During the past decade, there has been increased awareness of the need to improve the quality of care delivered to patients with coronary artery disease (CAD) and hypertension. In keeping consistent with this focus, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have developed guidelines and related performance measures that focus on these areas of care. In the July 12, 2011 issue of Circulation, the ACCF and AHA revised their original performance measures for adults with CAD and hypertension, which were developed in conjunction with the Physician Consortium for Performance Improvement (PCPI) and previously released in 2005.
More Than a “Routine” Update for CAD & Hypertension
With a general policy to revise performance measures no more than every 3 years, the AHA, ACCF, and PCPI had been working on revising the measurement sets for more than a year before they were published. “These new measurements represent a change in the science and methodology of how performance measures are typically developed,” says Joseph Drozda, Jr, MD, FACC, who co-chaired the PCPI panel. “The new measurements bring a focus on the outcomes of treatment rather than purely measures of process. We’re focusing on the things that make a difference and doing it in a way that will allow physicians to track their own performance in these key areas.”
The 2011 ACCF/AHA performance measure sets consist of 10 total measures derived from several professional guidelines. It includes revisions to measures that were released in the 2005 document and five new measures (Table 1). “There are robust guidelines for CAD, supported by strong levels of evidence with respect to each intervention in the measures,” says Dr. Drozda. “We know that the measures on CAD can be put into practice safely and effectively. That is why nine of the 10 measures are focused on CAD. With hypertension, such evidence is not available, aside from some things that are difficult to measure. For instance, lifestyle interventions are absolutely critical in treating high blood pressure (BP), but the data on these interventions are more challenging to find in medical records and are difficult to measure. The only feasible measure at this time is assessment of BP control.”
Important New Changes to Performance Measures
The 2011 ACCF/AHA/PCPI measures for tobacco use, smoking cessation and intervention, antiplatelet therapy, b-blocker therapy, and ACE inhibitor and angiotensin receptor-blocker therapy are fairly similar to the 2005 measures (Table 2), with the exception of an emphasis on referral to cardiac rehabilitation. “We recognized cardiac rehab as an underutilized intervention that has documented morbidity and mortality benefits for patients with established CAD,” says Dr. Drozda. More significant changes were made in the measures for BP and lipid control, as well as diabetes screening. “The 2005 measure for BP control concentrated on getting BP under 140/90 mm Hg, but it did not address the significant population of patients whose BP remains above that level,” explains Dr. Drozda. “The new performance measures aim to ensure that these patients are on at least two BP medications.”
The new lipid control measure goes beyond hitting the LDL target of 100 mg/dL in patients with CAD. It emphasizes the use of statins, a recommendation that was not made in the 2005 measures. “It’s pretty clear that statins are the standard of treatment in patients with established CAD,” adds Dr. Drozda. “While the original measures addressed some issues of symptoms and patient activity, the new measures are more specific. We wanted to make certain that physicians are regularly assessing patients for anginal symptoms and their level of activity, and then taking action when symptom control is inadequate.” Just as in 2005, the 2011 ACCF/AHA guidelines note that diabetes is a key comorbidity of CAD. “It’s critical to recognize that associated diabetes needs to be adequately managed in these patients,” Dr. Drozda says. “However, it can be difficult to assess whether screening for diabetes is carried out, making this an area of research that requires more attention.”
Seizing the Opportunity for Improvement
Performance measurements exist because there are opportunities for improvement. “Physicians can’t look for these opportunities unless they’re measuring how well or poorly they’re managing their patients,” says Dr. Drozda. “Physicians should incorporate these measures into their own practice assessments. These measures will hopefully be adopted by others, including CMS, and will find their way into meaningful use, maintenance of certification programs, and pay-for-performance programs. Physicians should become aware of them and understand how they’re derived because it’s likely their performance will be judged in the future based on measures like these.”
Readings & Resources (click to view)
Drozda J, Messer J, Spertus J, et al. ACCF/AHA/AMA–PCPI 2011 Performance measures for adults with coronary artery disease and hypertension. Circulation. 2011;124:248-270. Okada K, Kimura K, Iwahashi N, et al. Clinical usefulness of additional treatment with ezetimibe in patients with coronary artery disease on statin therapy. Circ J. 2011. Aug 2. [Epub ahead of print]. Available at www.jstage.jst.go.jp/article/circj/advpub/0/advpub_1107261349/_article. Schoenhagen P, Uno K. Coronary computer tomography in the evaluation of symptomatic patients with suspected coronary artery disease. Circ J. 2011. Aug 2. [Epub ahead of print]. Available at www.jstage.jst.go.jp/article/circj/advpub/0/advpub_1107261353/_article. Roberts R, Chen L, Wells G, Stewart A. Recent success in the discovery of coronary artery disease genes. Can J Physiol Pharmacol. 2011. Aug 4. [Epub ahead of print]. Available at www.nrcresearchpress.com/doi/abs/10.1139/y11-041. Gargiulo P, Petretta M, Bruzzese D, et al. Myocardial perfusion scintigraphy and echocardiography for detecting coronary artery disease in hypertensive patients: a meta-analysis. Eur J Nucl Med Mol Imaging. 2011. Aug 4. [Epub ahead of print]. Available at www.springerlink.com/content/m4373q569l157755 Dzierwa K, Pieniazek P, Musialek P, et al. Treatment strategies in severe symptomatic carotid and coronary artery disease. Med Sci Monit. 2011;17:RA191-RA197. Wu G, Wei G, Huang J, et al. Decreased gene expression of LC3 in peripheral leucocytes of patients with coronary artery disease. Eur J Clin Invest.2011;41:958-963.