AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services
2010; Lippincott Williams & Wilkins; Volume: 122; Issue: 13 Linguagem: Inglês
10.1161/cir.0b013e3181f5185b
ISSN1524-4539
AutoresRandal J. Thomas, Marjorie L. King, Karen Lui, Neil Oldridge, Ileana L. Piña, John A. Spertus,
Tópico(s)Acute Myocardial Infarction Research
ResumoHomeCirculationVol. 122, No. 13AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBAACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention ServicesA Report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation) Writing Committee Members Randal J. Thomas, Marjorie King, Karen Lui, Neil Oldridge, Ileana L. Piña and John Spertus Writing Committee Members , Randal J. ThomasRandal J. Thomas , Marjorie KingMarjorie King , Karen LuiKaren Lui , Neil OldridgeNeil Oldridge , Ileana L. PiñaIleana L. Piña and John SpertusJohn Spertus Originally published30 Aug 2010https://doi.org/10.1161/CIR.0b013e3181f5185bCirculation. 2010;122:1342–1350Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 30, 2010: Previous Version 1 TABLE OF CONTENTSPreamble……………………………………………1343 Update of Performance Measures for Referral to Cardiac Rehabilitation…………………………1345 1.1. Background………………………………….13451.2. Measure A-1. Cardiac Rehabilitation Patient Referral From an Inpatient Setting……………13451.3. Measure A-2. Cardiac Rehabilitation Patient Referral From an Outpatient Setting………….13451.4. Administrative Codes to Identify Denominator-Eligible Populations…………….1346References…………………………………………….1346Appendix A.………………………………………….1347Appendix B.………………………………………….1348PreambleOver the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality "chasm".1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability.Consistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas Table 1. The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate, incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements of cardiovascular care. The writing committees are also instructed to evaluate the extent to which existing nationally recognized performance measures conform to the attributes of performance measures described by the ACCF/AHA and to strive to create measures aligned with acceptable existing measures when this is feasible.Table 1. ACCF/AHA Performance Measure SetsTopicOriginal Publication DatePartnering OrganizationsStatusChronic heart failure22005ACC/AHA—Inpatient measures ACC/AHA/PCPI—Outpatient measuresCurrently undergoing update Currently undergoing updateChronic stable coronary artery disease32005ACC/AHA/PCPICurrently undergoing updateHypertension42005ACC/AHA/PCPICurrently undergoing updateST-elevation and non–ST-elevation myocardial infarction52006ACC/AHAUpdated 20086Cardiac rehabilitation72007AACVPR/ACC/AHAUpdated 2010 (referral measures only)Atrial fibrillation82008ACC/AHA/PCPIPrimary prevention of cardiovascular disease92009ACCF/AHAPeripheral artery disease2010*ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVSUnder developmentPercutaneous coronary intervention2011*ACCF/AHA/SCAI/PCPI/NCQAUnder development*Planned publication date.AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; ACR, American College of Radiology; NCQA, National Committee for Quality Assurance; PCPI indicates American Medical Association—Physician Consortium for Performance Improvement; SCAI, Society for Cardiac Angiography and Interventions; SIR, Society for Interventional Radiology; SVM, Society for Vascular Medicine; SVN, Society for Vascular Nursing; and SVS, Society for Vascular Surgery.The initial measure sets published by the ACCF/AHA focused primarily on processes of medical care or actions taken by healthcare providers, such as the prescription of a medication for a condition. These process measures are founded on the strongest recommendations contained in the ACCF/AHA clinical practice guidelines, delineating actions taken by clinicians in the care of patients, such as the prescription of a particular drug for a specific condition. Specifically, the writing committees consider as candidates for measures those processes of care that are recommended by the guidelines either as Class I, which identifies procedures/treatments that should be administered, or Class III, which identifies procedures/treatments that should not be administered Table 2. Class II recommendations are not considered as candidates for performance measures. The methodology guiding the translation of guideline recommendations into process measures has been explicitly delineated by the ACCF/AHA, providing guidance to the writing committees.10Table 2 Applying Classification of Recommendations and Level of EvidenceTable 2 Applying Classification of Recommendations and Level of Evidence*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.Although