Well, hello, everyone. I'm Barb Christensen. I'm a Senior Director for NCDR and Accreditation Services. And it is so wonderful to see so many of you here in person in Los Angeles. And I want to welcome all of our virtual attendees as well. Yesterday, we had over 800 people attending virtually. So welcome to Quality Summit 2022. We're transitioning back to a live event, and we're happy that we are able to be here. And hopefully, those of you who are attending virtually will be able to join us next year in person in Orlando, Florida. I want to take a few minutes just to thank our exhibitors for their generous sponsoring and being with us here. And please make sure that you visit their websites if you're virtual. And please stop by and see them during the breaks. And also a big thank you to all of you who submitted posters. We had over 80 posters submitted this year. Our top 25 are on our e-poster exhibits downstairs. And all of them are available on the app and virtually. A lot of good information. Please check that out. And as a reminder, if you haven't downloaded the app, please do so. It's got all the great information you need, as well as how you can claim your CE credits. So right now, I'd like to introduce Dr. David Winchester, who's Chair of the Quality Summit. He's Professor of Medicine at the University of Florida, Staff Cardiologist at Malcolm Randall VA Medical Center in Gainesville, Florida. And he's also the Governor of our ACC Florida Chapter. And I want to give him a big thank you for all of his leadership in helping us design this program and bring all of this great content to you. So David, thank you and welcome. Good morning, ACC Quality Summit. I think if you'll indulge me, we'll continue with the thanks for another minute or two before we get to our content. So I also would like to thank everybody for being here. It's so exciting to be back in person again. They've been talking about the quality of cardiovascular care, how we can work together to improve it. And I want to issue some special thanks for all of our staff. I would appreciate a round of applause for Barb, for Maria, for all of the folks at ACC. They've all worked incredibly hard to bring us back together here in Los Angeles. Thank you also to the virtual attendees. We're thrilled to be continuing to offer this as an option for the content of this meeting. So even if you can't be here with us in SoCal, we hope that you'll be able to join us again very soon. This morning, we've got the first of four general sessions that our planning committee has been working very hard to put together for you. And I think that we're going to enjoy some very high-yield discussions on healthcare equity, on dealing with the struggles of team building in the wake of COVID. We're going to be talking about patient-reported data, social determinants of health and the challenges that these bring. We're going to supplement these general sessions with some insightful talks across our Lead, Achieve, and Design channels and content from all of you. So dozens of you have submitted your posters telling us about your local improvement efforts, and we appreciate you participating in the meeting that way. We had a great time last night getting to know each other out on the pool deck, so I hope that you all will use the rest of this meeting not only to learn about what you can take back to your programs to improve quality at your facilities, but to spend some time connecting with each other, to exchange ideas amongst yourselves, share your best practices, and then head home invigorated to really drive some change. It's now my distinct pleasure to introduce Dr. Edward Fry, President of the ACC, for his remarks. He attended medical school residency and fellowship at Wash U and St. Louis. He currently practices at St. Vincent Health in Indianapolis, where he's Chair of the Ascension Health National CB Service Line, and he has served ACC in a variety of roles on the Board of Governors, on the Board of Trustees, on the Board of Managers for MedAxium, and numerous others. Please welcome Dr. Fry. Great. Can everybody hear me? I'm going to walk around a little bit. It's great to be here, and I would echo Barb and Dave's welcome and thanks, particularly to the organizers and to the entire staff, as well as to the entire quality community for cardiovascular care. You really, really make it a difference. Before I come to a meeting, I always ask myself, why am I here? Because there's often a lot of people asking me, why am I here anyhow? So one of the first reasons I think why you're here is that you bring a unique fund of knowledge and experiences focused on the cardiovascular outcomes of all of our patients, all of the people that we touch. You're dedicated. You bring a passion. You have this infectious desire to improve quality, and that really fuels the work that we're going to talk about here today. And with that comes a commitment to learn from one another, and as Dave said, to bring home best practices. It's no good if we just keep the knowledge that we acquire here in this room. We need to take it back, apply it in our institutions, our practices, our offices, and most importantly for our patients. We gather at a real time, a really trying time. Not only are we recovering from a global pandemic, we have economic headwinds, we have political turmoil. The state of medicine, and particularly cardiovascular medicine, is really under siege. And there's several areas of concern that we're addressing. We have a workforce crisis. All of you know that. Many of you may be at home or may be not able to attend this meeting because of that workforce crisis. We have an aging population, not only of the patients, but of the physicians, the technicians, and the nurses. We have runaway health care inflation, in addition to generalized inflation, and we have an unsustainable fee-for-service payment model. We essentially have a single-payer system in the United States now with more than 70% of our patients being covered by some form of public reimbursement. We have rising patient consumerism, and they're sick as hell and they're not going to take it anymore. And we have a very siloed delivery system in terms of our care structure. Shockingly, in the last two years, we have seen a drop in life expectancy of a year each of the past two years, and disproportionately in communities of color and those who are disadvantaged. And this has exposed the importance of social determinants of health and also the inequities in our health system. But not all is grim. There are a lot of opportunities, and I think the work that is being done by all of you exemplifies those opportunities. We live in an increasingly connected world. We live in a digital world where the internet of everything and the internet of health really have a whole great promise to solving some of the problems I just went through. And we live in a world where it's data, data, data. And this group is obviously driven by data. The challenge is, how do we filter that data, collate that data, and then use that data to really drive process improvement? So I think that's really what we want to focus on here today. So to do this, it's good to have a plan. And we do have a plan. The strategic plan of ACC, I think, applies to the job ahead of us very well. So just to refresh, the mission of the college is to transform cardiovascular care and improve health for all. It has a vision of a world where science, innovation, knowledge optimize cardiovascular care and outcomes. And it's built on the principles and the values of patient-centeredness, equity, teamwork and collaboration, professionalism, and excellence. You may notice that if you compare this to a recent version of the strategic plan, a couple of key words have been added, all science and quality. This denotes inclusion, a focus on science and the scientific method, and the importance of equity that we need to address the inequities in our health care delivery. A key foundation and pillar of the strategic plan and what the ACC's mission work is all about is to advance quality, equity, and the value of CV care, and that is really the driving force behind the entire quality program of ACC. So ACC, from this plan, has several key initiatives. Guideline optimization, to move from this concept of guidelines as we have known them in the past to tools of true clinical guidance. Optimization of NCDR to reduce burdens and costs of collecting data, and using this instead of just for scorecarding, but now really for process improvement and to improve the lives of the patients that we touch. Digital transformation, moving to a digital first strategy for the entire college. Advocacy, to be able to translate what our patients, our care team members, and the public want and need. And promoting diversity and inclusion across the entire organization, whether it's through the pipeline, leadership development, and the entire workforce. And all of this underlies care transformation. So what does care transformation look like and mean? This is kind of how I think about it, and it really starts with patient-centeredness and promotes wellness, use of digital tools and digital transformation, leveraging the team-based care that cardiovascular care is so well known for, providing innovative solutions at all parts of the care spectrum, focusing on populations and communities, and really looking towards delivering value as opposed to in isolation. So how do we transform care? There's a great book by Zeke Emanuel, and in it he has six elements, essential elements of transformation. Recognizing that there's a crisis is an important first step. Providing leadership, balancing incentives across an entire system of care, defining what those financial incentives are, creating a culture and governance around quality and patient-centeredness, and most importantly, to use data to drive process improvement. So just to sum up, to achieve this message, we really need to listen to everybody, all stakeholders, patients, members, chapters, governors, trustees, sections, councils, but most importantly, and our job today is to listen to one another within the quality community. So with that, I'll turn things over to Dr. Steve Bradley to introduce our Ralph Brindis lecturer. Thank you. Thanks, Ed. It's good morning, and thank you for being here with me today. I'm really honored to be here with you. I think one of the things that becomes apparent from Ed's talk is this group is a foundational component of the strengths of how we improve cardiovascular care and how we transform cardiovascular care. So kudos to you for being part of that foundational strength and excited to be with you for the next couple of days. It is my distinct honor and pleasure to introduce our keynote speaker, the Ralph G. Brindis Keynote, Past, Present and Future Directions of NCDR and Accreditation Services, Dr. Fred Masudi. Sir Isaac Newton has been quoted with saying, if you've seen further, it is by standing on the shoulders of giants. Fred is a true giant in our field of cardiovascular quality and quality improvement science. He has greater than 350 manuscripts. I've heard it said that the process of building scientific evidence is like putting little bricks in a wall. And each manuscript you're finding is something that we're continuing to build that wall of evidence and understanding. Fred himself has created a rather massive wall. He's done an amazing job of moving us forward in our understanding of quality, quality improvement in cardiovascular science. He's been involved in numerous guidelines. He has served in more than 15 years in the leadership at NCDR leadership as well as American College of Cardiology. And if you look at his CV, his service and accolades are numerous and it would take me the full time of this talk to really summarize the contributions that Fred has made for all of us. Fred, I found these pictures to be rather informative in the sense that the true nature of Fred is expressed in some of these pictures. So first of all, Fred is always supporting others. He is a selfless person. He is there to help you and your team and your efforts move forward in the important work of improving cardiovascular care and quality. So even though in all of these pictures he's being held up, the true relationship of Fred with the rest of the world is that he's holding up others. Fred is just a tremendous person and he's always there to support you and he's always there to support you with style. If you know Fred, he's well known for wearing bow ties. Apparently in the world of Zoom, he's also well known for wearing his ski outfit underneath the table so he's ready to go after his Zoom presentation. I had the honor of following in Fred's footsteps as the Oversight Chair for NCDR. And when we transitioned, this was a word cloud of thoughts of people who have worked with Fred over the past 15 plus years of describing Fred. And you can see all of the wonderful things that summarize who Fred is as a person and what they mean to individuals. When I had that opportunity, I said that Fred leads by touching your heart and I truly believe that. He's an amazing person and wonderful to have the opportunity to introduce him on the behalf of Ralph Brindison, the keynote speaker. Thank you very much, Fred. Thanks, Ken. Wow. Thanks, Steve, for that introduction. Particularly the incriminating photos, I think I have an idea where you got those and we'll be having words after this. I had that last picture just for some context. I was giving a talk for a group in Japan remotely and was doing it in the middle of a ski vacation and so had to look good at least from the chest up. Thanks for sharing that, Steve. Really appreciate it. What a pleasure it is to be at this meeting. This has always been one of my favorite events and is one of the things I miss most during the pandemic. Now, how many of you have been here and let's, of course, the staff have been here many, many times, but how many of you are first-time attendees at this meeting? Fantastic. That's fantastic. And I imagine