ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance Measures for Adults With Peripheral Artery Disease
2010; Lippincott Williams & Wilkins; Volume: 122; Issue: 24 Linguagem: Inglês
10.1161/cir.0b013e3182031a3c
ISSN1524-4539
AutoresJeffrey W. Olin, David E. Allie, Michael Belkin, Robert O. Bonow, Donald E. Casey, Mark A. Creager, Thomas C. Gerber, Alan T. Hirsch, Michael R. Jaff, John A. Kaufman, Curtis A. Lewis, Edward T. Martin, Louis G. Martin, Peter Sheehan, Kerry J. Stewart, Diane Treat‐Jacobson, Christopher J. White, Zhi-Jie Zheng,
Tópico(s)Cerebrovascular and Carotid Artery Diseases
ResumoHomeCirculationVol. 122, No. 24ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance Measures for Adults With Peripheral Artery Disease Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance Measures for Adults With Peripheral Artery DiseaseA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, the American College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular Nursing, and the Society for Vascular Surgery (Writing Committee to Develop Clinical Performance Measures for Peripheral Artery Disease) Jeffrey W. Olin, David E. Allie, Michael Belkin, Robert O. Bonow, Donald E. CaseyJr, Mark A. Creager, Thomas C. Gerber, Alan T. Hirsch, Michael R. Jaff, John A. Kaufman, Curtis A. Lewis, Edward T. Martin, Louis G. Martin, Peter Sheehan, Kerry J. Stewart, Diane Treat-Jacobson, Christopher J. White and Zhi-Jie Zheng Jeffrey W. OlinJeffrey W. Olin , David E. AllieDavid E. Allie , Michael BelkinMichael Belkin , Robert O. BonowRobert O. Bonow , Donald E. CaseyJrDonald E. CaseyJr , Mark A. CreagerMark A. Creager , Thomas C. GerberThomas C. Gerber , Alan T. HirschAlan T. Hirsch , Michael R. JaffMichael R. Jaff , John A. KaufmanJohn A. Kaufman , Curtis A. LewisCurtis A. Lewis , Edward T. MartinEdward T. Martin , Louis G. MartinLouis G. Martin , Peter SheehanPeter Sheehan , Kerry J. StewartKerry J. Stewart , Diane Treat-JacobsonDiane Treat-Jacobson , Christopher J. WhiteChristopher J. White and Zhi-Jie ZhengZhi-Jie Zheng Originally published29 Nov 2010https://doi.org/10.1161/CIR.0b013e3182031a3cCirculation. 2010;122:2583–2618Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2010: Previous Version 1 Masoudi Frederick A.PreambleOver 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 with assembling writing committees composed of clinical and methodological experts. When appropriate, these committees have included representation from other organizations involved in the care of patients with the condition of focus. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, to rely upon easily documented clinical criteria, and where appropriate, to 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 measuresCurrently undergoing updateACC/AHA/PCPI—outpatient measuresCurrently 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)7aAtrial fibrillation82008ACC/AHA/PCPIPrimary prevention of cardiovascular disease92009ACCF/AHAPeripheral artery disease2010*ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVSPercutaneous coronary intervention2011*ACCF/AHA/SCAI/PCPI/NCQAUnder development*Planned publication date.AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; ACR, American College of Radiology; AHA, American Heart Association; NCQA, National Committee for Quality Assurance; PCPI, 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 and/or treatments that should be administered, or Class III, which identifies procedures and/or 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.1. IntroductionThe ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS Peripheral Artery Disease Performance Measures Writing Committee was charged to develop performance measures for peripheral artery disease (PAD). These performance measures address lower extremity and abdominal aortic disease, as covered by the ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (hereafter, "PAD guidelines").12 The measures are intended for adults (age ≥18 years) evaluated in the outpatient setting. The writing committee acknowledges that the field is rapidly evolving due to the contributions of observational research, registries, and clinical trials. Hence, modifications to these performance measures for PAD will be necessary as the field advances. In addition, there has been a recent change in the nomenclature for vascular diseases.13 The term atherosclerotic vascular disease refers to disease of the arteries (other than the coronary arteries) caused by atherosclerosis.14 We have incorporated this new terminology into this document where it is feasible to do so.1.1. Scope of the ProblemThe PAD guidelines12 state that: the term "peripheral arterial disease" includes a diverse group of disorders that lead to progressive stenosis or occlusion, or aneurysmal dilation, of the aorta and its noncoronary branch arteries, including the carotid, upper extremity, visceral, and lower extremity arterial branches. Peripheral arterial disease is the preferred clinical term that should be used to denote stenotic, occlusive, and aneurysmal diseases of the aorta and its branch arteries, exclusive of the coronary arteries (page e7).For the purposes of these performance measures, the term peripheral artery disease in the title is used to denote atherosclerotic stenosis or occlusion of the aorta and arteries supplying the lower extremities and abdominal aortic aneurysms (AAAs).13,14PAD is a marker of systemic atherosclerosis. It has been estimated that approximately 8 million persons in the United States are afflicted with PAD.15 The prevalence of PAD is approximately 12% of the adult population, with men being affected slightly more than women.16,17 