Share this article on:

AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services

Thomas, Randal J. MD, MS, FAHA; King, Marjorie MD, FAACVPR, FACC; Lui, Karen MS, RN, FAACVPR; Oldridge, Neil PhD, FAACVPR; Piña, Ileana L. MD, FACC; Spertus, John MD, MPH, FACC; ACC/AHA Task Force Members

Journal of Cardiopulmonary Rehabilitation & Prevention: September/October 2007 - Volume 27 - Issue 5 - p 260–290
doi: 10.1097/01.HCR.0000291295.24776.7b
Aacvpr/Acc/Aha Statement

This article is being copublished in the October 2, 2007, issues of Circulation and the Journal of the American College of Cardiology.

Copies: This document is available on the World Wide Web sites of the American Association of Cardiovascular and Pulmonary Rehabilitation (www.aacvpr.org), American College of Cardiology (www.acc.org), and American Heart Association (my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail: reprints@elsevier.com.

Permissions: Modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Cardiology Foundation, or American Heart Association. Please contact the American Heart Association: Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier=4431.

Task Force members are as follows: Robert O. Bonow, MD, FACC, FAHA; N. A. Mark Estes III, MD, FACC; David C. Goff; Kathleen L. Grady, PhD, RN; Ann R. Hiniker, CNS; Frederick A. Masoudi, MD, MPH, FACC; Ileana L. Piña, MD, FACC; Martha J. Radford, MD; John S. Rumsfeld, MD, PhD, FACC; Gayle R. Whitman, PhD, RN.

Endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons.

This document was approved by the American Association of Cardiovascular and Pulmonary Rehabilitation Board of Directors in May 2007 and by the American College of Cardiology Foundation Board of Trustees and the American Heart Association Science Advisory and Coordinating Committee in April 2007. When citing this document, the AACVPR, American College of Cardiology Foundation, and the American Heart Association would appreciate the following citation format: Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. J Cardiopulmon Rehabil Prevent. 2007;27:260–290.

Back to Top | Article Outline

PREAMBLE

Medicine is experiencing an unprecedented focus on quantifying and improving healthcare quality. The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multifaceted strategy to facilitate the process of improving clinical care. The initial phase of this effort was to create clinical practice guidelines that carefully review and synthesize available evidence to better guide patient care. Such guidelines are written in a spirit of suggesting diagnostic or therapeutic interventions for patients in most circumstances. Accordingly, significant judgment by clinicians is required to adapt these guidelines for the care of individual patients, and these guidelines can be generated with varying degrees of confidence on the basis of available evidence.

Occasionally, the evidence supporting a particular structural aspect or process of care is so strong that failure to perform such actions reduces the likelihood that optimal patient outcomes will occur. Creating a mechanism for quantifying these opportunities to improve the outcomes of care is an important and pressing challenge. In the next phase of its quality improvement (QI) efforts, the ACC and the AHA created the ACC/AHA Task Force on Performance Measures in February 2000 to spearhead the development of performance measures that allow the quality of cardiovascular care to be assessed and improved. Three nominees from each organization were charged with the task of assembling teams of clinical and methodological experts, both from within the sponsoring organizations and from other organizations dedicated to the care of patients covered by the performance measurement set. These writing committees were given careful guidance with respect to the necessary attributes of good performance measures and the process of identifying, constructing, and refining these measures so that they can accurately achieve their desired goals.1

The role of performance measurement writing committees is not to perform a primary evaluation of the medical literature; this is undertaken by ACC/AHA guidelines committees. However, performance measurement writing committees work collaboratively with guidelines committees so that the guideline recommendations are written with a degree of specificity that supports performance measurement and so that new knowledge can be rapidly incorporated into performance measurement. Development of the ACC/AHA guidelines includes a detailed review of and ranking of the evidence available for the diagnosis and treatment of specific disease areas. Published guideline recommendations employ the ACC/AHA classification systems I, IIa, IIb, and III (Table 1).

So as not to duplicate performance measure development efforts, writing committees were also instructed to evaluate existing nationally recognized performance measures using the ACC/AHA “attributes of good performance measures.” The measure specifications were adopted for those performance measures that meet these criteria. Such measures have established validity, reliability, and feasibility and would form the foundation of the ACC/AHA measurement sets. Furthermore, writing committees are encouraged to identify additional performance measures that correspond to those key areas of quality proven to improve patient outcomes.

The ACC/AHA Performance Measurement Sets are to be applied in the inpatient and/or outpatient setting depending upon the topic. Although inpatient measures have traditionally been captured by retrospective data collection, the increased use of electronic medical records allows for prospective collection in the inpatient and outpatient settings. Prospective data collection is itself a continuous QI process. The performance measures quantify explicit actions performed in carefully specified patients for whom adherence should be advocated in all but the most unusual circumstances. In addition, the measures are constructed with the intent to facilitate both retrospective and prospective data collection using explicit administrative and/or easily documented clinical criteria. Furthermore, the data elements required to construct the performance measures are identified and linked to existing ACC/AHA Clinical Data Standards to encourage the standardization of cardiovascular measurement.

Although the focus of the performance measures writing committees is to develop measures for internal QI, it is appreciated that other organizations may use these measures for external reporting of provider performance. Therefore, it is within the scope of the writing committee's task to comment on the strengths and limitations of externally reporting potential performance measures. Specifically, this was done in the “Challenges to implementation” sections in each of the performance measures when appropriate (see Appendixes A and B).

All the measures contained in this set have limitations and challenges to implementation that could result in unintended consequences when used for accountability purposes. The implementation of these measures for purposes other than QI require field testing to address issues related to, but not limited to, sample size, reasonable frequency of use for an intervention, comparability, and audit requirements. The way in which these issues are addressed would be highly dependent on the type of accountability system developed, including data collection method, assignment of patients to physicians for measurement purposes, baseline measure setting, incentive system, and public reporting method among others. The ACC/AHA encourages those interested in working on implementation of these measures for purposes beyond QI to work with the ACC/AHA to understand these complex issues in pilot testing projects that can measure the impact of any limitations and provide guidance on possible refinements of the measures that would make them more suitable for additional purposes.

In the process of facilitating the measurement of cardiovascular healthcare quality, the ACC/AHA Performance Measurement Sets can serve as a vehicle for more rapidly translating the strongest clinical evidence into practice. These documents are intended to provide practitioners with “tools” for measuring the quality of care and for identifying opportunities to improve. Because the target audience and unit of analysis for these measures is the practitioner, they were constructed from the provider's perspective and were not intended to characterize “good” or “bad” practice but to be part of a system with which to assess and improve healthcare quality. It is our hope that an application of these performance measures within a system of QI will provide a mechanism through which the quality of medical care can be measured and improved.

