Nicole MacMillan, Cardiovascular Roundtable
In late April, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), and the American Medical Association- Physician Consortium for Performance Improvement (AMA- PCPI) released an updated set of performance measures for heart failure management. The measures, an update of the 2005 ACC/ AHA HF performance measures, place an increased emphasis on coordinated, cross-continuum care, while eight past measures deemed redundant and no longer useful were retired. Of the nine total measures, two are focused on the inpatient setting, five on the outpatient setting, and two bridge both settings.
The ACCF/ AHA/ AMA-PCPI writing committee included representatives from a broad spectrum of specialties, including cardiology, internal medicine, family medicine, preventive medicine, hospital medicine, cardiac electrophysiology, and cardiovascular nursing. The multidisciplinary makeup of the writing committee aimed to ensure the guidelines reflect the cross-continuum nature of heart failure care provided by a wide variety of professionals. Involving each specialty in formulating the guidelines helped to ensure that measures that may impede care or result in unnecessary work for busy physicians were eliminated.
For the inpatient setting, the 2011 measures are as follows:
Left ventricle ejection fraction (LVEF) assessment: The percentage of patients age 18 years or older with a principal discharge diagnosis of HF with documentation in the hospital record of the results of an LVEF assessment performed either before arrival or during hospitalization, or documentation in the hospital record that LVEF assessment is planned after discharge
Post-discharge appointment for HF patients: Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of HF for whom a follow-up appointment was scheduled and documented, including location, date, and time for a follow-up office visit or home healthcare visit (as specified)
While the former has been revised since the 2005 guidelines, the latter is a new measure entirely and further stresses the importance of cross-continuum care coordination. As readmissions penalties go into place in October for heart failure (as well as AMI and pneumonia), the authors sought to stress the importance of proactive involvement in post-discharge care to keep patients out of the hospital.
Measures for the outpatient setting are:
LVEF assessment: Percentage of adult HF patients for whom the quantitative or qualitative results of a recent or prior (any time in the past) LVEF assessment is documented within a 12-month period
Symptom and activity assessment: Percentage of adult HF patient visits with quantitative results of an evaluation of both current level of activity and clinical symptoms documented
Symptom management: Percentage of adult HF patient visits with quantitative results of an evaluation of both level of activity and clinical symptoms documented in which patient symptoms have improved or remained consistent with treatment goals since last assessment or patient symptoms have demonstrated clinically important deterioration since last assessment with a documented plan of care; to be used for internal quality improvement programs only
Patient self-care education: Percentage of adult HF patients who were provided with self-care education on three or more elements of education during one or more visits within a 12-month period. This is both a new measure and one for use in internal quality improvement programs only.
Counseling about implantable cardioverter-defibrillator (ICD) implantation for patients with left ventricular systolic dysfunction (LVSD) receiving combination medial therapy: Percentage of adult HF patients with current LVEF of 35 percent or less despite ACE inhibitor/ARB and beta-blocker therapy for at least three months who were counseled about ICD implantation as a treatment option for the prophylaxis of sudden death
Of the five measures specific to the outpatient setting, two are new for 2011 (ICD counseling and symptom management), while the three remaining have been significantly revised to more comprehensively assess patient status post-discharge. All five measures support the committee’s goal of more comprehensive disease management in the outpatient setting.
Finally, measures applying to both the inpatient and outpatient settings are:
Beta-blocker therapy for LVSD: Percentage of adult HF patients with a current or prior LVEF of less than 40 percent who were prescribed beta-blocker therapy with bisoprolol, carvedilol or sustained-release metoprolol succinate either within a 12-month period when seen in the outpatient setting or at hospital discharge
ACE inhibitor and ARB therapy for LVSD: Percentage of adult HF patients with a current or prior LVEF of less than 40 percent who were prescribed ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge
Both measures were included in the 2005 guidelines, though Beta blocker therapy was added to the inpatient setting in the most recent version.
The writing committee retired several measures such as smoking cessation, weight management, and blood pressure management from the 2005 measure set as they already exist within broader measure sets. In writing the 2011 guidelines, one of the committee’s aims was to minimize the reporting burden on practitioners while maximizing the use of EHRs. The elimination of duplicative measures is a tangible reflection of that goal. The current measures are designed to improve the quality of care, and provide a foundation from which to later add other meaningful measures.
For further reading
For additional information on coordinating care across settings and avoiding preventable readmissions, members can access our publications, Mastering the Care Continuumand Reducing Preventable Readmissions.