The Quality Mandate: Understanding New Regulatory Policies and Quality Superheroes

In the multi-part presentation entitled “The Quality Mandate: Understanding New Regulatory Policies and Quality Superheroes,” Robert Yeh, MD, a cardiologist at Massachusetts General Hospital (MGH), started the first session by reporting on the changing epidemiology of today’s cardiovascular disease patient. Dr Yeh pointed out that the frequency of myocardial infarction has declined over the past 10 years, and that today’s patients are more frequently older, female, diabetic, and generally more frail. There are far greater demands on the interventional cardiologist today. Dr Yeh noted a decline in the number of elective procedures, including percutaneous coronary intervention (PCI). At MGH they have placed great emphasis on performing perspective, not retrospective, analysis of outcomes toward achieving greater quality assurance.

Next, Charles E. Chambers, MD, cardiologist at the Penn State Hershey Heart and Vascular Institute, elaborated on how interventional cardiology is under tremendous scrutiny and so it is particularly essential to incorporate a well- designed peer review process in order to attain good quality assurance. A specific peer review policy should be designed and enacted with the following 3 characteristics: (1) strive for prospective peer review; (2) conflicts of interest must be considered and maintained with selection of members on the basis of unbiased experts with non-punitive policies; and (3) confidentiality must be maintained. Ideally there are external reviewers as well as internal reviewers, but Dr Chambers pointed out that he has not actually seen strong evidence against a purely internal review process, suggesting that this cannot be made to work as well as one with external reviewers. Nurses, while essential to good procedure, should not be a part of the peer review group. Most important, Dr Chambers emphasized that the physicians should regularly work together to organize and discuss the most challenging cases and that regular continuing education classes are essential to enable continuous quality improvement.

One of the biggest uncontrollable developing factors facing interventional cardiology has to be the major changes in government health insurance policies set to occur over the next few years. In a talk entitled “Will the Government Become the de facto Lab Director,” Dr Carl L. Tomasso, MD, described several case studies involving patients who would appear to benefit the most from catheterization, but the doctor would be judged as performing poor quality as defined by the new regulations and so their reimbursement would be reduced. Another major criticism highlighted by Dr Tomasso was the fact that under the current organizational design, a payment advisory board made up of 15 non-physicians will make determinations of quality. The general impression that Dr Tomasso conveyed was that these new government policies are terribly restrictive and lacking in good judgments by properly credentialed individuals. These policies will serve as a barrier to providing optimal individualized medicine.

In the final talk of the session, Jeptha P. Curtis, MD, interventional cardiologist and researcher at Yale University, discussed “Performance Measures: Crossing the Chasm With Hospital Quality.” This presentation covered the metrics for the gap between the stated goals of the Institute of Medicine compared with the actual practice in the clinic. There is increasing transparency and accountability to external parties for the care outcomes. He highlighted one major success within the field. The door-to-balloon time has really reduced itself, to just 102 minutes for the past 10 years. This is an amazing statistic that, on its own, warrants the moniker of “superheroes” for interventional cardiologists as a whole. Dr Curtis stressed that by far the most common rate-limiting step controlling the performance of a hospital is the leadership of the physicians. It is essential to have strong leadership in order for a hospital to achieve a high quality rating. He emphasized the importance of having a good administration as well.

Overall, the presentations were well received and attendance was above average. In summary, the cardiovascular disease patient is increasingly frail and policies must be in place to assure continuous quality improvements. The peer review process is key to this. Changes in government health insurance policies are key to a dynamic process that currently is headed in the wrong direction according to Dr Tomasso and more metrics than just PCI measures are going to be needed in order to improve hospital performance and achieve continuous quality improvements.