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Amanda Jekowsky , American College of
Cardiology, 202-375-6645, ajekowsk@acc.org
November
10, 2008
New performance measures refine tools
for improving care of heart attack patients
Data collection helps doctors and hospitals
do their best
A new set of clinical performance measures will
help doctors and hospitals give the best possible care to
heart attack patients by providing up-to-date tools for gauging
how closely they’re sticking to guideline recommendations
and where they need to improve.
Jointly developed by the American College of Cardiology and
the American Heart Association, the performance measures appear
in the December 9, 2008, issue of the Journal of the American
College of Cardiology and the December 9, 2008, issue
of Circulation. They identify some of the most important
steps in helping patients return to a healthy life after surviving
a heart attack—steps that sometimes are missed even
by well-intentioned doctors.
“We all do our best for our patients. Performance measures
are extraordinarily important in helping us learn how well
we are doing and in providing targets for improving quality,”
said Harlan M. Krumholz, M.D., chair of the writing committee
that developed the heart attack performance measures and a
professor of medicine at Yale University, New Haven, CT. “They
guide us to areas of opportunity where we can do better—and
our patients benefit from that.”
The new performance measures have been endorsed by the American
Academy of Family Physicians, American College of Emergency
Physicians, American Association of Cardiovascular and Pulmonary
Rehabilitation, Society of Hospital Medicine, and Society
for Cardiovascular Angiography and Interventions. They update
a previous version published in 2006.
Performance measures are derived from clinical guidelines
but serve a different purpose. Clinical guidelines make recommendations
that physicians should consider when managing patients, and
describe how strong the evidence is to support each recommendation.
Performance measures distill from the guidelines key therapies
that so clearly improve patient outcomes they literally define
high-quality care.
“A performance measure is more than a recommendation.
It’s a mandate. It defines high-quality care and sets
the expectation that doctors should either treat patients
according to the best evidence, or explain why not,”
Dr. Krumholz said. In addition, performance measures must
be quantifiable, so that data can be collected in a reliable
way. Performance measures also identify areas where there
is likely to be room for improvement in the quality of care.
Hospitals and doctors can begin using the new performance
measures to benchmark the quality of heart attack care in
several areas, including:
- The prescription of statins before patients are discharged
from the hospital. The previous performance measures were
more general, calling for “lipid lowering therapy.”
The new performance measures acknowledge that the evidence
for benefit is primarily related to statins.
- The timeliness of percutaneous coronary intervention (PCI)—a
term that includes angioplasty and stenting—when the
patient must be transferred from a hospital without a cardiac
catheterization laboratory to a PCI-capable hospital. Previous
performance measures did not track transferred heart attack
patients. The new performance measures call for collecting
data not only on how much time elapses from arrival at the
first hospital to departure to the second hospital, but
also from arrival at the first hospital to PCI at the second
hospital.
- Referral to a cardiac rehabilitation program. Studies
have shown that cardiac rehab markedly improves survival
after a heart attack, but only about one in three patients
participate in such programs. The new performance measures
call for hospitals to track referral to such programs. It
is hoped these data may also shed light on the obstacles
to referral.
- Elimination of a performance measure on treatment with
beta blockers within 24 hours of hospitalization for a heart
attack. New scientific evidence has made the clinical decision
to give or withhold beta blockers more complex, thereby
making measurement difficult.
- Evaluation of the heart’s pumping function, or left
ventricular systolic function, during hospitalization. This
measurement is essential for subsequent decisions about
care.
- Several “test” performance measures that are
intended for internal use by hospitals and doctors, including
evaluation of blood levels of low-density-lipoprotein (LDL,
or so-called “bad”) cholesterol, dosage of several
types of blood-thinning medications, and prescription at
hospital discharge of the anti-clotting medication clopidogrel.
As in their previous version, the new performance measures
continue to track use of aspirin therapy, both at hospital
arrival and as a discharge medication; beta blocker prescription
at discharge; prescription of an angiotensin-converting-enzyme
(ACE) inhibitor or angiotensin receptor blocker (ARB) at discharge
for patients with reduced pump function; time to delivery
of clot-busting medications or PCI (in patients who are not
transferred to another hospital); and counseling to stop smoking.
“We have made a commitment to continually update, refine,
and improve these performance measures, so that they represent
the very best and most recent science,” Dr. Krumholz
said. “We want to ensure that what we are measuring
is meaningful and relevant and is going to make a difference
for patients.”
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The American College of Cardiology is leading the way to optimal
cardiovascular care and disease prevention. The College is
a 36,000-member nonprofit medical society and bestows the
credential Fellow of the American College of Cardiology upon
physicians 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 www.acc.org .
The American College of Cardiology (ACC) provides these news
reports of clinical studies published in the Journal of
the American College of Cardiology as a service to physicians,
the media, the public and other interested parties. However,
statements or opinions expressed in these reports reflect
the view of the author(s) and do not represent official policy
of the ACC unless stated so.
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