Quality of Coronary Care: Reducing Practice Variability.

Ischemic heart disease remains the leading cause of death worldwide. In recent decades, developments in percutaneous coronary intervention (PCI) and the overall care for acute coronary syndrome (ACS) have resulted in improved, albeit still variable, outcomes.1Udell J.A. Koh M. Qiu F. et al.Outcomes of women and men with acute coronary syndrome treated with and without percutaneous coronary revascularisation.J Am Heart Assoc. 2017; 6e004319Crossref PubMed Scopus (50) Google Scholar The era of quality improvement (QI) in medicine was initiated through the Institute of Medicine’s pivotal 2000 publication, To Err Is Human, seeking to minimise preventable medical errors and reduce variations in clinical outcomes. Since then, multiple QI initiatives in cardiovascular medicine have been launched across the globe. In the United States, the Get With The Guidelines initiative by the American Heart Association in the early 2000s was associated with a gradual improvement of ACS outcomes.2Lewis W.R. Peterson E.D. Cannon C.P. et al.An organised approach to improvement in guideline adherence for acute myocardial infarction: results with the Get With The Guidelines quality improvement program.Arch Intern Med. 2008; 168: 1813-1819Crossref PubMed Scopus (105) Google Scholar More recently, the Cardiovascular Quality Improvement and Care Innovation Consortium was established to introduce and scale multicentre cardiovascular QI initiatives and serve as a resource and support for others to join in this endeavour.3Null N. Bradley S.M. Adusumalli S. et al.The Cardiovascular Quality Improvement and Care Innovation Consortium.Circ Cardiovasc Qual Outcomes. 2021; 14e006753Google Scholar In Europe, the Global Registry of Acute Coronary Events highlighted that adherence to QI metrics resulted in gradual reductions in ACS-related mortality.4Fox K.A.A. Steg P.G. Eagle K.A. et al.Decline in rates of death and heart failure in acute coronary syndromes 1999-2006.JAMA. 2007; 297: 1892-1900Crossref PubMed Scopus (702) Google Scholar Despite these ACS QI efforts in North America and Europe, it is unknown whether these patterns are also observed in other regions. In this issue of the Journal, Kanaoka et al.5Kanaoka K. Iwanaga Y. Nakai M. et al.Hospital- and patient-level analysis of quality indicators in acute coronary syndrome care: a nationwide database study.Can J Cardiol. 2023; 39: 515-523Abstract Full Text Full Text PDF Scopus (1) Google Scholar used Japan’s National Database of Health Insurance Claims and Specific Health Check-ups to assess the association of adherence to 12 QI indicators on all-cause mortality in ACS. From 2014 to 2018, 216,436 patients with ACS who underwent PCI across 1215 hospitals in Japan were included and analysed. The authors observed high adherence, defined as a median of > 90%, for PCI and aspirin use on arrival, P2Y12 inhibitor use, and left ventricular ejection fraction (LVEF) assessment. Conversely, low adherence (median < 10%) was observed for outpatient cardiac rehabilitation. At the hospital-level, the acute-phase QI composite score was associated with reduced risk-adjusted 30-day mortality rates. At the level of patients, all QI metrics (including acute and nonacute components) were inversely associated with 30-day and 2-year mortality rates. The study is unique in utilising a nationwide database that covers approximately 98% of the population in Japan. The application of standardised QI indicators, including 1 structural (ACS-PCI cases per year), 1 outcome (30-day mortality rate), and 10 acute and subacute process indicators, enables their association with patient- and hospital-level outcomes. To do so, the authors (appropriately) applied mixed-effects logistic regression and Cox proportional hazards models. However, the study is not without limitations. The authors evaluated only PCI-treated ACS, thereby excluding other patients with ACS. It is unclear whether patients who were not treated with PCI for ACS may have benefitted from PCI. In addition, there is an inherent risk of unmeasured confounding, which was not systematically evaluated. Finally, LVEF data were not available for all patients; the authors used some proxies (eg, assessment of beta-blockers, angiotensin-converting enzyme inhibitors [ACEis], and angiotensin II receptor blockers [ARBs] if on dobutamine or mechanical circulatory support), which may lead to a subset of the data being less accurate. Despite these limitations, the study by Kanaoka et al. is of high quality, can be generalisable to all the population of Japan, and is useful in identifying the remaining gaps of care in outpatient cardiac rehabilitation in Japan. This paper provides an opportunity to provide an indirect comparison of the quality of PCI care in ACS between Japan and Canada. Similar to the 12 QI indicators identified in this study, in Canada, the Canadian Cardiovascular Society has identified 13 indicators