Perspective:

Performance measures have been developed to assess practitioner and practice HF care, and are increasingly being used to guide practice/practitioner reimbursement. This study provides strong evidence (31-55% reduced odds) that practitioner adherence to HF process measures (with the exception of aldosterone antagonists) leads to improved patient outcomes, and may provide support for quality-based reimbursement practices. However, some important considerations must be taken into account. Such quality assessments assume that 1) practitioner adherence to process measures directly translates into patient adherence, which translates into the improved outcome (i.e., patients actually take the medications prescribed and follow HF education recommendations); 2) the cohort of patients and cardiology practices analyzed are reflective of the standard HF patient and practitioner in the United States; and 3) nonprescription without documentation of a contraindication is truly nonconformity to HF process measures and not just poor documentation (only 35% of patients were cared for at practices with an electronic medical record). Along these lines, practices that specialize in advanced HF care have an inherent referral bias, caring for patients referred from non-HF specialists who have failed best care attempts. Often, these patients have end-stage disease and multiple comorbidities that make them intolerant of evidenced-based therapies (few NYHA class IV patients in this study) or are ‘frequent fliers’ due to nonadherence. HF specialists may, therefore, be faced with severe underpayment if documentation is not pristine.