C. Michael Valentine

Comparison of Clinical Interpretation with Visual Assessment and Quantitative Coronary Angiography in Patients Undergoing Percutaneous Coronary Intervention in Contemporary Practice: The Assessing Angiography (A2) Project

Background— Studies conducted decades ago described substantial disagreement and errors in physicians’ angiographic interpretation of coronary stenosis severity. Despite the potential implications of such findings, no large-scale efforts to measure or improve clinical interpretation were subsequently undertaken. Methods and Results— We compared clinical interpretation of stenosis severity in coronary lesions with an independent assessment using quantitative coronary angiography (QCA) in 175 randomly selected patients undergoing elective percutaneous coronary intervention at 7 US hospitals in 2011. To assess agreement, we calculated mean difference in percent diameter stenosis between clinical interpretation and QCA and a Cohen weighted &kgr; statistic. Of 216 treated lesions, median percent diameter stenosis was 80.0% (quartiles 1 and 3, 80.0% and 90.0%), with 213 (98.6%) assessed as ≥70%. Mean difference in percent diameter stenosis between clinical interpretation and QCA was 8.2±8.4%, reflecting an average higher percent diameter stenosis by clinical interpretation (P<0.001). A weighted &kgr; of 0.27 (95% confidence interval, 0.18–0.36) was found between the 2 measurements. Of 213 lesions considered ≥70% by clinical interpretation, 56 (26.3%) were <70% by QCA, although none were <50%. Differences between the 2 measurements were largest for intermediate lesions by QCA (50% to <70%), with variation existing across sites. Conclusions— Physicians tended to assess coronary lesions treated with percutaneous coronary intervention as more severe than measurements by QCA. Almost all treated lesions were ≥70% by clinical interpretation, whereas approximately one quarter were <70% by QCA. These findings suggest opportunities to improve clinical interpretation of coronary angiography.

A Statewide Collaborative Initiative to Improve the Quality of Care for Patients With Acute Myocardial Infarction and Heart Failure

Background— To enhance quality improvement, we created a unique statewide collaboration among 3 organizations: the Virginia Health Quality Center (Virginia’s Medicare Quality Improvement Organization), the American College of Cardiology, and the American Heart Association. The goal was to improve discharge measures for acute myocardial infarction and heart failure. Methods and Results— In 2004, 29 hospitals participated in the collaborative initiative. Using Medicare data submitted from 2004 through the second quarter of 2006, we analyzed adherence to individual discharge measures and all-or-none appropriate care measures for acute myocardial infarction, heart failure, and both. To control for differences in hospital characteristics, we were able to match 21 of the participating hospitals with 21 similar nonparticipating hospitals. In this paired analysis, the total appropriate care measure increased from 61% to 77% in participating hospitals compared with an increase from 51% to 60% in nonparticipating hospitals (P<0.0001). A generalized linear mixed model examining the full data set at the patient level failed to show a clear advantage among participating hospitals. Participating hospitals had higher baseline rates for most quality measures, suggesting a possible effect of a prior collaborative. Further analysis of only hospitals that participated in a prior collaborative showed that participants in the current collaborative initiative had higher rates of improvement for 7 of 10 quality measures and appropriate care measures for heart failure, acute myocardial infarction, or both (all P<0.05). Conclusions— We report a unique collaboration of a Medicare Quality Improvement Organization and 2 national organizations to address quality of care for acute myocardial infarction and heart failure. A composite measure of quality (the total appropriate care measure) improved more in the participating hospitals during the timeframe of the intervention, although the greater improvement in this and other measures in the participating hospitals appeared to be dependent on participation in a prior collaborative initiative.

Comparison of Clinical Interpretation With Visual Assessment and Quantitative Coronary Angiography in Patients Undergoing Percutaneous Coronary Intervention in Contemporary Practice

