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CDA 10-199 – HSR&D Study

 
CDA 10-199
Appropriateness of Percutaneous Coronary Intervention
Steven M. Bradley MD MPH
Rocky Mountain Regional VA Medical Center, Aurora, CO
Aurora, CO
Funding Period: July 2012 - June 2017

BACKGROUND/RATIONALE:
My career goal is to improve the quality and value of health care. During my CDA, my initial efforts were directed at reducing the inappropriate use of expensive diagnostic studies and therapies for patients with cardiovascular disease. Specifically, I have worked to reduce the inappropriate use of percutaneous coronary interventions (PCIs) for patients with ischemic heart disease. We have been successful in our pilot effort that leveraged the Clinical Outcomes Assessment Program regional quality improvement program in Washington State, with resultant 56% reduction in the use of inappropriate PCI over a three year time period (Circulation. 2015;132:20-6). Similar efforts within the VA were hindered by a lack of data capture on symptom burden prior to PCI to support assess appropriateness. Accordingly, we successfully competed for IIR funding to support chart review necessary to assess PCI appropriateness within the VA. This project will also determine the value (cost relative to patient outcomes) of inappropriate PCI and use qualitative methods to determine the facilitators and barriers to appropriate patient selection for PCI. As I have transitioned from the VA, this work will be continued by my colleagues at the Denver VA.
As I've continued in my career, my focus has increasingly shifted to improving the value of care as determined by the costs relative to patient outcomes achieved. Barriers to improving value include a lack of detailed data on health status outcomes that matter to patients (symptoms, functional status, and health related quality of life) and a limited understanding of the processes that contribute unnecessary cost to care delivery. To improve capture of health status outcomes, I led a project of within the Triple Aim QUERI to capture health status measures in routine care delivery. The initial success of this project was outlined in a recent publication (JAMA. 2016;316:487-8). To improve our understanding of process inefficiency, I obtained my Green Belt in Lean-Six Sigma and partnered with the Harvard Business School (HBS) to apply Time-Driven Activity Based Costing methodologies in the identification of opportunities for cost reduction while maintaining optimal outcomes in high-value care. In my transition from the VA, the work within the Triple Aim QUERI will be continued by my Denver colleagues and the Clinical Outcomes Assessment and Tracking (CART) Program while the partnership with HSB continues through the work of VERC leadership in VISN 1. In recognition of the success of these programs, I was recruited to join the Minneapolis Heart Institute as the Associate Medical Director of their Center for Healthcare Delivery Innovation. This professional opportunity allowed me to continue to apply these skills across the continuum of cardiovascular disease in a location that brings my wife close to family. I will be forever indebted to the VA for the opportunity, skills, and leadership opportunities I was provided as a CDA recipient.
I have continued to lead high profile publications on appropriateness of cardiovascular care in the past 12 months. This included publications in Circulation summarizing our work in Washington State and JAMA summarizing our work to capture patient reported health status measures in routine care delivery. I was also successful in securing IIR funding and leadership of a project within the successfully funded Triple Aim QUERI. Most recently I was named the recipient of the 2017 American College of Cardiology Douglas P. Zipes Distinguished Young Scientist Award in recognition of my early career success.
Currently, we lack adequate capture of symptom data at the time of PCI to support the assessment of PCI appropriateness within the VA. I have taken a multipronged approach to address this issue. First, I we received HSR&D IIR funding to support chart review necessary to determine if stress test and PCI procedures for stable CAD are being used in the appropriate patients in the VA (Aim 1) and to understand how variation in appropriate use of these procedures impacts healthcare value (Aim 2). We will answer these questions in a cohort of 20,000 patients with coronary artery disease using VA National Clinical Assessment Reporting and Tracking (CART) Program data supplemented by focused chart review to determine procedural appropriateness. Informed by these analyses, we will identify best-practices for the delivery of appropriate and high-value care (Aim 3).
In addition to this IIR proposal with chart review to inform procedural appropriateness, we have developed an interactive voice recognition telephone system to administer and capture patient reported health status measures (symptom burden, functional status, and health related quality of life) to capture patient reported health status among patients undergoing procedures in the cardiac cath lab (JAMA. 2016;316:487-8). The national roll-out of this system is the focus of a project within the Triple Aim QUERI in partnership with the VA CART Program.
Appropriateness of care has potentially large implications for the value of care, reflected by the costs of care relative to patient outcomes. Inappropriate procedures add cost to the healthcare system without improving patient outcomes and therefore represent low-value care. The ongoing IIR will further inform the extent to which inappropriate PCI contributes to low-value care. In addition, the partnered work with the Harvard Business School will support the identification and implementation of process improvements to achieve more efficient and high-quality PCI care at lower cost.

