'A Long Way to Go' in US in Adherence to CAD, HF, AF Quality Measures

Pam Harrison

December 14, 2015

BOSTON, MA — Adherence to the American Heart Association's performance measures for coronary artery disease, heart failure, and atrial fibrillation is modest and variable across a wide range of outpatient cardiology practices in the US, according to an analysis of a contemporary cohort of cardiology patients[1]. The study was published online December 8, 2015 in Circulation: Cardiovascular Quality Outcomes.

"This is a good-news, bad-news story," Dr Lisa Fleming (Tufts Medical Center, Boston, MA) told heartwire in written correspondence. "The good news is that, on the metrics studies, market trends of increasing practice size, while not improving performance, are not worsening it, either." The findings come from an analysis based on the National Cardiovascular Disease Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry.

"Still, we have a long way to go in terms of attaining consistently high performance, even among PINNACLE registry participating practices, where performance is likely better than average."

The population consisted of patients with CAD, HF, and AF who entered the PINNACLE registry between 2009 and 2012. Using the most recent 12 months of data for each participating practice, investigators assessed performance for individual patients at their most recent encounter.

Data were available for 654,535 patients who were seen by 1094 providers in 71 practices. Overall, the mean age of patients was 68.5 years, and 60% of them were privately insured.

"We assessed four medication-related CAD performance measures: prescription of an ACE inhibitor or an ARB, a beta-blocker, lipid-lowering therapy, and antiplatelet agents," said Fleming. "Overall, 55% of patients were prescribed all therapies for which they were eligible."

Physicians in the highest tertile of provider volume were 14% more likely to have their patients meet 100% of eligible measures compared with those in the lowest tertile (adjusted odds ratio 1.14, P<0.001 for overall association). In contrast, no significant association was seen between monthly practice volume and adherence to prescription of the four key medications assessed.

For heart failure, overall concordance with performance measures was higher than it was for CAD, with 72% of patients meeting all eligible measures. Again, however, "neither provider nor practice volume was associated with guideline concordance," Fleming added. Still, "provider volume was significantly associated with beta-blocker therapy (P=0.04)."

For patients with AF, guideline concordance rates were similar to CAD, study authors note, with 58% of patients meeting the anticoagulation measure. Furthermore, providers in the highest-volume tertile were 15% more likely to prescribe anticoagulant therapy in eligible patients compared with those in the lowest-volume tertile (OR 1.15, P<0.001). Again, however, monthly practice volume was not significantly associated with guideline concordance.

"Our findings suggest that higher provider volumes are associated with better guideline concordance, but the variability in practice volumes—in other words, patients seen in the totality of the practice, not just by one provider—kept us from assessing the relationship of practice volume and guideline concordance," Fleming said.

"We had a wide array of practice systems, including varying numbers of providers, specialists, and advance practitioners who contributed to the variability so it is still unclear what type of practice system results in the best outcomes."

Effects of Extensive Restructuring

As the authors point out, the study sheds some light on the possible ramifications of the extensive restructuring that has been happening in the US healthcare system over the past number of years.

Hospitals and practices are merging, Fleming explained, and the implications for patient care of the amalgamation have been ill-defined in the outpatient setting to date. "What we know from this study is that providers who focus on specific problems and who see many patients with the same problems tend to adhere to the guidelines better," Fleming said.

"However, the study does not confirm that larger practices or practice systems will result in better compliance largely because of the variability in practice volume."

Good Illustration

The current report is a good illustration of the value that programs such as PINNACLE can have in terms of providing feedback on performance measures to individual clinicians and clinics, observed Dr Frederick Masoudi (University of Colorado and the Colorado Cardiovascular Outcomes Research Consortium, Aurora) told heartwire .

"The whole point of the program is to provide a perspective to practitioners and groups with an idea of how they conform to guideline recommended therapies for patients with specific conditions and, by so doing, provide practitioners with information and an impetus to improve that care with the ultimate goal of improving patient outcomes," said Masoudi, who is the NCDR senior medical advisor.

This is particularly important in an era of increasing accountability, he added, when providing physicians with feedback about how well they are meeting guidelines really does give them incentives to try harder if they are lagging behind.

"There are a number of programs that focus on trying to make a pivot in the healthcare system from paying for quantity to paying for quality, and the way you do that is by measuring quality with respect with established practice guidelines," Masoudi said.

"However, if you don't have the basis upon which to measure and improve—something that the PINNACLE registry provides—it is very difficult to know how to do that."

The current analysis was supported by the NCDR. The PINNACLE registry receives partial support from Bristol-Myers Squibb and Pfizer. The authors had no relevant financial relationships, nor did Masoudi.

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