Mauro Moscucci, M.D., M.B.A., Delivers Lemberg Lecture on Improving Care for Coronary Patients
Shortly after joining the University of Michigan faculty in 1994, interventional cardiologist Mauro Moscucci, M.D., M.B.A., was asked to explain why the mortality rate for patients who underwent angioplasty procedures at the university’s hospital was eight times higher than that of a regional medical center. He assumed it was because the sickest patients were being airlifted from the regional hospital to the university’s medical center, but he had no data to support his assumption.
Presenting the 21st Annual Miriam Lemberg Visiting Professorship in Cardiovascular Disease Lecture nearly 20 years later, Moscucci, now the Miller School’s Interim Chair of Medicine and Chief of the Cardiovascular Division, chronicled how his and his Michigan colleagues’ quest to pinpoint the reasons – and resolve them – led to the creation of a statewide registry of percutaneous coronary interventions that is used to assess risks and improve care and outcomes for patients undergoing the non-surgical procedures to open narrowed arteries.
Introducing Moscucci to a standing-room-only audience in a Rosenstiel Medical Science Building auditorium on March 6, Miller School Dean Pascal J. Goldschmidt, M.D., noted that Moscucci is not only an extraordinary cardiologist and professor of medicine, but an outstanding researcher who has established and shared quality, safety and risk assessment improvements “that have benefitted many.”
“We are really so lucky to have Mauro Moscucci here at the Miller School of Medicine,’’ the Dean said. “His research is truly outstanding and he is an asset to our medical school.”
Saying he was deeply honored to present the lecture established by the late Louis Lemberg, M.D., a pioneering cardiologist who helped found UM’s cardiovascular division in the 1950s, Moscucci kicked off his talk, “Improving Quality Care of Percutaneous Coronary Interventions: A Journey Over Two Decades,” by introducing the abiding principle that has guided his two decades of pioneering research.
As we all know, he said, “You can’t manage what you can’t measure.”
Armed with that knowledge, Moscucci said he and his Michigan colleagues set out to explain the hospital’s high mortality rate by reviewing the charts of 1,500 of their angioplasty patients “to determine how we are doing.’’ But realizing they needed a larger data set to understand the link between processes and outcomes, they also invited 16 competing hospitals to join forces with Blue Cross Blue Shield of Michigan to identify opportunities for improving the quality of care through the comparative exchange of information.
Initially, seven hospitals agreed to participate in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium, producing a robust database of cases that revealed substantial practice variations – and the statistical benchmarks that, if followed, would reduce complications and improve outcomes.
For instance, Moscucci said, numerous patients were not receiving aspirin before an angioplasty procedure, which would be unthinkable to any interventional cardiologist, because “nobody was checking.” Likewise, Moscucci said, the database unveiled wide variations in the amount of contrast used per case and the routine use of the anticoagulant heparin after procedures — despite data showing that too much contrast damages the kidneys and that heparin is not recommended after angioplasty because it can increase the risk of bleeding and doesn’t provide any added benefit after a successful procedure.
“Yet,’’ Moscucci said, “in one of those hospitals about 75 percent of those patients were started on heparin post-procedures.”
The first author on a global landmark study published in 2003 in the European Heart Journal that identified predictors of major bleeding in patients with acute coronary syndromes, Moscucci also noted that, even though post-procedure transfusions are associated with higher mortality, his Michigan hospital had the highest transfusion rate in the state, and according to the internal analysis he and his colleagues conducted, 64 percent of the transfusions were inappropriate. “What was going on was some patients who had low hemoglobin levels were being transfused before they were discharged, without needing it and just in case,” he said.
Today, Moscucci noted, every hospital in Michigan where percutaneous coronary interventions are performed is a member of the consortium, which to date has collected data on more than 302,000 cases, and reduced hospital deaths by 20 percent, contrast-induced nephropathy by 32 percent and post-angioplasty transfusions by 42 percent.
Switching gears, Moscucci said that the old golf adage that “practice makes perfect” still applies to interventional cardiologists, too. Though the American College of Cardiology determined that interventional cardiologists should perform at least 75 procedures a year to excel, Moscucci said data from the Michigan registry showed that interventionalists who performed more than 100 procedures annually tended to have far superior outcomes.
“There is nothing worse,” he said, “than being admitted to a hospital on a weekend and being treated by a low-volume operator,” Moscucci said. “Why is that? During weekdays we can call for help if we get in trouble, but on weekends we are alone, and there is no one to help.”
Joshua Hare, M.D., the Louis Lemberg Professor of Medicine and director of the Interdisciplinary Stem Cell Institute, concluded the program by introducing Miriam Lemberg, whose husband established the lecture series in her honor after she launched the effort to endow the Lemberg chair in his. Surrounded by her family, she presented Moscucci with a plaque honoring the 21st Lemberg lecturer.