As healthcare continues to shift toward prioritizing value over volume, what is the best way to determine—and improve—the quality of a percutaneous coronary intervention (PCI) program? The authors of a new commentary in JAMA Cardiology explored this subject at length, noting that assuring PCI quality remains “an enduring challenge.”
“Different stakeholders have vastly divergent notions of needs and quality, and there are multiple valid viewpoints,” wrote Lloyd W. Klein, MD, University of California, San Francisco, and colleagues. “Health care insurance payors, rating agencies, hospital systems, hospital administrators, physicians, patients, and regulators each assess quality from their own perspective, but none adequately capture its totality. Moreover, powerful economic forces drive the motivation to capture a larger market share, perform more procedures to remain competitive and financially viable, and ultimately generate more income. These are the concerns to which those implementing a quality-assessment mechanism and the metrics in a quality-appraisal process must react and adapt enthusiastically.”
Klein et al. emphasized the importance of identifying the right performance metrics and incentives. Collaborations between stakeholders are vital when it comes to making these decisions, and relative value unit (RVU) production should not be the sole way an employee can be recognized.
The authors also noted that quality improvement efforts should focus on improving “internal efforts” whenever possible.
“Clinicians are responsible for developing and implementing internal quality assurance systems not only by moral obligation but also by external accreditation requirements,” they wrote. “Leaders must set high performance standards and communicate the specific elements in every setting, so that they are not viewed as merely politically correct advertising but as a real aspiration, which is a message of paramount importance.”
‘The most critical parameter’
When it comes to working to improving the quality of a PCI program, Klein and colleagues added, “the most critical parameter … is whether the PCI procedure resulted in angina relief and improved quality of life.” Improved survival, length of stay, readmission rates, complication reductions and cost should also be collected and tracked—but there will be certain instances when some parameters are much more (or less) relevant than others.
“Case selection based on the risk posed by the patient’s anatomy is a valid quality indicator,” the authors wrote. “Furthermore, the correlation of coronary stenoses with regional function and viability should be included in the assessment. It is extremely important that in scenarios where the relative merits of PCI vs medical therapy or bypass surgery are debatable, substantial latitude for patient preference is created.”
The team also pointed out that a PCI program’s reputation or ranking are not as important as one might believe. A PCI may be performed from within a high-ranking program—but that doesn’t necessarily the patient outcome will be any better.
“A determined effort to assure PCI quality is an enduring challenge,” Klein et al. concluded. “While market forces favor high volume over many aspects of quality and reward RVU production with both prestige and financial gains, persistent, carefully considered activities aimed at achieving quality can and should be implemented.”