2020 ACC/AHA Heart Failure Performance Measures: Key Points

Heidenreich P, Fonarow GC, Breathett K, et al.
2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol 2020;Nov 2:[Epub ahead of print].

The following are key points to remember from the 2020 American College of Cardiology/American Heart Association (ACC/AHA) clinical performance and quality measures for adults with heart failure (HF):

  1. The 2020 ACC/AHA HF measures include new and revised performance measures for public reporting or pay for performance. These were added based on the strongest recommendations (Class I or Class III) in the 2017 ACC/AHA HF guidelines that were thought to be of high value by the ACC/AHA standards.
  2. The prior performance measure of assessing left ventricular ejection fraction (LVEF) during HF hospitalization has now been retired due to high compliance rates. Instead, this now includes evaluation of LVEF in the outpatient setting for patients with a diagnosis of HF, as this influences choice of pharmacotherapy.
  3. Documentation of clinical symptoms and current activity level for all HF patients in the outpatient setting remains a performance measure. This can include documentation of a New York Heart Association (NYHA) class or a disease-specific validated questionnaire such as the Kansas City Cardiomyopathy Questionnaire (KCCQ). Documentation of patient symptoms and level of activity quantitatively in outpatient visits includes using NYHA class, KCCQ, 6-minute walk test, or peak oxygen consumption. For patients with worsening symptoms compared to prior visit, a documented plan of care should be noted.
  4. Regarding medical therapy, use of an angiotensin receptor-neprilysin inhibitor (ARNI) is included after this class received a Class I recommendation in the most recent HF guidelines. Accordingly, the revised measure includes proportion of patients on beta-blockers and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin-receptor blocker (ARB)/ARNI in HF patients with an LVEF ≤40% in the outpatient setting or at hospital discharge. In addition, the proportion of HF patients with LVEF ≤40% who remain symptomatic with NYHA class II or III symptoms despite ACE inhibitor or ARB therapy for 3 months who are prescribed ARNI at hospital discharge or as an outpatient is a new performance measure. All patients who decline or are ineligible are excluded.
  5. Additional changes made with the goal of increasing use of guideline-directed medical therapy at maximally tolerated doses include new measures examining the proportion of HF patients with LVEF ≤40% who are treated with a guideline-recommended beta-blocker at a dose that is ≥50% of target dose. A similar measure is included for ACEI/ARB/ARNI. All patients who decline or are intolerant are excluded.
  6. Another change with regard to pharmacotherapy is the new inclusion of use of mineralocorticoid inhibitors among HF patients with LVEF ≤35% with NYHA class II-IV despite treatment with ACEI/ARB/ARNI and beta-blocker to increase adoption of these agents that receive a Class I indication in the current HF guidelines. To ensure safe use of these agents, lab monitoring of potassium and renal function within 1 week of initiation of mineralocorticoid inhibitors is also included as a measure. All patients who decline or are intolerant are excluded.
  7. Use of hydralazine/isosorbide dinitrate therapy in HF with LVEF ≤40% among self-identified black or African American patients receiving ACEI/ARB/ARNI and beta-blocker is also a performance measure. All patients who decline or are intolerant are excluded.
  8. To encourage appropriate adoption of device therapies while engaging in shared decision making, the proportion of HF patients with LVEF ≤35% despite guideline-directed medical therapy for ≥3 months who received counseling regarding an implantable cardioverter-defibrillator (ICD) remains unchanged.
  9. For cardiac resynchronization therapy (CRT), the proportion of HF patients who received this device with an LVEF ≤35% in the presence of LBBB with QRS duration ≥150 msec despite guideline-directed medical therapy for ≥3 months is a new measure. As opposed to the measure with ICD that only involves documentation of counseling, implantation of a CRT is included as a measure, as CRT is associated with both a morbidity and mortality benefit.
  10. The document also endorses four quality measures that were thought to not be ready for public reporting or pay for performance but may be useful for quality improvement. These include: a) provision of patient self-care education for HF during ≥1 outpatient visits in 1 year, b) use of an HF-specific patient-reported health status measure in each 6-month period, c) percentage of HF patients whose HF-specific heath status measure does not show a significant decline over 1 year, and d) percentage of patients discharged from an inpatient HF stay for whom an HF appointment was scheduled in 7 days and documented at discharge.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Adrenergic beta-Antagonists, Angiotensin-Converting Enzyme Inhibitors, Cardiac Resynchronization Therapy, Defibrillators, Implantable, Drug Therapy, Heart Failure, Isosorbide Dinitrate, Mineralocorticoids, Neprilysin, Quality Improvement, Quality Indicators, Health Care, Reimbursement, Incentive, Renal Insufficiency, Stroke Volume, Task Performance and Analysis, Ventricular Function, Left

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