Pathways for Quality Care: Echocardiographers Ponder a Playbook for Imaging in Myocardial Infarction
Physicians in fields like cardiology have traditionally looked to clinical practice guidelines to help articulate the best evidence-based care for patients. The rapidly growing movement to value-based care is prompting clinicians — including echocardiographers — to carefully weigh a more focused and integrative approach to delivering consistent, quality medicine: care pathways.
In the 1980s, Motorola led a revolution to identify and remove defects and variability from the manufacturing process. Known as Six Sigma, it spawned a bold set of analytical tools and techniques that soon became standard operating practice for the most progressive, cost-conscious companies. While few would put the medical profession in the class of early adopter, the field has been easing up to notions of process improvement and enhanced customer satisfaction through its own industry-specific methodology, known as clinical care pathways.
Signs of that movement are becoming more evident. Kaiser Permanente, the largest nonprofit health plan and integrated delivery system in the U.S., has been deploying care pathways for years through clearly defined roles and accountabilities for its multidisciplinary teams. Oncology also has gravitated over the past decade to the carefully sequenced and coordinated chain of activities that typically define a clinical care pathway. And the American College of Cardiology (ACC) released early this year what it called “decision pathways” to guide clinicians and hospitals in managing patients undergoing transcatheter aortic valve replacement (TAVR) as well as patients with nonvalvular atrial fibrillation who are on anticoagulant therapy (J Am Coll Cardiol 2017;69[10]:1313-46; J Am Coll Cardiol 2017;69[7]:871-98).
Add echocardiographers to the list of specialists warming to the value-based care approach. “Care pathways enable us to take what we know from evidence-based guidelines and from appropriate use criteria and create a kind of blueprint to navigate routine clinical situations and, in so doing, reliably achieve the best outcomes,” says Geoffrey Rose, MD, chief of cardiology at Sanger Heart & Vascular Institute with the Carolinas HealthCare System. “Care pathways should be thought of as playbooks, not cookbooks. There’s room for variation in how we treat each individual patient depending on his or her situation.”
Whether to develop a care pathway for acute myocardial infarction (AMI) will be a discussion topic when the American Society of Echocardiography (ASE) convenes its annual conference in June, says Rose, who is chairing the meeting. One of the branches of that decision tree could be, for example, guidance on how to determine post-MI left ventricular ejection fraction, one of the most important determinants of how a patient will fare over time after an AMI.
“You can get an ejection fraction from a cardiac MRI, from a CT scan of the heart, from nuclear imaging or from an echocardiogram,” Rose elaborates. “They’re all terrific modalities, but in our view a care pathway specifying echocardiography may be the most logical choice for assessing the ejection fraction question early on after an infarction.”
John Dent, MD, a cardiovascular disease specialist at the University of Virginia Health System in Charlottesville, envisions a care pathway that encourages the appropriate use of echocardiography following an AMI. “It could prompt the physician to order an echo at the most appropriate point in the pathway, then provide guidance on what medicines to give or which patients to send to the cath lab,” he says. “The point is not to make sure we increase the number of echocardiograms in the U.S., but to make sure we increase the number of appropriate echos.”
How much variability is there in the system? “Unfortunately, the practice of medicine is in many ways still a craft practice in that each doctor thinks they know best,” Dent says. “As a result, there are tremendous variations in how they interpret and apply clinical guidelines.” How much difference could a care pathway make for a patient who has suffered a heart attack? “We know that if we try to standardize what’s done for that patient, the outcomes will be better,” he adds, “and more importantly, it will impact waste by reducing the underuse or overuse of testing, as one example.”
Driving out waste from cardiac imaging
Variation in the quality and cost of medical care is well documented. In 2014, for example, the cost of treating Medicare patients who suffered an AMI or underwent bypass surgery varied by 50 percent across hospitals, and the share of patients readmitted to the hospital within 30 days varied by more than 50 percent, according to the Centers for Medicare and Medicaid Services. The previous year, Medicare data released by the federal government revealed price gaps across U.S. hospitals for common inpatient procedures. One example: The average cost of treating an AMI patient without major complications ranged from $3,334 at a hospital in Danville, Ark., to $92,057 at a hospital in Modesto, Calif.
Care pathways’ prescription for this yawning gap is a system of best clinical practices for well-defined groups of patients, such as AMI and TAVR, based on concurrent opinion by experts in that field. It can take a year or more for the ACC to hammer out and publish a detailed clinical care pathway as part of its expert consensus document process, says James Januzzi, Jr., MD, chair of the ACC Task Force on Expert Consensus and Healthcare Policy and a cardiologist at Massachusetts General Hospital in Boston. The goal of this extreme vetting is “to find space to fill relative to [clinical] guidelines and appropriate use criteria,” he says. “Clinical practice guidelines will articulate what the best care is for a patient, but they won’t articulate how that care should be delivered. Our expert consensus document process allows for that kind of guidance through care pathways, which are essentially an algorithm to consider—not to be bound by—for the application of specific therapies.”
The ACC’s decision pathway for TAVR is a case-in-point. Catherine Otto, MD, professor of medicine at the University of Washington in Seattle and chair of the ACC writing committee, describes the guidance as “checklists designed as a starting point for managing patients who are being considered for TAVR.” The ground rules, she adds, take clinicians through the steps needed to successfully perform the procedure, including which imaging tests are needed and how to ensure continuity of care when a patient transitions back to his or her personal physician.
At Kaiser Permanente, care pathways are designed to expose its 11.3 million members nationwide to “the best evidence-based care, whether it be from guidelines or from clinical trials,” says Ali Rahimi, MD, MPH, director of Performance Improvement Development and Cardiovascular Quality with Kaiser Permanente of Georgia. He cites hypertension as an example: “We have a pathway for hypertension so that when a member comes into a doctor’s office—whether it’s primary care, cardiology or any specialty—their blood pressure is checked and, if it’s abnormal, rechecked, and a follow-up visit scheduled within four weeks.” Rahimi reports that since the hypertension care pathway was implemented four years ago in Georgia, the number of patients whose blood pressure is under control has improved from 70 percent to 87 percent. Kaiser Permanente uses pathways as tools for managing a patient’s entire journey and defining the contributions of not just physicians but nurses, pharmacists, technologists and others working toward the goal of improved patient outcomes. Providing the connective thread for this support team is an electronic medical record platform that provides alerts, reminders, documentation templates and other clinical decision support tools at each step along the way.
Kaiser Permanente uses pathways as tools for managing a patient’s entire journey and defining the contributions of not just physicians but nurses, pharmacists, technologists and others working toward the goal of improved patient outcomes. Providing the connective thread for this support team is an electronic medical record platform that provides alerts, reminders, documentation templates and other clinical decision support tools at each step along the way.
Bundled care as a driver for better quality cardiac imaging
There is good reason to believe that care pathways will play to a widening audience as new payment models, particularly episode payment models (also known as bundled care models), make them more desirable, if not essential. “If you’re getting paid a set amount, then you need to look closely at everything that happens to your patient,” Dent says. “You need to make sure that all decisions are made in the best interests of the patient and that you don’t give either excessive treatment or withhold appropriate treatment. And there’s no way to do that better today than through a care pathway.”
Not everyone is sold on care pathways. Some professionals believe that with the emphasis on greater efficiency and cost reduction, the model actually detracts from the physician–patient relationship and reduces the patient’s choices. Rose has a much different take. “I think everyone in medicine should be thinking now about how we take those practices we agree represent the best of care and make sure they are routinely applied,” he says. “Care pathways make us think very hard about that opportunity.”