Continuous Quality Improvement Initiatives in the Cardiac Catheterization Laboratory: Can We Have Our Cake and Eat It Too?

The American Journal of Managed Care, August 2006, Volume 12, Issue 8

The number of percutaneous coronary and peripheral interventions has increased dramatically in recent years with more than a million such procedures now performed annually in the United States.1 With the advent of drug-eluting stents, even more percutaneous interventions will be performed as they replace a substantial proportion of coronary and vascular bypass procedures. With such a large number of patients undergoing percutaneous coronary interventions (PCIs) and percutaneous vascular interventions (PVIs), it is imperative to continuously monitor these procedures and strive to improve the quality of such care. Studies have suggested that closer adherence to published guidelines reduces variations in care and improves quality, which in turn may translate into improved patient outcomes.2


In this issue of the , Rihal et al3 report on a physician-led, multidisciplinary continuous quality improvement (CQI) effort and demonstrate that such efforts were successful at significantly reducing PCI-related costs while maintaining and perhaps improving quality of care. Although the study precludes ruling out temporal changes in clinical outcome and healthcare costs and may have an ascertainment bias, particularly in the diagnosis of periprocedural myocardial infarction, the research nevertheless allows several important observations. First, a multidisciplinary group can be created that consists of clinicians (physicians, nurses, technicians) and administrators (management accounting, revenue systems, administration) who can work effectively together with a common objective. Second, such a physician-led group can take steps that lead to overall improvement in quality of care provided to patients. Third, and most important, physician-led groups can meaningfully reduce PCI-related costs in an era of rapid technologic advancements. Reducing costs will be even more important in the near future with the almost ubiquitous use of drug-eluting stents. Overall, a win-win situation or a dominant strategy exists (Figure) where it is possible to provide better quality of care at a lower cost by (1) eliminating high-cost/low-clinical-benefit procedures, such as routine postprocedure antithrombotic infusions, routine postprocedure electrocardiograph monitoring, and use of arteriotomy closure devices; (2) promoting low-cost/high-clinical-benefit procedures such as point-of-care activated clotting time monitoring and use of aspirin preprocedure; and (3) judicious use of high-cost/high-clinical-benefit procedures such as the number of coronary artery stents implanted per procedure, use of platelet glycoprotein IIb/IIIa inhibitors, and use of nonionic or isoosmolar contrast material.

We have learned from experience that quality improvement exercises are quite successful when they promote using systems with guideline-based knowledge embedded into the care process itself. A good example is the Guidelines Applied in Practice (GAP) project in Michigan. Each participating hospital was assigned 1 physician and 1 nurse leader from a different hospital system to assist hospital teams as they worked with their internal champions to improve postmyocardial infarction care.4 The project demonstrated successful quality improvement among a variety of institutions, patients, and healthcare providers. The success of the GAP initiative could be attributed to emphasis on standard orders and discharge tools that reminded providers to consider evidence-based therapies for every patient from admission to discharge. Creation of a system and inclusion of the patient, nurse, and physician in a review of the care priorities were methods that promoted quality. Having a local physician opinion leader was a key factor in the success. Muoscucci et al recently reported that implementation of a regional CQI program for PCI was associated with enhanced adherence to quality indicators and improved outcomes.5 The number of PVIs has increased even more rapidly than PCI procedures. Monitoring and improving quality of care for peripheral interventional procedures remain important considerations, and a recent multicenter registry is attempting to foster achievement of long-term, quality-based clinical outcomes for patients with peripheral arterial disease.6 Data from this peripheral interventional registry have suggested that effective secondary prevention with appropriate lifestyle interventions and evidence-based medical therapy needs to be strongly encouraged and implemented in patients with peripheral arterial disease, and such measures significantly improve clinical outcomes.7

As healthcare costs continue to climb with use of increasingly expensive devices, purchasers will look for new ways to ensure that their increased healthcare expenditures will result in healthier patients and greater patient satisfaction. It appears likely that one of the most effective ways that purchasers and payers may accomplish this goal is by arranging for a portion of a provider's reimbursement to be tied to achieving high-quality outcomes. Ideally, purchasers, plans, providers, and patients should reach consensus on which outcomes are to be rewarded and which measures are appropriate to use. Purchasers and payers should link financial incentives to quality improvement efforts that will benefit the largest number of patients possible, have easily identifiable and measurable performance measures, and are feasible for providers to implement. Some purchasers and insurers are attempting to optimize quality of care by developing a system of "pay for performance" financial incentives. Some groups are considering specified services and outcomes, including clinical and preventive measures drawn from Health Plan Employer Data and Information Set (HEDIS) as well as performance scores from patient satisfaction surveys. An important factor in the success of pay for performance arrangements is whether payment will be large enough to influence physician behavior. Currently, several insurers are providing up to 10% additional reimbursement for demonstration of quality in episode-based care (eg, acute myocardial infarction) or disease management care (eg, diabetes). The long-term impact of this type of quality-based reimbursement is not known, but it is very likely that higher quality of care will mean higher reimbursement for physicians and hospitals in the future. An important benefit of CQI programs in the catheterization laboratory, therefore, may be increased reimbursement for hospitals and physicians.

Finally, quality improvement initiatives in the catheterization laboratory have marked health outcome and economic implications. Physicians need to partner with nurses, administrators, practice managers, insurers, and information technologists to improve quality of care while cutting costs. The analysis by Rihal and colleagues3 on the process and outcome of cost-containment efforts has important implications for cardiovascular units as well as other settings characterized by expensive new healthcare strategies. The authors should be congratulated on a provocative study with significant clinical and health policy implications.

From the Gill Heart Institute and the Division of Cardiovascular Medicine, University of Kentucky, Lexington, Ky.

Address correspondence to: Debabrata Mukherjee, MD, University of Kentucky, 326 Wethington Bldg, 900 S. Limestone, Lexington, KY 40436-0200. E-mail: