Quality of Highly Complex Care in Cardiology

Keywords
Cardiovascular Diseases: Hospitals, Special; Hospitals, Chronic Diseases/trends; Quality of Health Care/trends; Staff Committee

Factors like the high costs of currently available technologies, the work overload of health professionals, and population aging and consequent increase of chronic diseases have highlighted the need for special attention to the quality of health care provided, especially in high-complexity cardiovascular care.¹

Although there are several definitions of health-related quality, the present analysis is grounded in the concept that aspects like efficiency, or effectiveness, are associated with the safety of care provided, which in turn is closely related to patient centrality and protection of their rights.

When the concept of quality is discussed, structural or physical factors, including material, financial and human resources, assessment tools, education and research activities, clinical protocols, and process approaches should be addressed. Process approach is a method to plan activities and processes performed by health providers who are directly involved in patient care, that can lead to (desirable or undesirable) changes in individual or population health.²

The exhaustive search for reliable processes in health care has yielded remarkable achievements such as elimination of waste, undesirable waiting, unnecessary pain, and preventable death. One example is the “Enhanced Recovery After Surgery” (ERAS), a multimodal perioperative care pathway, already validated in cardiac surgeries.³ The ERAS refers to a multidisciplinary, patient-centered, evidence-based approach aimed to optimize patients’ physiologic function in the preoperative period, leading to improved patient outcomes and satisfaction, and reduced hospital stay, postoperative complications, and hospital costs.

In the Brazilian public health system, “highly complex” procedures are those involving technology and high costs, aiming at providing access to high-quality services that should be integrated to other levels of complexity (low and moderate complexity). The National Policy of Cardiovascular Care, launched in 2014 and updated in 2018, regulates the criteria for the habilitation of health care units and referral centers involved in the highly complex care of cardiovascular diseases.⁴,⁵ These health care units should provide technical conditions, physical facilities, equipment, and human resources and promote a close interaction and integration with the local and regional system. Procedures performed in these centers include adult and pediatric cardiovascular surgeries, interventional procedures, vascular, endovascular and extracardiac surgeries, and electrophysiological analyses. These units should also offer outpatient cardiovascular care, emergency care, preoperative and postoperative follow-up, laboratory tests and cardiovascular prevention measures.

The concern about the quality of care provided by institutions where cardiac surgery is performed has to do with the fact that surgical mortality rates were shown to vary across them.⁶

Indeed, the continuous analysis of mortality is crucial in the search for excellence. Mortality committee and surgical mortality meetings may help in this regard. The number and frequency of deaths, patient gender, action plans for potential failures of the processes, and the level of complexity of the cases should be analyzed. Many publications have reported the need for adjusting the risk to mortality found in cardiac intensive care units and during the postoperative period in children and adults post-cardiac surgery.⁷–⁹ In addition, the length of stay in the hospital and intensive care unit of patients undergoing highly complex procedures should be continuously analyzed.

The Health Technology Assessment (HTA) aims to produce knowledge about the basis for health care, potentiate the synthesis of evidence, and test suggested or required knowledge for health system planning, to ultimately improve all dimensions of quality in care, including disease prevention. A greater participation of the HTA in the implementation and use of technologies in health would reduce inequity in health care, optimize resource allocation, and improve effectiveness and quality of services and financial sustainability of the system.¹⁰ Considering the high costs of cardiac procedures, the benefits of HTA are unquestionable.

However, it is worth to mention that measuring is essential, but not sufficient. After data are collected, they should be analyzed and an action plan for their improvement and implementation should be developed. In this regard, predictive models with computerized solutions, aimed at making improvements in patient care, are currently available.¹¹

National databases are usually difficult to be generated in most countries, but there are exceptions, notably Denmark, in which analysis of specific diseases has been successfully performed through nationwide databases. Consolidated in the country for more than 40 years, the Danish Breast Cancer Group (DBCG) was the first to create a clinical database with the purpose of research. The Danish Lung Cancer Registry (DLCR) was the first database primarily focused on the quality of care. The Danish Heart Registry (DHR) is a national database for collecting medical and administrative data on patients referred for invasive cardiovascular procedures and cardiac surgeries and is used for analytical and planning purposes in health care quality and reimbursement of institutions.¹²,¹³

The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) is another example of nationwide registry that has an important impact on cardiovascular care. The STS ACSD also allowed the development of a score that has been widely used and continuously updated, for the assessment of mortality among patients undergoing cardiac surgery.¹⁴

In Brazil, despite the dissemination of private and public centers where highly complex cardiac procedures are performed, there is an evident lack of large databases of data related to these procedures. Besides, some of the available data are clearly underused, including the authorization for hospital admission that can provide valuable information on the diagnosis of cardiovascular diseases.¹⁵ There is also an undervaluation of data obtained from currently available registries.

In this brief analysis of highly complex care in cardiology, we conclude that:

• High-quality care not only gives the patient the best opportunity to achieve the results they seek, but also avoid inefficiency and waste;

• Improvement of quality and safety of care is challenging and has long term results, requiring the involvement of all members of the organization;

• Assessment is essential but not sufficient. Solving the problems detected requires action;

• An effective interaction between research, care, and management translates into better quality;

• Adequate registries of data are still scarce;

• Implementation of HTA is essential not only for the evaluation but also for the achievement of better results.

• Sources of Funding
  There were no external funding sources for this study.
• Study Association
  This study is not associated with any thesis or dissertation work.
• Ethics approval and consent to participate
  This article does not contain any studies with human participants or animals performed by any of the authors.

References

• ¹
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Publication Dates

• Publication in this collection
  16 May 2022
• Date of issue
  Sep-Oct 2022

History

• Received
  27 Apr 2021
• Reviewed
  24 Jan 2022
• Accepted
  11 Apr 2022