Since its foundation six decades ago, the goal of the American College of Cardiology (ACC) has been to improve the quality of cardiovascular care. The College’s founders initially sought to accomplish this goal by providing the College’s members with access to high-quality educational opportunities such as the ACC’s highly successful annual scientific sessions. In 1984, the quest for improved care of the cardiac patient took a new direction when the College and the American Heart Association (AHA) issued their first clinical practice guideline on the appropriate use of cardiac pacemakers “because of allegations of abuses of this technology.”1 This was an ironic turn from two standpoints. First, the guidelines were created in response to a cost and utilization concern, foreshadowing the College’s attempts to address similar concerns during the healthcare reform efforts in the Clinton years and again recently as the healthcare reform legislation convulsed its way through Congress and was ultimately passed into law. Second, the pacemaker guidelines could arguably be said to have been the ACC’s first set of appropriate use criteria (AUC)—a program that was not formally launched as such until 2005 with the publication of the first AUC sets. As described by the task force that developed that first set of guidelines, the task force was “formed to make recommendations regarding the appropriate utilization of technology in the diagnosis and treatment of patients with cardiovascular disease.”1 With that as a starting point, the ACC embarked on a new strategy for supporting and promoting clinical quality improvement—a strategy that continues to evolve based on member and societal needs.
Quality Improvement Tools
Seeing the value of practice guidelines in helping its members (and other providers as well) to wade their way through growing mountains of clinical evidence in order to find the best diagnostic and therapeutic approaches to the cardiovascular patient, the ACC and AHA have produced a succession of such documents. Over the years, the ACC and AHA have invited other specialty societies whose members are involved in the care of the cardiovascular patient to join in the development of the guidelines. Because of this inclusive approach and because of the explicit and standardized manner used to evaluate the evidence on which the guidelines are based,2 these documents are largely considered by providers, payers, and healthcare quality improvement entities of all kinds to represent the standard of care of the cardiovascular patient. This is true despite a recent analysis demonstrating that only 50% of the recommendations in the ACC/AHA guidelines are based on the highest level of evidence3—a fact that reflects not so much a weakness of the guidelines as the status of the evidence base in cardiovascular medicine.
In the late 1990s the ACC again partnered with the AHA, this time to develop performance measures in order to supply providers with tools that would help them assess the success of their efforts to follow the major recommendations in the guidelines. Having seen from the guidelines experience the benefit of partnering with other professional societies, the two organizations sought similar partnerships for the development of performance measures. One of the most productive of these partnerships has been that with the American Medical Association-sponsored Physician Consortium for Performance Improvement (PCPI), which has taken the lead in developing physician-level performance measures across all specialties. Again, as a result of these alliances and because of the disciplined methodology used in their development,4 the ACC/AHA performance measures have gained wide acceptance, with many of them receiving endorsement by the National Quality Forum (NQF) and being included in the Physician Quality Reporting Initiative (PQRI) of the Center for Medicare and Medicaid Services (CMS).
Progressing from guidelines and measures to information, the ACC launched the National Cardiovascular Data Registry (NCDR®)5 in 1997 to supply hospitals and cardiologists with the data infrastructure necessary to support quality improvement in the cardiac catheterization laboratory. The College has continued to invest in the NCDR over the years, expanding it from the original CathPCI Registry® to a total of six registries covering acute coronary syndromes (ACS), implantable cardioverter–defibrillators, carotid artery interventions, congenital heart disease, and now, with the advent of the PINNACLE Registry®, ambulatory care. The PINNACLE Registry incorporates the ACC/AHA performance measures and brings them to the outpatient clinic. It has been approved by CMS as a means of reporting for PQRI.
Parallel to the growth of the NCDR registries and the performance measures, the ACC/AHA developed data standards in five important clinical areas: ACS, atrial fibrillation, congestive heart failure, cardiac imaging, and electrophysiologic studies. The purpose of these standards was to facilitate the collection of data for research, epidemiologic, and quality improvement purposes. As with the guidelines and performance measures, these standards were developed using a rigorous methodology.6
The next step in the ACC’s quality journey, and one that captured the attention not only of the profession but also of policy-makers, was the introduction of the landmark AUC in 2005. The first criteria set dealt with single-photon-emission computed tomography myocardial perfusion imaging (SPECT MPI).7 Since then, seven additional sets have been added to the AUC collection, including criteria for nuclear imaging, echocardiography, CT imaging, and coronary revascularization. The AUC arose out of conversations College leadership had been having with medical directors from major national managed care organizations at the ACC’s Medical Director Institute (MDI)—a regular meeting held at least annually for the past eight years for the purpose of discussing matters of mutual concern.
