C3PO: Collaborative Research is no longer science fiction

Quality improvement efforts in pediatric medicine, especially in pediatric interventional cardiology, are particularly elusive, because it requires quality data-driven outcomes to change clinical decision making. Even high-volume pediatric institutions do not perform enough procedures to move the needle, and collaboration across facilities has been challenged by lack of standardization.

To overcome some of these barriers, C3PO (Congenital Cardiac Catheterization Project on Outcomes) has been prospectively collecting data using a web-based data entry tool on all catheterization cases at eight participating pediatric institutions since 2007. Through this collaborative effort, the group has already published on procedure-type risk categories and hemodynamic vulnerability.

“The first phase of the data collection project, between 2007 and 2010, was to develop a risk-adjustment tool to make equitable comparisons among physicians and institutions of adverse events for pediatric patients who are treated in cardiac catheterization labs,” says principal investigator Lisa Bergersen, MD, MPH, pediatric interventional cardiologist at Boston Children’s Hospital.

Now, C3PO is moving beyond definition toward quality improvement (QI) initiatives aimed at standardizing outcomes for all patients undergoing catheterization with congenital heart disease. The group has expanded participation to include 15 sites and began prospectively collecting data in May 2013.

Specifically, the initial goal of the new C3PO-QI collaboration is to reduce radiation exposure in pediatric cardiac catheterization interventions. The 15 sites are recording data on all catheterization procedures, as well as patient and procedural characteristics, explains Bergersen. In addition to radiation reduction, the C3PO-QI group is seeking to evaluate efficacy outcomes for procedures associated with six specific disease states: pulmonary stenosis, aortic stenosis, coarctation of the aorta, atrial septal defect, patent ductus arteriosus and transcatheter pulmonary valve placement. Therefore, the practitioners collecting outcomes data on these procedures.

“Each of the sites has formed a team, which includes physicians, radiation technologists, nurses and data coordinators, who are responsible for putting together ideas for change in their prospective labs,” says Bergersen. “Through comparative reporting, looking at radiation exposure at one facility versus another, we can seek to identify institutional best practices that can lower radiation doses to children and babies during these procedures.”

The group hosts a biweekly webinar. “As part of the iterative QI process, when we speak every two weeks, we collaboratively learn from each other to improve our decision making as we go,” says Bergersen.

In the spirit of collaboration and transparency, institutional data are available in comparison to other participating C3PO-QI sites in aggregate including procedure counts, limited patient and procedural characteristics and outcomes, such as highest severity adverse events and transfusion rates. Quality reports include outcome metrics such as risk-adjusted adverse event ratios. Control charts are distributed to report uncommon adverse events, time and/or number of cases between specific adverse events.