Abstract 13069: Submitting ACC-NCDR CathPCI Data Are Not Enough

Abstract

Introduction: The majority of facilities performing PCI in the US report data to the ACC-NCDR CathPCI Registry. The large number of records included in this dataset provide benchmark comparisons for facilities to consider however it is of concern that this may not result in the development of meaningful actions for improvement. The current analysis was undertaken to understand changes in Registry findings over time in facilities undergoing accreditation reviews. Methods: A component of site visits for accreditation, executive summaries or dashboards for each facility are reviewed and findings are categorized as being ≤ 50 th percentile or ≤ 10 th percentile when compared to the registry benchmark data at the time they are reported. Results: Twenty-one facilities underwent 32 reviews. (Figure 1). Although there is a trend in decreasing percentage of variables ≤ 50 th percentile with subsequent reviews, these differences were not statistically significant. No such trend was observed for variables ≤ 10 th percentile. In general, facilities deferred have higher rates of both findings, but these differences also are not statistically significant overall or at each review point.(Figure 2) Conclusions: Facilities undergoing accreditation reviews, irrespective of the accreditation decision have high rates of NCDR registry variables that are ≤50th and ≤10th percentile. These do not change significantly over time and suggest that insufficient attention is paid to these variables, corrective action is not identified or is not effectively implemented. Ongoing support is necessary to achieve these changes.