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Providing further guidance to clinicians on the provision of optimal patient care, the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Medical Association–Physician Consortium for Performance Improvement (AMA-PCPI) today released updated performance measures for adults with heart failure (HF). The 2011 performance measures include care provided in both the outpatient and inpatient setting, emphasizing the need to measure quality of care over time and across providers, while also focusing on functional outcomes.

The 2011 Performance Measures for Adults with Heart Failure were designed to define what should—and should not—be done to ensure that patients with cardiovascular disease receive optimal care. They were drafted after careful consideration of several documents, including ACCF/AHA practice guidelines and existing HF measures by The Joint Commission, the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality. Additionally, all of the 2011 performance measures support the Institute of Medicine’s six aims for quality improvement: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity.

“In order to improve the quality of heart failure care, one has to provide measures of quality. The Heart Failure Performance Measures were designed for that purpose—to allow physicians and their care teams to deliver evidence-based management designed to improve heart failure outcomes without disrupting the workflow,” said writing committee co-chair Robert O. Bonow, MD, MACC, Goldberg Distinguished Professor of Cardiology and director of the Center for Cardiovascular Innovation at Northwestern University Feinberg School of Medicine.

The 2011 performance measures consist of nine total measures, including three new measures and six revised measures. Two measures apply to care provided in both the inpatient and the outpatient settings, while five measures address outpatient care only and two measures address inpatient care only. Eight measures from the previous HF performance measures set, which were released in 2005, were retired. 

The measures' target population includes patients 18 years of age and older who have a diagnosis of HF. The measures are intended for prospective use to enhance the quality improvement process through initiatives such as pay for performance, physician ranking and public reporting. However, the measures may also be applied retrospectively. They address processes of care rather than patient outcomes, as outcomes measures are already publicly reported by CMS.

Among the significant updates to the 2011 measures set is the expansion of the beta-blocker measure to the inpatient setting. Included only as an outpatient measure in the 2005 set, this measure was added for the inpatient setting after inpatient care guidelines were developed in the 2009 ACCF/AHA’s HF guidelines update. In addition, clinical trial data showing that not all beta-blockers exhibit the same benefits prompted the writing committee to specify the use of one of three evidence-based beta-blockers: bisoprolol, carvedilol or sustained-release metoprolol.

Another significant change in the 2011 performance measures set is the conversion of the measure on patient education to a quality metric, which should be used for internal quality improvement purposes only, not public reporting. While the writing committee acknowledged that patient education about lifestyle, activity, diet and medication use is important for providing optimal care, they also understood that compliance with an education measure is easy to achieve without regard to the quality of education provided. Two other quality metrics are also included amongst the nine measures, including one on counseling about implantable cardioverter-defibrillators and another on symptom management.

Other changes to the 2011 performance measures include the combination of both the inpatient and outpatient settings in a measure about the use of ACE inhibitors or ARB therapy for left ventricular systolic dysfunction, the addition of a new measure on the postdischarge appointment at the time of hospital discharge, and the retirement of measures on weight measurement, blood pressure measurement, and warfarin therapy for patients with atrial fibrillation. These measures were retired either because they had been included as part of a broader measure in a different set, or they had become standards of care and were not likely to have a significant impact on care quality. 

According to the performance measures writing committee, consistent use of the set is key to the measures’ optimal usage. “To be successful as quality improvement tools, the HF Performance Measures need to be integrated as routine components of patient care across various care settings, with particular attention to transitions of care from inpatient to outpatient environments,” Bonow said.  

Writing committee members included cardiac specialists and general care physicians, as well as representatives of various physicians associations. Individuals with expertise in developing performance measures were also included, as were patient representatives, a payer representative, and representatives from the ACCF/AHA HF guidelines writing committee.

Check Out the Following HF-Related Resources The Heart Failure Practice Solutions Toolkit provides easy access to nine tools (one for patients and eight for clinicians) that allow cardiovascular professionals and others to brush up on guideline recommendations for HF care, understand what to report for HF performance measures, prescribe appropriate drug therapies for HF patients, provide quality education and self-management strategies to patients, and assess performance improvement. The Hospital to Home (H2H) Initiative, led by the ACC and the Institute for Healthcare Improvement, is another important resource for hospitals and cardiovascular care providers interested in improving transitions from "hospital to home," and more importantly avoiding any federal penalties associated with high readmissions rates. The H2H initiative challenges communities to better understand and tackle readmission problems through use of recommended tools and improvement strategies in three core concept areas: Early Follow-up, Post Discharge Medication Management, and Patient Recognition of Signs and Symptoms. The following Heart Failure Checklist was released as part of science released at ACC.12 in Chicago. Abhijeet Basoor, MD, the study’s lead investigator, who developed the checklist at St. Joseph Mercy Oakland Hospital in Pontiac, Mich., where he practices internal medicine and cardiology, said use of this simple checklist significantly reduced readmissions.

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