Robert O. Bonow, MD, FACC, FAHA, FACP

Chair, ACCF/AHA Task Force on Performance Measures

Over the past 4 decades, cardiac rehabilitation/secondary prevention (CR) services have become recognized as a significant component in the continuum of care for persons with cardiovascular disease (CVD). The role of CR services in the comprehensive secondary prevention of CVD events is well documented2–12 and has been promoted by various healthcare organizations and position statements.4,12–18 However, performance measures for CR services have not been published to date.

To formalize performance measures for CR services, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)/American College of Cardiology (ACC)/American Heart Association (AHA) Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee was convened in November 2005. The writing committee was given the charge of developing performance measures that cover 2 specific aspects of CR services: (1) referral of eligible patients to a CR program; and (2) delivery of CR services through multidisciplinary CR programs.

The ultimate purpose of these performance measure sets is to help improve the delivery of CR to reduce cardiovascular mortality and morbidity and optimize health in persons with CVD, including acute myocardial infarction (MI) or status post coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI), stable angina, and heart transplantation or heart valve surgery. Using the previously published methodology of the ACC and the AHA,1,19 performance measures for the referral of eligible patients to a CR program and the delivery of CR services through multidisciplinary CR programs were developed, focusing on processes of care that have been documented to help improve patient outcomes (using the ACC/AHA system for classification of recommendations and level of evidence for guidelines and clinical recommendations shown in Table 1). Both inpatient and outpatient settings of cardiovascular care were considered, resulting in performance measures being created for 3 specific settings: (1) hospitals; (2) office practices; and (3) CR programs.

Back to Top | Article Outline

Rationale for CR Performance Measures/Secondary Prevention

The rationale for developing and implementing performance measure sets for referral to and delivery of CR services is based on several key factors:

* There has been growing scientific evidence over the past 3 decades on the benefits of CR services for persons with CVD.2,17,20 Evidence suggests that the benefits of CR services are as significant in recent years as they were in the prethrombolytic era.9,21 Because of this mounting evidence, a number of healthcare organizations have endorsed the use of CR services in persons with CVD by including provisions for CR in their practice guidelines and practice management position papers.4,12,13,18,21–23

* Despite both the known benefits of CR and the widespread endorsement of its use, CR is vastly underutilized, with less than 30% of eligible patients participating in a CR program after a CVD event.24–26 Reasons for this gap in CR participation are numerous, but the most critical and potentially most correctable reasons revolve around obstacles in the initial referral of patients to CR programs. These obstacles can be reduced through the systematic adoption of standing orders and other similar tools for CR referral for appropriate hospitalized patients.27 Furthermore, physician accountability associated with the use of these performance measures may lead to new and novel approaches to improve both referral rates and the outcome of patients with CVD.

* Standards for CR programs have been previously published,28 and systems for CR program certification exist, such as the certification process offered through the AACVPR for CR programs that meet its standards of practice. Unfortunately, since such certification is not required for CR program operation or for reimbursement purposes, CR program certification is obtained by a relatively small portion of CR programs in the United States. As of October 2006, only 973 (37%) of an estimated 2,621 CR programs operating in the United States have AACVPR certification29 (A. Lynn, personal communication, October 31, 2006).

* Recommendations for CR referral and participation are included in many practice guidelines and position papers regarding the care of persons with CVD, but to date, no groups have included referral to CR services in their CVD-related performance measure sets. Likewise, there are no currently available performance measure sets that include measures for the delivery of CR services by outpatient CR programs.

Clearly, there is a need and also a prime opportunity to reduce the gap in delivery of CR services to persons with CVD. Such an improvement in CR delivery will require better approaches in the referral to, enrollment in, and completion of programs in CR. It is anticipated that the implementation of CR performance measure sets will stimulate changes in the clinical practice of preventive and rehabilitative care for persons with CVD.

Back to Top | Article Outline

Writing Committee Structure and Members

To formalize performance measures for CR services, the AACVPR/ACC/AHA Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee was convened in November 2005. The writing committee was composed of nominated representatives from the AACVPR, the ACC, and the AHA, including past and current representatives of the ACC Task Force on Performance Measures, past and current presidents of the AACVPR, and clinicians with expertise in general clinical cardiology, heart failure, CVD, and CR. An initial committee meeting was held in Kansas City, Missouri, on January 23 and 24, 2006. Committee meetings were otherwise held by teleconference, generally at weekly intervals.

Back to Top | Article Outline

Relationships With Industry

Committee members volunteered their time to participate in the writing committee and acknowledged any potential conflicts of interest (Appendix C). The AACVPR, the ACC, and the AHA supported the cost of both the initial committee meeting in January 2006 and conference calls. No commercial support was provided for any aspect of the committee's work.

Back to Top | Article Outline

Review and Endorsement

A public comment period was held for this document from December 11, 2006, until January 11, 2007. Reviewers were asked to provide comments on the document on the basis of the rating form and guide shown in Appendix D. Reviewer comments were considered and incorporated into a revised version of the document. Review and final approval of the final version of the paper was obtained through the governing bodies from the AACVPR, the ACC, and the AHA. Endorsement of the final paper was sought from key partnering organizations.

Back to Top | Article Outline

METHODOLOGY

Definition of CR

Over the past decade, various CR program delivery paradigms have evolved from the traditional definition where programs operate within a CR center and patients attend sessions in person. Some examples of these programs include those outpatient programs where staff members provide CR services to patients through novel methods such as those that are home-, telephone-, or Internet-based.

The definition for CR in general use today is based on a modification from the original World Health Organization 1964 definition of CR.30 This definition reinforced the observation that CR is an integral component in the overall management of patients with CVD, that the patient plays a significant role in the successful outcome of CR, and that CR is an important source of services aimed at the secondary prevention of CVD events.2,4,12

Building on this original definition, a number of other complementary definitions of CR have been promulgated by various organizations including the US Public Health Service, the AHA, the AACVPR, and the Canadian Association of Cardiac Rehabilitation.4,18 These updated definitions emphasize the integral role of CR in the secondary prevention of CVD.

The definition used by the US Public Health Service and by the Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee is as follows:

Cardiac rehabilitation services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counselling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or re-infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients.4

CR programs are generally divided into 3 main phases:

1. Inpatient CR (also known as phase I CR): A program that delivers preventive and rehabilitative services to hospitalized patients following an index CVD event, such as an MI/acute coronary syndrome.

2. Early outpatient CR (also known as phase II CR): A program that delivers preventive and rehabilitative services to patients in the outpatient setting early after a CVD event, generally within the first 3 to 6 months after the event but continuing for as much as 1 year after the event.

3. Long-term outpatient CR (also known as phase III or phase IV CR): A program that provides longer-term delivery of preventive and rehabilitative services for patients in the outpatient setting.