for PCI and cardiac rehabilitation.6Canadian Cardiovascular SocietyCCS data definitions & quality indicators.https://ccs.ca/ccs-data-definitions-quality-indicatorsDate accessed: December 30, 2022Google Scholar One major QI indicator is cardiac rehabilitation, with opportunities for improvement in its utilisation in both countries. In Japan, after PCI for ACS, an estimated 10% of patients underwent outpatient cardiac rehabilitation and 52% underwent inpatient cardiac rehabilitation, although in Ontario, after any PCI, 42.6% of patients were referred to outpatient rehabilitation,7Kanaoka K. Soeda T. Terasaki S. et al.Current status and effect of outpatient cardiac rehabilitation after percutaneous coronary intervention in Japan.Circ Rep. 2021; 3: 122-130Crossref PubMed Google Scholar,8Brady S. Purdham D. Oh P. Grace S. Clinical and sociodemographic correlates of referral for cardiac rehabilitation following cardiac revascularisation in Ontario.Heart Lung. 2013; 42: 320-325Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar and in Alberta, among patients referred to rehabilitation, 58.6% followed through and started rehabilitation and 49.3% completed rehabilitation.9Martin B.J. Hauer T. Arena R. et al.Cardiac rehabilitation attendance and outcomes in coronary artery disease patients.Circulation. 2012; 126: 677-687Crossref PubMed Scopus (208) Google Scholar In Canada, the national benchmark has been set at a referral rate of 85% and enrollment rate of 70%, although there is no recent evidence to demonstrate whether or not this has been achieved. Earlier data, however, suggest insufficient referrals, underrepresentation of women and non-White patients, and suboptimal risk factor reduction for patients who would benefit from cardiac rehabilitation in Canada.10Grace S.L. Parsons T.L. Heise K. Bacon S.L. The Canadian Cardiac Rehabilitation Registry: inaugural report on the status of cardiac rehabilitation in Canada.Rehabil Res Pract. 2015; 2015: 278979PubMed Google Scholar In Japan, there has been a push to increase rehabilitation rates, which has been evident in this study, with hospital-level inpatient rehabilitation improving over time (from a median of 50% [interquartile range: 0%-78%] in 2014 to 70% [9.5%-85%] in 2017). The higher rates of inpatient vs outpatient rehabilitation in Japan are notable, although hospital stays after PCI are longer in Japan (15 ± 6 days in the study vs 5.4 ± 11.6 days in Ontario), which may partially explain the increased usage of inpatient rehabilitation.11CorHealth OntarioReport on adult percutaneous coronary interventions (PCI) in Ontario.https://www.corhealthontario.ca/Report-on-Adult-PCI-in-Ontario-Octobe-2011-March-2016-April-2018.pdfGoogle Scholar Another explanation is that inpatient rehabilitation in Japan is more comparable to routine hospital discharge criteria in Canada. According to the 2021 Japanese cardiac rehabilitation guidelines,12Makita S. Yasu T. Akashi Y.J. et al.JCS/JACR 2021 guideline on rehabilitation in patients with cardiovascular disease.Circ J. 2022; 87: 155-235Crossref PubMed Scopus (7) Google Scholar inpatient rehabilitation consists of a 10- to 14-day pathway, starting from hospital admission, involving ward-based exercise and patient education. Outpatient cardiac rehabilitation, which is typically 12 weeks in duration, has been shown to provide additional benefits for exercise capacity, exercise tolerance, and quality of life, as well as to be associated with reduced rates of myocardial infarction and cardiovascular mortality.13Kanaoka K. Iwanaga Y. Nakai M. et al.Outpatient cardiac rehabilitation dose after acute coronary syndrome in a nationwide cohort.Heart. 2022; 109: 40-46Crossref PubMed Scopus (3) Google Scholar,14Huang R. Palmer S.C. Cao Y. et al.Cardiac rehabilitation programs for chronic heart disease: a bayesian network meta-analysis.Can J Cardiol. 2021; 37: 162-171Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar In Japan, strict regulatory requirements for outpatient cardiac rehabilitation facilities (rehabilitation centres require a full-time cardiologist/cardiac surgeon) and a lack of a referral system for cardiac rehabilitation (hospitals that do not provide outpatient rehabilitation do not refer to outside networks) may be barriers to the utilisation of outpatient cardiac rehabilitation.15Goto Y. Current state of cardiac rehabilitation in Japan.Prog Cardiovasc Dis. 2014; 56: 557-562Crossref PubMed Scopus (40) Google Scholar Efforts to improve access to outpatient cardiac rehabilitation in Japan continue, with the 2022 reform of the medical fee system in Japan anticipated to relax facility criteria, increasing the outpatient cardiac rehabilitation rate.16Tamura Y. Yasu T. There are not enough facilities for outpatient cardiac rehabilitation—what is the solution?.Circ J. 2022; 86: 2008-2009Crossref PubMed Scopus (1) Google Scholar In Canada, efforts to expand cardiac rehabilitation uptake across provinces have been in place for many years, although there remains a continued need to further identify patients who would benefit most from cardiac rehabilitation, increase rehabilitation capacity, and utilise lower-cost yet equally efficacious strategies such as “home” or “digital” cardiac rehabilitation.17Grace S.L. Turk-Adawi K. Santiago de Araújo Pio C. Alter D.A. Ensuring cardiac rehabilitation access for the majority of those in need: a call to action for Canada.Can J Cardiol. 