The study showed that as a result of applying processes associated with ACE review, such as implementation of new guidelines, clinical records are far more likely to show that patients who have angioplasty and stenting meet high-risk criteria, have tried medications to relieve chest pain or have undergone testing to pinpoint which blockages need to be treated with a stent.
“The accreditation process results in positive changes,” said Bonnie H. Weiner, M.D., FSCAI, board chair and chief medical officer for ACE, in Washington, DC. “We’re encouraged to see the shift we want to see when cath labs are accredited, a shift toward better documentation and improved patient care that is driven by clinical guidelines and appropriate use criteria.”
ACE, a nonprofit organization launched with support from SCAI and the American College of Cardiology Foundation, accredits facilities that perform invasive cardiovascular procedures such as cardiac catheterization and percutaneous coronary intervention (PCI).
The new study examined data from nine cardiac catheterization laboratories that participated in ACE accreditation and afterward received at least two quarterly reports from the ACC-National Cardiovascular Data Registry (NCDR) CathPCI data registry, in addition to a baseline data report. The NCDR takes raw data about patient characteristics and PCI procedures and analyzes it, providing reports that enable participating cath labs to see how they measure up to standards of excellence.
Better Documentation Results in Improved Care
After analyzing the initial and follow-up data, Dr. Weiner and her colleagues found several indicators that, after accreditation, patients who underwent angiography were more likely to have ischemia, or serious arterial blockages capable of depriving the heart muscle of oxygen-rich blood. This was largely due to the improved documentation involved in the accreditation process.
- The proportion of patients with mild chest pain (Canadian Cardiovascular class II) decreased from 19.4% to 13.0% (p=0.0326), whereas patients with documented high-risk stress tests increased from 5.3% to 8.3% (p=0.0051).
- Those who reported trying medications to control chest pain in the previous two weeks increased from 67.1% to 72.7% (p=0.0028).
Similar findings for the severity of angina were observed for the patients who ultimately underwent angioplasty and stenting.
Additionally, because of better documentation after accreditation, more patients were eligible to be evaluated against appropriate use criteria (AUC). Among patients who had pre-scheduled “elective” PCI, the proportion of cases categorized as “appropriate” according to AUC went down (p=0.0271), while those judged to be “uncertain” did not change. The frequency of cases classified as “inappropriate” went up (p=0.0164), reflecting the increase in attentiveness to AUC that is a goal of accreditation. The AUC criteria during the pre-accreditation period were different from those applied more recently and may contribute to the differences observed.
Increased Use of FFR to Guide Clinical Decisions
Similarly, following accreditation, more patients were evaluated by fractional flow reserve (FFR). Interventional cardiologists use this test to determine whether an arterial blockage is severe enough to cause ischemia and, therefore, require treatment with PCI.
Among patients with intermediate blockages, there was a significant increase (p<0.0001) after accreditation in those with abnormal FFR values (defined as ≤0.75). This test result would indicate a need for PCI.
There was also a significant increase in the number of patients who had higher “normal” FFR values (p=0.0054). This increase, however, does not indicate more frequent use of PCI to treat these lesions. Instead, it reflects greater overall utilization of FFR technology, and in the case of FFR values >0.75, possibly the deferral of PCI. (For FFR findings to be entered in the NCDR database, PCI must be selected as a procedure during data entry, even if no PCI was ultimately performed.)
“The important take-away from this study is that what we saw before as a gap in documentation has now been substantially improved in accredited cath labs,” said Dr. Weiner. “Improvements in documentation, like all elements of accreditation, are a key indicator of dedication to quality improvement and will surely result in more accurate reporting and improved patient care over time.”
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