News | June 14, 2011

New Performance Measures Set for Coronary Artery Disease and Hypertension

June 14, 2011 – New performance measures for adults with coronary artery disease (CAD) and hypertension were released today by the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), and the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement (PCPI). The measures reflect the standard of care for patients with coronary artery disease and hypertension, and are intended to provide practitioners and institutions with tools to measure and improve care quality.

The new measures update a set released by the three groups in 2005. According to the writing committee, however, the 2011 set represents a “significant departure” from the earlier document. Specifically, the committee noted that the 2011 measures “break new ground” by examining whether cardiac risk factors are not just “treated” but also “controlled” to target levels and by emphasizing patient-focused outcomes.

“The current measures represent an attempt to resolve some of the methodological issues associated with creating performance measures at the individual practitioner or practice level,” said writing committee co-chair Joseph Drozda, Jr., M.D., director of outcomes research at Sisters of Mercy Health System in St. Louis. “These issues arise because of the socioeconomic and clinical heterogeneity of patient populations and the relatively small number of patients treated by any one practitioner or group, prohibiting risk adjustment.”

“This measures set attempts to resolve those issues with the blood pressure and lipid control measures, as well as the symptom assessment and management measures. We believe these represent a significant advance in cardiovascular performance measurement and address issues of importance to policy makers and especially to patients.”

The 10 performance measures comprise both revisions of five measures from the 2005 set and the addition of five new measures. One measure from the previous set — that of screening for diabetes in patients with CAD — was retired. While the writing committee recognized the significance of diabetes as a comorbidity in patients with CAD (coronary artery disease), there were significant challenges to the implementation of this measure. The measures in the updated set include:

Coronary Artery Disease Measures
· Blood pressure control†—Patients* should obtain a blood pressure of less than 140/90 mm Hg; if they cannot reach this target, the physician should prescribe at least 2 antihypertensive medications.
· Lipid control†—Patients should obtain an LDL cholesterol level of less than 100 mg/dL; if they cannot reach this target, the physician should document a plan of care to lower their LDL level, which includes—at minimum—the prescription of a statin.
· Symptom and activity assessment—Physician should evaluate patients’ activity level and the corresponding presence or absence of angina symptoms.
· Symptom management‡—Physician should document a plan of care to manage angina symptoms, if present.
· Tobacco use, screening, cessation, and intervention†—Physician should screen patients for tobacco use, and patients should receive tobacco-cessation counseling if identified as a user.
· Antiplatelet therapy†—Physician should prescribe aspirin or clopidogrel for patients.
· Beta-blocker therapy (for patients with prior myocardial infarction or a left ventricular ejection fraction of less than 40 percent)—Physicians should prescribe beta-blocker therapy for patients.
· ACE inhibitor/ARB therapy (for patients with diabetes or left ventricular ejection fraction of less than 40 percent)—Physicians should prescribe an ACE-inhibitor or ARB therapy.
· Cardiac rehabilitation patient referral‡—Physician should refer patients who have had an acute heart attack, a coronary artery bypass graft surgery, stenting, cardiac valve surgery or cardiac transplantation to an early outpatient cardiac rehabilitation program.

Hypertension Measure
· Blood pressure control†—Patients should achieve a blood pressure of less than 140/90 mm Hg; if they are above that threshold, physician should prescribe at least 2 antihypertensive medications.

*Target patient population is defined as those patients who are at least 18 years of age and have had a diagnosis of coronary artery disease or hypertension (for each respective measure category) seen in an outpatient setting across a 12-month period.
† Performance measure that was revised from the 2005 set (two previous measures were combined to form the existing blood pressure control measure)
‡ Performance measure that was added

The performance measures were based on updated practice guidelines and were designed to harmonize with other national measure sets. Before being used in accountability programs, including public reporting or pay-for-performance programs, they will undergo testing developed by the AMA-PCPI and by the ACCF PINNACLE Registry. The recently launched American Cancer Society/American Diabetes Association/AHA The Guideline Advantage will be working to encourage practices to collect the necessary data elements needed to generate reports on the CAD/HTN measure set.

“These measures are primarily intended for the use of individual practitioners and group practices in their efforts to improve the care of patients with hypertension and those with stable coronary disease,” Drozda said. “By adhering to the specifications called for in this measures set, entities operating such accountability programs can be assured of having high-quality and clinically meaningful measures.”

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