However, this percentage is age dependent. Almost 20% of adults over the age of 70 years have PAD.18 Findings from a national cross-sectional survey of PARTNERS (PAD Awareness, Risk, and Treatment: New Resources for Survival) found that PAD afflicts 29% of patients who are age ≥70 years, age 50 to 69 years with at least a 10–pack-per-year history of smoking, or age 50 to 69 years with a history of diabetes.19 Despite the strikingly high prevalence of PAD, this disease is underdiagnosed because it often presents with atypical symptoms or no ischemic symptoms related to the legs at all. More than 70% of primary care providers in the PARTNERS study whose patients were screened were unaware of the presence of PAD in those with the disease.19The clinical presentation of PAD may vary from no symptoms to intermittent claudication, atypical leg pain, rest pain, ischemic ulcers, or gangrene. Claudication is the typical symptomatic expression of PAD. However, asymptomatic disease may occur in up to 50% of all patients with PAD.12 The Walking and Leg Circulation Study evaluated the symptoms in patients with PAD. Of the 460 patients with PAD, 19.8% had no exertional leg pain, 28.5% had atypical leg pain, 32.6% had classic intermittent claudication, and 19.1% had pain at rest.20 The results of these and other studies make it readily apparent that more patients with PAD are asymptomatic or have atypical leg symptoms than have classic intermittent claudication.PAD has 2 major consequences: The first is a decrease in overall well-being and quality of life due to claudication and atypical leg pain.21–25 This often leads to patients becoming sedentary and limiting the amount of walking they do because of pain and discomfort. This may be associated with depression.26 The second is a markedly increased cardiovascular morbidity (myocardial infarction and stroke) and mortality (cardiovascular and all-cause). Treatment should be directed at each of these facets.PAD is most often diagnosed by an ankle-brachial index (ABI) ≤0.9. A low ABI is an independent predictor of increased mortality.27–32 In the Framingham Study, mortality in patients with intermittent claudication was 2–3 times higher than in age- and sex-matched control patients, with 75% of PAD patients dying from cardiovascular events. In a 15-year review of patients with claudication, over 66% of mortality was attributable to CVD.17 In a 10-year prospective study by Criqui et al,33 PAD patients both with and without a history of CVD had significantly increased risk of dying from cardiovascular and coronary heart disease compared with age-matched control patients. The all-cause mortality was 3.1 times greater and the CVD mortality was 5.9 times greater in patients with PAD compared with patients without PAD. The risk of cardiovascular events has been found to be similar between PAD patients with claudication and PAD patients without symptoms.34 The extremely high morbidity and mortality in the PAD population is due to myocardial infarction and stroke.35,36 Both the Edinburgh Artery Study and the ARIC (Atherosclerosis Risk in Communities) study correlated an increased risk of stroke and transient ischemic attack with increased PAD severity.34,37 The combination of known coronary or cerebrovascular disease with PAD has been shown to increase mortality risk. The BARI (Bypass Angioplasty Revascularization Investigation) trial demonstrated that patients with multivessel coronary artery disease (CAD) and PAD had a 4.9 times greater relative risk of death compared with those individuals without PAD.38 In addition, in a pooled analysis of 8 randomized prospective trials involving 19,867 patients undergoing percutaneous coronary intervention, the 1-year mortality was 5% in patients with PAD and coronary disease compared with 2.1% in patients with coronary disease alone (P<0.001).39Despite the overwhelming evidence that patients with PAD are at a markedly increased risk of myocardial infarction, stroke, and death, these patients are often undertreated, in that they do not receive antiplatelet therapy or statins with the same frequency as do patients with coronary artery disease.19Thus, these PAD performance measures are directed at strategies to improve diagnosis and treatment of patients with PAD with an overall goal of improving patients' walking distance and speed, improving their quality of life, and decreasing cardiovascular event rates.1.2. Structure and Membership of the Writing CommitteeThe members of the writing committee included experienced clinicians and specialists in vascular medicine, cardiology, vascular surgery, exercise physiology, vascular and interventional radiology, interventional cardiology, endocrinology, and epidemiology. The writing committee also included representatives from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR); the American College of Physicians (ACP); the American College of Radiology (ACR); the American Diabetes Association (ADA); the National Heart, Lung, and Blood Institute (NHLBI); the PAD Coalition; the Society for Atherosclerosis Imaging and Prevention (SAIP); the Society for Cardiac Angiography and Interventions (SCAI); the Society of Cardiovascular Computed Tomography (SCCT); the Society for Cardiovascular Magnetic Resonance (SCMR); the Society for Interventional Radiology (SIR); the Society for Vascular Medicine (SVM); the Society for Vascular Nursing (SVN); and the Society for Vascular Surgery (SVS).1.3. Disclosure of Relationships With IndustryThe work of the writing committee was supported exclusively by the ACCF and AHA. Committee members volunteered their time, and there was no commercial support for