there are a lot of virtual hands being raised as well as first-time attendees. How many of you have been to more than, say, six of these meetings? Wow. So we have some veterans and we have some rookies. And those of you who have never been here before I think are starting to understand what a fantastic meeting this is. And certainly a great opportunity to be getting together after this terrible pandemic. For many of you, it may well be your first in-person meeting again. It almost brings tears to my eyes thinking about how wonderful it is to see people in person, many people I've worked with for so long. I'd love to thank the organizers for inviting me here to speak today. It's a tremendous honor to be able to do this. So I'm going to be talking about the ACC Quality Programs, the past, present, and future. And it's a terrific story that I'm really happy to tell. And I've been one of many players in this tremendous story. And you all have been players in this tremendous story as well. I'd like to talk first about our sponsor. This is a picture of me and Ralph in San Francisco recently. I had the pleasure of seeing him when we were traveling out there. Ralph lives and breathes the ACC. He loves the organization. He loves the quality programs. And he's been so dedicated to these before his presidency at ACC, during his presidential year. And then subsequently after his presidency, he's continued to serve ACC and NCDR in particular over these many years. As part of his service, he decided, as the generous man that he is, that he would endow a lecture for this conference. And I'm now the, let's see, two, four, six, seven, I'm the eighth speaker of this. I feel like I'm the person who doesn't belong on this list of luminaries, starting with my dear friend John Spertus, who developed the KCCQ and other health status instruments. And then these other leaders in healthcare, Tom Lee, Rob Califf, Doug Frisma, Dr. Z. Were any of you here for the Dr. Z? Yeah. All these people who raised their hands, they are tremendously disappointed by this presentation. Let's just put it this way, I'm no Dr. Z, unfortunately, but that was a terrific presentation. Quinn Capers and Cheryl Peggis, a great lineup of speakers, and it's such a personal honor, having worked so closely with Ralph for so many years, to be speaking at a lecture that he has endowed. You may ask, well, where is Dr. Brindis? I will say that Dr. Brindis loves golf. Dr. Brindis loves the ACC, but Dr. Brindis most of all loves his family. So in the order of family, ACC, golf. And so Ralph is now traveling with his family in Turkey and Greece on a long-awaited vacation that was canceled by COVID. And I know that he is sorry that he can't be here today, but he's doing the most important thing. And again, what a tremendous honor for me to be able to be speaking to you today, although I'm no Dr. Z, as the Brindis lecturer. So I started cardiology training in the last millennium, in 1996 or so, not to totally date myself. I'm much younger than I appear. But the, you know, the cardiology has evolved so dramatically since that time. So I remember when I was an intern and resident at UCSF, and an attending came up and said, we're going to have you take care of this patient who's just had a balloon angioplasty of their LAD. My heart would sink. Because it was likely going to be someone who had to go back to the lab. People were always having dissections of their coronary arteries. It was a complete mess. It was hard to believe that balloon angioplasty even survived as a procedure. It just seemed like things were so fraught. And the stent entirely revolutionized that. You know, people who see individuals getting stenting have no idea of the painful road that it took to get from the plain old balloon angioplasty to stenting, and to get a patient in and out on the same day. We were seeing patients there for a week, just getting an angioplasty. What a tremendous advance. And the VAD. I remember very well patients being in the hospital awaiting transplant on drips for months and months and months. And now there's mechanical circulatory support that has completely transformed the care of advanced heart failure. Think about imaging. The cardiac MRI. You go back 20 years ago, 30 years ago, and think that this is how we would be able to image the heart, you wouldn't even believe that it would be possible. And then electrophysiology. How much has that evolved? When I was in medical school, I remember hearing lectures about how ablations of WPW were done by cardiac surgeons. The implantable defibrillator were implanted in operating rooms by cardiac surgeons. And almost overnight, with the transvenous ICD and all these different technologies, things changed entirely. Now we're able to map arrhythmias and ablate them with tremendous precision and success. So it's been a tremendous time to be in cardiology, to watch this evolution of science, and how tremendous these advances have been. But I don't think that's the greatest story in cardiology over the last 30 years. The biggest story is the lost potential. The biggest story is the fact that we have this torrent of science that has been developed to help improve patient outcomes, but we lose a lot between the science and the evidence. We don't manage the insights well, but even when we have evidence, even when we have guidelines that have been painfully developed, painstakingly developed, we don't translate that evidence into care. That evidence is poorly used. And then finally, in delivering care, we don't capture the experience that patients have. So we've done this tremendous work in the front end, in the science and the evidence, and we've really failed in what I would call the final mile. This delivery of evidence into patient care and translating care into good patient experiences. This, to me, is the biggest story in cardiology, and this, to me, is the biggest story in medicine, and this is why we are all here. So when you see magazine covers, it's always going to be, you know, the Jarvik heart of the future of medicine. But what are they saying about quality? Well, this is from Demotivators. I don't know how many of you are familiar with Demotivators. It's a hilarious website, but this one says quality. The race for quality has no finish line, so technically it's more like a death march. So maybe it's not the final mile, maybe it's just an infinite number of miles, but I don't believe that that's true. I don't view quality as a death march. I think it's in itself so gratifying, and it may not get someone on the cover of Time magazine, but that's okay, because we're not doing it for Time magazine. We're doing it for our patients. I want to take a step back in time and think a little bit about the evolution of the quality story in medicine, and it all started with a nurse. That's right, here for nurses. With Florence Nightingale, who was a nurse with the British Army during the Crimean War back in the 1800s. And Florence Nightingale was absolutely appalled by the care that soldiers were