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As the science and practice of cardiovascular care continues to advance, refining methods to measure the quality of care delivered to patients with heart disease is critical and must reflect the latest diagnostics, therapeutic interventions and processes known to be effective in improving outcomes. Performance measures -- the current standard for measuring quality -- have only been used during the last decade.
To help ensure that performance measures keep pace with the evolving science of quality improvement, the American College of Cardiology (ACC) and American Heart Association (AHA) today issued a joint report outlining new insights into the methodology for the development and use of performance measures in cardiac care. This is an important update to the initial 2005 report.
“As performance measures have grown in importance, we must constantly be sure that they are created in the most sound scientific manner so that the goal of using these measures - to improve care - are most likely to be achieved,” said John A Spertus, M.D., M.P.H, Daniel Lauer/Missouri Endowed Chair and professor, University of Missouri Kansas City and chair of the 12-person writing committee. “This document provides guidance to the creators of performance measures so that they can create the most useful measures to improve the quality of care.”
Due to the inherent delay between the collection of new evidence and its adoption into routine clinical care, existing performance measures do not always take the emerging body of evidence into account. This updated report addresses this and seeks to insure that only the processes of care associated with the strongest evidence of an association with meaningful outcomes are endorsed, according to Dr. Spertus.
“Professional societies have learned a lot about new challenges and opportunities since the original recommendations for the methodology of performance measure development were written five years ago,” he said. “Since performance measures, once developed, almost always become mandatory clinical actions, it is very important that the issues raised in this paper be considered so that adverse consequences can be avoided.”
Although initially intended to help physicians improve the quality of care and patient outcomes, performance measures are, in fact, more often used as tools for accountability and performance-based reimbursement.
“As we use performance measures, we have learned how to make them more accurate, meaningful and actionable,” said Dr. Spertus. “Recently, insurers are starting to pay more for practices that more often comply with performance measures and major payers, such as Medicare, are increasingly publishing providers’ performance for the public to review.”
New insights provided in this report identify challenges and critical opportunities to improve the selection, construction, implementation and interpretation of performance measurement as a means to provide a higher quality of cardiovascular care.
- Selection: there is a need to elevate the rigor by which evidence supporting measures is evaluated to bring more focus on clinically meaningful outcomes, as well as more consideration of the cost-effectiveness and societal costs of performance measures.
- Construction: refinement of patient eligibility for a particular measure, considerations in the use of outcomes and the number of measures and their retirement.
- Implementation: challenges have emerged that require improved efforts to systematically collect the data for performance measurement within the routine flow of patient care.
- Analysis and Interpretation: attention to, and testing of, composite measures and the attribution of measures to accountable units need further testing before implementation.
An Example of a Performance Measure
Performance measures are specifically used to examine how often evidence-based recommendations are used in eligible patients (for example, proportion of patients receiving aspirin therapy following heart attack). Another example of a performance measure is the use of beta blockers in patients with heart failure, explains Dr. Spertus.
Numerous clinical studies have shown that the use of a medicine called beta-blockers improves survival among people with heart failure. Yet over a third of patients with heart failure are not treated with beta-blockers. Therefore, there is a performance measure for the use of beta-blockers among outpatients with heart failure. The measure has been carefully designed so that if there is a medical, patient-centered, or other system-based reason why the patient should not get a beta blocker, they are excluded from the denominator of eligible patients. Therefore, by measuring the proportion of a doctors' heart failure patients on beta-blockers (where the optimal rate would be 100 percent of eligible patients being treated), one can know how diligent that doctor is in optimally treating his heart failure patients.
Full text of this report will be published in the November 16, 2010, issue of the Journal of the American College of Cardiology and available on the ACC (www.cardiosource.org) and AHA (www.heart.org) web sites. It will also be co-published in Circulation: Journal of the American Heart Association.
Dr. Spertus reports no conflicts of interest for this work, other than his copyright for measures that quantify the symptoms, function and quality of life of patients with coronary artery disease (the Seattle Angina Questionnaire) and heart failure (the Kansas City Cardiomyopathy Questionnaire).
The American College of Cardiology is transforming cardiovascular care and improving heart health through continuous quality improvement, patient-centered care, payment innovation and professionalism. The College is a 39,000-member nonprofit medical society comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers, and bestows credentials upon cardiovascular specialists who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at http://www.cardiosource.org/ACC.
The American Heart Association, founded in 1924, is the nation’s oldest and largest voluntary health organization dedicated to building healthier lives, free of heart disease and stroke. To help prevent, treat and defeat these diseases — America’s No. 1 and No. 3 killers — we fund cutting-edge research, conduct lifesaving public and professional educational programs, and advocate to protect public health. To learn more or join us in helping all Americans, call 1-800-AHA-USA1 or visit www.heart.org.