Ambulatory CV care in the US is improving

Ambulatory care for cardiovascular conditions has improved in the U.S. over the past decade, according to data published in the Journal of the American College of Cardiology—but there’s still plenty of room to grow.

Thomas M. Maddox, MD, MSc, and colleagues’ analysis of the PINNACLE (Practice Innovation and Clinical Excellence) Registry revealed that treatment rates for heart failure, coronary artery disease (CAD) and atrial fibrillation all rose between 2013 and 2017, while blood pressure control rates among hypertensive patients remained somewhat flat. PINNACLE has been tracking the management and quality of ambulatory care for the four CV conditions since 2008, and by 2017 the registry contained information on 6,040,996 patients cared for by 8,853 providers across 724 practices.

PINNACLE is one of the American College of Cardiology’s National Cardiovascular Data Registry (NCDR) 10 cardiovascular programs, established to measure adherence to CV performance measures and quality metrics and provide direct feedback to participating sites over time. The last review of PINNACLE data was published in 2013, at which point the registry was tracking just 2.8 million patients.

Maddox, of Washington University School of Medicine in St. Louis, and co-authors evaluated 2013-2017 data from the registry, finding that in that time period, care processes for PINNACLE patients “generally improved.” For patients with heart failure, combined beta-blocker and renin-angiotensin antagonist medication rates rose from 60.7% to 72.8%, and among patients with CAD, statin medication rates increased from 66% to 80.1%. Those with atrial fibrillation saw a boost in oral anticoagulation rates—from 52.7% in 2013 to 65.2% in 2017—though BP control rates among people with hypertension remained largely stagnant.

“The data from 2013 to 2017 indicates that, in most cases, care is improving in PINNACLE Registry practices and becoming more standardized,” the authors wrote. “However, it also highlights areas where improvements should occur.”

Each of the four CV conditions PINNACLE covers have their own set of care measures, but Maddox et al. said there are seven areas that have “clear links to optimal clinical outcomes.” They include:

  • Renin-angiotensin aldosterone system (RAAS) drugs/beta-blocker use for patients with HF and a reduced ejection fraction (HFrEF)
  • Carvedilol, metoprolol succinate or bisoprolol use in HFrEF patients
  • RAAS use in HFrEF patients
  • Antiplatelet, statin, beta-blocker and RAAS use in CAD patients
  • High-intensity statin use in CAD patients
  • Oral anticoagulant use in AFib patients
  • Blood pressure control

“Optimizing delivery of these measures would be a promising approach to improve cardiovascular outcomes,” the team wrote. “These insights can provide a national perspective on the quality of care for common conditions seen in ambulatory cardiovascular practices, inform clinical practice and policy and suggest future directions for quality improvement programs and research programs.”