receiving after they were wounded. Soldiers would die wholesale. They weren't dying in battle, they get wounded in battle, and they would die of gangrene days, weeks, or months later. And she said, this has got to stop. And she fought sexism, and she fought a variety of other forces, you know, tradition, by changing how British soldiers were cared for after battle, and transformed the way things were cared for. And through her whole life, doggedly pursued quality. She was also a pioneer in data visualization, by the way. I would encourage you to look at the graphs that she developed to demonstrate how things needed to change. Another one of the heroes is Ernest Codman. Ernest Codman was a surgeon in Boston in the early 1900s, and he worked at a hospital that goes by MGH, I guess is what it was called at the time, and is now. It's a different place now than it was then. But he was very disaffected by the culture of practice at MGH, and he decided he was going to open a separate hospital called the End Results Hospital, where he would report all of his errors publicly. He was completely ostracized by the surgical community. He had been the chair of the Surgical Society in the state. He lost his chair. He lost his position. But he never stopped fighting in the name of quality. Another hero is Evita Stonobedian, who developed this process, structure, and outcome framework for quality to help us think about how we deliver the best care to patients. And he developed a lot of his work in the 60s and 70s, and some of it lay fallow for a while, but then it was picked up, and it was understood how important this framework was to understanding and advancing the quality agenda. And then finally, Don Berwick, who's been head of CMS, but more importantly started the Institute of Healthcare Improvement, who's really brought quality onto the map in the United States healthcare. He may well have been on the cover of Time magazine, I don't know, but he's a special man and tremendous advocate of quality. And so the story of quality is a story of heroes. It is not a story of a death march. And ACC quality programs have been fundamental in cardiovascular care, in advancing the quality agenda, now for 25 years. And it just, every time I tell the origin story of NCDR, one of the ACC's key quality programs, it always amazes me to even say it again, which is that back 25 years ago, think of what the payment models were. Entirely fee-for-service. Now we've made a little progress since then, but value-based payment was not on the map. That wasn't even a concept that existed. And leaders from the college got together and said, why don't we develop a program to help understand and improve quality in the cath lab? And started the Cath PCI registry that was focused on collecting data and transforming that data into information that would allow centers to improve the quality of care that they delivered. And you think about it, a professional organization representing cardiovascular professionals in a fee-for-service environment. What would you think that organization would be doing? Well, a number of professional organizations spent most of their time lobbying to maintain payment to their members. And the college invested a substantial amount, a substantial amount of resources into the Cath PCI registry. And there were many points where leaders of the college were faced with the decision to continue to put money into the Cath PCI registry or to cut it off. And there were times where it was hanging by a thread. But this is an example of the leadership of ACC investing in a quality program at a time where you think there's just absolutely no reason to be doing this. And they developed a foundational program that now 25 years later is one of the keystones of the ACC's quality programs. It is a remarkable story of non-conformity at that time. And those of you who work with NCR, I'm actually going to go back a slide. I don't know how many of you remember the old PDF reports. If any of you from the PDF report era, yeah, a number of you raise your hands with a little box and whisker plots and the arrows and so on. And our reporting has evolved dramatically. It's now electronic. But those reports have supported local quality improvement over the last 25 years, have galvanized teams to focus on those issues that are most relevant to the patients that they serve. And NCDR has also contributed, we'll go through some highlights here, of some of the ACC's quality programs and their contributions to national quality improvement. So many of you are familiar, I think, with the D2B program. Story behind that is a perfect example of this failure of translating science to evidence, to care, to good patient experience. Before the D2B initiative, it was remarkable that despite the fact that primary PCI had been well established as the form of treatment for individuals with ST segment elevation myocardial infarction, remarkably few patients were getting this within the guideline-directed time of 90 minutes. And the evidence had been around forever, well 10 years, but you know, it's like an eternity. But it still had not been adopted. And door-to-balloon initiative, which was led by Harlan Krumholz and supported by the American College of Cardiology, said, hey, let's look at sites that are doing well with respect to their door-to-balloon times, and let's figure out what are these sites doing well? And identified several factors that were associated with sites doing well, one of which was something simple like a single paging number to call in the event of a STEMI. Now we all use this now, but at the time I remember, before this, as a fellow getting called, oh we have a STEMI, it's like, well I'm not the person to call, I think you're supposed to call this person who's on this, you need to call that operator who does that, and before you know it, that valuable time was wasting away. So by instituting these practices of successful institutions, the D2B initiative entirely transformed the landscape of primary reperfusion. There's very little reason to believe that the numbers that were present before D2B would have changed nearly as much had it not been for this program. And I can tell you, in my experience at the University of Colorado when I was there, going through with our quality committee that focused on time to reperfusion, those failures were rare. You know, it's almost a never event now that a patient is not reperfused promptly. That is a remarkable accomplishment for the benefit of our patients. And as you can see, look for instance between 2005 and 2010, the median door-to-balloon time dropped by 30 minutes, by one-third, and the proportion of patients getting kindly reperfusion increased from about 44 percent, that's embarrassing, 44 percent, to 91 percent in September of 2010. And I can guarantee you, I know for a fact, looking at NCDR data subsequently, that this is, again, approaching never event status. A remarkable accomplishment. NCDR has also advanced patient safety. In fact, one of the first papers that