A set of nine performance measures aimed at assessing whether adults with heart failure are receiving the best care was issued by the American College of Cardiology Foundation, the American Heart Association, and the American Medical Association’s Physician Consortium for Performance Improvement.
The measure set, which was published April 23 in the Journal of the American College of Cardiology, includes three new performance measures and six revised measures. The new measure set was drafted by a panel of physicians, pharmacists, and patient advocates (J. Am. Coll. Cardiol. April 23, 2012;doi:10.1016/j.jacc.2012.03.013). The performance measures were last revised in 2005.
The measure set includes two performance metrics for inpatient care, five that address care in the outpatient setting, and two measures that apply to care in both settings. The idea, according to the sponsors, was to stress the need to measure quality over time and across providers, not in silos.
"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," Dr. Robert O. Bonow, cochair of the work group that developed the measure set and director of the center for cardiovascular innovation at Northwestern University, Chicago, said in a statement.
Improving care transitions is likely to be a major focus for physicians in and out of the hospital as officials at the Centers for Medicare and Medicaid Services begin to test a series of alternative payment and care delivery models, from Accountable Care Organizations to bundled payments. Adding to that pressure, this October, the CMS will begin cutting Medicare payments to hospitals whose heart failure and acute myocardial infarction readmission rates are considered too high.
The updated measure set will help prepare physicians for the payment and care delivery changes, Dr. Kathleen Blake, a member of the measure work group and a senior research director at the Center for Medical Technology Policy in Baltimore, said in an interview.
Performance measures, by definition, address areas where there are gaps in care, said Dr. Blake, who is a cardiologist. So physicians can take the updated heart failure measure set and embed it in their care, like a checklist, to ensure that patients are being considered for all appropriate evidence-based treatments.
"We are inundated with medical literature these days. This basically distills it into a measure set," she said.
The work group considered the ACCF/AHA 2009 practice guidelines on heart failure as well as existing heart failure performance measures from the Joint Commission, the CMS, and the Agency for Healthcare Research and Quality in putting together the updated set of measures. Along with the new and revised measures, they retired eight performance measures from the 2005 list.
The updated measure set includes:
1. Left Ventricular Ejection Fraction (LVEF) assessment in the outpatient setting.
2. LVEF in the inpatient setting.
3. Symptom and activity assessment in the outpatient setting.
4. NEW: Symptom management in the outpatient setting (for quality improvement only).
5. Patient self-care education in the outpatient setting (for quality improvement only).
6. Beta-blocker therapy for left ventricular systolic dysfunction in the outpatient and inpatient settings.
7. ACE inhibitor for angiotensin receptor blocker therapy for left ventricular systolic dysfunction in the inpatient and outpatient setting.
8. NEW: Counseling regarding implantable cardioverter-defibrillator (ICD) implantation for patients with left ventricular systolic dysfunction combination medical therapy in the outpatient setting (for quality improvement only).
9. NEW: Postdischarge appointment for heart failure patients in the inpatient setting.
One of the significant changes in the updated measure set, according to the ACCF, is the expansion of the beta-blocker measure to the inpatient setting. In the 2005 set, the measure was only recommended for outpatient care. The panel sought to expand its use based on inpatient care information in the 2009 ACCF-AHA heart failure guidelines.
The work group also recommended that measures 6 and 7, which call for the use of beta-blockers, and ACE and ARB therapy, respectively, should be used together.
Another change in the updated measure set is the addition of a measure calling for a postdischarge appointment to be in place at the time of discharge from the hospital.
While most of the measures are considered appropriate for use in pay-for-performance programs, physician rankings, and public reporting, the writing panel recommended that the measures related to symptom management, patient self-care education, and counseling for ICD implantation be used only for internal quality improvement purposes.
Dr. Blake said these are areas where the work group wanted to give physicians time to collect data. In the case of the ICD counseling measure, they wanted to include a quality improvement measure that would serve as a reminder to physicians to discuss this option with eligible patients. "It doesn’t mean the patient should receive the device," she said. "It means that it should be a topic for discussion as part of a comprehensive review of the patient. It’s also an opportunity to discern what their goals and objectives are."