they possess several strengths, processes of care are limited as the sole measures of quality. Thus, current ACCF/AHA performance measures writing committees are instructed to consider measures of structures of care, outcomes, and efficiency as complements to process measures. In developing such measures, the committees are guided by methodology established by the ACCF/AHA.11 Although implementation of measures of outcomes and efficiency is currently not as well established as that of process measures, it is expected that such measures will become more pervasive over time.Although the focus of the performance measures writing committees is on measures intended for quality improvement efforts, other organizations may use these measures for external review or public reporting of provider performance. Therefore, it is within the scope of the writing committee's task to comment, when appropriate, on the strengths and limitations of such external reporting for a particular CVD state or patient population. Thus, the metrics contained within this document are categorized as either performance measures or test measures. Performance measures are those metrics that the committee designates as appropriate for use for both quality improvement and external reporting. In contrast, test measures are those appropriate for the purposes of quality improvement but not for external reporting until further validation and testing are performed.All measures have limitations and pose challenges to implementation that could result in unintended consequences when used for accountability. The implementation of measures for purposes other than quality improvement requires field testing to address issues related but not limited to sample size, frequency of use of an intervention, comparability, and audit requirements. The manner in which these issues are addressed is dependent on several factors, including the method of data collection, performance attribution, baseline performance rates, incentives, and public reporting methods. The ACCF/AHA encourages those interested in implementing these measures for purposes beyond quality improvement to work with the ACCF/AHA to consider these complex issues in pilot implementation projects, to assess limitations and confounding factors, and to guide refinements of the measures to enhance their utility for these additional purposes.By facilitating measurements of cardiovascular healthcare quality, ACCF/AHA performance measurement sets may serve as vehicles to accelerate appropriate translation of scientific evidence into clinical practice. These documents are intended to provide practitioners and institutions that deliver care with tools to measure the quality of their care and identify opportunities for improvement. It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved.Frederick A. Masoudi, MD, MSPH, FACC, FAHAChair, ACCF/AHA Task Force on Performance Measures1. Update of Performance Measures for Referral to Cardiac Rehabilitation1.1. BackgroundThe AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services were published in October 2007.7 This document updates the 2 measures that articulate the opportunities to improve referrals to outpatient Cardiac Rehabilitation that were embodied in Measure Set A from that 2007 paper (Appendix A7) Measure A-1 (Cardiac Rehabilitation Patient Referral From an Inpatient Setting) and measure A-2 (Cardiac Rehabilitation Patient Referral From an Outpatient Setting) have been revised to clarify several aspects of the measures and to facilitate their implementation. The updated measures (Appendix B) have been revised as described in the following text. The measures in Measure Set B from the 2007 paper related to the structure and processes of care for cardiac rehabilitation programs remain unchanged and are not included in this update.1.2. Measure A-1. Cardiac Rehabilitation Patient Referral From an Inpatient SettingNumerator Exclusion Criteria:"Patient-oriented barriers" was revised to "patient-oriented factors," and the example provided was changed. Patient refusal, which was listed as an example in the 2007 paper, should not be considered a reason not to provide a referral. Whether the patient chooses to act upon the referral or not is beyond the provider's control. The example provided in this update clarifies that patients discharged to a nursing care facility for long-term care can be excluded."Provider-oriented barriers" was revised to "medical factors," and the examples provided were changed. The 2007 measures listed "patient deemed to have a high-risk condition or a contraindication to exercise" as an example. This was revised to specify "medically unstable, life-threatening condition" as an example