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BACKGROUND: Poor patient uptake of cardiac rehabilitation (CR) remains a challenge for multiple reasons including geographic, time, cultural, cost, and psychological constraints. OBJECTIVE: We evaluated the impact on CR participation rates associated with the addition of the option of mobile app-based CR (Cardihab) for patients declining conventional CR. METHODS: A total of 204 consecutive patients were offered CR following angioplasty; of these, 99 were in cohort 1 (offered conventional CR only) and 105 were in cohort 2 (app-based CR offered to those declining conventional CR). Patients in each cohort were followed throughout a 6-week CR program and participation rates were compared for both groups. Patients in cohort 2 declining both forms of CR were interviewed to assess reasons for nonparticipation. RESULTS: CR participation improved from 21% (95% CI 14%-30%) to 63% (95% CI 53%-71%) with the addition of the app (P<.001). Approximately 25% (9/39) of the group declining the app-based program identified technology issues as the reason for nonparticipation. The remainder declined both CR programs or were ineligible due to frailty or comorbidities. CONCLUSIONS: Providing patients with the additional option of an app-based CR program substantially improved CR participation. Technology and psychological barriers can limit CR participation. Further innovation in CR delivery systems is required to improve uptake.

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AIMS: It has been previously demonstrated that use of appropriate frame rates coupled with minimal use of high-dose digital acquisition can limit radiation risk to patients undergoing diagnostic and therapeutic electrophysiology (EP). Imaging without the anti-scatter grid has been proposed as a means of achieving further radiation reduction. We evaluate application of a gridless imaging technique to deliver further reductions in radiation risk to both patients and personnel. METHODS AND RESULTS: Radiation and clinical data for EP procedures performed for 16 months from March 2012 were monitored. The period was divided into three phases: Phase 1 (March 2012-June 2012) provided a performance baseline (radiation output modelling and procedural risk adjustment calibration), Phase 2 (July 2012-September 2012) confirmation of performance with the grid, and Phase 3 (September 2012-June 2013) gridless imaging period. Statistical process control (SPC) charts were used to monitor for changes in radiation use and clinical outcomes (procedural success). Imaging without the grid halved the levels of radiation delivered in undertaking EP procedures. Although there was a perceptible impact on image quality with the grid removed. Review of the SPC chart monitoring procedural outcomes did not identify any discernable adverse impact on success rates. Selected use of the gridless technique is recommended with re-introduction of the grid in larger patients or during aspects of the procedure where image quality is important (e.g. transeptal punctures). CONCLUSION: Use of a gridless imaging technique can contribute to a significant reduction in radiation risk to both patients and operators during cardiac EP procedures.

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BACKGROUND: Graphical Statistical Process Control (SPC) tools have been shown to promptly identify significant variations in clinical outcomes in a range of health care settings. We explored the application of these techniques to quantitatively inform the routine cardiac surgical (CAS) morbidity and mortality (M&M) review processes at a single site. METHODS: Baseline clinical and procedural data relating to 5265 consecutive cardiac surgical procedures, performed at St Andrew's War Memorial Hospital (SAWMH) between the 1st January 2003 and the 30th April 2012, were retrospectively evaluated. A range of appropriate clinical outcome indicators (COIs) were developed and evaluated using a combination of Cumulative Sum charts, Exponentially Weighted Moving Average charts and Funnel Plots. Charts were updated regularly and discussed at the cardiac surgery unit's bi-monthly M&M meetings. Risk adjustment (RA) for the COIs was developed and validated for incorporation into the charts to improve monitoring performance. RESULTS: Discrete and aggregated measures, including blood product/reoperation, major acute post-procedural complications, cardiopulmonary bypass duration and Length of Stay/Readmission < 28 days have proved to be valuable measures for monitoring outcomes. Instances of variation in performance identified using the charts were examined thoroughly and could be related to changes in clinical practice (e.g. antifibrinolytic use) as well as differences in individual operator performance (in some instances, driven by case mix). CONCLUSIONS: SPC tools can promptly detect meaningful changes in clinical outcome thereby allowing early intervention to address altered performance. Careful interpretation of charts for group and individual operators has proven helpful in detecting and differentiating systemic versus individual variation.

