Hospital Ranking Based on Discharge Prescriptions After Acute Myocardial Infarction:

A National Assessment over Three Consecutive Years

François Schiele1, Frédéric Capuano2, Geneviève Derumeaux3,

Nicolas Danchin1, Christine Gardel2 , Melanie Couralet2,

Jean-François Thebaut2, Armelle Desplanques-Leperre2,

Catherine Grenier2 , Raymond Le Moign2

(1) French Society of Cardiology , Paris, France

(2) Haute Autorité de Santé, Saint Denis, France

(3) National Professional Board of Cardiology, Paris, France

F Schiele reports receiving grant supports paid to his institution and travel

support for scientific meetings from Astra Zeneca, Boehringer Ingelheim,

Daiichi –Sankyo, Lilly, Medtronic, Pfizer, Sanofi, Servier, Takeda.

G Derumeaux reports receiving grant supports paid to her institution from:

Astra Zeneca, Actelion, Bayer, Brahms, General Electrics, Medtronic, Pfizer,

Servier, Toshiba, Trophos, and travel support for scientific meetings from:

Actelion, Astra Zeneca, Boehringer Ingelheim, Medtronic, Pfizer, Sanofi,

Servier.

F. Capuano, P. Loirat, L Thebaut, A. Desplanques-Leperre, and C. Gardel

have no conflict of interest to report.

Disclosures

Evaluation of the quality of care provides key information for health authorities, health insurance providers, patients, the general public and physicians themselves. Measuring the actual process of care rather than merely outcomes is an alternative approach to assessing overall quality of care. Processes of care can be estimated by quality indicators (QIs) defined specifically for certain diseases. Acute myocardial infarction (AMI) is one such situation where QIs have been developed. In France, 3 campaigns to measure QIs for AMI at discharge have been implemented to date throughout the whole country, and in all centers admitting patients for chest pain.

We report the results of these three consecutive campaigns of assessment of QIs in survivors after AMI, and discuss their

interpretation, as well as the method used for public reporting.

Assessment of Quality of Care

National Authority for Health (Haute Autorité de Santé)

launched a nationwide program of assessment of quality of

care to evaluate management of AMI, benchmark

performance and follow the evolution of AMI management

from initial onset of symptoms up to 1 year after discharge.

Specific QIs were defined for each situation.

Periods of analysis: Three campaigns to measure QIs for

AMI have been implemented to date, namely in 2008, 2009

and 2010, throughout the whole country, and in all 635

centres admitting patients for chest pain.

Patient record selection: up to 80 patient files were

randomly selected among those with discharge diagnosis of

acute MI (ICD10).

Data were recorded by an independent team after specific

training in completion of the CRF.

Methods (1): Design

Aspirin and Clopidogrel: CI= allergy, haemorrhagic process,

uncontrolled gastric ulcer, pregnancy or lactation

Beta-blockers : absolute or relative CI

• Absolute CI= uncontrolled heart failure, shock, bradycardia,

severe COPD, hypersensitivity

• Relative CI = COPD, diabetes, asthma, AV block heart failure

Assessment of LVEF and ACEI in patients with LVEF<0.40

• CI= Intolerance or hypotension

Statins regardless of cholesterol level

• CI= Intolerance

Composite QI

• Composite indicator: aggregate of the 4 individual indicators

using the All or None strategy (= 1 if all QI score 1, 0 if one or

more QI score 0)

Methods (2): QIs at discharge

AP = prescription in the absence of contra-indication(CI) or non-prescription (NP) in case of documented CI

39776 patient records

All

Indicators Medical records (N) 39776

Aspirin AP (%) 38924(97.9)

Justified NP/NP (%) 55.2

Clopidogrel AP (%) 37492(94.3)

Justified NP/NP (%) 54.0

Beta Blockers AP (%) 35539(89.3)

Justified NP/NP (%) 60.4

ACEI or ARB

(LVEF<0.40) AP(%) 6455(89.4)

Justified NP/NP (%) 52.6

Statins AP (%) 37119(93.3)

Justified NP/NP (%) 41.8

Composite

(All or None) Number (%) 28976(72.9)

QI Rates and Temporal trends

Composite Indicator According to Age, Gender,

Type of Center and Year

0.001

0.001

0.001

0.001

0.001

0.001

0.001

0.038

0.599

0.001

0.008

Typical patients with failure of composite indicator: Women, age>75, admitted in 2008 in a non-university centre at low activity volume

Hospital Ranking according to the Composite Indicator Composite indicator (95% CI) for each centre with >30 records, compared with national mean of the year and according to a

threshold (80%)

Theoretical threshold 80%

2008 campaign

National mean vs theoretical threshold

2009 campaign 2010 campaign

Hospital Ranking according to the Composite Indicator Results of the 3 campaigns: 2008, 2009 and 2010

Yearly Hospital Ranking: 3 categories according to the Composite Indicator

Public Reporting

http://www.has-sante.fr/portail/jcms/

Discussion Positive points:

Driven by HAS => strong methodology (all centers, random

selection of records), repeated over 3 years, total of 46,000 records.

Construction of a composite indicator (all or none).

Public reporting available on internet.

Points of discussion:

Suitable only for centres with > 30 AMI per year

Analysis of the quality of prescription at discharge: relation

between quality and age, gender, center categories and volume.

No outcome indicator: adjusted mortality not included yet.

Public reporting: Center classification but no benchmarking.

Limited action for Class C and D Centers.

Future actions: Evaluation extended to management of STEMI (pilot

evaluation for reperfusion ongoing) and secondary prevention.

Need for reassessment of the QIs, according to new guidelines and

task forces.

Conclusions

Feasibility of assessment of quality of care at a national

level, repeated over 3 years, with public reporting in 2010.

Trend towards better performance between 2008 and

2010, but 16% of centers present suboptimal performance:

Class C.

Extension of evaluation to other clinical situations would

be easier with ESC defined Quality Indicators in

Cardiovascular Situations and clear recommendations for

assessment of the QI.