OBJECTIVE(S):
Please see prior reports of the work to date. I was successful in obtaining IIR funding to support an evaluation of the appropriate use of percutaneous coronary intervention. This work is now being led by Mike Ho, MD, PhD as I transition from the VA.

METHODS:
Please see prior reports.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
The proposed research will provide a foundation to develop an intervention to influence the appropriateness of PCI-an invasive and costly procedure for a highly prevalent disease condition in Veterans-and thus have a large impact on the efficiency and quality of health care in VA. The ongoing IIR funding that I procured while a CDA will support completion of this work.


External Links for this Project

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PUBLICATIONS:

Journal Articles

  1. Ho PM, O'Donnell CI, Bradley SM, Grunwald GK, Helfrich C, Chapko M, Liu CF, Maddox TM, Tsai TT, Jesse RL, Fihn SD, Rumsfeld JS. 1-year risk-adjusted mortality and costs of percutaneous coronary intervention in the Veterans Health Administration: insights from the VA CART Program. Journal of the American College of Cardiology. 2015 Jan 27; 65(3):236-42. [view]
  2. Bradley SM, Maynard C, Bryson CL. Appropriateness of percutaneous coronary interventions in Washington State. Circulation. Cardiovascular quality and outcomes. 2012 Jul 1; 5(4):445-53. [view]
  3. Anderson ML, Nichol G, Dai D, Chan PS, Thomas L, Al-Khatib SM, Berg RA, Bradley SM, Peterson ED, American Heart Association’s Get With the Guidelines–Resuscitation Investigators. Association Between Hospital Process Composite Performance and Patient Outcomes After In-Hospital Cardiac Arrest Care. JAMA cardiology. 2016 Apr 1; 1(1):37-45. [view]
  4. Ogunnaike BO, Whitten CW, Minhajuddin A, Melikman E, Joshi GP, Moon TS, Schneider PM, Bradley SM, American Heart Association's Get With The Guidelines(®)-Resuscitation Investigators. Body mass index and outcomes of in-hospital ventricular tachycardia and ventricular fibrillation arrest. Resuscitation. 2016 Aug 1; 105:156-60. [view]
  5. Bradley SM, Contractor H, Shore S, Schneider PM. Cardiovascular highlights from non-cardiology journals. Heart (British Cardiac Society). 2014 Feb 1; 100(4):348. [view]
  6. Bradley SM, Rao SV, Curtis JP, Parzynski CS, Messenger JC, Daugherty SL, Rumsfeld JS, Gurm HS. Change in hospital-level use of transradial percutaneous coronary intervention and periprocedural outcomes: insights from the national cardiovascular data registry. Circulation. Cardiovascular quality and outcomes. 2014 Jul 1; 7(4):550-9. [view]
  7. Bradley SM, Liu W, Chan PS, Nallamothu BK, Grunwald GK, Self A, Sasson C, Varosy PD, Anderson ML, Schneider PM, Ho PM, American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Defibrillation time intervals and outcomes of cardiac arrest in hospital: retrospective cohort study from Get With The Guidelines-Resuscitation registry. BMJ (Clinical research ed.). 2016 Apr 6; 353:i1653. [view]
  8. Bradley SM, Rumsfeld JS. Depression and cardiovascular disease. Trends in cardiovascular medicine. 2015 Oct 1; 25(7):614-22. [view]
  9. Evidence Review Committee Members, Bittl JA, Baber U, Bradley SM, Wijeysundera DN. Duration of Dual Antiplatelet Therapy: A Systematic Review for the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2016 Sep 6; 134(10):e156-78. [view]
  10. Bittl JA, Baber U, Bradley SM, Wijeysundera DN. Duration of Dual Antiplatelet Therapy: A Systematic Review for the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2016 Sep 6; 68(10):1116-39. [view]
  11. Keach JW, Bradley SM, Turakhia MP, Maddox TM. Early detection of occult atrial fibrillation and stroke prevention. Heart (British Cardiac Society). 2015 Jul 1; 101(14):1097-102. [view]
  12. Bradley SM, O'Donnell CI, Grunwald GK, Liu CF, Hebert PL, Maddox TM, Jesse RL, Fihn SD, Rumsfeld JS, Ho PM. Facility-Level Variation in Hospitalization, Mortality, and Costs in the 30 Days After Percutaneous Coronary Intervention: Insights on Short-Term Healthcare Value From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System (VA CART) Program. Circulation. 2015 Jul 14; 132(2):101-8. [view]
  13. Valle JA, O'Donnell CI, Armstrong EJ, Bradley SM, Maddox TM, Ho PM. Guideline Recommended Medical Therapy for Cardiovascular Diseases in the Obese: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program. Journal of the American Heart Association. 2016 May 16; 5(5). [view]
  14. Bradley SM, Otto CM. Heartbeat: Rule-out of acute myocardial infarction - risky business. Heart (British Cardiac Society). 2016 Aug 15; 102(16):1249-50. [view]
  15. Bradley SM, Chan PS, Spertus JA, Kennedy KF, Douglas PS, Patel MR, Anderson HV, Ting HH, Rumsfeld JS, Nallamothu BK. Hospital percutaneous coronary intervention appropriateness and in-hospital procedural outcomes: insights from the NCDR. Circulation. Cardiovascular quality and outcomes. 2012 May 10; 5(3):290-7. [view]
  16. Vigen R, Spertus JA, Maddox TM, Ho PM, Jones PG, Arnold SV, Masoudi FA, Bradley SM. Hospital-level variation in angina and mortality at 1 year after myocardial infarction: insights from the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) Registry. Circulation. Cardiovascular quality and outcomes. 2014 Nov 11; 7(6):851-6. [view]