Quality Improvement Initiatives
Over the past 10 years the College has gone from merely supplying its membership with quality improvement tools such as the guidelines and performance measures to actually leading major clinical quality improvement initiatives, starting with the Guidelines Applied in Practice (GAP) programs in 2001. The Michigan GAP was successful at reducing mortality at 30 days and one year following acute myocardial infarction (MI).8 The Door to Balloon (D2B): An Alliance for Quality™ campaign was also successful in assisting its more than 1,000 hospitals to reduce their D2B times for patients presenting with ST-elevation MI (STEMI) to 90 minutes or less.9 That program continues as Door to Balloon—Sustain the Gain (D2B-STG). The most recent initiative is the Hospital to Home (H2H): Excellence in Transitions program, which is a co-operative effort with the Institute for Healthcare Improvement (IHI) and is the most ambitious yet. The aim of H2H: Excellence in Transitions is to reduce 30-day all-cause, risk-standardized re-admission rates among patients discharged with heart failure or acute MI by 20% by 2012. The H2H team has enlisted the support of over 700 healthcare organizations in this ambitious effort.10
In 2006, as CMS and private payers began pressing for demonstration of value in healthcare, the College saw the need to bring its quality and advocacy efforts together around specific projects that affected both areas. As a result, the Physician Assessment, Reporting, Recognition and Reward (PAR 3) Task Force was born. (It later became the PAR 4 Task Force when ‘Reinforcement’ was added to its title.) Among its many accomplishments was the Cardiovascular Recognition Program (CVRP), which is being developed in partnership with Bridges to Excellence and with medical directors from leading national managed care organizations through the MDI. The intention of those working on this effort is to replace individual managed care physician recognition programs with a single program that will be more comprehensive and more reflective of provider quality. CVRP is currently in the pilot stage and looks very promising.
Organizational Changes to Support Quality
The success of the PAR 4 Task Force led to the establishment of the Clinical Quality Committee (CQC) in 2010. The CQC combines the quality functions of the prior Quality Strategic Directions Committee with the advocacy functions previously performed by the PAR 4 Task Force. The CQC’s principal task is to co-ordinate all of the ACC’s varied quality activities and to focus them on the needs of the College’s membership. These activities include documents such as the guidelines, performance measures, and AUC. They also encompass initiatives such as H2H and D2B and partnerships with external organizations such as PCPI and the NQF. The CQC is on point to help the College maintain a leadership position in the national healthcare quality enterprise in the area of cardiovascular disease and to work with other professional societies and important external constituencies in accomplishing that goal.
The CQC is accomplishing its work through a complex yet functional collection of subcommittees and work groups that makes the best use of volunteer talents and divides the committee’s diverse and somewhat daunting charge into more manageable pieces (see Figure 1). Three of these groups provide examples of how this works. First, the Science and Clinical Policy (SCP) Subcommittee is responsible for the College’s clinical documents, including the guidelines, performance measures (both in partnership with AHA), and the AUC. The SCP has developed a strict new ‘relationships with industry’ policy to protect the integrity of the College’s clinical quality work. That policy was adopted by the Board of Trustees and is now ACC policy. Second, the Partners in Quality (PIQ) Subcommittee handles the complex task of managing the College’s relationships with the NQF, the PCPI, other professional societies, and entities such as the AQA that are playing various roles in the national healthcare quality movement. Third, the Quality in Technology (QIT) Work Group has addressed the many challenges facing the use of cardiovascular technology, which is at the epicenter of the healthcare cost discussions. The QIT has led the ACC’s response to the call for comparative effectiveness research (CER), including recommending research priorities, advocating for the use of the NCDR registries in CER, and instigating the ACC’s CER position statement, which was published in 2009.11 The QIT also worked with the AUC Implementation and Evaluation Work Group to develop appropriate use measures, which are currently being considered for endorsement by the NQF.
