NCDR Report Evaluates 2011 Cardiovascular Care Quality and Outcomes

September 18, 2013—The American College of Cardiology (ACC) announced the publication of a report from the National Cardiovascular Data Registry (NCDR) that evaluates cardiovascular care facts for the year 2011, including the increased use of radial access for transcatheter percutaneous coronary intervention (PCI) procedures. The NCDR is the ACC's worldwide suite of data registries, designed to help hospitals and private practices measure and improve the quality of cardiovascular care they provide.

The report by Frederick A. Masoudi, MD, et al is available online ahead of print in the Journal of the American College of Cardiology. Dr. Masoudi is Senior Medical Officer of the NCDR.

As summarized in the abstract of the report, the investigators advised that the background of the report is that cardiovascular disease (CVD) is a leading cause of death and disability in the United States, and the quality of care for patients with CVD is suboptimal. National registry programs such as NCDR permit assessments of the quality of care and outcomes for broad populations of patients with CVD.

The investigators stated that the objective of the report is to characterize the patients, participating centers, and measures of quality of care and outcomes for five NCDR programs: the ACTION Registry-GWTG “get-with-the-guidelines” program for acute coronary syndrome (ACS); the CathPCI registry for coronary angiography and PCI; the CARE registry for carotid artery revascularization and endarterectomy procedures; the ICD registry for implantable cardioverter defibrillators and lead; and the PINNACLE registry for outpatients with CVD.

The report presents data on performance metrics and outcomes, in some cases risk-adjusted using validated NCDR models. The NCDR provides a unique opportunity to understand the characteristics of large populations of patients with CVD, the centers that provide their care, quality of care provided, and important patient outcomes, concluded the investigators.

For the year 2011, the investigators assessed the following characteristics for each of the five NCDR programs: demographic and clinical characteristics of enrolled patients, key characteristics of participating centers, measures of processes of care, and patient outcomes. For selected variables, the investigators assessed trends over time.

In 2011, ACTION-GWTG enrolled 119,967 patients in 567 hospitals, CathPCI enrolled 632,557 patients in 1,337 hospitals, CARE enrolled 4,934 patients in 130 hospitals, ICD enrolled 139,991 patients in 1,435 hospitals, and PINNACLE enrolled 249,198 patients (1,436,328 individual encounters) in 74 practices (1,222 individual providers), noted the investigators.

In correspondence with Endovascular Today, Dr. Masoudi addressed the CARE registry findings. He stated, “As far as carotid revascularization specifically is concerned, the report suggests the need for improvement in the extent to which patients receive follow-up and formal evaluation for symptoms of stroke following carotid revascularization procedures. The CARE registry has focused on this particular process of care as a point for care improvement in the future.”

According to the ACC, the NCDR report showed that PCI performed at the radial access site increased from 2.9% of cases in 2009 to 10.9% of cases in 2011, and stenting performed at the femoral access site decreased from 96.5% to 88.8% of cases during the same time period. The ACC noted that the radial approach is new and still being studied, but that research has shown that radial access can reduce discomfort, recovery time, and risk of complications in some patients. The NCDR report suggests that clinicians who perform PCI are becoming more comfortable with this approach, and it is becoming more commonly used, stated the ACC.

In the ACC press release, Dr. Masoudi commented, “The data in this report demonstrate the value of national registries in providing an unprecedented and broad perspective on the care and outcomes of patients with cardiovascular disease. These registries are key tools in understanding and improving care for cardiovascular patients across the United States.”

As summarized by the ACC, other top findings from the report outline several successes in heart disease care as well as opportunities for further improving a patient's treatment and follow-up care experience.

There have been continued improvements in meeting guideline-recommended door-to-balloon times of 90 minutes or less for patients with ST-segment elevation myocardial infarction. In ACTION-GWTG alone, the proportion of patients with door-to-balloon times of ≤ 90 minutes for nontransfer patients increased from 81% in 2008 to 94.2% in 2011, while this proportion increased from 18% in 2008 to 30.4% in 2011 among patients who were transferred for PCI.

Findings from the CathPCI registry showed that providers are consistently prescribing optimal medical therapy, including aspirin, thienopyridine/P2Y12 inhibitor, lipid-lowering agents, and beta blockers, at discharge for PCI patients. Prescription of aspirin and thienopyridine at discharge has remained relatively steady (between 96% and 98%) between 2009 and 2011, while prescription of lipid-lowering agents and beta blockers has increased. Prescription of lipid-lowering agents rose from 89.7% in 2009 to 92.5% in 2011. Beta blocker prescriptions have increased from 83.1% to 86.3%.

In the PINNACLE registry, data show there continues to be an opportunity for increased education for patients and clinicians about optimal anticoagulation strategies for stroke prevention in atrial fibrillation, as 57.2% of eligible patients with atrial fibrillation were prescribed anticoagulation therapy.

The ICD registry identifies an opportunity for the use of medical therapy for patients with previous myocardial infarction or left ventricular systolic dysfunction; approximately 25% of ICD patients did not receive optimal medical therapy with ACE inhibitors and/or beta blockers at discharge.

PINNACLE data overwhelmingly show providers regularly recording patient blood pressures (95.1%), with only a minority of providers (34.5%) taking a step further to implement hypertension care plans.

According to CathPCI data, opportunities exist to improve adherence to appropriate use criteria in patients without ACS and to potentially clarify areas of uncertainty. While a little more than half of patients without ACS (52.8%) were evaluated appropriately for PCI procedures, 37.3% fell into the uncertain category, and approximately 10% were categorized as inappropriate. In contrast, patients with ACS were appropriately evaluated for PCI procedures 99.1% of the time, reported the ACC.