  17. Bradley SM, Rumsfeld JS, Ho PM. Incorporating Health Status in Routine Care to Improve Health Care Value: The VA Patient Reported Health Status Assessment (PROST) System. JAMA. 2016 Aug 2; 316(5):487-8. [view]
  18. Elhoff JJ, Chowdhury SM, Zyblewski SC, Atz AM, Bradley SM, Graham EM. Intraoperative Steroid Use and Outcomes Following the Norwood Procedure: An Analysis of the Pediatric Heart Network's Public Database. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2016 Jan 1; 17(1):30-5. [view]
  19. Bradley SM, Stanislawski MA, Bekelman DB, Monteith LL, Cohen BE, Schilling JH, Hunt SC, Milek D, Maddox TM, Ho PM, Shore S, Varosy PD, Matthieu MM, Rumsfeld JS. Invasive coronary procedure use and outcomes among veterans with posttraumatic stress disorder: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. American heart journal. 2014 Sep 1; 168(3):381-390.e6. [view]
  20. Shore S, Jones PG, Maddox TM, Bradley SM, Stolker JM, Arnold SV, Parashar S, Peterson P, Bhatt DL, Spertus J, Ho PM. Longitudinal persistence with secondary prevention therapies relative to patient risk after myocardial infarction. Heart (British Cardiac Society). 2015 May 15; 101(10):800-7. [view]
  21. Winchester DE, Kitchen A, Brandt JC, Dusaj RS, Virani SS, Bradley SM, Shaw LJ, Beyth RJ. Metrics of quality care in veterans: correlation between primary-care performance measures and inappropriate myocardial perfusion imaging. Clinical Cardiology. 2015 Apr 13; 38(4):195-9. [view]
  22. Bradley SM, Maddox TM, Stanislawski MA, O'Donnell CI, Grunwald GK, Tsai TT, Ho PM, Peterson ED, Rumsfeld JS. Normal coronary rates for elective angiography in the Veterans Affairs Healthcare System: insights from the VA CART program (veterans affairs clinical assessment reporting and tracking). Journal of the American College of Cardiology. 2014 Feb 11; 63(5):417-26. [view]
  23. Bradley SM, Spertus JA, Kennedy KF, Nallamothu BK, Chan PS, Patel MR, Bryson CL, Malenka DJ, Rumsfeld JS. Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry. JAMA internal medicine. 2014 Oct 1; 174(10):1630-9. [view]
  24. Thomas MP, Parzynski CS, Curtis JP, Seth M, Nallamothu BK, Chan PS, Spertus JA, Patel MR, Bradley SM, Gurm HS. Percutaneous Coronary Intervention Utilization and Appropriateness across the United States. PLoS ONE. 2015 Sep 17; 10(9):e0138251. [view]
  25. Girotra S, Chan PS, Bradley SM. Post-resuscitation care following out-of-hospital and in-hospital cardiac arrest. Heart (British Cardiac Society). 2015 Dec 1; 101(24):1943-9. [view]
  26. Bradley SM, Bohn CM, Malenka DJ, Graham MM, Bryson CL, McCabe JM, Curtis JP, Lambert-Kerzner A, Maynard C. Response to Letter Regarding Article, "Temporal Trends in Percutaneous Coronary Intervention Appropriateness: Insights From the Clinical Outcomes Assessment Program". Circulation. 2016 Mar 1; 133(9):e424. [view]
  27. Bradley SM, Hess E, Winchester DE, Sussman JB, Aggarwal V, Maddox TM, Barón AE, Rumsfeld JS, Ho PM. Stress Testing After Percutaneous Coronary Intervention in the Veterans Affairs HealthCare System: Insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circulation. Cardiovascular quality and outcomes. 2015 Sep 1; 8(5):486-92. [view]
  28. Bradley SM, Bohn CM, Malenka DJ, Graham MM, Bryson CL, McCabe JM, Curtis JP, Lambert-Kerzner A, Maynard C. Temporal Trends in Percutaneous Coronary Intervention Appropriateness: Insights From the Clinical Outcomes Assessment Program. Circulation. 2015 Jul 7; 132(1):20-6. [view]
  29. Bradley SM. The routine clinical capture of patient-reported outcomes: how competition on value will lead to change. Circulation. Cardiovascular quality and outcomes. 2014 Sep 2; 7(5):635-6. [view]
  30. Barnes GD, Stanislawski MA, Liu W, Barón AE, Armstrong EJ, Ho PM, Klein A, Maddox TM, Nallamothu BK, Rumsfeld JS, Tsai TT, Bradley SM. Use of Contraindicated Antiplatelet Medications in the Setting of Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circulation. Cardiovascular quality and outcomes. 2016 Jul 1; 9(4):406-13. [view]
  31. Sandhu A, McCoy LA, Negi SI, Hameed I, Atri P, Al'Aref SJ, Curtis J, McNulty E, Anderson HV, Shroff A, Menegus M, Swaminathan RV, Gurm H, Messenger J, Wang T, Bradley SM. Use of mechanical circulatory support in patients undergoing percutaneous coronary intervention: insights from the National Cardiovascular Data Registry. Circulation. 2015 Sep 29; 132(13):1243-51. [view]
  32. Rumsfeld JS, Brooks SC, Aufderheide TP, Leary M, Bradley SM, Nkonde-Price C, Schwamm LH, Jessup M, Ferrer JM, Merchant RM, American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Quality of Care and Outcomes Research; Council on Cardiovascular and Stroke Nursing; and Council on Epidemiology and Prevention. Use of Mobile Devices, Social Media, and Crowdsourcing as Digital Strategies to Improve Emergency Cardiovascular Care: A Scientific Statement From the American Heart Association. Circulation. 2016 Aug 23; 134(8):e87-e108. [view]
  33. Bradley SM, Chan PS, Hartigan PM, Nallamothu BK, Weintraub WS, Sedlis SP, Dada M, Maron DJ, Kostuk WJ, Berman DS, Teo KK, Mancini GB, Boden WE, Spertus JA. Validation of the appropriate use criteria for percutaneous coronary intervention in patients with stable coronary artery disease (from the COURAGE trial). The American journal of cardiology. 2015 Jul 15; 116(2):167-73. [view]
Journal Other

