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    SCAI’s Quality Improvement Apps Boost AUC Scores, Support Discussion About Risk

    July 28, 2014

    This content is from the Summer 2014 issue of SCAI News & Highlights.

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    Since coronary revascularization appropriate use criteria (AUC) were released, hospitals across the country have worked to improve their AUC scores. Now two busy cath labs have achieved real-world success using SCAI’s quality improvement tools. One of the most helpful: SCAI’s easy-to-use software app that transforms the 25-page AUC document into simple dropdown menus and, with just a few mouse clicks, provides real-time information to help interventional cardiologists determine whether a PCI would be considered appropriate.

    “SCAI’s online AUC app is great,” said Nanette Jackson, director of cardiovascular services for Baptist Health in Lexington, Ky., who reported on the AUC project at the SCAI 2014 Scientific Sessions. “You get immediate feedback and can decide where you need to go from there.”

    The coronary revascularization AUC app is part of SCAI’s Quality Improvement Toolkit (QIT), which also includes two new PCI risk assessment tools and a forthcoming app for the diagnostic cardiac catheterization AUC.

    “The goal of all of these apps is to allow clinicians to assess the appropriateness and risks associated with a procedure. Doing that more accurately and consistently not only improves the quality of the care we deliver, it allows us to have a more informed discussion with the patient,” said Kalon Ho, MD, FSCAI, director for quality assurance in the Cardiovascular Division at Beth Israel Deaconess Medical Center in Boston, vice-chair of SCAI’s Quality Improvement Committee and the architect of several of SCAI’s quality improvement tools.


    New APP-ROACH to AUC Yields Realworld Success

    In 2011, Baptist Health took a look at its initial AUC scores and realized that—like many health systems—it had a big problem. Only about one in four PCI procedures was deemed appropriate. So they got to work, and over about a two-year period, more than doubled that number. 

    The key to success for Baptist Health was coming up with new cath lab processes that seamlessly incorporate the revascularization AUC app and the information it provides, Ms. Jackson said. Today physician assistants in the patient prep area fill out a data form with all of the clinical information needed for the online AUC calculator. That form goes to the cath lab, where staff input the information into the AUC calculator using a hyperlink that Baptist Health incorporated directly into the cath lab’s structured reporting system. They then print out a chart-ready Revascularization AUC Data Reporting Sheet, which lists AUC rankings individualized for each patient. 

    AUC results are monitored weekly, and immediate feedback is sent to interventional cardiologists by email. Physicians also receive scorecards with information on theirperformance and that of the department overall. By early 2014, this program resulted in 62.1 percent of PCI cases being rated appropriate, more than double the 2011 starting point of 27.7 percent.

    Beth Israel Deaconess Medical Center in Boston instituted a similar procedure, with cardiology fellows entering each patient’s clinical information in the online AUC calculator before the cardiac catheterization procedure and posting the print-out in the cath lab. After PCI, the fellows enter the angiographic findings to come up with a final AUC rating. SCAI 2014 featured an abstract by cardiology fellow Stuart Chen, MD, who reported on Beth Israel Deaconess’s use of the AUC calculator in 308 consecutive elective PCI procedures. The result: 63.6 percent of cases were rated appropriate;

    25.6 percent, uncertain; and 0.6 percent, inappropriate. Another 10.1 percent of cases were not rated, because the AUC did not include a suitable clinical scenario. 

    “Our study shows that the AUC tool is valuable and essential for ensuring quality in the lab,” Dr. Chen said. “Incorporating the key elements of AUC improves documentation, and it allows operators to provide justification when decisions contrary to the scoring system are made.”


    New Risk Assessment APP-TITUDE

    SCAI’s new PCI risk assessment apps draw on different data sources, both allowing physicians to enter pre-procedural clinical information and receive an estimate of PCI-related risks. They can be accessed at www.SCAI.org/QIT and are available in formats compatible with smartphones, tablets, laptops and PCs. 

    • Click on “PCI Risk Calculator App” for a tool developed in collaboration with the Blue Cross and Blue Shield of Michigan Percutaneous Coronary Intervention Quality Improvement Initiative (BMC2 PCI). This app estimates the risk of mortality, contrast-induced nephropathy and transfusion.

    • Click on “PCI Risk Assessment Tool” for models developed using data fromthe National Cardiovascular Data

    Registry (NCDR) CathPCI Registry, the Massachusetts Data Analysis Center (Mass-DAC) and the DELTA Network.

    It predicts the risk of in-hospital mortality, significant bleeding, vascular injury, kidney injury, need for dialysis, repeat revascularization, and 30-day hospital readmission. In addition to web-based formats, it is available as an Excel spreadsheet, which can be used to create graphs that may help patients understand their risks.

    Dr. Ho said he foresees cardiologists using the new apps at the bedside, in the cath lab and in the office before sending patients for procedures. 

    “The goal is to facilitate discussions with patients and improve shared decision-making,” he said. “Until now, cardiologists have not had tools for predicting risk in an easy way. Now they do.”

    Staying Ahead of Legislation: New Mandates for AUC, Clinical Decision Support Tools

    Recent legislation may offer additional reasons for interventional cardiologists to incorporate AUC apps into everyday practice. In March, Congress passed the latest “patch” to the sustainable growth rate (SGR) formula, which would have otherwise mandated a significant cut in Medicare physician payments. Woven into the patch were provisions requiring the use of AUC and clinical decision support tools for advanced diagnostic imaging studies.

    Beginning in 2017, Medicare claims for advanced imaging studies will not be paid unless such tools are used. AUC must be developed or endorsed by professional medical societies, and clinical decision support software must be available free of charge, according to the new legislation.

    For now, diagnostic cardiac catheterization does not fall within the legislative definition of advanced imaging, said Dr. Ho. However, invasive imaging studies could be subject to this type of mandate in the future, or assessment of appropriateness may be required by some private payers.

    “The concept is out there, and it’s embedded in law,” Dr. Ho said. “SCAI is getting ahead of the game. We’re providing AUC and other decision-support tools that comply with the letter and spirit of heathcare reform. We want to help members to do the right thing.”


    Acknowledgments

    The SCAI-Quality Improvement Toolkit was developed with founding support from Daiichi-Sankyo, Inc. and Lilly, USA, LLC, and support from AstraZeneca. The PCI Risk Calculator App was supported by The Medicines Company. The Society gratefully acknowledges this support while taking sole responsibility for all content developed and disseminated through these efforts.