2016; 32: S358-S364Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Another major QI indicator is prescription of medication at discharge. In this study, high adherence to prescription rates for aspirin (99%), P2Y12 inhibitors (98%), statins (84%), beta-blockers (63%), and ACEi or ARBs (76%) is a strength, placing it in between countries such as the Netherlands and the United Kingdom.18Bebb O. Hall M. Fox K.A.A. et al.Performance of hospitals according to the ESC ACCA quality indicators and 30-day mortality for acute myocardial infarction: national cohort study using the United Kingdom Myocardial Ischemia National Audit Project (MINAP) register.Eur Heart J. 2017; 38: 974-982Crossref PubMed Scopus (59) Google Scholar,19Hoedemaker N.P.G. Damman P. Ottervanger J.P. et al.Trends in optimal medical therapy prescription and mortality after admission for acute coronary syndrome: a 9-year experience in a real-world setting.Eur Heart J Cardiovasc Pharmacother. 2018; 4: 102-110Crossref PubMed Scopus (18) Google Scholar In Canada, adherence is similar for aspirin (98.5%) and dual antiplatelet therapy (96.7%), and higher for statins (96%); however, contemporary data on beta-blockers and ACEis or ARBs prescription rates are lacking.20Czarnecki A. Prasad T.J. Wang J. et al.Adherence to process of care quality indicators after percutaneous coronary intervention in Ontario, Canada: a retrospective observational cohort study.Open Heart. 2015; 2e000200Crossref PubMed Google Scholar Although both countries provide universal health coverage, the health systems vary, particularly regarding outpatient medications and rehabilitation. In Japan, the health insurance system covers 70% of the cost of cardiac rehabilitation for patients < 70 years old and 90% for patients ≥ 70 years old, resulting in a 1-hour session costing roughly $18 for patients < 70 years old and $6 for patients ≥ 70 years old.15Goto Y. Current state of cardiac rehabilitation in Japan.Prog Cardiovasc Dis. 2014; 56: 557-562Crossref PubMed Scopus (40) Google Scholar Medications are similarly covered, with a national pricing for medications and a 30% co-pay for patients < 70, 20% for patients aged 70-74, and 10% for patients ≥ 75.21Nakagawa S. Kume N. Pharmacy practice in japan.Can J Hosp Pharm. 2017; 70: 232-242PubMed Google Scholar In Canada, most cardiac rehabilitation programs are funded by the provinces, but in one-third of programs, patients pay some or all of the program’s cost.22Tran M. Pesah E. Turk-Adawi K. et al.Cardiac rehabilitation availability and delivery in Canada: how does it compare with other high-income countries?.Can J Cardiol. 2018; 34: S252-S262Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar In addition, prescription drug coverage is not universal and varies by province. In many provinces, most costs for cardiac medications are covered in certain patient groups, such as in patients > 65 years old, children, those with low income, and those who are disabled. Patients who are not included in these groups often rely on private insurance, which is typically employer sponsored, for medication coverage. Although many of these quality indicators remain relatively affordable in both countries, it is likely that adherence may be reduced among certain patients owing to affordability issues, with up to 1 in 12 patients in Canada reporting not filling a prescription because of costs.23Law M.R. Cheng L. Kolhatkar A. et al.The consequences of patient charges for prescription drugs in Canada: a cross-sectional survey.CMAJ Open. 2018; 6: e63-e70Crossref PubMed Scopus (44) Google Scholar Quality improvement is indispensable to continuously apply evidence-based medicine and improve health care delivery for our patients. Therefore, the uptake of QI processes and metrics should be promoted in cardiovascular medicine. Drivers to expand QI efforts include comprehensive data infrastructures, QI teams and champions, and patient advocacy, all of which must be facilitated. Barriers, which include fragmented health systems and electronic health records, health care costs, and inadequate metrics (ie, not measuring what matters), should be addressed through sustainable solutions. Ultimately, QI should keep the patient in mind: Health systems should measure and prioritise outcomes that matter to patients and centre patients in the development, monitoring, and evaluation of QI efforts over time. Dr Vervoort is supported by a Canadian Institutes of Health Research Vanier Canada Graduate Scholarship.