  1. Otto CM, Bradley SM, Newby DE. Research integrity: we are all accountable. [Editorial]. Heart. 2015 Mar 1; 101(6):414-5. [view]
  2. Bradley SM, O CI, Grunwald GK, Liu CF, Hebert PL, Maddox TM, Jesse RL, Fihn SD, Rumsfeld JS, Ho PM. Response to Letter Regarding Article, "Facility Level Variation in Hospitalization, Mortality, and Costs in the 30 Days After Percutaneous Coronary Intervention: Insights on Short-Term Healthcare Value From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System (VA CART) Program". [Letter to the Editor]. Circulation. 2016 Feb 2; 133(5):e377. [view]
  3. Bradley SM. Surgery for anomalous aortic origin of a coronary artery: More is better? [Abstract]. The Journal of Thoracic and Cardiovascular Surgery. 2015 Aug 1; 150(2):425-6. [view]
  4. Bradley SM, Spertus JA, Nallamothu BK, Chan PS, Kennedy KF, Patel MR, Bryson CL, Malenka DJ, Rumsfeld JS. The Association Between Patient Selection for Diagnostic Coronary Angiography and Hospital-Level PCI Appropriateness: Insights from the NCDR. [Abstract]. Circulation. Cardiovascular quality and outcomes. 2013 Sep 10; 6(3 Suppl):A1. [view]
  5. Bradley SM, Carey EP, Michael Ho P. US growth in PCI care--less than ideal, but is the ideal less? [Abstract]. Journal of the American Heart Association. 2013 Nov 19; 2(6):e000552. [view]
Conference Presentations

