April 24, 2012—Providing more guidance to clinicians on the provision of optimal patient care, the American College of Cardiology Foundation (ACCF), American Heart Association (AHA) and American Medical Association–convened Physician Consortium for Performance Improvement (AMA-PCPI) released a publication highlighting updated performance measures for adults with heart failure (HF). The 2011 performance measures include care provided in both the outpatient and inpatient setting, emphasizing the need to measure care quality over time and across providers, while also focusing on patient outcomes.
The 2011 Performance Measures for Adults with Heart Failure were designed to assess whether patients with cardiovascular disease receive optimal care. They were drafted after careful consideration of several documents, including ACCF/AHA practice guidelines and existing HF measures by The Joint Commission, Centers for Medicare and Medicaid Services, and the Agency for Healthcare Research and Quality.
“In order to improve the quality of heart failure care, one has to provide measures of quality. The heart failure performance measures were designed for that purpose — to allow physicians and their care teams to deliver evidence-based management designed to improve heart failure outcomes without disrupting the workflow,” said writing committee co-chair Robert O. Bonow, M.D., MACC, FAHA, MACP, Goldberg distinguished professor of cardiology and director of the Center for Cardiovascular Innovation at Northwestern University Feinberg School of Medicine.
There are nine 2011 performance measures, including three new measures and six revised measures. Two measures apply to care provided in both the inpatient and the outpatient settings, while five measures address outpatient care only and two measures address inpatient care only. Eight measures from the previous HF performance measures set, which were released in 2005, were retired.
The target population for the measures is patients 18 years of age and older who have a diagnosis of HF. The measures are intended for prospective use to enhance quality improvement, but may also be applied retrospectively. While six of the measures are appropriate for initiatives such as pay for performance, physician ranking and public reporting, three of them are intended only for internal quality improvement purposes.
Among the significant updates to the 2011 measures set is the expansion of the beta-blocker measure to the inpatient setting. Included only as an outpatient measure in the 2005 set, this measure was added for the inpatient setting after inpatient care guidelines were developed in the 2009 ACCF/AHA HF guidelines update. Clinical trial data showing that not all beta-blockers exhibit the same benefits prompted the writing committee to specify the use of one of three evidence-based beta-blockers: bisoprolol, carvedilol or sustained-release metoprolol.
Another significant change in the 2011 performance measures set was the conversion of the measure on patient education to a quality metric, which should be used for internal quality improvement purposes only, not public reporting and accountability. While the writing committee acknowledged that patient education about lifestyle, activity, diet and medication use is important for providing optimal care, they also understood that compliance with an education measure is easy to achieve without regard to the quality of education provided. Two other quality metrics are also included among the nine measures, including one on counseling about implantable cardioverter-defibrillators and another on symptom management.
Other changes to the 2011 performance measures include the combination of both the inpatient and outpatient settings in a measure about the use of ACE inhibitors or ARB therapy for left ventricular systolic dysfunction; the addition of a new measure on the post-discharge appointment at the time of hospital discharge; and the retirement of measures on weight measurement, blood pressure measurement, and warfarin therapy for patients with atrial fibrillation. These measures were retired either because they had been included as part of a broader measure in a different set or they had become standards of care.
According to the performance measures writing committee, consistent use of the set is key to the measures’ adoption. “To be successful as quality improvement tools, the heart failure performance measures need to be integrated as routine components of patient care across various care settings, with particular attention to transitions of care from inpatient to outpatient environments,” Bonow said.
Writing committee members included cardiac specialists and general care physicians, as well as representatives of various physicians associations. Individuals with expertise in developing performance measures were also included, as were patient representatives, a payer representative, and representatives from the ACCF/AHA HF guidelines writing committee. The work of the writing committee was supported exclusively by the ACCF, AHA and AMA-PCPI without commercial support.
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