of an appropriate medical exclusion. The rationale reflects the capacity of cardiac rehabilitation programs to modify their program to the medical needs of individual patients and that, other than life-threatening conditions, there are no a priori reasons to presume that a patient might not be able to participate in a rehabilitation and secondary prevention program."Health care system barriers" was revised to "healthcare system factors," and the examples provided were changed. "Financial barriers" was deleted and "lack of CR programs near a patient's home" was clarified to specify no cardiac rehabilitation program available within 60 minutes of travel time from the patient's home.Denominator:A note was added to clarify that patients with a qualifying event who are to be discharged for a short-term stay in an inpatient medical rehabilitation facility are still expected to be referred to an outpatient cardiac rehabilitation program by the inpatient team during the index hospitalization. This referral should be reinforced by the care team at the medical rehabilitation facility.Corresponding Guidelines and Clinical Recommendations:The recommendations in this section were updated to reflect the most recent iterations of the guidelines cited.1.3 Measure A-2. Cardiac Rehabilitation Patient Referral From an Outpatient SettingNumerator:The note describing what constitutes a referral has been expanded to clarify that standards of practice for cardiac rehabilitation programs require care coordination communications to be sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new nonemergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program.Exclusion criteria: The same revisions made to the patient, medical, and health system factors described for Measure A-1 in Section 1.2 were made to this measure.Denominator:The denominator statement was clarified to specify that only patients who have had a qualifying event/diagnosis during the previous 12 months and have not participated in an outpatient cardiac rehabilitation program since the qualifying event/diagnosis should be included.Attribution/Aggregation:This section was added to clarify that (1) the measure should be reported by the clinician who provides the primary cardiovascular-related care for the patient (In general, this would be the patient's cardiologist, but in some cases it might be a family physician, internist, nurse practitioner, or other healthcare provider.); and (2) the level of aggregation (clinician versus practice) will depend upon the availability of adequate sample sizes to provide stable estimates of performance.1.4 Administrative Codes to Identify Denominator-Eligible PopulationsTo facilitate implementation of these measures in a variety of systems, we have included administrative codes that may be useful in identifying the population of patients who are eligible for inclusion in the denominator for each of the updated measures. See the online-only Data Supplement at: http://circ.ahajournals.org/cgi/content/full/122/13/1342/DC1. for details.StaffAmerican Association of Cardiovascular and Pulmonary RehabilitationP. Joanne Ray, CFRE, Executive DirectorAbigail Lynn, Senior CoordinatorAmerican College of Cardiology FoundationJohn C. Lewin, MD, Chief Executive OfficerCharlene May, Senior Director, Clinical Policy and DocumentsMelanie Shahriary, RN, BSN, Associate Director, Performance Measures and Data StandardsJensen S. Chiu, MHA, Specialist, Clinical Performance MeasurementErin A. Barrett, MPS, Senior Specialist, Clinical Policy and DocumentsAmerican Heart AssociationNancy Brown, Chief Executive OfficerRose Marie Robertson, MD, FACC, FAHA, Chief Science OfficerGayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science OperationsDorothea K. Vafiadis, MS, Science and Medicine AdvisorFootnotesEndorsed by the American College of Chest Physicians, the American College of Sports Medicine, the American Physical Therapy Association, the Canadian Association of Cardiac Rehabilitation, the Clinical Exercise Physiology Association, the European Association for Cardiovascular Prevention and Rehabilitation, the Inter-American Heart Foundation, the National Association of Clinical Nurse Specialists, the Preventive Cardiovascular Nurses Association, and the Society of Thoracic SurgeonsACCF/AHA Task Force on Performance MeasuresFrederick A. Masoudi, MD, MSPH, FACC, FAHA, Chair; Elizabeth DeLong, PhD; John P. Erwin III, MD, FACC; David C. Goff, Jr, MD, PhD, FAHA, FACP; Kathleen Grady, PhD, RN, FAHA, FAAN; Lee A. Green, MD, MPH; Paul A. Heidenreich, MD, FACC; Kathy J. Jenkins, MD, MPH, FACC; Ann R. Loth, RN, MS, CNS; Eric D. Peterson, MD, MPH, FACC, FAHA; David M. Shahian, MD, FACCThis document was approved by the American College of Cardiology Foundation Executive Committee in April 2010, by the American Heart Association Science Advisory and Coordinating Committee in April 2010, and by the AACVPR Document Oversight Committee and Board of Directors in June 2010.The American Heart Association requests that this document be cited as follows: Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation). Circulation. 