came out of the NCDR-CAF-PCI registry generated the data on the left there, which was an assessment of bleeding events among individuals receiving different approaches to vascular closure, either manual compression or different approaches, be it the Cybex patch per close. Well, as you can see, among all these different varieties, one was not like the other. And in fact, the one that was not like the other, the vasocele, was, as a result of this work, removed from the market, because all of the other approaches had certain amounts of bleeding, and there was one that didn't fit in. It was not safe. And that, the legacy of that work has now been continued by Fred Resnick. Fred's done some terrific work with his Delta project with data that you can see on the right. This was published in the New England Journal of Medicine, where you can see over time, this is the cumulative incidence of events with a particular closure device. As you can see here, I'll just tell you that those blue boxes are the overall number of adverse events in the entire population, and the dots above are with a particular device. As you can see, in the first period, higher rates. There's a green dot there, though, because it's not statistically clear that those are different. But even in the third quarter already, it became quite apparent that this particular device was a problem. And so doing real-time safety surveillance is now possible because of the ACC quality programs, because of NCDR. And this is a tremendous example of taking the data that are generated in NCDR, and one of our quality programs, and translating it into information that advances patient care. So ACC did something very much out of the box when it came to thinking about quality, thinking about quality programs in the context of a fee-for- service environment. Touched another third rail when it came to assessing appropriateness, and the ACC committed itself to developing appropriate use criteria for procedures, which was highly controversial. And I think in retrospect is another example of how an organization can lead for the betterment of patients, and lead its members in the right direction. This is work that was done from the cath PCI registry by colleagues from Yale, looking at trends in the appropriateness of PCIs over time, and the variation in this appropriateness over time. And what we found in analyzing these data, and this is just a function of starting to report, when is a procedure appropriate? When may it be appropriate? When is it rarely appropriate? These terms have changed from this slide here. But as you can see over time, the proportion of procedures that were deemed appropriate increased. Those that were uncertain decreased, and those that were inappropriate decreased. On the right you can see the variation in the rate of inappropriate or rarely appropriate procedures declined over time. This is again an example of leadership, of quality leadership. I'm saying we will hold ourselves responsible to making sure we are doing the right thing for the right patient at the right time. And we'll take a look in the mirror, and we'll decide if we're doing these things correctly. NCDR and the ACC quality programs have also advanced cardiovascular science. This is a graph of publications from ACC quality programs over the last many years. And as you can see, NCDR itself has supported almost 700 peer-reviewed studies, and they've been published in the highest profile journals, including JAC, New England Journal, JAMA, Circulation. So this is just one contribution that NCDR and the ACC quality programs have made to transforming cardiovascular science. ACC has also been a trusted partner in advancing care. I think you're all aware of the coverage with evidence development decisions that CMS has issued for a number of cardiovascular procedures. This started back in the early 2000s when CMS decided after ScudHeft was published that it was going to be difficult for them not to reimburse for primary prevention defibrillators. And they recognized, though, that this was potentially an immense population of individuals who'd be getting this technology, that the trials did not focus on the patients that Medicare cares for, and concerns about the possibility that they may not be used in practice or may not deliver the same outcomes in practice that they did in the clinical trials. So Medicare made a very revolutionary decision to issue a national coverage decision with evidence development for ICDs. And thanks to Ralph Brindis and others, some at the HRS, some at ACC, the ICD registry was formed to support our members and to support hospitals in getting reimbursement for primary prevention ICDs in the Medicare population. And that coverage with evidence paradigm is one that is now translated into the STS-ACC TBT registry for percutaneous valves and the LAO registry, left atrial appendage occlusion registry, which assesses care and outcomes after Watchman and now other device deployment for LAO. And these programs have generated tremendous insights. Again, data that's translated into information. And these are the kinds of data that you just simply could not have without NCER, without ACC's quality programs. For instance, looking at the expansion of indications for percutaneous aortic valves, the evolution over time from the extreme and high-risk patients, uptake in intermediate-risk patients, and now uptake even in low-risk patients as a response to the evolution of science now getting into care. And also, for instance, on the right here, and this is something if you've been involved in percutaneous valves, you saw this happening in real time, how access site changed over time, how there was this brief period where transapical access was a big deal. We're doing a lot of transapical procedures, and it became quickly apparent with the evolution of technology as well that the transfemoral approach was the way to go. And you can see that now almost all percutaneous valves are done transfemorally. Again, these are data that simply would not exist if it weren't for TBT registry. One of the, I think, most important developments over the last decade in the registry programs has been the incorporation of health status measurement. This is that part about listening to the patient and hearing the patient's experience. The fact now, as part of the TBT registry, the KCCQ, the Kansas City Cardiomyopathy Questionnaire, which was developed by John Spertus, the first Ralph Brindis lecturer, is now collected in the TBT registry. And what is remarkable is that this is collected at all at scale. This is, I think, one of the few examples where health status is collected in a national sample. It's not even a sample. The national population of patients getting percutaneous valves. It just doesn't exist somewhere else. Now, you can see that we have challenges in terms of completeness with KCCQ data at one year. Not necessarily surprising given what we know about how patients are referred for these percutaneous valves and how difficult it can be to follow