The purpose of American College of Cardiology (ACC)/American Heart Association (AHA) performance measures is to help accelerate appropriate translation of scientific evidence into clinical practice. The performance measures are meant to cover the most important recommended care practices and to be appropriate for public reporting or use in pay-for-performance programs.

The 2015 ACC/AHA Focused Update of Secondary Lipid Performance Measures¹ are intended to update previous lipid performance measures and are based on the most recent 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.² Five performance measures are presented; three of these are intended for ambulatory settings and two for hospital (inpatient) settings. These were also revisions of measures appearing in prior performance measure statements for patients with peripheral artery disease (PAD),³ ST-elevation myocardial infarction (STEMI) and non−ST-elevation myocardial infarction (NSTEMI),⁴ percutaneous coronary interventions (PCI).⁵ and coronary disease and hypertension.⁶ The specific updated performance measures include:

1. PAD: Percentage of patients 18-75 years of age with PAD who were offered moderate-to-high-intensity statin.
2. STEMI/NSTEMI: Percentage of patients 18-75 years of age with acute MI who were offered moderate-to-high-intensity statin at hospital discharge.
3. PCI: Percentage of patients 18-75 years of age for whom PCI was performed who were offered optimal medical therapy at discharge.
4. Coronary Artery Disease: Percentage of patients 18-75 years of age with coronary artery disease who were offered moderate-to-high-intensity statin.
5. Atherosclerotic Cardiovascular Disease (ASCVD): Percentage of patients 18-75 years of age with clinical ASCVD who were offered moderate-to-high-intensity statin.

The authors correctly note that important gaps remain in secondary prevention lipid management, which forms a major rationale for this current performance measure update. For instance, the Reduction of Atherothrombosis for Continued Health (REACH) Registry of ambulatory patients shows only 83% of such patients with known ASCVD were receiving lipid-lowering agents,⁷ and the ACC NCDR PINNACLE Registry involving ambulatory patients with CAD shows only 66.5% of patients were receiving optimal medical therapy including statins.⁸ We have further noted among US adults in the National Health and Nutrition Examination Survey that despite statin therapy, only 27.3% of those with coronary heart disease and 36.1% of those with CVD overall were at previously specified low-density cholesterol targets.⁹

New to this performance measure set is the broader denominator of ASCVD that includes those adults 18-75 years of age with acute coronary syndrome (ACS), history of MI, stable or unstable angina, coronary (including PCI) or other arterial revascularization, stroke, transient ischemic attack, or PAD. This is valuable, given that treatment rates have traditionally been lower in some of these groups, particularly those with stroke or transient ischemic attack and PAD. It will be important for payers to consider incorporating these into their performance measures to which they hold providers accountable. 

The broader ASCVD denominator is also consistent with the 2013 ACC/AHA Guideline on Management of Blood Cholesterol that also focuses on this more encompassing group for statin recommendations. But while the numerators and denominators of the performance measures include those who are offered high-intensity statin therapy, they also include those with medical exceptions to high-intensity statin therapy who are offered moderate-intensity statin therapy instead. However, excluded from both the numerators and denominators are those who have medical exceptions to being offered moderate-intensity statin therapy. This ensures that providers are not penalized for those patients who have appropriately documented contraindications to high-or-moderate intensity statin therapy, or for patients who decide that statin therapy is not the best course of action after thorough shared decision making with their clinicians.

Most importantly, the current performance measures are patient-centered and emphasize shared decision making. While previous lipid performance measures have focused on the percentage of patients “prescribed” a statin, the current performance measures focus on the percentage of patients who are “offered” a statin. This is an important distinction, as the former term assesses an action (prescribing medication) that is completely under a provider’s control without necessarily any input from the patient. It will be important for payers to make this distinction in their future updates of performance measures and to emphasize to providers and provide them with the guidance and resources to implement these performance measures in a true patient-centered manner involving shared decision making. This was also a key feature of both the 2013 ACC/AHA guideline and a subsequently published report by Martin and colleagues¹⁰ that provided significant detail about the guideline-recommended clinician-patient risk discussion, concept of shared decision making and decision aids, use of the ACC/AHA ASCVD Risk Estimator application as an implementation tool (for primary prevention), and potential barriers to implementation.

The dialogue between the clinician and patient about the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and patient preferences is a key feature of shared decision and needs to be promoted to providers by payers and institutions alike. Since this is a measure that reflects the proportion of patients who participated in shared decision making, it is intended to promote patient participation in the treatment plan that would hopefully improve adherence to guideline-recommended care as well as outcomes. This new, rebranded performance measure emphasizes the point that physicians need to understand: evidence-based guidelines alone are not sufficient to reach a decision about prescribing a medicine. It also shifts emphasis away from the patient encounter during which the physician is focused on convincing the patient of the “right” answer to an encounter during which the patient and physician deliberate and collaborate to arrive at what is the “best” answer.   

