are “quite sobering,” Dr. Brener commented.

In addition, he noted, the percentage of NSTEMI patients who underwent catheterization within the recommended 48 hours (67.4%) leaves much to be desired. Nonetheless, adjusted post-PCI mortality for all patients excluding those with STEMI (as reported in CathPCI data) was extremely low (0.66% in both 2009 and 2011). 

CathPCI Registry: Positive Trends in Discharge Medications, Radial PCI

In general, clinicians appear to be providing optimal medical therapy after PCI. Between 2009 and 2011, prescription of aspirin and thienopyridine/P2Y12 inhibitors remained high and steady, while prescription of lipid-lowering agents and beta blockers increased over the same period (table 2).

Table 2. Trends in Discharge Medication Prescription

 
Dr. Masoudi cited these findings as evidence that focusing on relatively simple but historically neglected practices “ultimately leads to high performance.” It also illustrates an important goal of quality improvement: to eliminate unwarranted variations in care, he added.

Another interesting trend, Dr. Masoudi said, was the relatively rapid increase in adoption of radial PCI over 2 years, rising from 2.9% of procedures in 2009 to 10.9% in 2011, “suggesting that practitioners are becoming more comfortable with the approach.” But Dr. Brener was less impressed, noting that the increase started from a very low baseline; he predicted further progress in this area would be slow.

In addition, 2011 data show that the vast majority (99.1%) of ACS patients received PCI appropriately. However, among non-ACS patients who underwent PCI, just over half (52.8%) were deemed appropriate candidates for the procedure by 2009 Appropriate Use Criteria (AUC), while 37.3% were considered to be of uncertain appropriateness and 9.9% were deemed inappropriate for PCI. But Dr. Brener noted that the large “uncertain” percentage reflects a limitation of the AUC.

CARE: Carotid Revascularization Shortcoming

The CARE registry is small and should not be used as a platform for comparing carotid stenting with endarterectomy, Dr. Masoudi said. “But it does identify an area where we can do better,” he remarked, “and that is in providing appropriate follow-up for neurological complications.” For 2011, the rate of 30-day follow-up with NIH stroke scale assessment was 58.6% after stenting. The rate after endarterectomy was only 3.7%, although surgical patients were more likely to be asymptomatic and lower-risk.

ICD Registry: Room for Improvement in Medical Therapy

The proportion of patients with ICDs who received appropriate medical therapy, including ACE inhibitors or angiotensin receptor blockers for those with left ventricular systolic dysfunction or beta blockers for those with prior MI, increased somewhat between 2007 and 2011 (71.5% to 76.6%). But that still left almost one-quarter of patients without optimal medical therapy in the wake of ICD implantation. 

PINNACLE Registry: Suboptimal Care for Outpatients? 

Unlike the other registries, PINNACLE compares performance for clinical practices and individual physicians against the registry averages. Prescription of several evidence-based medicines, including antiplatelet therapy, beta blockers, and ACE inhibitors or angiotensin receptor blockers, in only about three-quarters of eligible CAD patients leaves much room for improvement, Dr. Brener observed. Even more disappointing was underuse of anticoagulation in A-fib patients (57.2%), he added. 

Meeting New Challenges 

Dr. Brener said a limitation of in-hospital registries is that, aside from linkage to Medicare mortality data, they provide only 30-day follow-up. While agreeing that this represents a challenge, Dr. Masoudi said the problem is being partly remedied by growing participation in the PINNACLE registry, which follows outpatients over time.

“I think the NCDR has been critical in many of these [treatment] areas,” Dr. Masoudi concluded. “But [positive practice changes in the report] really reflect the work of the larger cardiovascular community that has become very dedicated to the mission of improving quality and making sure that the right patients get the right treatment at the right time.” 

Dr. Brener, however, sounded a note of caution. Participation in NCDR registries is voluntary and expensive, he noted, “so it is possible that we’re overestimating the quality of care. Hospitals that cannot keep up simply do not report.”

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