The main focus of this position paper is on the referral to and delivery of early outpatient CR services principally because it is the component of CR that has been most widely documented to help reduce the risk of CVD mortality among its participants.

Back to Top | Article Outline

Definition of Appropriate Patients for CR

Patients who are considered eligible for CR include those who have experienced 1 or more of the following conditions as a primary diagnosis sometime within the previous year:

* MI/acute coronary syndrome*

* CABG surgery*

* PCI*

* Stable angina*

* Heart valve surgical repair or replacement

* Heart or heart/lung transplantation

The thrust of this document is focused on the management of persons with coronary artery disease—related conditions (noted in the list above with an asterisk), but CR services are considered appropriate and beneficial for persons (1) after heart valve surgical repair or replacement and (2) after heart or heart/lung transplantation (as previously listed).31–34 Furthermore, growing evidence from published studies supports a CR benefit for persons with chronic heart failure or peripheral arterial disease.35,36 However, formal recommendations by healthcare organizations to approve and/or cover CR services in these patient populations will depend upon policy decision makers and, particularly, in the case of chronic heart failure, the results of ongoing research studies.

Persons who are potentially eligible for CR may, in fact, have barriers that limit their participation in CR. Such barriers include those that are patient-oriented (eg, patient refusal), others that are provider-oriented (eg, provider deems the patient ineligible for CR due to a high-risk medical condition and/or an absolute contraindication to exercise), and still others that are related to the healthcare system and/or societal barriers (eg, lack of a CR program, lack of insurance coverage).17 Patients with such barriers may be excluded from the number of patients who are considered to be eligible for CR referral (Appendix A, under the “Numerator” criteria for assessing the percentage of eligible patients who have been referred to a CR program). It should be noted, however, that even though some persons may have significant patient- or provider-oriented barriers to CR referral, nearly all patients with CVD could benefit from at least some components of a comprehensive, secondary prevention CR program.

Back to Top | Article Outline

Overview of Performance Measures Created

Both structure- and process-based performance measures are included in the Cardiac Rehabilitation/ Secondary Prevention Performance Measurement Sets. While important and related, specific measures focused on clinical outcomes are not included. The performance measures that are included are designed to help healthcare groups identify potentially correctable and actionable “upstream” sources of suboptimal clinical care, such as structure- and process-based gaps in CR services. Details for the dimensions of care included in the Cardiac Rehabilitation/Secondary Prevention Performance Measurement Sets are outlined as follows:

1. Structure-based measures quantify the infrastructure from which CR is provided and are based on the provision of appropriate personnel and equipment to satisfy high-quality standards of care for CR services. For example, a structure-based performance measure for a CR program is one that specifies that a CR program has appropriate personnel and equipment to provide rapid care in medical emergencies that may occur during CR program sessions.

2. Process-based measures quantify specific aspects of care and are designed to capture all relevant dimensions of CR care. For example, a process-based performance measure for a CR program is one that specifies that all patients in a CR program undergo comprehensive, standardized assessment of their cardiovascular risk factors upon entry to the CR program.

It should also be noted that the Cardiac Rehabilitation/ Secondary Prevention Performance Measurement Sets have been designed for 3 different geographical settings of care: (1) the hospital; (2) the physician office; and (3) the CR program settings. Staff members within each of these areas who help provide care to persons with CVD are held accountable for the various aspects of CR services (referral to, enrollment in, and delivery of CR services).

Back to Top | Article Outline

Literature Review and Evidence Base

There is substantial evidence to conclude that CR is reasonable and necessary following MI, CABG surgery, stable angina, heart valve repair or replacement, PCI, and heart or heart/lung transplantion.12 Outpatient, medically supervised CR, as described by the US Public Health Service, is a comprehensive, long-term intervention including medical evaluation, prescribed exercise, cardiac risk-factor modification, education, and counseling typically initiated 1 to 3 weeks after hospital discharge and typically including electrocardiographic monitoring of patients (see “Definition of CR” section).4

Meta-analyses and systematic reviews2,3,5–11 provide and summarize the extensive evidence that has been generated from published randomized clinical trials demonstrating that exercise-based CR services are beneficial for patients with established CVD. These benefits include improved processes of care and risk-factor profiles that are closely linked to subsequent mortality and morbidity. Pooled data from randomized clinical trials of CR demonstrate a mortality benefit of approximately 20% to 25%2,3,5–11 and a trend toward reduction in nonfatal recurrent MI over a median follow-up of 12 months.10

Back to Top | Article Outline

Definition and Selection of Measures

The Cardiac Rehabilitation/Secondary Prevention Performance Measure Writing Committee initially identified 39 factors from various practice guidelines and other reports that were considered potential performance measures for the Cardiac Rehabilitation/Secondary Prevention Performance Measurement Sets (see Table 1 for standard guidelines that were used to rate the classification of recommendations and level of evidence for assessing these factors). The group evaluated these factors according to guidelines established by the ACC/AHA Task Force on Performance Measures.1 Those measures that were deemed to be most evidence-based, interpretable, actionable, clinically meaningful, valid, reliable, and feasible were included in the final performance measurement sets. Once these measures were identified, the writing committee then discussed and refined, over a series of months, the definition, content, and other details of each of the selected measures.

While most performance measures are designed for a specific condition and phase of a particular disease, CR referral is applicable and appropriate for a number of different conditions and phases of CVD. Accordingly, the writing committee created 2 sets of performance measures, one related to the appropriate referral of patients to a CR program and another set related to optimal performance of a CR program itself. In creating the first set, the writing committee sought to create a measure that would be appropriate for insertion into other performance measurement sets for which CR referral would be appropriate (eg, performance measurement sets for care of patients following MI, PCI, or CABG surgery). Figure 1 outlines the overall organization of these 2 types of measures and their intended applications.

Back to Top | Article Outline

MEASURES RELATED TO EARLY OUTPATIENT CR REFERRAL

The performance measures that are related to the referral of appropriate patients to an early outpatient CR program are described in the next section.

Back to Top | Article Outline

Populations, Care Period, and Responsible Parties

Patients who are appropriate for referral to an early outpatient CR program include those patients who, in the previous 12 months, have had any of the diagnoses listed in the “Definition of appropriate patients for CR” section. The CR services are generally most beneficial when delivered soon after the index hospitalization. However, there are often clinical, social, and logistical reasons that delay enrollment in CR. For this reason, many third-party payers allow CR services to begin up to 6 to 12 months following a cardiac event. Because patients can be referred to CR at varying times following a CVD event, parties responsible for the referral of patients to CR include hospitals and healthcare systems as well as physician practices and other healthcare settings with primary responsibility for the care of patients after a CVD event.