The CQC is also forming strong ‘internal’ partnerships within the ACC itself in order to bring cohesion to the College’s quality agenda. As a result, it has established working relationships with the NCDR Management Board, the Informatics Committee, and the Prevention Committee. More recently, the CQC began working with the CardioSource Oversight Committee to provide supervision for the clinical content on the new CardioSource website, and it is teaming with the Education Committee to bring a quality improvement focus to the College’s continuing medical education (CME) programs.
Quality Improvement and Healthcare Reform—The PINNACLE Network
Over the past year the ACC’s quality programs have taken a new and more action-oriented turn. During this time the College has faced some of the most significant challenges in its history as the financial crisis gripping healthcare, and in particular Medicare, began to squeeze its members. Faced with mounting costs and with few arrows in its quiver, the CMS has chosen to institute draconian cuts in cardiology reimbursement, which, when combined with the flat fees affecting all Medicare Part B providers, are making the private practice of cardiology more and more difficult. All of this came about as healthcare reform was being discussed and eventually passed by Congress. The focus of Congress’ reform efforts was on expanding coverage to the uninsured even in the face of rising healthcare costs. How to control these costs remains an open question, and the fear is that bureaucrats will use the usual tools of reducing fees and placing arbitrary controls on utilization in order to achieve this goal. This, of course, would be bad not only for cardiovascular specialists but also for patients, who would suffer from reduced access to cardiovascular specialists and to needed diagnostic and therapeutic technologies and services.
Faced by these daunting challenges, the ACC recognizes that physicians must lead the development of alternative strategies that address the cost issue by promoting improved quality and increased efficiency. The College has therefore re-grouped to offer such strategies for achieving value in cardiovascular care and for doing so in a patient-centered manner. The ACC’s approach builds on the foundation of quality that it has established over the years and brings to bear the many tools the College has at its disposal that can help its members create systems of cardiovascular care that are safe, effective, patient-centered, timely, equitable, and efficient— the Institute of Medicine’s aims for healthcare quality.
This strategy is embodied in the College’s new PINNACLE Network,12 a cardiovascular network based on the PINNACLE Registry that is designed to provide practices with the tools they need to promote innovations and achieve clinical excellence. The PINNACLE Registry, using the ACC/AHA performance measures, provides practices with feedback on the quality of care they provide and enables them to use that information in pay-for-reporting and pay-for-performance programs as well as for internal quality improvement. In addition to the registry, the PINNACLE Network offers its members many more services, including: practice management tools; workflow and workforce solutions; educational resources to meet maintenance of certification requirements; advocacy opportunities; quality improvement initiatives, strategies, and communities; health IT tools; and risk management strategies for lowering medical liability costs. In addition, if the CVRP is successful at the pilot stage, it will become an integral part of the Network’s offerings.
The ACC is developing a number of other initiatives in support of the PINNACLE Network that are aimed at increasing healthcare value. One of these is Formation of Optimal Cardiovascular Utilization Strategies (FOCUS), a national quality improvement initiative designed to help cardiovascular professionals use AUC and ultimately reduce inappropriate imaging. The College is in conversations with payers to implement the FOCUS program, which should be more effective at reducing inappropriate utilization of diagnostic imaging than are the intrusive prior authorization programs of radiology benefits managers, while at the same time being much more acceptable to providers and patients. In a study performed with United Healthcare, the College documented that the inappropriate use of cardiovascular imaging remains a significant problem despite current utilization management efforts.13 The ACC recognizes that, at its core, the inappropriate use of healthcare services is a quality issue, and is addressing the problem of inappropriate utilization of diagnostic imaging through the FOCUS program using quality improvement techniques that include point-of-care decision support, feedback to the provider on any identified inappropriate ordering patterns, and focused education based on the individual provider’s performance. Finally, FOCUS will facilitate peer-to-peer discussions of inappropriate use if necessary.
