ATLANTA – While quality improvement measures in the inpatient setting may have been described and collected at healthcare practices for years, performance measures in the outpatient setting have not been systematically collected and the current performance in the outpatient setting is unknown, according to a presentation at the “Comparative Effectiveness and Outcomes” session at the 59th annual American College of Cardiology (ACC) conference on March 16.
Paul Chan, MD, of the Mid America Heart Institute in Kansas City presented his study during the presentation, which investigated the results of the ACC's PINNACLE Program -- the first national-based prospective outpatient registry launched in 2008 for cardiac diseases, currently supported by the ACC and the National Cardiovascular Disease Registry (NCDR).
“In the past decade, there have been substantial improvements in performance measure compliance, demonstrated in a number of cardiac and noncardiac registries and impatient registries throughout the country,” said Chan.
Noting the need for a cardiac-specific outpatient registry, he said the PINNACLE Program is helping to clarify a lack of consensus on what that optimal performance measure would be and is meeting the challenge associated with measuring performance in the outpatient setting. “Performance measures represent a subset of clinical practice guidelines and really describe what must be done in clinical practice to optimize care quality. Until this benchmark had been established, quality improvement was unlikely to occur in the outpatient setting,” he said.
Chan explained that the outpatient registry differs from inpatient registries in a number of ways. First, the program does not have the luxury that the inpatient registry does in terms of data collection timeframes. While the inpatient program has days and even weeks in some cases, the outpatient program must collect that data during the patient visits. In addition, the program collects data on patients repeatedly over time on a number of variables, including vital signs, laboratory values and medications, he said.
The PINNACLE Program allows for data collection in two ways, said Chan. For practices without an EMR, paper forms can be used and for practices with EMRs, the data are extracted from that database. Data are submitted to the program by the practice on an ongoing, typically quarterly basis, he noted.
In addition, a benefit of the program for providers is that the registry can report on performance measure compliance on behalf of practices at the end of the year to other stakeholders, including CMS for the Physician Quality Reporting Initiative (PQRI), as well as other payors, said Chan.
The study conducted by Chan and colleagues focused on performance measures for the treatment of high-risk patients with atrial fibrillation in the outpatient setting and consisted of 27 cardiology subspecialty clinics nationwide. The sample size utilized was 18,021 patient encounters among 20,464 different patients, between July 2008 and June 2009.
The primary outcome for the study was compliance with a given performance measure, defined as the number of patients that meet that performance measure divided by the number of eligible patients for that performance measure, excluding those with medical and personal considerations, said Chan. The secondary outcome was to measure whether treatment differed by subgroups, including age, sex and race.
The researchers found that the rate for annual assessment of thombolic risk was 74 percent and the rate of warfarin use for a high-risk patient was 79 percent. In addition, there were found to be no differences in the subgroups of age and race for warfarin use, but modest differences in sex. “Women were slightly less likely to receive warfarin even if their case was serious," noted Chan.
“We found that the overall performance measure compliance rates among patients with atrial fibrillation from the first report from the PINNACLE Project ranged from 73 to 79 percent,” he said. "We believe that the findings highlight important gaps in the quality of outpatient care for patients with atrial fibrillation.”