"Quality" in Cardiovascular Imaging – Getting to the Heart of the Meaning

In 2001, the Institute of Medicine (IOM) Committee on Quality of Health Care in America published “Crossing the Quality Chasm: A New Health System for the 21st Century”.¹ In its agenda is a call:

"That all health care constituencies… commit to a national statement of purpose for the health care system as a whole and to a shared agenda of six aims for improvement that can raise the quality of care to unprecedented levels."

These aims define high quality care as that which is safe, effective, patient-centered, timely, efficient and equitable.

The American Heart Association’s Cardiovascular Imaging and Intervention Subcommittee of the Council on Clinical Cardiology has responded to this call by the IOM with its publication of “Defining Quality in Cardiovascular Imaging.”²

This is an ambitious document that is extremely relevant within the current health policy landscape. The authors emphasize the importance of moving beyond the historic, outdated notion of quality in cardiovascular (CV) imaging, which refers to “excellence in technical standards and interpretive acumen”. To reorient the CV imaging community to this new comprehensive definition of quality, the writing committee used relevant, influential and landmark evidence to illustrate and guide their readers through a detailed outline of the IOMs mandate, carefully curated for the CV imaging considerations.

This text has a relevant historical context, influenced by an evolving healthcare marketplace. In 2006, the American College of Cardiology and Duke University initiated efforts to develop new metrics to measure quality.³ At their first meeting, they recognized that the clinical effectiveness of imaging technology should be investigated to substantiate their rapid proliferation and adoption. In the interim, both clinical practice (driven by healthcare reform, free-market economic policy, and patient engagement) and research have aligned to make patient level outcomes, including Patient Reported Outcome Measures (PROMs), mortality, and satisfaction, a priority. These goals were updated during a second meeting in 2009.⁴ Of note, national radiology and cardiology societies have independently developed their own mandates for improving quality.⁵ Nonetheless, both statements touched upon many of the six aims set forth by the IOM, yet none have explicitly used it to build their guidance documents.

Cardiovascular imaging, especially related to ischemic and valvular pathology, is deserving of its own quality treatise. Imaging has a pivotal role in immediate patient care, yet also a fundamental influence over downstream resource allocation. Inappropriate patient selection, imaging modality, technique, or diagnostic error can lead to further unnecessary testing, inappropriate care and potentially patient morbidity or mortality. It is no coincidence that the Choosing Wisely campaign, along with other resource vigilance initiatives, has taken special aim at this clinical sphere.^6-8 To the credit of the cardiology community, cardiac health has some of the strongest evidence base linking diagnosis, treatment and outcomes. Grounding these initiatives in evidence is the only way to ensure that patients’ best interests are protected, and to secure stakeholder buy-in.

As this new paradigm of quality gains a stronger foothold in shaping healthcare, it is imperative that stakeholders are consistent in using a shared definition. This has become an issue beyond semantics. Several attempts have been made to define quality in healthcare. The Institute for Healthcare Improvement (IHI) has developed the ‘Triple Aim’, a framework that describes an approach to optimizing health system performance by improving the individual experience of care, improving the health of populations, and reducing the per capita costs of care for populations.⁹ In the United States, the Triple Aim became part of the US national strategy in the implementation of the Patient Protection and Affordable Care Act (ACA) in 2010. The Triple Aim’s core values are captured within the IOMs definition and allow for a more structured breakdown of the individual attributes of quality. Nonetheless, whichever definition is chosen with regard to CV imaging, quality can be seen as a move from measuring imaging diagnostic performance toward an emphasis on systems performance.

For this type of quality statement to have impact, it needs to be relevant within the iterative process of quality improvement. By retooling the current evidence landscape into the IOMs framework, it becomes apparent where the gaps exist, and therefore, it can act as a true vehicle for progress. What this report achieves is to set forward a mandate for both knowledge translation (by informing changes in practice based on current best evidence), and also guides the research community regarding priorities for the future. This conversation is vital and must result in stakeholder engagement, thereby hopefully leading to achieving the quality ideal set forth.