some of them up. To me, this is a glass-half-full picture. Glass is like 90% full. The idea that we're collecting health status from patients in a registry in hundreds of thousands of patients. This is not something you see anywhere else. This is listening to the patient. And health status matters. Health status doesn't matter just because it reflects the patient's experience, which is incredibly important, but health status is also prognostically important. These are some data from the TBT registry that show that those patients, even after adjustment for other factors, who have poor health status going into percutaneous valve procedures, have high rates of mortality. These data could not have been generated in any other context. These are remarkable data showing the importance of listening to the patient, not only because we want to know how the patient feels, but because this is an important marker of downstream outcomes. And we get questions about the data. Are our data good? And for those of you who've seen this before, I apologize for the repetition, but it's hard to resist. I think one of the most important lessons about data quality, one of the most important cautions about data quality, comes from The Simpsons, where most of our important information comes. And this comes from one of the newscasts on The Simpsons by Kent Brockman, who said that at 3 p.m. Friday, local autocrat—I would love to be a local autocrat, that'd be amazing—local autocrat seen Montgomery Burns was shot following a tense confrontation at Town Hall. Burns was rushed to a nearby hospital where he was pronounced dead. He was then transferred to a better hospital where doctors upgraded his condition to alive. That sounds like playing with the data to me. Are the data from NCDR good? And the answer is a resounding yes. The data are good. And you are the reason why the data are good. The data are exceptional for a program—for programs at this scale. It is amazing. The quality of the data are simply remarkable. And if you have a chance to read the paper that David Malenka led around the NCDR data quality program, I would encourage you to do it. It is an uplifting story. And don't just ask me, I'm totally biased, of course. I think we're awesome. But if you look in the literature, I'm not alone in thinking that. Veronique Roget, who's a leading health outcome scientist, wrote an editorial on circulation cardiovascular quality and outcomes years ago and called out the NCDR data as particularly high quality. That's a tribute to everyone in this room. Because what you get out, the information you get out, is only as good as the data that go in. And accreditation has played such an important role in optimizing the care environment. And this is a paper that my colleague, Dr. Winchester, led, it was published just recently in Jack, that highlighted the importance of accreditation in establishing these structures of care that are necessary to take the best care of patients with chest pain. So helping systems of care implement performance improvement, closing these gaps in essential chest pain characteristics. I'd encourage you to read this paper. Again, it's a very uplifting story about the importance of accreditation, making sure that we have the structures in place to deliver the right care to the right patient at the right time. ACC quality programs are also fundamental to building communities of care. And I think one of the other big evolutions in cardiovascular care over the many years has been recognizing the importance of every member of the care team to the success of care. It's not about, it's not just about the physician. It's about the nurse. It's about the physician's assistant. It's about the scheduler. And in the case of people with chest pain, it's about EMS. And so the quality programs of the American College of Cardiology have recognized this in developing communities of care, bringing together the registry programs, accreditation programs, built upon the guidelines, the evidence base, and engaging EMS with eReports EMS and the chest pain MI registry. And then the EHAC program, Dr. Bargh's program, of engaging the community in the care of chest pain is a tremendous story as well. Of building these communities, recognizing the importance that everyone who touches this program or this type of care has to offer, has to contribute, bringing them all together to do the best job possible. It's also thinking about the role of the clinician in the quality community, thinking about issues when it comes to the quadruple aim, not just the triple aim, the quadruple aim, and these issues of clinician well-being. The important issue of diversity, inclusiveness, and equity in cardiovascular professionals. And then thinking as well about how our multiple quality programs, so in the case NCDR, and accreditation, and MedAxian can work together to achieve the quadruple aim, to achieve clinician well-being in addition to working on quality, value, access. Thinking about the important role of the cardiovascular professional, particularly in this era of the pandemic, when everyone is really at their wits' end. So I told you about the origin story of NCDR as one of the ACC's quality programs, and I think when I presented about NCDR as one of the programs to the Board of Trustees, and I saw this slide, it really, it really put me, it really, I was in awe, completely in awe, knowing all this, of course, but thinking about how things have evolved so much since that time 25 years ago when leaders of the college said, you know, quality is important, because this is all about the patient. And ACC quality programs are now ingrained locally, regionally, nationally, in the cardiovascular quality enterprise across the country. And despite our success, of course, we need to think about the challenges ahead. You know, healthcare is moving very, very quickly. I talked about all the transformative science that occurred, that's occurred over my career, but healthcare is changing ever more quickly. This omnipresence of the electronic health record, of course, the pandemic and other disruptions to care. And, you know, it's, I think many have observed that in Chinese, the characters for the term crisis are danger and opportunity. Another way to think of this is what Winston Churchill said about the pessimist and the optimist. Winston Churchill says the pessimist sees challenges in every opportunity, and optimists see opportunities in every challenge, and I'm very optimistic about ACC's quality programs in the future. But the things we need to think about are data burden, for example. We understand how much burden it is to generate the data that are translated into information. And this all derives from the original sin of the electronic health record, in my mind. The original sin was the decision to forego interoperability in order to get hospitals and physicians' offices, health systems, to use EHRs. And it was a critical decision for the worse, because as you can imagine, if you had an interoperable electronic health