Societies Update Clinical Competency Criteria for Quality Coronary Interventions

May 8, 2013—Criteria for evaluating operator competency for performing coronary interventions should be expanded beyond procedure volume and include an evaluation of risk-adjusted outcomes, periodic case reviews of patient selection, and other factors, according to a new report from the American College of Cardiology (ACC), the American Heart Association (AHA), and the Society for Cardiovascular Angiography and Interventions (SCAI).

The medical societies announced the issuance of a joint statement to outline the core competencies and technical skills required to optimize clinical outcomes when performing coronary-based interventions.

The new report, which is an update to the initial 2007 statement, is available online ahead of print and will be published in full in the June 11, 2013, issue of the Journal of the American College of Cardiology and copublished online in AHA's Circulation and SCAI's Catheterization and Cardiovascular Interventions. The document will also be available on the ACC (www.cardiosource.org), AHA (www. heart.org), and SCAI (www.scai.org) websites.

According to the societies' announcement, the new report responds to challenges presented by the changing landscape of the interventional cardiology field and evolving views on how best to define and assess clinical competency specifically related to percutaneous coronary intervention (PCI) and other coronary-based interventions in adult patients.

New and adjusted benchmarks are outlined in the revised document to assist with measuring and judging operator and institution performance of coronary-related procedures.

The announcement noted that more than 600,000 coronary interventional procedures are performed annually in the United States. Although there has been a decline in the number of procedures performed during the last decade, these interventions continue to evolve and are being performed in more complex and often more infirmed patient populations. Due to dramatic advances in PCI, including new technological innovations and its expanded use to treat increasingly complex types of coronary artery disease, clinicians and hospitals must stay current through practice-based learning, formalized training, and continuing education.

SCAI President Theodore A. Bass, MD, served as Vice Chair of the new report's writing committee. Dr. Bass is the Cardiovascular Division Chief and Medical Director of the University of Florida Shands Cardiovascular Center in Jacksonville, Florida.

In the societies' announcement, Dr. Bass commented, “We can't be in every cath lab across the country, so one way to track competency is to define and measure key outcomes. In the past, we focused mostly on cognitive competency—what does someone know. But when we talk about procedurally based skills, competency also involves the actual performance of the procedure. Practicing physicians and hospitals need to ensure that these skill sets and support systems are in place to facilitate delivering optimal care to our patients.”

Procedural volume has been widely used as a surrogate for competency, which implies that higher volumes are associated with greater success rates in PCI. Although volume has historically served as a useful measure, Dr. Bass cautions that it is “not the be-all and end-all.” Consequently, institution and operator volume measures have been revised in the current report to be more compatible with current practice patterns, societal needs, and patient accessibility to coronary interventions and catheterization labs, keeping in mind desired clinical quality outcomes.

Dr. Bass observed that the process of evaluating physicians' knowledge and skills has become more complex as procedures continue to advance and that the report provides a roadmap for what is desirable in terms of clinical experience and skill sets. Dr. Bass added, “It's not simply a matter of how many are being done or whether we are putting the stent in the right place. It's also about our ability to appropriately select patients and, once selected, deliver safe care with optimal outcomes.”

ACC President John Gordon Harold, MD, who served as Chair of the writing committee, stressed that the document goes beyond volume and focuses on competency or outcome-based training and performance requirements. Dr. Harold commented, “It is the first cardiovascular competency statement to fully utilize the six domains structure promulgated by the Accreditation Council of Graduate Medical Education and adopted and endorsed by the American Board of Internal Medicine.” He added, “It goes beyond medical knowledge and procedure performance to include the important issues of leading an interdisciplinary team, working in a complex system, communicating effectively, engaging in continuous quality improvement at the individual and system levels, adhering to evidence-based medicine, and demonstrating the highest levels of professionalism.”

Dr. Bass said that other basic tenets of clinical competency should also come into play. For example, good clinical decision making, the ability to provide optimal health care in a resource-conscious way, clear communication with patients about the risks and benefits of procedures, participation in continuous quality-improvement efforts, achieving and maintaining board certification, and taking advantage of new tools including internet-based education, just to name a few.

“We hope this report will be used as a tool to help health care systems and physicians provide the best possible care to patients receiving coronary-based interventions,” concluded Dr. Bass. “It reflects a greater appreciation of the multiple dimensions shaping physician competency and provides much broader guidance in these areas.”

In addition to addressing components of physician competence, which the societies noted is at the core of providing quality health care, the document provides facilities that have (or are seeking to start) PCI programs with recommendations to meet certain requirements, closely monitor clinical outcomes, and provide quality assurance. The present document assesses the use of coronary-based procedures in patients with structural disease. The report also recommends participation in local or national registries to measure performance and promote continued quality improvement.