February 25th, 2010
Proposed Performance Measures for Hypertension and Stable Coronary Artery Disease Now Available for Public Comment!
Frederick Masoudi, MD, MSPH
The American College of Cardiology and the American Heart Association, collaborating with the American Medical Association’s Physician Consortium for Performance Improvement (PCPI), have drafted an updated set of clinical performance measures for assessing and improving the quality of ambulatory care of patients with hypertension and stable coronary artery disease. These measures, which assess processes of care (e.g., medication prescription) and intermediate outcomes (e.g., risk factor levels), are designed to address either quality improvement or accountability. They will be submitted for endorsement by the National Quality Forum (NQF) when completed.
The measures defined in each condition are listed below. An * indicates a new measure introduced since the last update.
A) Hypertension
Measure #1: Blood pressure control
B) Coronary artery disease
Measure #1: Blood Pressure Control
Measure #2: Lipid Control
Measure #3: Symptom & Activity Assessment
Measure #4: Symptom Management*
Measure #5: Tobacco Cessation and Intervention
Measure #6: Antiplatelet Therapy
Measure #7: Beta-Blocker Therapy — Prior Myocardial Infarction or Left Ventricular Systolic Dysfunction (LVEF) <40%
Measure #8: ACE Inhibitor or ARB Therapy — Diabetes or LVEF <40%
Measure #9: Patient Referral to Cardiac Rehabilitation from an Outpatient Setting*
Measure #10: Overuse of Stress Testing*
These measures were developed to support the delivery of high quality health care by meeting criteria in the Institute of Medicine’s six domains of quality improvement: Safe, Effective, Patient-centered, Timely, Efficient, and Equitable.
The ACC/AHA/PCPI have made draft versions of these measures available for public comment. All practitioners who care for outpatients with hypertension and coronary artery disease have an interest in understanding these measures and in providing recommendations on how to improve them. Make sure that your opinion is heard — visit http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-consortium-performance-improvement/public-comments.shtml to download draft versions of the measures and submit your comments.
Of course, we also welcome comment on these measures here in your responses to this post.
Dr. Masoudi is the Chair of the ACC/AHA Performance Measures Task Force, which commissioned these measures in collaboration with the PCPI.
5 Responses to “Proposed Performance Measures for Hypertension and Stable Coronary Artery Disease Now Available for Public Comment!”
NEJM Journal Watch — Recent Cardiology Articles- Does Lowering High Childhood Lipid Levels Prevent Adverse Cardiovascular Events in Adulthood?
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- A New TAVR Prosthesis for Aortic Regurgitation Shows Promise
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- Preventive PCI of Vulnerable Plaques Linked to Fewer Cardiac Events
I am curious whether there was any discussion about the appropriateness of specifying “how” to control blood pressure or lipid levels, not just whether these risk factors were controlled. For instance, should hypertensive patients first be offered diet and exercise, then a diuretic, then whatever seems next most appropriate? Obviously, there are patients for whom diet and exercise are not effective, but these should be offered first. Similarly, current evidence suggests patients are more likely to achieve better clinical outcomes using statins, as opposed to ezetimibe — but both might meet targets for lipid control.
What about hard outcomes?
Instead of measuring surrogate measures of success as listed above, why are we not interested in acuity based hard outcomes such as MI and stroke incidence, coronary death, hospital admissions and costs? It seems like these outcomes are more important than getting credit for using atenolol for CHF. The “evidence based” recommendations will change with the wind. Outcomes will always matter.
Competing interests pertaining specifically to this post, comment, or both:
I have received honoraria from GSK, Pfizer, and Abbott labs. I have an ownership interest in a facility that can do ultrasound imaging and coronary calcium imaging. I hate telling surviving family members that their loved one died on my watch following “evidence based” guidelines.
Surrogates
I agree with Joe — aren’t we moving away from an assumption that all drugs that affect a surrogate like LDL or blood pressure or glucose produce the same effect on patient risk and outcome. The evidence here seems clear that the drugs have different effects on people — so how can we persist with measures that are simply assessing how we are moving the surrogates.
Fred: was there any discussion of this issue?
Measuring Quality
Dr. Blanchet, I think we can all agree that hard, clinical outcomes are what we all care about. However, it is a tremendous “measurement” challenge to accurately assess physician performance using outcomes such as MI and stroke incidence because they (thankfully) happen relatively infrequently. Thus, the “less-good” focus on surrogate outcomes, such as LDL and hypertension control within physicians’ practices. I don’t think any one of us enjoys telling surviving family members that their mother/father/grandparent died despite our following “evidence-based guidelines” — but isn’t it better to explain that you followed all of the known best care practices, as opposed to doing “what seemed right”? Evidence-based guidelines are simply a road map to better outcomes. Clearly, there are lots of ways to travel somewhere — but if you want to direct the most people in the most expedient manner to a location, there is often only 1 or 2 best routes to take.
evidence based guidelines are not the answer
By the time something enters the realm of “evidence based”, it is generally old and often already proven invalid (ACE inhibitors in pts post CABG, atenolol as an acceptable beta blocker to name a couple).
For example, the guidelines do not understand the benefit of omega-3 fatty acids for CHF even though the studies are rather startlingly good. Guidelines do not recognize the value of treating sleep apnea and hypogonadism in both CAD and CHF however alert clinicians who read the literature know this.
Should we reward those who have their CHF patients on atenolol and give demerits to those who go beyond, have few if any adverse outcomes but do not limit their practice to guidelines that are cumbersomely compiled years after they should have been implemented.
Perhaps 10% of what I do can be defined by guidelines and most of them are in my opinion substandard. I think we are barking up the wrong tree with this concept. It is very good to create evidence based guidelines, but it is a mistake to consider that they can lead to best practice.