Bree Collaborative Meeting November 30, 2012

1. Bree Collaborative Cardiology Report: Appropriateness of Percutaneous Cardiac Interventions (PCI) Bree Collaborative Meeting November 30, 2012

2. Purpose of Presentation • To present and seek feedback on Cardiology draft report, by section. • To brainstorm/discuss BreeCollaborative’s recommendation ideas to HCA (“what should HCA do with the report”). • Potential next steps – Adopt Cardiology final report at next Bree Collaborative meeting, on February 1st.

3. Purpose of Report • A written summary of Bree Collaborative/COAP appropriateness of PCI partnership (“product” of cardiology topic) • After it’s finalized, Report will be submitted to HCA administrator for adoption • COAP medical director and staff consulted and edits included in report

4. Outline of Report • Executive Summary • BreeCollaborative and its Charge • Background on Appropriate Use of PCI & National Standards • COAP & Appropriateness of PCI • Variability of Appropriate Use of PCI in WA • Causes of Variability of Appropriate Use of PCI for nonacute indications and insufficient data • Bree Collaborative and COAP • Bree Collaborative Recommendation – Increase Measurement and Reporting of Appropriate Use of PCI • Status of Collaborative Recommendation • Next Steps for Implementing Recommended Actions • Future efforts to Promote Measurement and Transparency of Cardiac Procedures and Interventions • New Section - Recommendations

5. Executive Summary & Bree Collaborative and Its Charge • Pages 1 & 2 • Questions? Comments?

6. Background on Appropriate Use of PCI & National Standards (pgs 2 & 3) • Since the 1990s, PCI has been a remarkable and valuable tool in the management of coronary heart and artery disease in both acutely ill and stable patients with coronary artery disease, decreasing mortality and increasing quality of life when used in appropriately selected patients. • In appropriate situations, there is both scientific evidence and professional consensus PCI can improve quality of life for patients with symptomatic angina refractory to appropriate medical therapy. • However, performing PCIs for nonacute indications with limited or no evidence of benefit results in unnecessary care, and excess costs, and exposes patients to risks, which would be considered an inappropriate PCI. • Recently, PCI appropriateness has received more attention because it is seen as an emerging quality metric that provides an assessment of anticipated procedural benefit relative to the risk of the procedure. • Description of Appropriate Use Criteria

7. COAP & Appropriateness of PCI (pgs 3 & 4) • In 2011, COAP started applying the AUC algorithm to its database – which includes data on all interventional cardiac procedures performed at all Washington State hospitals - to measure appropriate use of PCI in Washington State. • Hospitals receive appropriate use of PCI analyses on their own performance at both the facility and provider level in the form of a risk-adjusted dashboard and descriptive reports to hospitals, quarterly and annually. • Not available to the public at this time.

8. Variability of Appropriate Use of PCI in WA (pgs 4–6) • A major study on appropriate use of PCI in Washington State was conducted by Bradley and COAP staff in 2011. • Using COAP data and AUC, the study authors applied “appropriateness” ratings to all PCI procedures done in 2010. The main conclusions from the study were: • The majority of PCI done for acute indications in Washington State are classified as appropriate; • A large number of PCI done for nonacute indications are classified as inappropriate, and inappropriate use varies significantly by facility; and • An appropriate use score could not be applied to a large number of indications, mostly nonacute indications, because of missing or insufficient data, hindering accurate measurement of appropriate use.

9. Causes of Variability of Appropriate Use of PCI for nonacute indications and insufficient data (page 6) • Process of care (practice patterns) and data collection deficiencies are the main causes of the large number and variability of unclassified cases for nonacute indications. • A high proportion of nonacute PCI were performed without documentation of preproceduraltests. • Lack of documentation is the result of one or two issues: 1) the prepocedural test was not performed; or 2) some hospitals may not routinely collect or reliably document all of the information necessary in order to evaluate whether a procedure can be classified as appropriate.

10. Bree Collaborative and COAP (pg 7) • Medical director of COAP presented data on appropriate use of PCI at the January, March and May Collaborative meetings. • Appropriate use of PCI was identified as a topic where the Collaborative’s unique voice could accelerate well-established quality improvement efforts to the next level. • During the first part of 2012, Collaborative staff and members along with COAP staff worked together to identify ways the Collaborative could help increase appropriate use of PCI and increase better data collection practices. • The Collaborative relied on the clinical expertise of COAP staff, the COAP management committee, special advisors to COAP, and a small informal group of Collaborative members and representatives for clinical advice and recommendations.

11. Bree Collaborative Recommendation – Increase Measurement and Reporting of Appropriate Use of PCI (pgs 7 & 8) • The COAP management committee in February 2012 approved the Collaborative's request and agreed to provide technical assistance to hospitals to reduce the amount of missing data and improve the ability to classify the appropriateness of procedures. • In July, the Collaborative proposed a timeline with target due dates; COAP approved timeline. • 4 Steps to Improve Reporting, Measurement, and Transparency

12. Status of Collaborative Recommendation (pg 8) • Step 1 was completed in August, and Step 2 is in process of being completed. • To date, COAP staff has met with several hospitals that have requested assistance. COAP staff is working on a patient-level report for each hospital which identifies the specific reasons the hospital had either inappropriate or insufficient data for evaluation. In addition, COAP staff will reach out to review this report with hospitals before the end of December 2012.

13. Next Steps for Implementing Recommended Actions (pgs 8 & 9) • Per requirements of the Bree Collaborative legislation, the Bree Collaborative must deliver a copy of this report to the administrator of the Washington State Health Care Authority. The administrator must review the strategies and recommendations and decide whether to adopt and apply recommended strategies to state purchased health care programs. • Following the administrator’s review, the Bree Collaborative must report to the Washington State Legislature and the Governor regarding proposed strategies and the results of the administrator’s review.

14. Future efforts to Promote Measurement and Transparency of Cardiac Procedures and Interventions (pg 9) COAP and Collaborative staff will continue to meet to discuss additional ways the Collaborative can support and incent improved measurement and transparency of additional COAP cardiac measures.

15. Recommendations to HCA • How can HCA support the Cardiology/COAP partnership? • Ideas: Encourage hospitals to disclose insufficient PCI rates? Encourage continued participation in COAP?