Background— Studies conducted decades ago described substantial disagreement and errors in physicians’ angiographic interpretation of coronary stenosis severity. Despite the potential implications of such findings, no large-scale efforts to measure or improve clinical interpretation were subsequently undertaken. Methods and Results— We compared clinical interpretation of stenosis severity in coronary lesions with an independent assessment using quantitative coronary angiography (QCA) in 175 randomly selected patients undergoing elective percutaneous coronary intervention at 7 US hospitals in 2011. To assess agreement, we calculated mean difference in percent diameter stenosis between clinical interpretation and QCA and a Cohen weighted &kgr; statistic. Of 216 treated lesions, median percent diameter stenosis was 80.0% (quartiles 1 and 3, 80.0% and 90.0%), with 213 (98.6%) assessed as ≥70%. Mean difference in percent diameter stenosis between clinical interpretation and QCA was 8.2±8.4%, reflecting an average higher percent diameter stenosis by clinical interpretation (P<0.001). A weighted &kgr; of 0.27 (95% confidence interval, 0.18–0.36) was found between the 2 measurements. Of 213 lesions considered ≥70% by clinical interpretation, 56 (26.3%) were <70% by QCA, although none were <50%. Differences between the 2 measurements were largest for intermediate lesions by QCA (50% to <70%), with variation existing across sites. Conclusions— Physicians tended to assess coronary lesions treated with percutaneous coronary intervention as more severe than measurements by QCA. Almost all treated lesions were ≥70% by clinical interpretation, whereas approximately one quarter were <70% by QCA. These findings suggest opportunities to improve clinical interpretation of coronary angiography.

Helping ACC Members Deliver Higher-Quality Care

![Figure][1] nnnnWe have come a long way since the concept of “pay-for-performance” first emerged on the scene nearly 2 decades ago. Faced with both increasing cuts in Medicare reimbursement and rising overhead costs, it was difficult for practices at the time to make a business case for,

Tackling the Quadruple Aim: Helping Cardiovascular Professionals Find Work-Life Balance

![Figure][1] nnnnThe concept of the “triple aim” was first introduced by the Institute for Healthcare Improvement in 2007, right in the middle of fierce debate over reforming health care in the United States. The goal: to provide a framework for a health care system focused not on volume,

The ACC Is Your Advocate

![Figure][1] nnnn![Figure][1] nnEach year the American College of Cardiology’s (ACC’s) Legislative Conference brings together hundreds of cardiovascular professionals from across the United States for 3xa0days of advocacy training and opportunities to meet with federal lawmakers and

ABIM Maintenance of Certification: Options for ACC Members

![Figure][1] nnnn![Figure][1] nn![Figure][1] nnThe American Board of Internal Medicine’s (ABIM’s) Maintenance of Certification (MOC) process continues to be one of the biggest concerns facing American College of Cardiology (ACC) members. Input from cardiovascular professionals

The American College of Cardiology: Strategically Aligning for the Next 5 Years

![Figure][1] nnnn![Figure][1] nn![Figure][1] nnFive years ago, the American College of Cardiology (ACC) embarked on a 5-year strategic plan to guide the College and its members through 2018. The plan centered around the concept of the then-“Triple Aim” of better care, improved

ACC as the Professional Home for All Cardiovascular Professionals

![Figure][1] nnnn![Figure][1] nn![Figure][1] nnAs cardiovascular care continues to undergo dramatic change, the American College of Cardiology (ACC) is acutely aware of the myriad challenges and opportunities facing its members, both now and in the years to come. Given this, 1 of the

Response to Letters Regarding Article, “Comparison of Clinical Interpretation With Visual Assessment and Quantitative Coronary Angiography in Patients Undergoing Percutaneous Coronary Intervention in Contemporary Practice: The Assessing Angiography (A2) Project”

We appreciate the concerns raised by Drs Khandelwal and Kern about our recent analysis of the visual assessment of angiographic stenosis among percutaneous coronary intervention (PCI)–treated lesions in contemporary practice.1 In sum, their concerns involve the admittedly imperfect nature of quantitative coronary angiography (QCA), which they suggest should not be used as a tool for clinical assessments in the catheterization laboratory. We agree that QCA has limitations (and noted many of their points in our Discussion). In particular, we specifically acknowledged that QCA ‘as it is currently used’ does not account for many factors that should influence clinical decisions on revascularization.nnNonetheless, we do believe that QCA, as an unbiased and highly reliable technique, may help quality improvement efforts by identifying (and perhaps narrowing) gaps in performance related to visual assessment. This was the overarching goal of our study, and we believe our findings strongly suggest a need to improve visual assessment. Despite several previous studies that have demonstrated deficiencies with visual assessment over the last several decades, there has been no concerted effort by the cardiology community to address extensive interobserver and intraoperator variability in the …