NCDR UpdateNCDR Update
Board of GovernorsBoard of GovernorsMeetingMeeting
September 16, 2007September 16, 2007John Brush, MD, FACC
Chair, Quality Strategic Directions CommitteeACC Governor, Virginia Chapter
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20 Years of Performance Measurement1987 20071997
HCFA hospital mortality reports
JCAHO “Agenda for Change”
HCFA CCP Pilot
HCFA National CCP
NCQA HEDIS measures
QPM to JCAHO
IOM RptIOM Rpt
HCFA 6 Nat’l Conditions
NQF
JCAHOORYX
QPM to CMSHealthgrades
NCQA website JCAHO CoreMeasures
JCAHO Core Pilot
Leapfrog
HCFA HCQII IOM Rpt
PQRI
AQA
CED
Hospitals Physicians
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QCAREACC’s Commitment To You• Continuous review of new science• Evidence-based guidelines and standards• Comprehensive education• Data reporting and collection through registries
(NCDR)• National Quality Initiatives (D2B)• Adoption and appropriate use of new technology• Evaluation through self-assessment tools,
performance testing and longitudinal studies
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Science
Technology
Evaluation
Standards
EducationReporting
Quality Initiatives
PatientPatientCenteredCentered
CareCare
QCARE
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1997….. 2004 2005 2006 2007 2008 beyond
CathPCICathPCIRegistryRegistry
ICDICDRegistryRegistry
CARECARERegistryRegistry
ACTIONACTIONRegistryRegistry
IC3 CADOffice
Imaging
HFRegistry
PracMgtRegistry
PADRegistry
EPRegistry
Ped.Registry
CHD
ICD Long
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PartnersCathPCI• Society for Cardiovascular Angiography and InterventionICD• Heart Rhythm SocietyCARE• Society for Cardiovascular Angiography and Intervention• Society for Interventional Radiology• American Academy of Neurology• American Academy of Neurosurgery• Society of Vascular Medicine and BiologyACTION• In discussion with American Heart Association
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Registry/QI• >950 hospitals• 6 million patient records• Online data entry tool
launch 4/07• Support D2B AllianceARS• States – MA, OH, WV, ?CT,
?NJ• Payers – United, BCBSA,
WellPointResearch and Publications• DCRI analytic center• 8* abstracts at AHA
190272
321 362472
547658
825
1000
0
100
200
300
400
500
600
700
800
900
1000
Faci
litie
s
1999 2000 2001 2002 2003 2004 2005 2006 2007F
CathPCI Registry Enrollment
Participants
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Registry• 1450 enrolled• 150,000 patient recordsFunding• 2007 support from WellPoint• $1,895/yearARS• UHC added ICD Registry
participation for sites with EP Labs
• Discussions underway with BCBSA
• Provide data to CMS for reimbursement
Research• ICD Longitudinal Study• Performing analysis for FDA
110
325
746
11541206 1243
1324 1338 13501420 1438 1442 1450
0
200
400
600
800
1000
1200
1400
1600
Faci
litie
s
2/1/2006 4/1/2006 6/1/2006 8/1/2006 10/1/2006 12/1/2006 2/107
ICD Registry Enrollmennt
Participants
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Registry• 235 Participants• Data entry tool• $3195.00/yearARS• CMS requiredResearch• Performing analysis
for FDA• Discussion with CAS
makers re: PMS
8 13 2542 45 57
7487 98
154
198
235
0
50
100
150
200
250
Faci
litie
s
Sep-06
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
CARE Registry Participationt
Participants
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Registry• 250+ participants• No charge• Funding provided by
– Genentech– Bristol-Myers
Squibb/Sanofi Partnership
– Schering Plough Corporation
ARS• Early discussions with
payers0
50
100
150
200
250
Faci
litie
s
Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07
ACTION Registry Participationt
Participant
NCDR CathPCI% Patients with D2B Time
0%10%20%30%40%50%60%70%80%90%
100%
Timeframe
90 min 120 min 150 min
Data Source: NCDR CathPCI Database, 2004Q2 - 2006Q4
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Percentage of Primary PCI with D2B <= 90 minutesNCDR CathPCI v3
0%
10%
20%
30%
40%
50%
60%
70%
80%
Timeframe
Perc
enta
ge
D2B
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PCI Statins on Discharge
72.0%
74.0%
76.0%
78.0%
80.0%
82.0%
84.0%
86.0%
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ACTION Registry™ (Acute Coronary Treatment and Intervention
Outcomes Network)
Initial Report1st Quarter 2007 Results
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2006-07 Data Submission Summary
Admission # of # of # of Timeframe Sites NSTEMI Records STEMI Records
ACTION Jan. 1, 2007 – 227 6,917 4,259 Mar. 31, 2007
CRUSADE April 1, 2006 – 280 20,084 4,391 Dec. 31, 2006
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ACTION Registry 2007 Patient Enrollment
41693787
40044241 4154
0
1000
2000
3000
4000
5000
Jan-07 Feb-07 Mar-07 Apr-07 May-07
Num
ber o
f Pat
ient
s en
rolle
d
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NSTEMI Patient - Baseline Characteristics
NSTEMI Variable (n = 26,902)
Mean age ± SD (yrs) 69 ± 14Female 40%Diabetes mellitus 33%Prior MI 29%Prior CHF 16%Prior PCI 23%Prior CABG 19%
ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n=26,902)
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In-Hospital OutcomesVariable NSTEMI
(n = 26,902)
Death 3.8%Re-infarction 1.5%CHF 6.8%Cardiogenic Shock 2.4%Stroke 0.7%RBC Transfusion* 8.9%
*Excluding CABG patientsACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n=26,902)
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NSTEMI Acute Medications
ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007
97%93%
85%
53%60%
0%
20%
40%
60%
80%
100%
ASA BetaBlockers
Heparin(LMW+UHF)
GP llb-lllaInhibitors
Clopidogrel
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*LVEF < 40%, CHF, DM, HTN# Known hyperlipidemia, TC, LDL ACTION/CRUSADE DATA: April 1, 2006 – May 31, 2007 (n= 26,902)
NSTEMI Discharge Medications96% 95%
73%
91%
74%
0%
20%
40%
60%
80%
100%
ASA B-Blocker ACE-I or ARB* Lipid LoweringAgent#
Clopidogrel
% U
se
New Hospital-Based Registries
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• Transcatheter device occlusion of CV malformations– Atrial Septal Defect– Ventricular Septal Defect– Patent Ductus Arteriosus– Fistula/Collateral Vessels—Blood Vessel
