Pediatric/Congenital Cardiac Catheterization Quality: An Analysis of Existing Metrics
O’Byrne ML, Huang J, Asztalos I, Smith CL, Dori Y, Gillespie MJ, Rome JJ, Glatz AC.
JACC Cardiovasc Interv. 2020 Dec 28;13(24):2853-2864. doi: 10.1016/j.jcin.2020.09.002.
Take Home Points:
- Existing quality metrics in the pediatric cardiac catheterization lab nearly all currently focus on safety, either as an outcome (adverse events, radiation, etc.) or as a safety structure (procedural volume, operator experience).
- There is not currently a good metric for procedural efficacy, despite this measure being a perceived priority by practicing interventionalists.
- Risk adjustment is particularly important when comparing outcomes between and within centers, in the heterogenous world of congenital heart disease, however there is little confidence among interventionalists about current risk-adjustment methodologies.
Commentary from Dr. Wendy Whiteside (Ann Arbor, MI, USA), section editor of Congenital Heart Disease Interventions Journal Watch: In this article, O’Byrne et al provide a systematic evaluation of the current state of quality metrics in the pediatric cardiac catheterization lab (PCCL). Their review involved evaluation of quality metrics via 3 mechanisms: 1. Review of peer-reviewed research, 2. Review of metrics from organizations/professional societies interested in quality, and 3. Survey of pediatric interventional cardiologists in the US. This manuscript provides insight into many of the deficiencies of the current quality landscape in the PCCL.
All of the metrics identified in the 9 papers reviewed, were related to patient safety. The majority of these were related to outcome metrics including adverse events, failure to rescue, and radiation, with the remainder (33%) of the references referring to safety structures including procedural and operator volume and experience. While there is no question that safety is of paramount importance in a procedural space such as the PCCL, there are multiple other areas of quality in the Institute of Medicine Quality Domains (including effectiveness, efficiency, timeliness, equity, and patient-centeredness) which are currently voids in the PCCL quality literature and need to be areas of future study within this field. Additionally, consensus on the structures and processes associated with good quality care in the PCCL needs to be reached.
Among quality-measuring organizations/societies, a minority (only 4, 22%) propose or measure quality metrics from PCCL programs. The majority of the US News & World Report score for pediatric cardiology and cardiovascular surgery programs involving the cath lab are related to procedural volume and not at all to procedural safety or efficacy. This is a problem as this tells only part of the story related to the quality of a particular program’s cath lab. Part of why this problem likely exists is because good metrics for procedural safety, and even more so, for procedural efficacy don’t currently exist for many procedures. Three existing registries, including the IMPACT registry, the Congenital Cardiac Catheterization Project on Outcomes (C3PO) collaborative, and the Congenital Cardiovascular Interventional Study Consortium (CCISC) Risk Registry, provide member institutions their own quality metrics for review, but none are flawless. The IMPACT registry, while large, is not risk -adjusted and includes a simplified dichotomy for procedural success which is not clinically useful for many of the procedures evaluated. C3PO reports provide risk adjusted adverse events and radiation data and allows for comparison to other member institutions, but is limited in its scope with only a small subset of programs participating. While safety has been the focus, is reported by the 3 physician organized registries (IMPACT, C3PO, and CCISC), and is a stated priority of the surveyed interventionalists, there is still not consensus on how to properly measure this, with the majority of survey respondents not confident with the effectiveness of current risk adjustment methodologies.
When we look at areas within pediatric cardiology who have done well with collecting, using, and acting on quality data, cardiac intensive care (PC4—the Pediatric Cardiac Critical Care Consortium) and cardiac surgery (STS—the Society of Thoracic Surgeons—Congenital Database) are two areas to learn from. While the PCCL still has room to improve on risk adjustment methodologies, much work also needs to be focused on procedural efficacy and providing a metric that can account for the subtleties of procedural outcomes in this field (Less residual aortic stenosis after aortic balloon valvuloplasty may not be better if it creates more aortic insufficiency). Additionally, trust and transparency in the data is necessary and will need to be built into existing registries moving forward. While our intentions in assessing PCCL quality have always been true, the focus now needs to be on tackling the more challenging metrics to define and measure. We need to move as a field towards better defining those metrics we know are important to us, and how best to measure and compare these to allow for learning and improvement in the field as a whole.