the development of these performance measures. Meetings of the writing committee were confidential and attended only by committee members and staff. Writing committee members were required to disclose in writing all financial relationships with industry relevant to this topic according to standard ACCF and AHA reporting policies and verbally acknowledged these relationships to the other members at each meeting (see Appendix A). A confidential final vote was conducted on each measure proposed for inclusion in this set. Committee members with relationships relevant to a specific measure did not participate in the voting regarding that measure but were allowed to participate in the discussion after disclosing the relationship. In addition, Appendix B includes relevant relationships with industry information for all peer reviewers of this document.1.4. Review and EndorsementBetween July 20, 2009, and August 18, 2009, this performance measure document underwent a 30-day public comment period, during which ACCF and AHA members and other health professionals had an opportunity to review and comment on the text in advance of its final approval and publication. Sixteen public responses were received.The official peer and content review of the document was conducted simultaneously with the 30-day public comment period, with 2 peer reviewers nominated by the ACCF, 2 nominated by the AHA, and 2 peer reviewers nominated by each of the other partnering organizations (ACR, SCAI, SIR, SVM, SVN, and SVS) and by each collaborating organization (AACVPR, ADA, PAD Coalition, SAIP, SCCT, and SCMR). Additional comments were sought from clinical content experts and performance measurement experts, and 8 individual content reviewer responses were received. All peer and content reviewer relationships with industry information was collected and distributed to the writing committee and is published in this document. (See Appendix B for details.)The ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance Measures for Adults With Peripheral Artery Disease was adopted by the respective Boards of Directors of the ACCF and AHA in August 2010. These measures will be reviewed for currency once annually and updated as needed. They should be considered valid until either updated or rescinded by the ACCF/AHA Task Force on Performance Measures.2. MethodologyThe development of performance systems involves identification of a set of measures targeting a specific patient population observed over a particular time period. To achieve this goal, the ACCF/AHA Task Force on Performance Measures has outlined 5 mandatory sequential steps. Sections 2.1 through 2.5 outline how the writing committee addressed these elements.2.1. Target Population and Care PeriodThe target population consists of patients age ≥18 years. The writing committee developed exclusion criteria specific to each measure to further specify the target population.2.2. Dimensions of CareGiven the multiple potential domains of treatment that can be measured, the writing committee identified the relevant dimensions of care that should be evaluated. We placed each potential performance measure into the relevant dimension of care categories. Performance measures and test measures selected for inclusion in the final set and their dimensions of care are summarized in Table 3. Appendix C provides the detailed specifications for each measure.Table 3. ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS PAD Performance Measurement Set: Dimension of Care Measures MatrixMeasure NameRisk AssessmentDiagnosticsPatient EducationTreatmentSelf-Management/ComplianceMonitoring of Disease Status1. Ankle brachial index✓✓2. Cholesterol-lowering medications (statin)✓3. Smoking cessation✓✓✓4. Antiplatelet therapy✓5. Supervised exercise✓✓✓✓6. Lower extremity vein bypass graft surveillance✓✓7. Monitoring of abdominal aortic aneurysms✓T-1. Vascular review of systems for lower extremity PAD*✓✓T-2. PAD "at risk" population pulse examination*✓✓*Test measure (T-1 and T-2): This measure has been designated for use in internal quality improvement programs only. It is not appropriate for any other use (e.g., pay for performance, physician ranking, or public reporting programs).ACCF indicates American College of Cardiology Foundation; ACR, American College of Radiology; AHA, American Heart Association; PAD, peripheral artery disease; SCAI, Society for Cardiac Angiography and Interventions; SIR, Society of Interventional Radiology; SVM, Society for Vascular Medicine; SVN, Society of Vascular Nursing; and SVS, Society for Vascular Surgery.Although the writing committee considered a number of additional measures that focus on equally important aspects of care, length and complexity considerations did not allow their inclusion in the set. Some of the reasons for this are discussed later in this paper.2.3. Literature ReviewThe writing committee used the PAD guidelines as the primary source for deriving these measures.12 In addition, the writing committee also reviewed guidelines in "Transatlantic Inter-Societal Consensus for the Management of Peripheral Arterial Disease (TASC II)"40 and the "AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services".72.4. Definition of Potential MeasuresExplicit criteria exist for the development of performance measures that accurately reflect quality of care. These criteria include: 1) defining the numerators and denominators of potential measures, and 2) evaluating their applicability, interpretability, and feasibility. To select measures for inclusion in the performance measurement set, the writing committee prioritized the recommendations from the PAD guidelines.122.5. Selection