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AIMS: This paper describes the development of a risk adjustment (RA) model predictive of individual lesion treatment failure in percutaneous coronary interventions (PCI) for use in a quality monitoring and improvement program. METHODS AND RESULTS: Prospectively collected data for 3972 consecutive revascularisation procedures (5601 lesions) performed between January 2003 and September 2011 were studied. Data on procedures to September 2009 (n=3100) were used to identify factors predictive of lesion treatment failure. Factors identified included lesion risk class (p<0.001), occlusion type (p<0.001), patient age (p=0.001), vessel system (p<0.04), vessel diameter (p<0.001), unstable angina (p=0.003) and presence of major cardiac risk factors (p=0.01). A Bayesian RA model was built using these factors with predictive performance of the model tested on the remaining procedures (area under the receiver operating curve: 0.765, Hosmer-Lemeshow p value: 0.11). Cumulative sum, exponentially weighted moving average and funnel plots were constructed using the RA model and subjectively evaluated. CONCLUSION: A RA model was developed and applied to SPC monitoring for lesion failure in a PCI database. If linked to appropriate quality improvement governance response protocols, SPC using this RA tool might improve quality control and risk management by identifying variation in performance based on a comparison of observed and expected outcomes.

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Audit of and feedback on both group and individual data provided immediately after the point of care and compared with realistic benchmarks of excellence have been demonstrated to drive change. This study sought to evaluate the impact of immediate benchmarked quantitative case-based performance feedback on the clinical practice of cardiologists practicing at a private hospital in Brisbane, Australia. The participating cardiologists were assigned to one of two groups: Group 1 received patient and procedural details for review and Group 2 received Group 1 data plus detailed radiation data relating to the procedures and comparative benchmarks. In Group 2, Linear-by-Linear Association analysis suggests a link between change in radiation use and initial radiation dose category (p=0.014) with only those initially 'challenged' by the benchmarks showing improvement. Those not 'challenged' by the benchmarks deteriorated in performance compared with those starting well below the benchmarks showing greatest increase in radiation use. Conversely, those blinded to their radiation use (Group 1) showed general improvement in radiation use throughout the study compared with those performing initially close to the benchmarks showing greatest improvement. This study shows that use of non-challenging benchmarks in case-based radiation risk feedback does not promote a reduction in radiation use; indeed, it may contribute to increased doses. Paradoxically, cardiologists who are aware of performance monitoring but blinded to individual case data appear to maintain, if not reduce, their radiation use.

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BACKGROUND: Graphical Statistical Process Control (SPC) tools have been shown to promptly identify significant variations in clinical outcomes in a range of health care settings. We explored the application of these techniques to qualitatively inform the routine cardiac surgical morbidity and mortality (M&M) review process at a single site. METHODS: Baseline clinical and procedural data relating to 4774 consecutive cardiac surgical procedures, performed between the 1st January 2003 and the 30th April 2011, were retrospectively evaluated. A range of appropriate performance measures and benchmarks were developed and evaluated using a combination of CUmulative SUM (CUSUM) charts, Exponentially Weighted Moving Average (EWMA) charts and Funnel Plots. Charts have been discussed at the unit's routine M&M meetings. Risk adjustment (RA) based on EuroSCORE has been incorporated into the charts to improve performance. RESULTS: Discrete and aggregated measures, including Blood Product/Reoperation, major acute post-procedural complications and Length of Stay/Readmission<28 days have proved to be usable measures for monitoring outcomes. Monitoring trends in minor morbidities provides a valuable warning of impending changes in significant events. Instances of variation in performance have been examined and could be related to differences in individual operator performance via individual operator curves. CONCLUSION: SPC tools facilitate near "real-time" performance monitoring allowing early detection and intervention in altered performance. Careful interpretation of charts for group and individual operators has proven helpful in detecting and differentiating systemic vs. individual variation.

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OBJECTIVE: To evaluate the benefits of radiation education with and without feedback reporting in altering clinician radiation use behaviour in performing coronary angiography (CA). DESIGN: A retrospective review of radiation use (fluoroscopy time) in coronary angiograms performed between July 1996 and December 2005 by 10 cardiologists to assess the impact of various interventions aimed at minimizing radiation risk. The impact of interventions such as education and audit/feedback was correlated against radiation use using cumulative sum and cumulative expected minus observed charts. SETTING: Private Hospital in Brisbane, Australia. PARTICIPANTS: Ten cardiologists. INTERVENTION: Education and audit/feedback. RESULTS: Baseline radiation use subject to standard guidelines was stable. Group performance charts show a modest transient improvement in radiation use associated with an education intervention alone. However, regular detailed personalized feedback comparing an individual's radiation use to group and external benchmarks was successful in achieving sustained reduction in overall radiation use. For individual participants, significant improvement was noted in 7 of 10 cardiologists. CONCLUSION: Although an improved theoretical understanding of effective radiation hygiene strategies might contribute to reduced radiation use, this study suggests that regular detailed quantitative feedback supporting education is an effective tool in altering radiation use in CA. Understanding triggers that stimulate change in clinician behaviour is critical to the design of systems to optimize clinical performance. Confidentially reported benchmarking systems may be a useful tool to alter clinician behaviour.