Back to Top | Article Outline

Brief Summary of the Measures

The Cardiac Rehabilitation/Secondary Prevention Performance Measurement Set A (Appendix A) is based on 2 criteria for the appropriate referral of patients to an early outpatient CR program:

1. all hospitalized patients with a qualifying CVD event are referred to an early outpatient CR program prior to hospital discharge; and

2. all outpatients with a qualifying diagnosis within the past year who have not already participated in an early outpatient CR program are referred to an early outpatient CR program by their healthcare provider.

It should be noted that the healthcare system and its providers who care for patients during and/or after CVD events are accountable for these performance measures. Physicians or other healthcare providers who see patients with CVD but who do not have a primary role in managing their CVD are not accountable for meeting these criteria. For example, an ophthalmologist who is performing an annual retinal examination on a diabetic patient in the year after his or her MI would not be responsible for referring the patient to a CR program. Additional details regarding this performance measurement set are included in Appendix A.

Back to Top | Article Outline

Data Collection Instruments

Examples of tools that may be of help in applying the Cardiac Rehabilitation/Secondary Prevention Performance Measurement Set A (Appendix A) into practice are included in Figures 2 and 3. Figure 2 shows an example of a standardized CR referral tool that healthcare systems could potentially use in the inpatient setting, whereas Figure 3 shows an example of a potential CR referral tool for outpatient practice settings. Figure 4 shows an example of a performance measure tracking tool that can be used by healthcare systems following an MI, with the performance measure of CR referral included in the performance measurement tool. These tools are given as examples and not as endorsed instruments. Healthcare systems and providers are encouraged to develop and implement systematic tools that are most appropriate and most effective for their particular setting and patient population groups.

Back to Top | Article Outline

Inclusion in Other Performance Measurement Sets

The Cardiac Rehabilitation/Secondary Prevention Performance Measurement Set A (Appendix A) is designed to be included in (ie, “plugged into”) other related performance measurement sets for which referral to a CR program would be considered an appropriate component of high-quality care (eg, can be “plugged into” the performance measurement set for management of patients with MI).

Back to Top | Article Outline

MEASURES TO DEFINE QUALITY EARLY OUTPATIENT CR PROGRAMS

The second set of performance measures included in the Cardiac Rehabilitation/Secondary Prevention Performance Measurement Sets—Performance Measurement Set B (Appendix B)—relates to the optimal structure and processes of care for CR programs themselves and is described in the next section.

Back to Top | Article Outline

Populations, Care Period, and Responsible Parties

Patients who are appropriate for entry into a CR program include persons 18 years or older who, during the previous year, have had 1 or more of the qualifying diagnoses listed in the “Definition of appropriate patients for CR” section. Patients who are considered ineligible for CR services, by patient-oriented or provider-oriented criteria (see the “Definition of appropriate patients for CR” section), may still be appropriate candidates for enrollment in modified CR programs that adapt their services to a given patient's limitations, geographic or otherwise. The period of care for early outpatient CR typically begins 1 to 3 weeks after the index CVD event and lasts up to 3 to 6 months.

The unit of analysis for the Cardiac Rehabilitation/ Secondary Prevention Performance Measurement Set B is the healthcare system's CR program(s). Therefore, the responsible parties for the performance of early outpatient CR services include members of the CR program staff—the medical director, nurses, exercise specialists, cardiovascular administrators, and other members of the CR team.

Back to Top | Article Outline

Brief Summary of the Outpatient CR Program Measurement Set

The Cardiac Rehabilitation/Secondary Prevention Performance Measurement Set B for the delivery of CR services includes those measures that were considered by the writing committee to have the highest level of evidence and consensus support among its members.

The measures selected include both structure- and process-based measures that are used to assess the following policies and procedures by CR programs:

Back to Top | Article Outline

Structural Measures (Appendix B: Performance Measure B-1)

* A physician medical director is responsible for the program

* An emergency response team with appropriate emergency equipment and trained staff is available during patient care hours

Back to Top | Article Outline

Process Measures (Appendix B: Performance Measure B-2, B-3, and B-4)

* Assessment and documentation of each patient's risk for adverse events during exercise

* A process to assess patients for intercurrent changes in symptoms

* Individualized assessment and evaluation of modifiable CVD risk factors

* Development of individualized risk-reduction interventions for identified conditions and coordination of care with other healthcare providers

* Evidence of a plan to monitor response and document program effectiveness through ongoing analysis of aggregate data. This includes:

* a plan to assess completion of the prescribed course of CR;

* a standardized plan to reassess patient outcomes at the completion of CR; and

* methodology to document program effectiveness and initiate quality improvement (QI) strategies. Appendix B provides the detailed specifications for each outpatient performance measure.

Back to Top | Article Outline

Data Collection Instruments

The Cardiac Rehabilitation/Secondary Prevention Performance Measurement Set B is intended to be used prospectively to review a program's internal procedures with the ultimate goal of enhancing the QI process. To aid in data compilation, ideally collected prospectively, a data collection tool or flow sheet is recommended. An example of such a collection tool is shown in Table 2.

Healthcare systems and practices are encouraged to develop and/or use a tool that conforms to local practice patterns and standards.

Back to Top | Article Outline

DISCUSSION

The aim of the Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee was to address 2 important, persistent gaps in the quality of care for patients with CVD: namely, inadequate referral rates to CR programs and the need for minimum performance standards for such CR programs. Currently, a minority of patients receives CR services and secondary prevention services due, in general, to a number of patient-, provider-, and healthcare system—related barriers. The writing committee designed performance measurement sets that hold healthcare providers, CR program staff members, and leaders of healthcare systems accountable for the ultimate goal of linking eligible patients to the appropriate CR services following a qualifying CVD event.

The writing committee focused its attention on 2 general performance measurement sets: (1) referral of eligible patients to an outpatient CR program; and (2) delivery of appropriate CR services by CR programs. The first performance measure is designed to be used as a plug-in component to other performance measurement sets for which CR referral is deemed appropriate (eg, post-MI, post-CABG surgery, post-PCI). The second performance measurement set is designed to clarify structure- and process-based performance measures that serve as a standard for CR programs, as they work to continually improve the quality of care provided to their patients with CVD and thereby optimize their patients' health-related outcomes.

The writing committee did not include performance measures for all patient groups that may benefit from CR services, but focused on those groups of patients with the most current scientific evidence and other supporting evidence for benefits from CR. Other patient groups, including those patients who have undergone heart valve surgery or who have received heart or heart/lung transplantation, are also appropriate for CR referral. In addition, there is growing evidence for the benefits of CR in persons with other cardiovascular conditions, including heart failure and peripheral vascular disease. As more evidence becomes available for the benefits of CR in these patient groups, they would be included in future iterations of the Cardiac Rehabilitation/Secondary Prevention Performance Measurement Sets.