of Measures for Inclusion in the Performance Measure SetFrom analysis of these recommendations, the writing committee identified potential measures relevant to adults with PAD and then independently evaluated their potential for use as performance measures using 9 exclusion criteria adapted from the ACCF/AHA Attributes of Performance Measures (Table 4) and the Performance Measure Survey Form and Exclusion Criteria Definitions (Appendix D). Member ratings of all the potential measures were collated and discussed by the full committee so that members could reach consensus about which measures should advance for inclusion in the final measure set. There were 37 potential measures initially advanced for full specification to assess their suitability as performance measures. Through an iterative process of repeated surveys within the writing committee, these potential measures were eventually reduced to 7 final performance measures and 2 test measures. After additional discussion and refinement of measure specifications, the writing committee conducted a confidential vote on whether to include each measure and whether to designate any of the measures as test measures in the final set. Writing committee members were required to recuse themselves from voting on any measures for which they had significant relevant relationships with industry.Table 4. ACCF/AHA Attributes of Performance MeasuresConsiderationAttributeUseful in improving patient outcomesEvidence-basedInterpretableActionableMeasure designDenominator precisely definedNumerator precisely definedValidity typeFaceContentConstructReliabilityMeasure implementationFeasibilityReasonable effortReasonable costReasonable time period for collectionOverall assessmentOverall assessment of measure for inclusion in measurement setAdapted from Normand et al.413. Peripheral Artery Disease Performance Measures3.1. Definition of Peripheral Artery Disease and Abdominal Aortic AneurysmAtherosclerotic vascular disease encompasses a range of noncoronary arterial syndromes that are caused by the altered structure and function of the arteries that supply the brain, visceral organs, and the limbs. Numerous pathophysiologic processes can contribute to the creation of stenosis or aneurysms of the noncoronary arterial circulation, but atherosclerosis remains the most common disease process affecting the aorta and its branch arteries.3.2. Brief Summary of the Measurement SetTable 5 summarizes the ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS PAD Performance Measurement Set—those measures with the highest level of evidence and support among the writing committee members. Appendix C provides the detailed specifications for each performance measure, including the numerator, denominator, period of assessment, method of reporting, sources of data, rationale, clinical recommendations, recommended level of attribution and/or aggregation, and challenges to implementation.Table 5 ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS PAD Performance Measurement SetMeasure NameDescriptionAttributionPerformance Measures 1. ABIMeasurement of ABI in patients at risk for PADAll clinicians managing patients with cardiovascular disease 2. Cholesterol-Lowering Medications (Statin)Drug therapy for lowering low-density lipoprotein cholesterol in patients with PADAll primary care and cardiovascular medicine physicians 3. Smoking CessationSmoking-cessation intervention for active smoking in patients with PADAll clinicians managing patients with cardiovascular disease 4. Antiplatelet TherapyAntiplatelet therapy to reduce the risk of myocardial infarction, stroke, or vascular death in patients with a history of symptomatic PADAll clinicians managing patients with cardiovascular disease 5. Supervised ExerciseSupervised exercise training for patients with intermittent claudicationAll clinicians managing patients with cardiovascular disease 6. Lower Extremity Vein Bypass Graft SurveillanceABI and Duplex ultrasound of lower extremity vein bypass siteVascular specialists only 7. Monitoring of Abdominal Aortic AneurysmsMonitoring of asymptomatic abdominal aortic aneurysms between 4.0 and 5.4 cm in diameterAll clinicians managing patients with cardiovascular diseaseTest Measures T-1. Vascular Review of Systems for Lower Extremity PAD*Medical or personal history of walking impairment, claudication or ischemic rest pain, and nonhealing wounds in patients at risk for lower extremity PADAll clinicians managing patients with cardiovascular disease T-2. PAD "At Risk" Population Pulse Examination*Measurement of pulses in the lower extremities in patients at risk for PADAll clinicians managing patients with cardiovascular disease*Test measure (T-1 and T-2): This measure has been designated for use in internal quality improvement programs only. It is not appropriate for any other use (e.g., pay for performance, physician ranking, or public reporting programs).ABI indicates ankle brachial index; ACCF, American College of Cardiology Foundation; ACR, American College of Radiology; AHA, American Heart Association; PAD, peripheral arterial disease; SCAI, Society for Cardiac Angiography and Interventions; SIR, Society of Interventional Radiology; SVM, Society for Vascular Medicine; SVN, Society of Vascular Nursing; and SVS, Society for Vascular Surgery.3.3. Data CollectionThese performance measures for PAD are ideally intended for prospective use to enhance the quality improvement process but may also be applied retrospectively. We recommend use of a data collection instrument to aid compilation (see Appendix E). Individual institutions
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