While the measurement of shared decision making is an evolving science, the article suggests possible questions that could be asked to determine whether shared decision making occurred, such as: 1) does the patient know his or her personalized cardiovascular risk? 2) was a statin offered to reduce risk? and 3) what decision did the patient make about whether or not to initiate statins? Importantly, the article points to the need for measures of shared decision making that are developed and derived from electronic health records and clinical registries as they are not available from insurance claim information.

Patient adherence to the recommended therapies is not included in the current performance measures. The writing group notes that adherence measures have similar problems as prescription measures do, such as they would not be optimal for assessing provider performance or quality of care. They do, however, note the importance of the concept of shared accountability as related to long-term adherence with the ultimate goal of improved patient outcomes and quality of life. Shared accountability includes the health care team, the health care system, the patient and the clinician, with ongoing discussions about statin therapy and the reasons for less than optimal adherence, if this is found to be the case.  

A number of reasons for both intentional and unintentional nonadherence are noted, including the following: 1) cost of medication, 2) inability of the patient to afford the co-pay, 3) unclear label instructions, 4) patient forgetfulness, 5) adverse effects from medication that the patient is too embarrassed to discuss with the doctor, 6) the patient does not like the idea of having to take medication, 7) the patient does not understand the importance of a given medication for a condition for which he or she has no symptoms, 8) the patient-practitioner relationship is suboptimal, and 9) polypharmacy and complexity of regimen. Clearly, it is important both for providers to document these issues when present and for health care systems, payers, and manufacturers to provide resources to help address them among patients and providers alike.

The new 2015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance measures represent an important effort to improve quality of care and patient outcomes as related to improved utilization of evidence-based statin therapy as supported by the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.² The use of shared decision making in implementation of these and other performance measures needs to be embraced both by payers and providers with development and implementation of appropriate measures. Future efforts need to better address long-term adherence and barriers to achieving long-term adherence.  

References:

1. Drozda JP Jr, Ferguson TB Jr, Jneid H, et al. 2015 ACC/AHA focused update of secondary prevention lipid performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol 14 December 2015. [Epub ahead of print]
2. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-934.
3. Olin JW, Allie DE, Belkin M, et al. ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 performance measures for adults with peripheral artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, the American College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular Nursing, and the Society for Vascular Surgery (Writing Committee to Develop Clinical Performance Measures for Peripheral Artery Disease). Developed in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation; the American Diabetes Association; the Society for Atherosclerosis Imaging and Prevention; the Society for Cardiovascular Magnetic Resonance; the Society of Cardiovascular Computed Tomography; and the PAD Coalition. J Am Coll Cardiol 2010;56:2147-81.
4. Krumholz HM, Anderson JL, Bachelder BL, et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non-ST-Elevation Myocardial Infarction). Developed in collaboration with the American Academy of Family Physicians and American College of Emergency Physicians. J Am Coll Cardiol 2008;52:2046-99.
5. Nallamothu BK, Tommaso CL, Anderson HV, et al. ACC/AHA/SCAI/AMA convened PCPI/NCQA 2013 performance measures for adults undergoing percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance. J Am Coll Cardiol 2014;63:722-45.
6. Drozda J, Messer JV, Spertus J, et al. ACCF/AHA/AMA PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association Physician Consortium for Performance Improvement. J Am Coll Cardiol 2011;58:316-36.
7. Kumar A, Fonarow GC, Eagle KA, et al. Regional and practice variation in adherence to guideline recommendations for secondary and primary prevention among outpatients with atherothrombosis or risk factors in the United States: a report from the REACH Registry. Crit Pathw Cardiol 2009;8:104-11.
8. Maddox TM, Chan PS, Spertus JA, et al. Variations in coronary artery disease secondary prevention prescriptions among outpatient cardiology practices: insights from the NCDR (National Cardiovascular Data Registry). J Am Coll Cardiol 2014;63:539-46.
9. Wong ND, Chuang J, Zhao Y, Rosenblit PD. Residual dyslipidemia according to low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B among statin-treated US adults: National Health and Nutrition Examination Survey 2009-2010. J Clin Lipidol 2015; 9:525-32.
10. Martin SS, Sperling LS, Blaha MJ, Wilson PW, Gluckman TJ, Blumenthal RS, Stone NJ.  Clinician-patient risk discussion for atherosclerotic cardiovascular disease prevention: importance to implementation of the 2013 ACC/AHA guidelines. J Am Coll Cardiol 2015;65:1361-8.

Keywords: Acute Coronary Syndrome, Adult, American Heart Association, Angina, Unstable, Cardiology, Cardiovascular Diseases, Cholesterol, Coronary Artery Disease, Decision Making, Decision Support Techniques, Drug Interactions, Electronic Health Records, Female, Humans, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Inpatients, Ischemic Attack, Transient, Lipids, Male, Myocardial Infarction, Nutrition Surveys, Patient Care Team, Patient Compliance, Patient Participation, Patient Preference, Percutaneous Coronary Intervention, Peripheral Arterial Disease, Polypharmacy, Primary Prevention, Quality of Life, Registries, Reimbursement, Incentive, Risk Factors, Risk Reduction Behavior, Secondary Prevention, Social Responsibility, Stroke, United States

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