To be effective, the recommendations of the writing committee would need to be adapted, adopted, and implemented by healthcare systems, healthcare providers, health insurance carriers, chronic disease management organizations, and other groups in the healthcare field that have responsibility for the delivery of care to persons with CVD. Such strategies should be part of an overall systems-based approach to minimize inappropriate gaps and variation in patient care, optimize delivery of health-promoting services, and improve patient-centered health outcomes.

Back to Top | Article Outline

—Acknowledgments—

The authors acknowledge special thanks to Costas Lambrew, MD, FACC; Tilithia McBride; Joseph Allen; Abigail Lynn; Marie Bass; and Megan Dunn.

Staff

American College of Cardiology Foundation

John C. Lewin, MD, Chief Executive Officer

Thomas E. Arend, Jr., Esq., Chief Operating Officer

Tilithia McBride, Associate Director, Data Standards and Performance Measures

Erin A. Barrett, Senior Specialist, Clinical Policy and Documents

American Heart Association

M. Cass Wheeler, Chief Executive Officer

Rose Marie Robertson, MD, FACC, FAHA, Chief Science Officer

Kathryn A. Taubert, PhD, FAHA, Senior Science Advisor

American Association of Cardiovascular and Pulmonary Rehabilitation

Marie A. Bass, MS, CAE, Executive Director

Abigail Lynn, Senior Associate, National Office

Back to Top | Article Outline

References

1. Spertus JA, Eagle KA, Krumholz HM, Mitchell KR, Normand SL. American College of Cardiology and American Heart Association methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. J Am Coll Cardiol. 2005;45:1147–1156.
2. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA. 1988;260:945–950.
3. O'Connor GT, Buring JE, Yusuf S, et al. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation. 1989;80:234–244.
4. Wenger NK, Froelicher ES, Smith LK, Ades PA, et al. Cardiac Rehabilitation: Clinical Practice Guideline. Rockville, Md: US Agency for Healthcare Research and Quality, Department of Health & Human Services; 1995. Clinical Guideline No. 17 (AHCPR 96-0672).
5. Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med. 1996;156:745–752.
6. Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2001:CD001800.
7. McAlister FA, Lawson FM, Teo KK, Armstrong PW. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ. 2001;323:957–962.
8. Brown ATR, Noorani H, Stone J, Skidmore B. Exercise-Based Cardiac Rehabilitation Programs for Coronary Artery Disease: A Systematic Clinical and Economic Review. Ottawa, Ontario: Canadian Coordinating Office for Health Technology Assessment; 2003. Technical Overview #11.
9. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682–692.
10. Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med. 2005;143:659–672.
11. Agency for Health Care Research Technology Assessment Program. Randomized Trials of Secondary Prevention Programs in Coronary Artery Disease: A Systematic Review. Rockville, MD: Agency for Health Care Research and Quality; 2005.
12. Centers for Medicare and Medicaid Services. Decision Memo for Cardiac Rehabilitation Programs. Baltimore: Centers for Medicare and Medicaid Services, US Department of Health & Human Services; 2006. CAG-00089R.
13. Goble AJ, Worchester M. Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention: A Synopsis. Produced on behalf of Victoria Department of Human Services. Melbourne, Australia: Heart Research Centre. Available at: http://www.heartresearchcentre.org/images/assets/Forms/bpgsynopsis.pdf. Published 1999. Accessed June 22, 2007.
14. New Zealand Guidelines Group. Cardiac Rehabilitation. Wellington, New Zealand: New Zealand Guidelines Group; 2002.
15. Giannuzzi P, Mezzani A, Saner H, et al. Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur J Cardiovasc Prev Rehabil. 2003;10:319–327.
16. Working Group on Cardiac Rehabilitation and Secondary Prevention of the Austrian Society of Cardiology. Guidelines for Outpatient Cardiac Rehabilitation and Prevention. Conclusions of the Austrian Society of Cardiology. Vienna: Working Group on Cardiac Rehabilitation and Secondary Prevention of the Austrian Society of Cardiology; 2005.
17. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111:369–376.
18. Stone JA, Arthur HM. Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention. 2nd ed. 2004. Executive summary. Can J Cardiol. 2005;21(suppl D):3D–19D.
19. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003; 107:149–158.
20. Witt BJ, Jacobsen SJ, Weston SA, et al. Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol. 2004;44:988–996.
21. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 2004;110:1168–1176.
22. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007;115:1481–1501.
23. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention—-summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol. 2006;47:216–235.
24. Thomas RJ, Miller NH, Lamendola C, et al. National survey on gender differences in cardiac rehabilitation programs. Patient characteristics and enrollment patterns. J Cardiopulm Rehabil. 1996;16:402–412.
25. Receipt of cardiac rehabilitation services among heart attack survivors—-19 states and the District of Columbia, 2001. MMWR Morb Mortal Wkly Rep. 2003;52:1072–1075.
26. Cortes O, Arthur HM. Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review. Am Heart J. 2006;151:249–256.
27. Fonarow GC, Gawlinski A, Moughrabi S, Tillisch JH. Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol. 2001;87:819–822.
28. Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac Rehabilitation/Secondary prevention programs: a statement for health care professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation. 2000;102:1069–1073.
29. Curnier DY, Savage PD, Ades PA. Geographic distribution of cardiac rehabilitation programs in the United States. J Cardiopulm Rehabil. 2005;25:80–84.
30. Brown RA. Rehabilitation of patients with cardiovascular diseases. Report of a WHO expert committee. World Health Organ Tech Rep Ser. 1964;270:3–46.
31. Squires R. Cardiac rehabilitation issues for heart transplant patient. J Cardiopulm Rehabil. 1990:10159–10168.
32. Kobashigawa JA, Leaf DA, Lee N, et al. A controlled trial of exercise rehabilitation after heart transplantation. N Engl J Med. 1999;340:272–277.
33. Stewart KJ, Badenhop D, Brubaker PH, Keteyian SJ, King M. Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery, and for chronic heart failure. Chest. 2003;123:2104–2111.
34. Kavanagh T, Mertens DJ, Shephard RJ, et al. Long-term cardiorespiratory results of exercise training following cardiac transplantation. Am J Cardiol. 2003;91:190–194.
35. Falcone RA, Hirsch AT, Regensteiner JG, et al. Peripheral arterial disease rehabilitation: a review. J Cardiopulm Rehabil. 2003;23:170–175.
36. Austin J, Williams R, Ross L, Moseley L, Hutchison S. Randomised controlled trial of cardiac rehabilitation in elderly patients with heart failure. Eur J Heart Fail. 2005;7:411–417.
37. Zarling KK, Schad SP, Salz KA, et al. Mayo Clinic's Order Set for Provider Referral to Outpatient Cardiac Rehabilitation (Phase II). Rochester, Minn: Mayo Foundation for Medical Education and Research; 2005.
38. American Heart Association. Multidisciplinary cardiac discharge checklist/instructions [Get With The Guidelines Web site]. Available at: http://www.americanheart.org/downloadable/heart/1055429944221GWTG_CAD_Discharge_Template.doc. Accessed March 14, 2007.
39. Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2006;47:2130–2139.
40. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol. 2004;44:E1–E211.
41. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002;40:1366–1374.
42. Hunt SA. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2005;46:e1–e82.
43. King ML, Williams MA, Fletcher GF, et al. Medical director responsibilities for outpatient cardiac Rehabilitation/Secondary prevention programs: a scientific statement from the American Heart Association/American Association for Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;112: 3354–3360.
44. Pina IL, Balady GJ, Hanson P, Labovitz AJ, Madonna DW, Myers J. Guidelines for clinical exercise testing laboratories. A statement for health care professionals from the Committee on Exercise and Cardiac Rehabilitation, American Heart Association. Circulation. 1995;91:912–921.
45. Centers for Medicare and Medicaid Services. CMS National Coverage Determination for Cardiac Rehabilitation Programs. Baltimore: Centers for Medicare and Medicaid Services. Publication Number 100-3; Manual Section Number 20:10; Version Number 2.
46. American Heart Association. Fundamentals of BLS for Health Care Providers. Dallas, Tex: American Heart Association; 2001.
47. American Heart Association. ACLS Provider Manual. Dallas, Tex: American Heart Association; 2001.
48. Richardson LA, Buckenmeyer PJ, Bauman BD, Rosneck JS, Newman I, Josephson RA. Contemporary cardiac rehabilitation: patient characteristics and temporal trends over the past decade. J Cardiopulm Rehabil. 2000;20:57–64.
49. Van Camp SP, Peterson RA. Cardiovascular complications of outpatient cardiac rehabilitation programs. JAMA. 1986;256: 1160–1163.
50. Bunch TJ, White RD, Gersh BJ, et al. Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation. N Engl J Med. 2003;348:2626–2633.
51. AACVPR. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. Champaign, Ill: Human Kinetics; 2004.
52. Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for health care professionals from the American Heart Association. Circulation. 2001;104:1694–1740.
53. Jokhadar M, Jacobsen SJ, Reeder GS, Weston SA, Roger VL. Sudden death and recurrent ischemic events after myocardial infarction in the community. Am J Epidemiol. 2004;159: 1040–1046.
54. Paul-Labrador M, Vongvanich P, Merz CN. Risk stratification for exercise training in cardiac patients: do the proposed guidelines work?. J Cardiopulm Rehabil. 1999;19:118–125.
55. Zoghbi GJ, Sanderson B, Breland J, Adams C, Schumann C, Bittner V. Optimizing risk stratification in cardiac rehabilitation with inclusion of a comorbidity index. J Cardiopulm Rehabil. 2004;24:8–13.; quiz 14–15
56. Iestra JA, Kromhout D, van der Schouw YT, Grobbee DE, Boshuizen HC, van Staveren WA. Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review. Circulation. 2005;112:924–934.
57. Balady G, Williams MA, Bittner V, et al. Core components of cardiac Rehabilitation/Secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115:2675–2682.
58. Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006;114:82–96.
59. American College of Cardiology, American Heart Association, Physician Consortium for Performance Improvement. Clinical Performance Measures: Chronic Stable Coronary Artery Disease. Tools Developed by Physicians for Physicians. Physician Consortium for Performance Improvement; 2005.
60. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–2572.
61. Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107:3109–3116.
62. American Diabetes Association. Standards of medical care in diabetes—-2006. Diabetes Care. 2006;29(suppl 1):S4–S42.
63. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:1433–1438.
64. Schleifer SJ, Macari-Hinson MM, Coyle DA, et al. The nature and course of depression following myocardial infarction. Arch Intern Med. 1989;149:1785–1789.
65. Lane D, Carroll D, Ring C, Beevers DG, Lip GY. The prevalence and persistence of depression and anxiety following myocardial infarction. Br J Health Psychol. 2002;7:11–21.
66. Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction. Impact on 6-month survival. JAMA. 1993;270:1819–1825.
67. Lesperance F, Frasure-Smith N, Juneau M, Theroux P. Depression and 1-year prognosis in unstable angina. Arch Intern Med. 2000;160:1354–1360.
68. Zellweger MJ, Osterwalder RH, Langewitz W, Pfisterer ME. Coronary artery disease and depression. Eur Heart J. 2004;25:3–9.
69. Herridge ML, Stimler CE, Southard DR, King ML. Depression screening in cardiac rehabilitation: AACVPR Task Force report. J Cardiopulm Rehabil. 2005;25:11–13.
70. Whaley MH, Brubacker PH, Olto RM, eds. Guidelines for Exercise Testing and Prescription. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2005.
71. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40:1531–1540.
72. Krumholz HM, Anderson JL, Brooks NH, et al. ACC/AHA Clinical Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures on ST-Elevation and Non-ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2006;47:236–265.
73. Krumholz HM, Peterson ED, Ayanian JZ, et al. Report of the National Heart, Lung, and Blood Institute Working Group on Outcomes Research in Cardiovascular Disease. Circulation. 2005;111:3158–3166.
74. Sanderson BK, Southard D, Oldridge N. AACVPR consensus statement. Outcomes evaluation in cardiac Rehabilitation/ Secondary prevention programs: improving patient care and program effectiveness. J Cardiopulm Rehabil. 2004;24:68–79.
Back to Top | Article Outline

Appendix A

Cardiac Rehabilitation/Secondary Prevention Performance Measurement Set A

PERFORMANCE MEASURE A-1
Back to Top | Article Outline
Cardiac Rehabilitation Patient Referral From an Inpatient Setting

All patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina (CSA), or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation are to be referred to an early outpatient cardiac rehabilitation/ secondary prevention (CR) program.

Numerator: Number of eligible patients with a qualifying event/diagnosis who have been referred to an outpatient CR program prior to hospital discharge or have a documented medical or patient-centered reason why such a referral was not made.

(Note: The program may include a traditional CR program based on face-to-face interactions and training sessions or may include other options such as home-based approaches. If alternative CR approaches are used, they should be designed to meet appropriate safety standards).

A referral is defined as an official communication between the healthcare provider and the patient to recommend and carry out a referral order to an early outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an early outpatient CR program. This also includes a communication between the healthcare provider or healthcare system and the CR program that includes the patient's referral information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program [the patient's cardiovascular history, testing, and treatments, for instance]. All communications must maintain appropriate confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act [HIPAA].)

