ACC/AHA Classification of Care Metrics

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ACC/AHA Classification of Care Metrics
Clinical performance measures Those measures
specifically suitable for public reporting,
external comparisons, and possibly
pay-for-performance programs. Performance
measurements are developed using evidence based
guidelines for life-extending or life-hancing
therapies Quality metrics Those measures that
have been developed to support self assessment
and quality improvement at the provider,
hospital, and/or health care system level. These
metrics represent valuable tools to aid
clinicians and hospitals in improving quality of
care and enhancing patient outcomes but may not
have the rigor to be considered as clinical
performance measures
Bonow R J Am Coll Cardiol (Published online 10
November 2008)
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Key Publications
(2) Bonow RO et al. JACC 2005461144-78 (3)
AMA Physician Consortium AMA-assn.org (4)
AHA Physician Consortium AMA-ass.org (5)
Krumholtz HM et al JACC 2006 47236-65 (6)
Thomas RJ et al JACC 2007 50 1400-33 (7)
Estes NA et al JACC 2008 51865-84
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ACC/AHA 2008 Care Metrics for AMI
Krumholz HM et al J Am Coll Cardiol (Published
online 14 November 2008)
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• Caveats
• Does not include UA
• Includes only patients admitted with the
  diagnosis of AMI not those who develop AMI while
  in-hospital
• Retrospective identification of cases for review
• General alignment with CMS/TJC measures
• Documentation by nursing or medical students not
  sufficient

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Omitted Performance Measure Early B Blocker
therapy Early B Blocker therapy has been shown
to reduce recurrent angina and MI but not
mortality. The COMMIT study showed that B
blocker therapy reduced arrhythmic death and reMI
but significantly increased the incidence of
cardiogenic shock, particularly with CHF and
hemodynamic instability
Krumholz HM J Am Coll Cardiol (Published online
14 November 2008)
6
ACC/AHA 2008 Specific Changes
Revised Performance Measure Statins at
Discharge HMG Co-A reductase inhibitors reduce
the risk of death/reMI to the same magnitude of
ACE inhibitors and BB, irrespective of the
baseline LDL concentration. Patients with a
known LDL cholesterol lt 100 mg/dL are not
included
LDL cholesterol measurement moved to Test Measure
New Performance Measure Evaluation of LV
systolic function Patients with reduced LVEF may
be candidates for additional therapies, including
ACEI or ARBs or invasive therapy. May also
document intention to measure LVEF as outpatient
Measurements more concordant with the CMS-TJC
Krumholz HM J Am Coll Cardiol (Published online
14 November 2008)
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New Performance Measures
Krumholz HM J Am Coll Cardiol (Published online
14 November 2008)
8
ACC/AHA 2008 Specific Changes

• New Performance Measurement Timely Reperfusion
• For Primary PCI, measurement stops with use of
  1st device, including thrombectomy devices,
  balloon, and stent
• Performance metric now includes transfer times
  and door in-door out at referring hospital ?
  total door-to-balloon time.
• Although a benchmark value has not been set,
  incentives now present to short this time (v.
  fibrinolytic therapy)
• New integrated measurements will facilitate
  communications between transferring and receiving
  hospitals
• Quality assurance analysis of false alarms
  encouraged

Masoudi FA et al. ACC/AHA 2008 Statement on
Performance Measurement and Reperfusion Therapy
JACC on line Nov 10, 2008
Krumholz HM J Am Coll Cardiol (Published online
14 November 2008)
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• New test measures rather than performance measures

Krumholz HM J Am Coll Cardiol (Published online
14 November 2008)
10
ACC/AHA 2008 Specific Changes

• Initial Parenteral Anticoagulation and
  Antiplatelet Dosing
• Concern over over-dosing of anticoagulation
  therapy, particularly with the use of GPI and in
  the eldery
• Collection of GFR using Cockroft-Gault or MDRD
  formula
• As a test measure, these indices are useful for
  internal QA activities and not as a performance
  measure

• New Test Measure Clopidogrel at Discharge
• Dual anti-platelet therapy received in high
  percentage of patients who receive PCI and stents
  with hospitalization. This measure focuses on
  those patients treated with medical therapy alone
  (PCI and CABG patients excluded)
• Requires careful documentation of reasons why DAP
  not given in this heterogeneous patient
  population

Krumholz HM J Am Coll Cardiol (Published online
14 November 2008)
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Take Home Messages

• ACC/AHA Care Metrics including both Quality
  Performance Measures and Care Metrics for AMI
  (STEMI and NSTEMI)
• Updated ACC/AHA statement moves these criteria
  more in line with CMS and TLC Core Measures for
  AMI
• Key points in review
• - Early B blocker therapy removed as Performance
  Measure
• - Statin therapy initiated on all patients with
  AMI
• - Addition of additional markers for reperfusion
  times that account for interhospital transfer
  delays
• - Cardiac rehabilitation referrals as part of
  Performance Measures
• Addition of a series of Quality Metrics focused
  on appropriate dosing of anticoagulation and
  avoidance of bleeding complications, particular
  in patients with renal insufficiency and in the
  elderly