Morbidity and Mortality Conference for Percutaneous Coronary Intervention

Abstract

Background-Morbidity and mortality conference is a common educational and quality improvement activity performed in cardiac catheterization laboratories, but best practices for case selection and for maximizing the effectiveness of peer review have not been determined. Methods and Results-We reviewed the 10-year percutaneous coronary intervention morbidity and mortality conference experience of an academic medical center. Cases were triggered for review by the occurrence of prespecified procedural events. Summary reports from morbidity and mortality conference discussions were linked to clinical data from the Duke Databank for Cardiovascular Disease to compare baseline and procedural characteristics and to assess postdischarge outcomes. Of 11 786 procedures, from 2004 to 2013, 157 (1.3%) were triggered for review. The most frequent triggering events were cardioversion/defibrillation (72, 0.6%), unplanned use of mechanical circulatory support (64, 0.5%), and major dissection (41, 0.3%). Selected procedures were more likely to include high-risk features, such as ST-segmentelevation myocardial infarction, cardiogenic shock, and multivessel disease, and were associated with higher mortality at 30 days. Only a minority of triggering events were caused by controversial or unacceptable physician behavior. Conclusions-This 10-year experience outlines the processes for conduct of an effective percutaneous coronary intervention morbidity and mortality conference, including a novel approach to case selection and structured peer review leading to actionable quality interventions. The prespecified clinical triggers, captured in the natural workflow by laboratory staff, identified complex cases that were associated with poor patient outcomes. (Circ Cardiovasc Qual Outcomes.

Characteristics of the Quality Improvement Content of Cardiac Catheterization Peer Reviews in the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

“…Only 25 cases (16.4%) over 5 years were determined to not meet the standard of care, and concerns about physician competency were very rare. This is similar to a single-center report of morbidity and mortality activities for PCI, 2 in which physician performance was judged “very controversial or unacceptable” in only 5.9% of reviewed cases.…”

“…Prior reports of peer review processes for PCI have focused on structural aspects of peer review and have not examined the QI output of the programs. 2,3 For example, a 2017 report described review of 157 PCI cases over 10 years at a single academic center. 2 Cases were triggered for review by the occurrence of at least 1 of 9 clinical triggers entered into the clinical record by catheterization laboratory staff.…”

“…2,3 For example, a 2017 report described review of 157 PCI cases over 10 years at a single academic center. 2 Cases were triggered for review by the occurrence of at least 1 of 9 clinical triggers entered into the clinical record by catheterization laboratory staff. Cases were reviewed monthly by faculty using a standardized scoring system.…”

“…This resulted in complication rates that are low compared with other health systems. 2,6 A review of deaths occurring on the same day of the procedure but after the patient was transferred out of the catheterization laboratory revealed that most were potentially associated with care received in the laboratory. We are therefore exploring alternative mechanisms to identify poor procedural outcomes and improve capture of MAE.…”

“…Peer review is recommended for all cardiac catheterization programs as a mechanism to promote clinical proficiency and identify opportunities for quality improvement (QI). 1 Review of cases with poor outcomes or unexpected complications (ie, morbidity and mortality conference) is a common form of peer review, 2,3 but whether this activity yields content that may guide performance improvement has not been described, to our knowledge. In 2004, the US Department of Veterans Affairs (VA) launched the Clinical Assessment, Reporting, and Tracking (CART) program to study and address concerns about cardiovascular care quality.…”