Paul S. Chan, MD MSc William J. Oetgen, MD Donna Buchanan, PhD Kristi Mitchell MPH

1. The IC3 (Improving Continuous Cardiac Care) - PINNACLE Program:A Report of the first 14,000+ Patients Paul S. Chan, MD MSc William J. Oetgen, MD Donna Buchanan, PhD Kristi Mitchell MPH Fran F. Fiocchi, MPH Fengming Tang, MS Philip G. Jones, MS Duane Thrutchley, RNTracie Breeding, RN BSN John S. Rumsfeld, MD PhDJohn A. Spertus, MD MPH

2. Disclosures • Funding for IC3/PINNACLE: • American College of Cardiology • - Bristol-Myers Sanofi

3. Overview of Performance Measurement • Performance measures represent a subset of the Guidelines – What must be done in care… • Much improvement in inpatient care has emerged from performance measurement • While numerous outpatient performance measures exist… • These have not been systematically collected • Current performance is unknown • Until measured, QI can not occur

4. Current ACC/AHA Performance Measures • CAD Performance Measures • BP Measurement • Symptom & Activity Assessment • Smoking Assessment • Counseled to quit • Anti-platelet Therapy • Lipid Profile • Use of Lipid Therapy • -blocker post-MI • ACE/ARB in EF & DM • Screening for Diabetes • CHF Performance Measures • LVEF Assessment • Weight Measurements • BP Measurements • Clinical Symptom Assessment • Activity Assessment • Signs of Volume Overload • Patient Education • -blocker in EF • ACE/ARB in EF • Warfarin for Afib • Initial Lab Tests

5. A Fib Performance Measures Thromboembolic Risk Prior CVA/TIA Age ≥75 Hypertension Diabetes Heart failure or EF Warfarin use in High-risk pts Monthly INR in pts on warfarin Current ACC/AHA Performance Measures • Cardiac Rehabilitation PMs • Referral to a Rehab Program • Within 12 months of • ACS • PCI • CABG • Valve Surgery • Transplant • Stable Angina

6. Challenges with the Current Quality Model Consensus on Optimal Performance Measures Payers often use their own measures Accurately Capturing Performance Measures Administrative data often used Reporting Performance to Payers Administratively cumbersome to practices, especially with different measures for different payers

7. What is IC3/PINNACLE? • Prospective collection of outpatient clinical data • Use of that data to assist in the office visit • Use of that data to coordinate/communicate care • Use of that data to generate performance reports • Physician-level reports for QI • Practice-level reports for QI and P4P Programs

8. Implementation • Modes of data collection • Existing EMRs • Specifications provided to EMR Vendors • Quarterly transmission to ACC for Benchmarking reports • Paper forms • For practices without an EMR

9. IC3 Program: Incentives for Practices To improve care Provide measurement of quality indicators from guidelines and performance measures Frequent assessment of performance so that improvements can be made and monitored Trusted mechanism for reporting performance Support evolving CMS PQRI initiatives Support Pay-for-Performance programs with payers Collect once, report to all

10. Objectives of this Study • Descriptive report of first 14,000+ outpatients • Focus on 11 CAD performance measures (PMs) • Definition of CAD: • prior MI • prior coronary revascularization • known coronary stenosis >70%

11. Methods • Primary Outcome: Compliance with PMs # patients (or visits) which met a PM # of eligible patients (or visits) for that PM • Denominator exclusions • medical (e.g., allergies) • personal (e.g., cost, refusal) reasons • Patients could be excluded for some, but included in other, CAD PMs

12. RESULTS

13. Enrollment Period: • July 2008 to June 2009 • Study Sample • 18,021 encounters among 14,464 patients from 26 practices • Of these, 10,337 encounters among 8132 CAD patients

15. Limitations • First report of 14,000+ patients from 26 practices - small practice numbers - practices highly-motivated • No way of determining whether data on some cardiac patients were excluded from submission  however, this would preclude use of data for P4P and PQRI • Clinicians could ‘game’ the system by assigning exclusions for patients who are otherwise not compliant with a particular PM  still found gaps in compliance with various PMs

16. Next Steps • Examine PM adherence in other cardiac diseases (HF, A Fib) • Examine whether PM adherence differs by gender, race • Examine if participation in IC3 (quarterly reports, benchmarking) improves PM adherence over time • Develop real-time decision support to improve adherence

17. Conclusions • Compliance rates for CAD among outpatients enrolled in IC3 varied substantially, ranging from 13% to 94% • These results highlight important gaps in the quality of outpatient CAD care and provide a valuable benchmark for future improvement