Feature: New HF performance measures promote continuity in care
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The nine performance measures include two measures focused on the inpatient setting, five on the outpatient setting and two that bridge the two settings. In determining the measures, the writing committee identified and retired eight past measures that were deemed redundant or no longer useful.
“There are many factors that go into how you define a measure and what is a good measure,” said Bonow, director of the Center for Cardiovascular Innovation at Northwestern University Feinberg School of Medicine in Chicago. “They may be just extra work and not what you are trying to achieve, which is improvement in quality. That is why we also retired some measures.”
The measures, published online April 23 in Circulation, reflect the findings in guidelines, with a focus on what is feasible, measurable and will lead to quality improvements. They also incorporate the perspectives of authors representing the American College of Cardiology, the American Heart Association, the American Medical Association-Physician Consortium for Performance Improvement and other collaborators. This multidisciplinary effort helped to ensure a continuum of care by a spectrum of healthcare professionals who treat HF patients.
By involving hospitalists, palliative care specialists and family practice and internal medicine physicians, for instance, the committee eliminated several measures that potentially might impede care, Bonow explained. “In a busy office practice, the internist is seeing many patients with multiple conditions and possibly multiple factors being measured,” he said. “You don’t want to create a lot of busy work; that hinders the flow of patients in a busy office.”
Elements of the measure set for the inpatient setting are:
- Left ventricle ejection fraction (LVEF) assessment: The percentage of patients age 18 years or older with a principal discharge diagnosis of HF with documentation in the hospital record of the results of an LVEF assessment performed either before arrival or during hospitalization, or documentation in the hospital record that LVEF assessment is planned after discharge; and
- Post-discharge appointment for HF patients: Percentage of HF patients, regardless of age, discharged from an inpatient facility to ambulatory care or home healthcare for whom a follow-up appointment was scheduled and documented, including location, date and time for a follow-up office visit or home healthcare visit. The post-discharge appointment is a new measure.“We wanted it to be specific,” Bonow said. “You made the appointment and this is what it is.” He added that most readmissions occur within the first two weeks, but it is unclear when is the ideal time to hold the post-discharge appointment or whether it is best that the patient see a physician, nurse or have a skilled home nurse visit him or her.
“This is where continuity becomes important,” Bonow says. “We are trying to get into the continuity of care issue but there is not sufficient data.”
Measures for the outpatient setting are:
- LVEF assessment: Percentage of adult HF patients for whom the quantitative or qualitative results of a recent or prior (any time in the past) LVEF assessment is documented within a 12-month period;
- Symptom and activity assessment: Percentage of adult HF patient visits with quantitative results of an evaluation of both current level of activity and clinical symptoms documented;
- Symptom management: Percentage of adult HF patient visits with quantitative results of an evaluation of both level of activity and clinical symptoms documented in which patient symptoms have improved or remained consistent with treatment goals since last assessment or patient symptoms have demonstrated clinically important deterioration since last assessment with a documented plan of care; to be used for internal quality improvement programs only;
- Patient self-care education: Percentage of adult HF patients who were provided with self-care education on three or more elements of education during one or more visits within a 12-month period. This is both a new measure and one for use in internal quality improvement programs only; and
- Counseling about implantable cardioverter-defibrillator (ICD) implantation for patients with left ventricular systolic dysfunction (LVSD) receiving combination medial therapy: Percentage of adult HF patients with current LVEF of 35 percent or less despite ACE inhibitor/ARB and beta-blocker therapy for at least three months who were counseled about ICD implantation as a treatment option for the prophylaxis of sudden death. This is both a new measure and one for use in internal quality improvement programs only.
Measures that include both inpatient and outpatient settings are:
- Beta-blocker therapy for LVSD: Percentage of adult HF patients with a current or prior LVEF of less than 40 percent who were prescribed beta-blocker therapy with bisoprolol, carvedilol or sustained-release metoprolol succinate either within a 12-month period when seen in the outpatient setting or at hospital discharge; and
- ACE inhibitor and ARB therapy for LVSD: Percentage of adult HF patients with a current or prior LVEF of less than 40 percent who were prescribed ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge.
The authors added exclusion criteria to the measures, arguing that there were justifiable reasons for not meeting the performance measures. “You need to create some degree of flexibility so doctors can use their judgment,” Bonow said.
The writing committee retired several measures such as smoking cessation from the 2005 measure set because they already exist within broader measure sets. The current measures are designed to improve the quality of care, and provide a foundation from which to later add other meaningful measures.
“There is still evidence of gaps in most of these areas,” he said. “You start at this level and as the playing field becomes even, you start raising the bar.”