NCDR is leading another ACC value initiative, which is a program of voluntary public reporting of hospital level performance using the CathPCI Registry®. The demand for public reporting from payers and from consumer groups is becoming increasingly strident. Nationally, there is growing pressure to use measures derived from claims data for public reporting despite the acknowledged limitations of administrative data. The rationale for this approach proffered by those who espouse it is the lack of access to robust clinical data and the ready availability of claims data: ‘It is all we have.’ In addition, payers and some consumer groups are calling for reporting on individual physicians, even though it has been demonstrated that such reporting may not be possible because of the low numbers of patients and events encountered at the physician level.14 ACC has chosen to be pre-emptive in the area of public reporting by using the rich source of clinical data in the CathPCI Registry to develop a robust set of measures that can be used by participating hospitals, if they choose to do so, to report publicly on the performance of their cardiac catheterization laboratories. Such reporting is likely to stimulate increased efforts at quality improvement by both the hospitals that choose to publicly report and by those that do not initially participate in the program but anticipate doing so in the future.
While advocating for the use of clinical data in public reporting programs, the ACC recognizes that claims data can also be a good source of information, especially for outcomes such as resource use, including procedures and hospital admissions. With this in mind, the College worked with the Yale New Haven Hospital—Center for Outcomes Research and Evaluation (YNHH-CORE) on the development of percutaneous coronary intervention (PCI) 30-day mortality rates for CMS. These measures involved linking Medicare fee-for-service claims data with CathPCI Registry data in order to risk-adjust for patient characteristics at the time of PCI. It is anticipated that in the future there will be many such opportunities to combine clinical and administrative data in ways that will provide payers, providers, and patients with information that cannot be provided with either type of data alone. In addition, NCDR, in a co-operative effort with the ACC Informatics Committee, is also investigating linking its registries with electronic health records (EHRs) to further enrich the clinical data available for purposes of public reporting and, more importantly, to inform provider quality improvement efforts including maintenance of certification.
A third and perhaps the most exciting quality initiative currently under way at the ACC is the development of Performance Improvement Continuing Medical Education (PI-CME) programs.15 The first to launch was Keeping PACE (Patient-centered ACS Care Education), addressing ACS, and the second will be A New ERA (Evidence-based stroke Reduction in Atrial fibrillation). The unique aspect of these programs is that they start with an analysis of the physician’s or practice’s performance using NCDR registry data, with the educational component then focused on identified gaps in care. Keeping PACE utilizes the ACTION Registry®-GTWG™, while data for A New ERA will come from the PINNACLE Registry. This is truly needs-based CME and clinical quality improvement at the practice level. These programs have joined D2B in being accepted by the American Board of Internal Medicine as means by which cardiovascular specialists can fulfill the requirements of Part 4 maintenance of certification. Other PI-CME programs will follow these first two as resources and registry development permit. They will also become an integral part of the PINNACLE Network and could conceivably become a platform that PINNACLE participants can use to share best practices.
With an impressive array of quality improvement tools and with the PINNACLE Network providing a means for bringing them together at the practice level in a patient-focused way, the ACC has a lot to offer in the way of action—not merely discussion—when it comes to achieving true value in healthcare. The College has been active in advocating these approaches at the national level and more recently in support of individual state chapters in California and Wisconsin. The CQC is currently developing a new subcommittee made up of College leaders that will work on public reporting programs and other quality initiatives with outside entities such as CMS/YNHH-CORE and state-based organizations. The new sub-committee will also work to implement the College’s comprehensive quality improvement programs in order to pre-empt well-intentioned but clinically less effective efforts by those outside cardiovascular medicine.
The next few years promise to be no less challenging for the cardiovascular specialist and for the ACC than have been the 61+ years since the ACC’s foundation. Major questions abound: Where does specialty care fit within the context of the patient-centered medical home? What will ‘bundling’ and other new compensation methodologies mean for cardiovascular specialists? What will be the impact of healthcare reform on the development of new drugs and technologies? Where is patient-centered quality care in all of this? The College has positioned itself to be a credible leader in answering these questions. With a large number of dedicated and talented volunteers at both the state and national levels and with equally talented and dedicated staff, the ACC has given its members, whether in a physician-owned practice or employed by another healthcare entity, every reason to be optimistic about the future—both for themselves and for their patients.