record, a lot of this work in generating data, clinical data, not billing data, clinical data that could be transformed into clinical insights, could happen automatically. But it doesn't. For any of you who work in health systems that have more than one hospital, many of you are dealing with EHRs, and they may be the same on the surface, but they're different instances of that EHR, and so they don't talk to each other. And so even in health systems, it can be very challenging to do the kind of work that you would like to do to transform that digital exhaust of healthcare into something meaningful. And EHRs have failed substantially in this regard. The NCDR Optimization Program, which Dr. Fry made mention of, is focused specifically on this issue of data burden, thinking about infrastructure alignment, efficiency, flexibility of operations, and workflow integration. And ACC has entered into a strategic partnership as well with Carta Healthcare, thinking about how AI and natural language processing can be used to help facilitate data abstraction and reduce the burden of participating in quality programs. I think we need to think more about measuring what matters. And as Bill Gates says, struck again and again by how important measurement is to improving the human condition. That's quite a statement, but it's absolutely true. And that's what these quality programs have been all about, is measuring to improve the human condition. And we need to measure more. We need to think about value of care. We focused a lot on quality. We need to be thinking much more about value. And when I think about value, I don't think about value like an insurer thinks about value. When a payer thinks about value or talks about value, they're talking about cost. And that's not what value is. Value is what are the results that you achieve as a function of the cost it takes to deliver those results. And ACC quality programs have been key to understanding how we can deliver higher value care. This is a terrific paper that was led by Amin who implemented John Spertus' E-PRISM program at his hospital. And that E-PRISM program was based on risk models that were developed from NCDR. So evidence-based risk models that say what is a patient's risk of developing acute kidney injury after coronary angiography and intervention? And taking that clinical data that had been translated to information and taking those risks, they did something relatively simple, which was to say during the timeout for the procedure, the team is going to announce this person's risk of developing acute kidney injury is X% based on an evidence-based model developed through CAF PCI. And as a result of their parameters, this is the maximum contrast that we would recommend using during this procedure. And this is not a randomized trial, it's a before and after observation. But what you can see in terms of contrast use, before in gray, after in green, the proportion of patients who got contrast above that specified limit. And then the outcomes of acute kidney injury, length of stay and cost. You can see particularly in those that were at high risk of acute kidney injury, lower volumes of contrast, much lower proportions of patients who got the amount of contrast above the recommended limit, a reduction in the risk of AKI of almost 4%, a reduction in length of stay and a reduction in cost. This was all based on data from the NCDR. What a win. Right? Right? Right? Right? Right? Right? Right? Better outcomes at lower cost. That is shocking. That's what you call a dominant strategy. No one loses there, everyone wins. We also need to find a better way to involve more people. And when I, avoiding the use of the word patients, these are people, involve more people more often. And I've shown you the data that we've generated that have been generated out of the TBT registry in terms of capturing KCCQ. But we need to continue to think and to strive as to how to collect health status data in the programs and to incorporate that patient experience into what we do. Because there's not always a coverage with evidence decision that'll help support those efforts. But if we develop ways of getting those data, getting those data even from patients, that will transform cardiovascular care. Another thing I think we need to think about is the health system and the hospital and the clinic as organisms, as complex organisms. And just like when we think about introducing a drug into a human organism, we like to think about what are the benefits and what are the downsides? What are the unintended consequences of, say, using drug X for condition Y? And I think we need to think more about this as well as we strive to advance quality of care. Because just like when we disrupt any complex organism, has intended consequences and has unintended consequences. And this series by Lisa Rosenbaum in the New England Journal I think it was quite sobering and makes us think a lot about our efforts and think about how we need to think more about the consequences of what we do. This recent study that examined CMS's Merit-Based Incentive Program, or MIPS, found that clinicians and administrators invested about 200 hours per year to meet each physician's MIPS requirements. These hours could be spent in countless other ways, especially caring for patients raises the obvious question, is the system we created to fix the system even working? Which highlights this really important difference between the collaborative community of quality that works together to elevate care at an institution versus what happens with accountability programs. So we need to be wary and thoughtful about how what we do perturbs the system. Dr. Fry made an allusion to the NCDR Optimization Plan. The NCDR Strategic Plan is embedded in the college's strategic plan. The pillars of our strategic plan are to reduce the burden and enhance the scope of data collection, increase NCDR value to stakeholders, promoting quality improvement and supporting population health management. There are 13 programs in the Optimization Plan, all of which are focused on these strategic pillars. So the NCDR and the ACC quality programs continue to evolve in this challenging and rapidly changing healthcare environment. So, you know, as I've said, there's this glory in medicine, these great scientific advances. And then there's the reality, the fact that were it not for you, we would not be addressing this final mile. Some have said it's final million miles. And I talked about the pantheon of quality heroes, but I think it goes without saying that you are the heroes in this story. That because of you, all these things have happened. You here, you attending virtually, I wanna thank you from the bottom of my heart for your contributions to the 100 million patients that ACC quality programs have touched. With that, I will thank you. Thank you. Thank you for the children's book. Fantastic. So much to think about. I had a question for you. We'll go ahead and move into the Q&A in an hour where we have more on the agenda. I'm not