  1. Bradley SM. Appropriate Use Criteria as a Strategy to Improve Public Health at the Cardiovascular Seminar - Challenges and Opportunities with Appropriate Use Criteria: Strategies to Improve Care. Paper presented at: American Heart Association Annual Scientific Sessions; 2012 Nov 5; Los Angeles, CA. [view]
  2. Bradley SM. Appropriate Use, Interventional Cardiology Breakout Session. Paper presented at: Obstetrics Clinical Outcomes Assessment Program Annual Meeting; 2012 May 14; Seattle, WA. [view]
  3. Bradley SM. Appropriateness of PCI in Washington State: Update Interventional Cardiology Breakout Session. Paper presented at: Clinical Outcomes Assessment Program Annual Meeting; 2013 Jun 7; Seattle, WA. [view]
  4. Bradley SM. Clinical Approaches to Modifying Risk of In-Hospital Cardiac Arrest Cardiovascular Seminar - Predicting and Modifying Risk of Cardiac Arrest and Sudden Death. Paper presented at: American Heart Association Annual Scientific Sessions; 2012 Nov 6; Los Angeles, CA. [view]
  5. Bradley SM. Early Career Roundtable. Paper presented at: Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Forum; 2016 Feb 28; Phoenix, AZ. [view]
  6. Bradley SM. Facility-level Variation in 30-Day PCI Mortality, Readmission, and Costs in the VA Health Care System: Insights About Short-term Healthcare Value From the VA CART Program. Paper presented at: Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Scientific Annual Forum; 2014 Jun 2; Baltimore, MD. [view]
  7. Bradley SM, Chan PS, Spertus JA, Kennedy KF, Douglas PS, Patel MR, Anderson HV, Ting HH, Rumsfeld JS, Nallamothu BK. Hospital PCI appropriateness and in-hospital procedural outcomes: Insights from the NCDR. Poster session presented at: American Congress of Rehabilitation Medicine / American Society of Neuroradiology Annual Meeting; 2012 Nov 5; Los Angeles, CA. [view]
  8. Bradley SM. Normal Coronary Rates for Elective Angiography in the VA Health Care System: Insights from the VA CART Program. Poster session presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2013 May 16; Washington, DC. [view]
  9. Bradley SM, Maddox TM, Stanislawski M, O CI, Grunwald GK, Tsai TT, Ho M, Peterson ED, Rumsfeld JS. Normal Coronary Rates for Elective Angiography in the VA Health Care System: Insights from the VA CART Program. Paper presented at: VA Eastern Colorado Healthcare System Research Week; 2013 May 29; Denver, CO. [view]
  10. McCreight M, Bradley SM, Plomondon ME, Rumsfeld JS, Ho M. Role of Advanced Care Providers in Post Percutaneous Coronary Intervention Care: Analysis of Clinical Outcomes and Insights from 1 year Cohort Study. Poster session presented at: Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Forum; 2014 Jun 2; Baltimore, MD. [view]
  11. Bradley SM. Stress Testing Following PCI in the VA Health Care System: Insights from the VA CART Program. Poster session presented at: Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Forum; 2014 Jun 2; Baltimore, MD. [view]
  12. Bradley SM, Spertus JA, Nallamothu BK, Chan PS, Kennedy KF, Patel MR, Bryson CL, Malenka DJ, Rumsfeld JS. The Association Between Patient Selection for Diagnostic Coronary Angiography and Hospital-Level PCI Appropriateness: Insights from the NCDR. Paper presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2013 May 16; Baltimore, MD. [view]


DRA: Aging, Older Veterans' Health and Care, Health Systems, Cardiovascular Disease
DRE: Technology Development and Assessment
Keywords: none
MeSH Terms: none

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