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    Original Investigation
    August 2, 2019

    Characteristics of the Quality Improvement Content of Cardiac Catheterization Peer Reviews in the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

    Author Affiliations
    • 1Section of Cardiology, VA Puget Sound Health Care System, Seattle, Washington
    • 2Division of Cardiology, Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, Colorado
    JAMA Netw Open. 2019;2(8):e198393. doi:10.1001/jamanetworkopen.2019.8393
    Key Points español 中文 (chinese)

    Question  Do peer reviews of cardiac catheterization laboratory complications provide useful content for quality improvement?

    Findings  In this quality improvement study, 152 cardiac catheterization cases selected for peer review because of the occurrence of a major adverse event were analyzed, and only 16.4% of cases were adjudicated as not meeting the standard of care. Concerns about operator performance and judgment were more common, and reviewers recommended improvements in operator performance and care processes in 41.4% and 38.2% of cases, respectively.

    Meaning  Peer review programs should focus on maximizing quality improvement opportunities even when the standard of care is met.


    Importance  Peer review is recommended for quality assessment in all cardiac catheterization programs, but, to our knowledge, the content of peer reviews and the potential for quality improvement has not been described.

    Objective  To characterize the quality improvement content of cardiac catheterization peer reviews.

    Design, Setting, and Participants  This quality improvement study used retrospective case review of diagnostic angiography and percutaneous coronary intervention procedures to characterize the major adverse event review process of the US Department of Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) program from January 1, 2012, to December 31, 2016. Data review and analysis took place from November 2017 to August 2018.

    Main Outcomes and Measures  Percentage of peer reviews reporting substandard care and opportunities for quality improvement.

    Results  A total of 196 643 diagnostic coronary angiograms and 62 576 percutaneous coronary interventions were performed in the Department of Veterans Affairs. Of these, 168 (0.1%) were triggered for review because of a self-reported major adverse event during the procedure. Of 152 cases with complete peer review data, care was adjudicated as not meeting the standard of care in 25 cases (16.4%). Concerns about operator judgment were identified in 46 cases (30.3%), about case selection in 26 (17.1%), about trainee supervision in 21 (13.8%), and about technical performance in 46 (30.3%). Reviewers made recommendations to improve operator performance in 63 cases (41.4%) and catheterization laboratory or hospital processes in 58 (38.2%).

    Conclusions and Relevance  While substandard care is infrequently identified in peer review of catheterization laboratory complications in the Department of Veterans Affairs, the process often generates recommendations for quality improvement. Peer review programs should focus on identifying quality improvement opportunities and providing meaningful feedback to operators.