E-Journal of the Society of Chest Pain Centers

Spring 2002, Volume I, Number I

PRESIDENT'S MESSAGE

Louis Graff, MD

"Missed MI/I Error" Quality Performance Indicator

It is time for a 'Missed Myocardial Infarction/Ischemia (MI/1) Effort' Quality Performance Indicator. Many research studies have shown there is a 4% to 5% miss rate for identifying acute MI/1. It is the number one malpractice problem for emergency physicians in the hospital as well as the internist and family practitioner in the office. With measurement of this performance indicator, physicians would be able to react to an identified problem in quality of patient care. Without this performance indicator, everyone adopts an ' Emperor without Clothes ' approach that this problem doesn't exist for them. For communities which have implemented a Chest Pain Unit at their hospitals, the value of their extra efforts would become obvious to all.

Present HCFA Activity Measuring and Tracking Quality of Care

CMS 6th Scope of Work identified quality performance indicators for 5 conditions (acute MI, pneumonia, CVA, atrial fibrillation, CHF). These quality indicators were chosen based on efficacy evidence for the process of care and inclusion into widely accepted specialty society guidelines. They have performed structured abstractions of hospital charts to quantify performance. The results of each hospital's performance on these quality measures for 1998 were distributed to all hospitals in mid-2000 as feedback for hospitals and physicians to use in quality improvement efforts. The summary results for all states have been published in the medical literature (Jencks SF, Cuerdon T, Burwen DR et al JAMA 2000:284; 1670-1676). Multiple studies have documented the power of this approach to improve physician performance and patient outcome (i.e., lower the death rate).

In the area of acute MI, CMS used the ACC/AHA guidelines to deliver the following quality performance indicators: early administration of aspirin, early administration of beta blockers, timely reperfusion, ACE inhibitors for low left ventricular ejection fraction,smoking cessation counseling during hospitalization; aspirin at discharge; beta blockers at discharge. Compliance with each of these quality indicators improves outcome with decrease in patient death rate from 10% to 25 %.

Future Joint Commission Activity Measuring and Tracking Quality of Care

The Joint Commission is now pilot testing core measures to assess quality of care provided at hospitals. The first set of measures is for 3 conditions: MI, heart failure, pneumonia. They are deriving them from CMS's 6th Scope of Work measures so hospitals will not have to measure quality one way for one organization and another way for another organization. They will expand the 3-set of measures to 5 at later time (add surgical procedures and pregnancy). These measures are to determine how often patients are given an evidence-based, specialty society endorsed treatment when there are no contraindications.

Level of Evidence for the 'Missed MI/I Error' Quality Indicator

There is considerable evidence that missing the acute coronary syndrome diagnosis adversely affects outcome with increased mortality. The CHEPER study summarizes much of this evidence (Graff et al. Amer J Card 1997:80;530-568). More recently Pope et al (New Engl J Med 2000:342; 1163-70) confirmed these findings - mortality doubles for patients whose myocardial infarction or myocardial ischemia is missed at the initial evaluation by a physician. The CHEPER study and others have demonstrated that Chest Pain Units can nearly eliminate ÔMissed MI/I errors' and the resulting mortality. Thus, a 'Missed MI/I errors' quality indicator fulfills all the criteria for a quality performance measure - the errors are numerically important, there is a process outcome link, and there are effective interventions.

Feasibility

Measurement of the proposed quality indicator is very feasible with minor modifications of the present data abstraction instrument used by HCFA and being piloted by Joint Commission. The CHEPER study (Graff et al. Amer J Card 1997:80;530-568) reviewed the literature on missed AMI/ACS, and abstracted from charts whether the patient was previously seen by a physician and the diagnosis missed. The Connecticut Peer Review Organization (Qualidigm) published its project (Academic Emergency Medicine 2000: 7;1244-55.) in which it abstracted from charts information about previous medical encounters and missed appendicitis diagnosis in 1026 appendectomy patients at 12 acute care hospitals. Of the 916 patients with appendicitis, 170 (18.6 %) false negative decisions were identified with an equal number attributed to the office physicians and emergency physicians. This data abstraction process was similar to the data abstraction process used by CMS in its 6th Scope of Work with a central data center with professional abstractors using a data abstraction instrument with explicit abstraction instructions.

Thus, it is expected that emergency physicians and private physicians do note in their daily charting when the cardiac patient has an atypical clinical presentation and a previous care giver has missed the diagnosis and inadvertently given false reassurance on the state of the patient's health. It is time we start tracking such errors and use the Continuing Quality Improvement process to give confidential feedback to practitioners and hospitals so they can emulate best practice by implementing their own Cheat Pain Unit program.

It Is Time

Thus, I state again it is time for a ÔMissed Myocardial Infarction/Ischemia (MI/1) Error' Quality Performance Indicator. We can dramatically improve the quality of patient care for those with acute myocardial infarction or ischemia. Members of SCPCP have already committed themselves to these efforts but there is no excuse for all hospitals not implementing these advances. Ignorance is not bliss for many patients who are evaluated without a chest pain unit; it is all too often their silent death knell. We can do better.

Present CMS Quality Indicators - Date Abstracted from Medical Records
(Jencks SF, Cuerdon T, Burwen DR et al JAMA 2000:284;1670-1676)

AMI

• Early administration of aspirin
• Early administration of beta blockers
• Timely reperfusion
• ACE inhibitors for low left ventricular ejection
• Smoking cessation counseling during hospitalization
• Aspirin at discharge
• Beta blockers at discharge

Heart Failure

• Angiotensin-related drugs for left ventricular ejection fraction when appropriate

Pneumonia

• Blood culture before antibiotics are administered
• Appropriate initial empiric antibiotic selection
• Initial antibiotic dose within 8 hours of hospital arrival
• Influenza vaccination or appropriate screening
• Pneurnococcal vaccination or appropriate screening

Stroke / Atrial Fibrillation

• Discharged on warfarin, aspirin, or other antiplatelet drug (stroke or TIA only)
• Discharged on warfarin (chronic atrial fibrillation only)
• Avoiding inappropriate use of sublingual nifedipine (stroke or TIA only)

Louis Graff, MD, FACP, FACEP
Department of Emergency Medicine
University of Connecticut Medical School