2010;122:1342–1350.This article has been copublished in the Journal of the American College of Cardiology and the Journal of Cardiopulmonary Rehabilitation and Prevention.Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Association (my.americanheart.org). A copy of the document is also available at http://www.americanheart.org/presenter.jhtml?identifier=3003999 by selecting either the "topic list" link or the "chronological list" link (No. KB-0081). To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifier=3023366.Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier=4431. A link to the "Permission Request Form" appears on the right side of the page.These measures and specifications are provided "as is" without warranty of any kind. Neither the AACVPR, the ACCF, nor the AHA shall be responsible for any use of these performance measures.Limited proprietary coding is contained in the measure specifications (online-only Data Supplement at: http://circ.ahajournals.org/cgi/content/full/122/13/1342/DC1.) for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AACVPR, the ACCF, and the AHA disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT™) or other coding contained in the specifications.CPT™ contained in the online data supplement is ©2009 American Medical Association.References1. Institute of MedicineCrossing the Quality Chasm: A New Health System for the 21st Century.Washington, DC: National Academy Press; 2001.Google Scholar2. Bonow RO, Bennett S, Casey DE, et al. ACC/AHA clinical performance measures for adults with chronic heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart Failure Clinical Performance Measures). Circulation. 2005; 112:1853–87.LinkGoogle Scholar3. American Medical Association. Physician Consortium for Performance Improvement. Clinical Performance Measures: Chronic Stable Coronary Artery Disease. 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Author Relationships With Industry and Other Entities—AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention ServicesNameEmploymentConsultantSpeakerOwnership/Partnership/PrincipalResearchInstitutional, Organizational, or Other Financial BenefitExpert WitnessRandal J. ThomasMayo ClinicNoneNoneNoneBlue Cross/Blue Shield of Minnesota*Marriott Family Program in Individualized Medicine*AACVPR (President)Stratis Health (Community Health Award)*NoneMarjorie KingHelen Hayes Hospital and Hudson Heart AssociatesNoneNoneNoneNoneNoneNoneKaren LuiGRQ, LLCNoneNoneNoneNoneNoneNoneNeil OldridgeUniversity of Wisconsin School of Medicine and Public HealthNoneNoneCopyright for MacNewNoneNoneNoneIleana L. PiñaUniversity Hospitals Case Medical CenterFood and Drug AdministrationSanofi-AventisAstraZenecaMerckNovartisNoneNoneNoneNoneJohn SpertusMidAmerica Heart Institute of St. Luke's HospitalSt. Jude MedicalUnited Healthcare Scientific Advisory BoardNoneCopyright for Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, and Peripheral Artery Questionnaire*PRISM TechnologyAmerican College of Cardiology Foundation*Amgen*Bristol-Myers Squibb/Sanofi-Aventis Partnership*Johnson & Johnson*Eli Lilly & Co.*CV Outcomes, Inc. (President of this 501(C)3 organization)Health Outcomes Sciences, LLC (ownership interest)Outcomes Instruments, LLC (ownership interest)NoneThis table represents the relationships of committee members with industry and other entities that were reported by authors to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10,000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person's gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted.*Significant (greater than $10,000) relationship.Appendix B. AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention ServicesPerformance Measure A-1A-1. Cardiac Rehabilitation Patient Referral From an Inpatient SettingAll patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina (CSA), or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation are to be referred to an early outpatient cardiac rehabilitation/secondary prevention (CR) program.NumeratorNumber of eligible patients with a qualifying event/diagnosis who have been referred to an outpatient CR program prior to hospital discharge or have a documented medical or patient-centered reason why such a referral was not made.(Note: The program may include a traditional
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