Exclusion Criteria:

* Patient-oriented barriers (patient refusal, for example)

* Provider-oriented criteria (patient deemed to have a high-risk condition or a contraindication to exercise, for example)

* Healthcare system barriers (financial barriers or lack of CR programs near a patient's home, for example)

Denominator: Number of hospitalized patients in the reporting period hospitalized with a qualifying event/diagnosis who do not meet any of the exclusion criteria mentioned above.

Period of Assessment: Inpatient hospitalization.

Method of Reporting: Proportion of healthcare system's patients with a qualifying event/diagnosis who had documentation of their referral to an outpatient CR program.

Sources of Data: Administrative data and/or medical records.

Back to Top | Article Outline
Rationale

A key component to outpatient CR program utilization is the appropriate and timely referral of patients. Generally, the most important time for this referral to take place is while the patient is hospitalized for a qualifying event/ diagnosis (MI, CSA, CABG, PCI, cardiac valve surgery, or cardiac transplantation).

This performance measure has been developed to help healthcare systems implement effective steps in their systems of care that will optimize the appropriate referral of a patient to an outpatient CR program.

This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that involve disease states or other conditions for which CR services have been found to be appropriate and beneficial (eg, following MI, CABG surgery). This performance measure is provided in a format that is meant to allow easy and flexible inclusion into such performance measurement sets.

Effective referral of appropriate inpatients to an outpatient CR program is the responsibility of the healthcare team within a healthcare system that is primarily responsible for providing cardiovascular care to the patient during the hospitalization.

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery21

Class I (for the description of the class of recommendations and level of evidence used in this document, see Table 1): Cardiac rehabilitation should be offered to all eligible patients after CABG surgery (level of evidence: B).

ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction40

Class I: CR programs, when available, are recommended for patients with ST-elevation MI, particularly those with multiple modifiable risk factors and/or those with moderate- to high-risk patients in whom supervised exercise training is warranted (level of evidence: C)

ACC/AHA 2002 Guideline Update for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction41

Class I: Consider the referral of patients who are smokers to a smoking cessation program or clinic and/or an outpatient CR program (level of evidence: B).

ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic Stable Angina19

Class I: Comprehensive CR program (including exercise) (level of evidence: B).

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary42

Class I: Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (level of evidence: B).

Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women22

Class I: A comprehensive risk-reduction regimen, such as cardiovascular or stroke rehabilitation or a physician-guided home- or community-based exercise training program, should be recommended to women with a recent acute coronary syndrome or coronary intervention, new-onset or chronic angina, recent cerebrovascular event, peripheral arterial disease (level of evidence: A), or current/prior symptoms of heart failure and a left ventricular ejection fraction of less than 40% (level of evidence: B).

Back to Top | Article Outline
Challenges to Implementation

Identification of all eligible patients in an inpatient setting will require that a timely, accurate, and effective system be in place. Communication of referral information by the inpatient hospital service team to the outpatient CR program represents a potential challenge to the implementation of this performance measure. However, this task is generally performed by an inpatient cardiovascular care team member, such as an inpatient CR team member or a hospital discharge planning team member.

Back to Top | Article Outline
PERFORMANCE MEASURE A-2
Back to Top | Article Outline
Cardiac Rehabilitation Patient Referral From an Outpatient Setting

All patients evaluated in an outpatient setting who within the past 12 months have experienced an acute MI, CABG surgery, a PCI, cardiac valve surgery, or cardiac transplantation, or who have CSA and have not already participated in an early outpatient CR program for the qualifying event/diagnosis are to be referred to such a program.

Numerator: Number of patients in an outpatient clinical practice who have had a qualifying event/diagnosis during the previous 12 months, who have been referred to an outpatient CR program.

(Note: The program may include a traditional CR program based on face-to-face interactions and training sessions or other options that include home-based approaches. If alternative CR approaches are used, they should be designed to meet appropriate safety standards.

A referral is defined as an official communication between the healthcare provider and the patient to recommend and carry out a referral order to an outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an outpatient CR program. This also includes a communication from the healthcare provider and/or healthcare system to the CR program that includes necessary information for the patient's referral information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program [the patient's cardiovascular history, testing, and treatments, for instance]. All communications must maintain an appropriate level of confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act [HIPAA].)

Exclusion Criteria:

* Patient-oriented barriers (patient refusal, for example)

* Provider-oriented criteria (patient deemed to have a high-risk condition or a contraindication to exercise, for example)

* Healthcare system barriers (financial barriers or lack of CR programs near a patient's home, for example)

Denominator: Number of patients in an outpatient clinical practice who have had a qualifying event/diagnosis during the previous 12 months and who do not meet any of the exclusion criteria mentioned in the “Numerator” section above.

Period of Assessment: Twelve months following a qualifying event/diagnosis.

Method of Reporting: Proportion of patients in an outpatient practice who have had a qualifying event/ diagnosis during the past 12 months and have been referred to a CR program.

Sources of Data: Administrative data and/or medical records.

Back to Top | Article Outline
Rationale

Cardiac rehabilitation services have been shown to help reduce morbidity and mortality in persons who have experienced a recent coronary artery disease event, but these services are used in less than 30% of eligible patients.26 A key component for CR utilization is the appropriate and timely referral of patients to an outpatient CR program. While referral takes place generally when the patient is hospitalized for a qualifying event (MI, CSA, CABG surgery, PCI, cardiac valve surgery, or heart transplantation), there are many instances in which a patient can and should be referred from an outpatient clinical practice setting (eg, when a patient does not receive such a referral while in the hospital, or when the patient fails to follow through with the referral for whatever reason).

This performance measure has been developed to help healthcare systems implement effective steps in their systems of care that would optimize the appropriate referral of a patient to an outpatient CR program.

This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that involve disease states or other conditions for which CR services have been found to be appropriate and beneficial (eg, following MI, CABG surgery). This performance measure is provided in a format that is meant to allow easy and flexible inclusion into such performance measurement sets.

Referral of appropriate outpatients to a CR program is the responsibility of the healthcare provider within a healthcare system that is providing the primary cardiovascular care to the patient in the outpatient setting.

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

See the “Clinical recommendations” section from Performance Measure A-1 above.

Back to Top | Article Outline
Challenges to Implementation

Identification of all eligible patients in an outpatient clinical practice will require that a timely, accurate, and effective system be in place. Communication of referral information by the outpatient clinical practice team to the outpatient CR program represents a potential challenge to the implementation of this performance measure. Cited Here...