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AIMS: Graphical Statistical Process Control (SPC) tools have been shown to promptly identify significant variations in clinical outcomes in a range of health care settings, but as yet have not been widely applied to performance monitoring in percutaneous coronary intervention (PCI). We explored the application of these techniques to a prospective PCI registry at a single site. METHODS AND RESULTS: Baseline clinical and procedural data along with one and twelve month major adverse cardiac event (MACE) details were prospectively collected in relation to 2,697 consecutive PCI procedures (2,417 patients) performed between the 1st January 2003 and the 31st December 2007. We investigated outcome measures which were both clinically relevant and occurred at a sufficient frequency (>1%) to allow valid application of SPC techniques, and found procedural and lesion failure, major postprocedural complications, and one and 12 month MACE to be suitable endpoints. Cumulative Sum (CUSUM) charts, Variable Life-Adjusted Display (VLAD) charts and Funnel Plots were employed in combination to evaluate both group and individual performance on a near "real time" basis. We found that the use of these charts provided complimentary prospective audit of clinical performance to identify variations in group and individual operator performance and to clarify these as either systemic or individual operator-related. We propose a system of integrating SPC tools as a component of the audit function of a PCI unit. CONCLUSIONS: SPC tools have the potential to provide near "real-time" performance monitoring and may allow early detection and intervention in altered performance for both the group and the individual operator. A clinically-integrated system of SPC tools may thus complement and enhance effectiveness of the traditional case-based morbidity and mortality audit.

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BACKGROUND: Electrophysiology (EP) procedures have been reported to carry a significantly greater radiation risk than that of coronary angiography (CA). This is largely due to numerous reports linking severe deterministic radiation effects to long procedure and fluoroscopy times (FTs). This study documents low radiation doses achieved by strategies involving operator training and education as well as equipment and technique optimisation to reduce radiation risks. METHODS: Records relating to 732 diagnostic EP and 1744 therapeutic EP procedures performed between January 2002 and December 2007 were analysed. Data from 1458 diagnostic only CA procedures performed in 2006 was used for comparison. For each procedure type, FT, number of digital frames acquired and estimated effective dose (E) were compared. RESULTS: Although the FT for CA procedures is significantly less than for therapeutic EP procedures (FT for diagnostic EP being similar), EP procedures generally are associated with lower E, the exception being procedures for atrial fibrillation (AF). CONCLUSION: Through the application of a comprehensive exposure minimisation strategy, the radiation risk to patients undergoing diagnostic and, therapeutic EP procedures (except AF ablation procedures) is significantly less than that faced by patients undergoing CA. E, however, is heavily dependent on procedure type and as such care must be taken in undertaking generalised comparisons for audit and benchmarking purposes.

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BACKGROUND: Although it is important for a patient's radiation related risks to be considered when recommending a cardiac imaging procedure, few clinicians appreciate the level of exposure involved. This paper provides a comprehensive set of radiation exposure metrics for common angiography procedures highlighting links to factors that influence radiation dose. METHODS: Radiation use metrics and various clinical findings for diagnostic procedures and number of lesions treated, vessels treated and stents deployed for interventional cases were analysed. RESULTS: Data relating to 1088 coronary angiography (CA), 256 angioplasty and 167 CA/angioplasty procedures were examined. The median effective dose (E) (mSv) for these procedures (including inter-quartile range) were, respectively, 3.3 (2.1-5.1), 7.5 (4.5-14.1) and 11.6 (6.9-16.1). For CA, E varied with the number of vessels (p<0.01) while for angioplasty E was linked to the number of vessels (p<0.01), lesions (p<0.01) and stents (p<0.01). CONCLUSION: Radiation exposure metrics for common cardiac angiography imaging procedures have been documented and linked to procedure complexity. This has implications for performance monitoring when comparing radiation usage between users, facilities, times and technologies.

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