taking questions. I'm sorry. Yeah. Where do you think, what do you think of the low-hanging fruit in terms of involving more patient or people gathered data within our program? So you think there's particular things that are on the horizon we should be working on? Well, I don't know that there's any low-hanging fruit. Honestly, it's a big challenge. And one of the things I think we've learned from TBT is that anchoring that data collection to the institution where the procedure was originally performed is one where you're naturally gonna have some loss of capture as time goes by. It only makes sense, right? So in my experience, you have patients referred to Denver from Wyoming, Montana, all over the place. And people move, and so anchor it with the institution is a problem. I wouldn't say it's necessarily low-hanging fruit, but there are potential opportunities to be gathering data from patients directly and then bringing those into programs. Now, those are not, those are big projects. But I think ultimately, that's the kind of thing that might make it possible to say, for instance, start to incorporate the Seattle angina questionnaire into the cath PCI registry. And to really think about how much angina are we treating when we do percutaneous interventions and in a manner where, again, you're not relying on the institution to have to provide those data. Not an easy approach, but I think ultimately that may well be the answer, is working more directly with patients. Barbara, have you got questions for us? Testing, testing, testing. We do have one. In the fee-for-service reality we live in, how do you see the payment model reforming with time? So I'll turn, I mean, I think anyone here would be perfectly able to answer this. I would say that what I've been shocked by is the amount of talking there has been about value-based purchasing. And on the other hand, how little progress there's been in that respect. And I think part of that is that it's very, very hard. It's hard because there are these structural advantages to a fee-for-service. I think it's hard to develop really robust payment models that really reflect quality. The evolution has just been slower than certainly I've expected. Although I think ultimately it will become a dominant force. I just don't know when that's going to be. There are just a number of challenges in developing models. I don't know what your experience has been, Dr. Fryer, what your thoughts are about value-based payment versus fee-for-service. Well, I think it's a great question because I think we are at truly a pivotal moment. And this has actually been talked about at the college. We're very good at describing the problem. We haven't been very good at offering solutions or pilots that could be potentially utilized and explored in terms of changing our reimbursement model. I mean, it's pretty clear to date that the things, and Fred, you touched upon this in your talk, that have been tried to date, whether it's ACOs, whether it's bundles, whether it's MIPS, MACRA, really have not moved the needle. And there are fundamental structural challenges. And we're probably approaching a point where the system may need to be blown up and rebuilt from the ground up. The challenges are also some of the advantages, which is that patients have great mobility and choice in their care, which is great at the patient level. It's very difficult then to manage a system of care when there's that fluidity in it. And so that's the balance that has to be struck. Nobody has the answer, but I think as we leverage data that is being collected on patients, as we bring together patient-level data, those are gonna give us the tools to help formulate the ideas as to what may be the systems of the future. We have another question around the international. So this is specific. What's the status of NCDR in involving international institutions? Any specific observations for that? So I think several of you could talk about what the international presence is and how that might, I'll add, how does that affect our global community around quality? Well, we have been working on national versions of a number of the registry programs in the international setting, trying to overcome a few particular issues. One is language can be an issue, of course. The other is where the data live. There are many countries in which data can't exit the country, health data can't exit the country. And so those, I think, in our most recent iteration are specific issues we have been able to address in bringing some of the programs nationally and also some of the accreditation programs as well, the certification programs internationally. And I think these are things where it's taken some learning in terms of understanding local cultures and local incentives, but we're at a point where I think we're making a pretty important step forward in bringing these platforms to accelerate higher quality patient care internationally. And I think it's gonna be, there's a real hunger for that, I think, despite the variations in cultures and incentives elsewhere. There's a tremendous hunger for this sort of capacity. And so it's been a tremendous honor to be working in spreading these quality programs internationally. I'll just put a plug in for the work that's being done with the National Quality Solutions. Hector Emanuele and the international group are working with various countries in their health systems to bring the registry sort of mentality, if you will, to those countries, and it's been greatly accepted. A good example of where the power of registries lie is the GADI initiative, the Global Heart Attack Initiative, and being able to collect global level data so that countries can benchmark themselves once against another in terms of STEMI care. And I think we have time for one more question here. Do you feel that focusing on wellness versus illness would improve care overall? Maybe that one gets punched into me. Yeah, I think one of the examples is made about healthcare delivery and Kodak and how Kodak saw themselves in the process of film rather than developing images or image, and as a result, they missed the boat. And I think healthcare has an important moment to understand that really it's about delivering health rather than care for ill patients. The challenges are the aspects of care delivery or health and promoting health that live outside of the traditional walls of healthcare delivery. And I think there's a tremendous tension of where healthcare is best suited to answer those ills around social determinants of health disparities and what our role is as we work with others that have worked in that space for a long time. So I think overall, yes, the answer is we need to be thinking about how we promote wellness. The challenge is how we do that in a way that we recognize where our strengths are and where we need to partner with others.

NCDR

Accreditation Services

quality improvement

healthcare

ACC

door-to-balloon times

appropriate use criteria

patient safety

data burden

payment model reform