Background: New York State (NYS) began monitoring and reporting back hospital’s adherence to the Appropriate Use Criteria for Coronary revascularization (AU) in 2010. NYS plans to publicly report as well as decrease payments for procedures deemed rarely appropriate based on these data. Utilizing the data in these reports on AU, our hospital made strenuous efforts to improve documentation and decrease inappropriate procedures. Results from NYS data from 2011 through 2013 were continuously tracked and charted to monitor progress and to identify areas to focus on for needed remediation. Methods: 2010 data from NYS was utilized as the baseline. A multipronged approach was taken to improve appropriateness. A monthly multidisciplinary task force was organized to review opportunities, change policies and procedures, and review ongoing results. A worksheet was developed and used to provide education and data collection. The electronic catheterization report was changed to incorporate appropriateness criteria documentation previously missing from the chart. Challenges included education and achieving compliance from a diverse group of faculty captive and private cardiology groups supported by a large and constantly changing group of support staff. The summary of data from NYS was compared from 2010 through 2013 against the hospitals results and NYS as a whole. Results: Cases rated appropriate increased from 26% (102 of 391) in 2010 to 62% (75 of 121) in 2013. Cases rated inappropriate decreased from 24.8% (97 of 391) in 2010 to 8.3% (10 of 121) in 2013. The cases rated uncertain also decreased from 49% (192 of 391) in 2010 to 29.8% (36 of 121) in 2013. This is statistically significant with p < 0.05 by chi-square. Conclusions: Appropriate use dramatically improved with the effective implementation of a multipronged strategy utilizing: a task force, AU worksheet, electronic documentation tools, data review, practitioner feedback and education. Compliance with appropriate use metrics is assuming increasing importance with QHIP in 2015 designating 2 AU measures (unclassifiable and inappropriate) as determinants of hospital payments. Our effective improvement of AU results serves as an institutional template for other ongoing quality improvement efforts.

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Background: For the hospital, the cardiac catheterization lab is a high risk, high volume, high cost center. With the evolving imperative to provide value over volume, cardiac catheterization lab utilization, processes, and outcomes are an increasing focus of both internal and external scrutiny on an individual operator and aggregate basis. A hospital initiated multidisciplinary task force reviews real time and quarterly data from the NCDR and New York State to provide operator and cath lab managerial feedback, modify practice, and to assess progress. Ongoing interventions include; worksheets, EMR and Cath Lab templates, timely data review and feedback to managerial staff and operators. Methods: Stony Brook University has an open Cardiac Cath Lab with services provided by 5 full time faculty and 12 voluntary (private practice) interventional cardiologists. Using internal, NYS [2009-2015], and 2015 NCDR data, utilization, processes, and outcomes of high volume [HV] operators [>100 PCI/yr] and those with a disproportionate rate of cath to PCI conversions [>50%] were compared to lower volume [LV] and low conversion rate operators. Results: High volume operators [6] performed an average of 171 interventions compared to an average of 36 for LV operators [11]. Cases rated appropriate increased from 26% (102 of 391) in 2010 to 96.4% (1448 of 1502) in 2015. Cases rated inappropriate decreased from 24.8% (97 of 391) in 2010 to 1.0% (15 of 1502) in 2015; HV operators 0.5% versus 2.2% LV operators in 2015. The cases rated uncertain also decreased from 49% (192 of 391) in 2010 to 2.6% (39 of 1502) in 2015; HV operators 1.6% versus 5.1% for LV operators in 2015. This is statistically significant with p < 0.05 by chi-square. Process indicators of stent utilization/case [1.8 vs 1.6] and contrast use [179 vs 166 cc/case] were similar in HV and LV operators with an increase in fluoroscopy times [20.2 vs 18.3 min], Total Area Dose [11,017 vs 9,154], Skin Dose 1,759 vs 1,536] in the LV operators. Bleeding complications were higher [5.8% vs 2.1%] in HV operators and mortalities were confined to the HV operators and those performing STEMI interventions. Conclusions: A multidisciplinary task force is an effective method of targeting multiple variables impacting on cath lab value metrics. Marked progress has been made towards the consistent and appropriate use of cardiac catheterization and angioplasty. The highest rates of cath-PCI conversion, bleeding complications and mortality were for HV full time cardiologists, providing 7x24 coverage for STEMI interventions and caring for a disproportionate number of ACS patients. Initiated processes, oversight and feedback changes have effectively minimized process and potential outcome differences between high and low volume operators.