HCFA’s CCP to improve Medicare AMI care
PROs become partners, not punitive overseers
Should your hospital join the new quality improvement project being launched by the federal Health Care Financing Administration (HCFA)? Aimed at acute myocardial infarction (AMI) patients, the Cooperative Cardiovascular Project (CCP) is an ambitious endeavor which aims to improve care received by Medicare beneficiaries. Peer review and quality improvement organizations nationwide have volunteered to take part.
The CCP is the first project of its kind to be undertaken by HCFA. Jeanne Sandecki, RN, acted as liaison for CCP at Promina-Gwinnett Health System in Lawrenceville, GA, but also is in charge of coordinating the action plan of Gwinnett’s participation in a National Registry of AMI patients. She was in an ideal spot to compare the two projects.
"We definitely benefitted from our participation in the Cooperative Cardiovascular Project," Sandecki explains. "When CCP’s contractor abstracted data on our patients with AMI, the investigators looked at many of the same indicators we looked for through the National Registry. But smoking cessation, specifically documenting counseling efforts, was not one of our indicators for the registry. In fact, the registry paid little attention to cardiac rehabilitation or patient education. When we got our data back from CCP and HCFA last year, it got us thinking about our registry indicators, and now we’ve incorporated some of the CCP’s benchmarks."
Since Gwinnett volunteered for CCP, the facility has been involved in various HCFA projects, one of which tracks heart failure and another dealing with pneumonia.
Some laud accomplishments, others wary
The CCP was initiated in 1991, but redrawn two years later to become more user-friendly. PROs began to receive the first batches of data toward the end of 1995. HCFA has abstractions on 212,000 Medicare AMI patients from 1994 as its baseline data set. One of CCP’s goals has been to convert the perception of state Medicare PROs from punitive overseers to hospitals’ partners in the process of quality improvement. Reception has been positive for the most part, even though results have shown there’s a lot of room for improvement. Some quality managers see CCP’s findings as an incentive to staff. Others, however fear the data are being warehoused for use against them in the future. Physicians tend to appreciate the fact that the monitoring is done at the hospital level as opposed to the development of "report cards."
HCFA contracts with local companies to collect data from the institutions that volunteer for the scrutiny. Investigators analyze patterns of care regarding 11 clinical indicators of AMI derived from the American College of Cardiology and American Hospital Association guidelines. The indicators relate to the timing of thromboembolization, the use and timing of aspirin, reperfusion, beta-blockers, and ACE inhibitors. Other indicators include avoidance of calcium channel blockers in left ventricular systolic dysfunction and documentation of smoking cessation counseling. The information is reported back to HCFA, which supplies hospitals with their findings. By becoming a part of the project, the institutions can identify areas needing improvement. For example, some hospitals have written new or adjusted existing clinical pathways. Other hospitals have focused on emergency department protocols for improvement.
The University of Connecticut Health Center, for example, scored high on all but two quality of care indicators — time to thrombolytic therapy and documentation of smoking cessation counseling. Following their CCP report, the hospital has reduced time to thrombolytic therapy from two hours to 30-40 minutes; smoking cessation counseling is now tied to a new care path for AMI.
Cardiovascular care, specifically AMI, was chosen as a focus for the project because of the disease’s high frequency, high cost to the Medicare program, and high preventable mortality rate. Practice patterns and outcomes of AMI vary considerably despite the availability of widely-accepted evidence-based guidelines for diagnosis and treatment. The objective of the CCP is to bring care for AMI patients closer to those guidelines. They accomplish this by collecting data from hospitals and other medical facilities treating more than 20 AMI cases. HCFA analyzes patterns of care, then state Medicare Peer Review Organizations provide those analyses to the facilities and works with them to identify areas for improvement in processes or outcomes. Facilities with fewer than 20 AMI cases are provided with information about the project and given the option of participating in telephone conferences.
HCFA plans to re-abstract the data from a national random sample of several thousand patients during 1997 to confirm improvements in AMI care as reported by participating hospitals. The large volume of data generated by CCP is expected to lead to a number of spin-off projects, such as an overall analysis of hospital practices in providing care to patients with AMI.
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