Communication– Closure of Fontan Fenestration
• Transcatheter Balloon Dilation• Transcatheter Stent Placement
CathLab Congenital Heart Disease
Registry
Pilot StudyEvaluation of
Appropriateness ofSPECT MPI
The American College of Cardiology The American Society of Nuclear Cardiology
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SPECT MPI Registry Objectives
• Evaluate appropriateness • Promote awareness of appropriateness
criteria in practice• Provide feedback reports to improve both
practice-level and individual physician-level adherence to the criteria
• Establish benchmarks to guide performance improvement
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NCDR QI
• National QI Programs– Implement guidelines
recommendations– Improve physician adherence– Improve patient compliance
• Our Goal? – Reduce complications– Improve Structure and Process– Efficient Systems
NCDR & D2BNCDR & D2BTake ACTIONTake ACTIONField Field ConsultantsConsultants
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“Take ACTION” Campaign• Nationwide QI Program
– Increase awareness about relevant CPG recommended therapies for ACS and chronic stable coronary disease
– Improve physician adherence and patient compliance
• Long-term Goal– Reduce secondary events post ACS– Measured incrementally through behavioral changes
• Multiple, overlapping Phases beginning ACC.07– Phase I - What is the ACC doing to Take ACTION to improve care
of patients with ACS? – Phase II - What are you doing as a physician to Take ACTION? – Phase III - What are you doing as patients to Take ACTION?
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Improving Continuous Cardiac Care
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Measuring the Continuum of CAD Care
Patient withstable angina
Onset of AcuteCoronary Syndrome
Post-Hospitalization:Risk factor modificationCardiac rehabilitationD/C
PCI/CABGAdmit
AMI Care
ACC-NCDR
ACTION IC3IC3
ACTION Follow-up
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The IC3 Program• First office-based registry designed to
assess physician adherence to ACC/AHA Performance Measures.
• Provides a powerful tool to assess the current state of office-based clinical care for CAD and CHF patients.
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Philosophy of the IC3 Program• Make it easier for busy clinicians to do the right thing for
the right patient at the right time– Track key performance measures for CAD/CHF
• Internal QI and P4P reporting at the practice level• Performance measures for DM also captured
– Make care more efficient• A worksheet that readily identifies opportunities to
apply CAD/ CHF guideline recommendations and performance measures
– Coordinate care• Create a visit summary to communicate with patients
and other providers
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IC3 Program: Incentives for Practices
• Develop tools to improve care– Provide real-time reporting of office-based
quality indicators for CAD and CHF derived from clinical practice guidelines
• Create a trusted mechanism for measuring performance– Support evolving CMS outpatient quality
measures and regulatory reporting initiatives– Support Pay-for-Performance programs with
payers
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United (5)BCBS (9)Medicare (26)Medicaid (10)
40%76%100%
100%
Payer Perspective of
my Performance
Physician X’s Practice
Physician X’s Overall Performance = 90%
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Partnering with Health Plans –
Benefits to Plans…• Health Plans get Better Picture of Practice
Performance– Clinical data prospectively measured– More accurate assessment of practice
performance from larger sample sizes than individual plans
– Capture of complete ACC/AHA performance measures
• Plans need not develop their own
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Other IC3 Program Goals• Position the profession (ACC) to take a leadership
role in quality assessment and improvement• Support the evolution of quality assessment and
improvement– Identify new opportunities to improve and coordinate CAD
and CHF care• Create a research agenda to improve care
– Document the distribution of cardiac patients’ health status
– Identify new performance measures– Support research of appropriateness
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Office Flow in IC3
Pt presents for visit, reports
med changes
Vitals, health status
assessed
Physician Visit & Rx
Data entered
and Clinic Visit Form Generate
d
Treatment plan Data
entered
Patient Letter &
Visit Summary dispensed
Visit Summary
sent to other care
providers
Data Entered through
NCDR IC3
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Data Collection• Types of data
– Site Profile captured once – Patient History captured on entry– Treatment monitored longitudinally – Clinical event data captured longitudinally – Patient health status for CAD and CHF (optional)
• Data collection tools– Web-based data collection tool– Paper forms– Working on EMR integration for Decision
Support
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Data Submission and Reporting• Data will be subjected to completeness
and consistency reviews– On-site audit to ensure accuracy (2009)
• Quarterly aggregate practice-level data reports and benchmark reports
• National benchmark performance• Peer group benchmark performance• Individual hospital performance
• Real-time QI reports generated for individual and practice-level data
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Release• Enrollment begins October 1, 2007• Web-based data collection begins Jan
1, 2008 • Training and roll-out for participants• Client and contract support for
participants• Marketing and communications to
broader physician community
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Participant Training and Education
• NCDR Online website• Information packet/Welcome Kit• Online training manual• Annual User Group Meeting• Workshops• Special web casts• On-line community development for
collaborative learning and sharing