Back to Top | Article Outline

Appendix B

Cardiac Rehabilitation/Secondary Prevention Performance Measurement Set B

PERFORMANCE MEASURE B-1
Back to Top | Article Outline
Structure-Based Measurement Set

The CR program has policies in place to demonstrate that:

1. A physician-director is responsible for the oversight of CR program policies and procedures and ensures that policies and procedures are consistent with evidence-based guidelines, safety standards, and regulatory standards.43 This includes appropriate policies and procedures for the provision of alternative CR program services, such as home-based CR.

2. An emergency response team is immediately available to respond to medical emergencies.44

I. In a hospital setting, physician supervision is presumed to be met when services are performed on hospital premises.45

II. In the setting of a freestanding outpatient CR program (owned/operated by a hospital, but not located on the main campus), a physician-directed emergency response team must be present and immediately available to respond to emergencies.

III. In the setting of a physician-directed clinic or practice, a physician-directed emergency response team must be present and immediately available to respond to emergencies.

3. All professional staff members have successfully completed the National Cognitive and Skills examination in accordance with the AHA curriculum for basic life support (BLS) with at least 1 staff member present who has completed the National Cognitive and Skills examination in accordance with the AHA curriculum for advanced cardiac life support (ACLS) and has met state and hospital or facility medico-legal requirements for defibrillation and other related practices.43,46,47

4. Functional emergency resuscitation equipment and supplies for handling cardiovascular emergencies are immediately available in the exercise area.44

Numerator: The number of CR programs in the healthcare system that meet these structure-based performance measure criteria.

Denominator: All CR programs within a healthcare system.

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Written program policies

Back to Top | Article Outline
Rationale

The delivery of CR services is physician directed and provided by a multidisciplinary staff of healthcare professionals. A system for communication between a physician-director with expertise in CVD management and a referring or primary physician enhances the program's success in helping that patient achieve individualized target goals. It is the responsibility of the physician-director to assure that the information and instruction given to patients in CR is consistent with the most current clinical practice guidelines.

There is a growing trend among patients referred to and completing early outpatient CR to be older, at higher risk, and have more chronic comorbidities.48 Medical supervision is the most important day-to-day safety factor in CR.43 Personnel and equipment for ACLS are essential to the adequate delivery of emergency care for patients who experience cardiac arrest or other life-threatening events during CR sessions.

Although rare, cardiovascular emergencies can occur during exercise training in CR programs. Studies suggest that the incidence of cardiac arrest requiring defibrillation is approximately 1 arrest every 100,000 patient-hours.49 Practice guidelines for management of cardiac arrest include the use of BLS and ACLS strategies, such as early defibrillation. Such strategies have been shown to help improve outcomes in persons who experience cardiac arrest.50

Some CR programs seek certification of their program by healthcare organizations, such as the AACVPR, in order to show that they meet certain standards for the delivery of CR services. Such a certification process, while outside the scope of this document, may result in documentation of a program's ability to meet this (B-1) and other CR performance measures mentioned in this document. Currently, for instance, CR program certification through the AACVPR requires that all of the above policies (items 1 to 4 above) are in place and operational.

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs43 (no class of recommendation or level of evidence given)

There is a physician-director responsible for program oversight and to ensure that policies and procedures are consistent with evidence-based guidelines, safety standards, and regulatory standards.

AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs51 (no class of recommendation or level of evidence given)

All professional staff members have completed BLS training; at least 1 staff member is present who has successfully completed training in ACLS.

Medical supervision for moderate- to high-risk patients will be provided by a physician, registered nurse, or other appropriately trained staff member who has successfully completed AHA curriculum for ACLS and has met state and hospital or facility medico-legal requirements for defibrillation and other related practices.

Exercise Standards for Testing and Training: A statement for health professionals from the American Heart Association. The AHA Scientific Statement52 (no class of recommendation or level of evidence given)

An emergency response team is immediately available to respond to medical emergencies.

CMS National Coverage Determination for Cardiac Rehabilitation Programs45 (no class of recommendation or level of evidence given)

Functional emergency resuscitation equipment and supplies for handling cardiovascular emergencies are immediately available in the exercise area.

Back to Top | Article Outline
Challenges to Implementation

Adherence to this measure requires the engagement of a physician-director who is accountable for policy development and implementation.

Back to Top | Article Outline
PERFORMANCE MEASURE B-2
Back to Top | Article Outline
Assessment of Risk for Adverse Cardiovascular Events

The CR program has the following processes in place:

1. Documentation, at program entry, that each patient undergoes an assessment of clinical status (eg, symptoms, medical history) in order to identify high-risk conditions for adverse cardiovascular events.

2. A policy to provide recurrent assessments for each patient during the time of participation in the CR program in order to identify any changes in clinical status that increase the patient's risk of adverse cardiovascular events. If such findings are noted, the CR staff contacts the program's physician director and/or the patient's primary healthcare provider according to thresholds for communication included in the policies developed for Performance Measure B-3j.

Numerator: Number of CR programs in the healthcare system that meet the performance measure for assessment of risk for adverse cardiovascular events

Denominator: Number of CR programs in the healthcare system

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Written program policies

Back to Top | Article Outline
Rationale

A standardized assessment should be performed to identify patients with unstable symptoms and other factors that place the patient at increased risk for adverse cardiovascular events.17

When high-risk findings are noted, a patient should be considered for prompt evaluation and treatment, and rehabilitation recommendations should be adjusted accordingly.

Recurrent adverse cardiovascular events are relatively common in persons with CVD. In one study from Olmsted County, Minnesota, nearly half of patients discharged from the hospital following an MI had a recurrent adverse cardiovascular event in the 3 years following their MI.53

However, adverse events are rare during CR early after a CVD event, occurring approximately once in every 100,000 patient-hours.49 This safety record is likely due in part to standard procedures that exist in CR programs to frequently screen patients for signs and symptoms that increase their risk for adverse cardiovascular events.17,50 If a CR participant develops abnormal cardiovascular signs (significant arrhythmias or blood pressure abnormalities, for example) or symptoms (exertional chest pain, for instance), they typically receive prompt evaluation and care.

Published reports suggest limited accuracy of the risk stratification methods from the AACVPR, ACC/AHA, and the American College of Physicians in identifying patients at risk for adverse events during CR sessions.54 However, one study found that a combination of the AACVPR criteria with a comorbidity index helped improve the accuracy of risk stratification, particularly among female patients.55 A significant limitation to these studies is the fact that patients identified at high risk undergo additional evaluation and treatment to lower their risk, thereby dampening the ability of such screening measures to accurately identify individuals at increased risk of adverse cardiovascular events.

This performance measure does not cover the assessment of modifiable risk factors, such as blood pressure, cholesterol, and diabetes. Assessment of modifiable risk factors related to CVD progression and recurrent CVD events is covered in Performance Measure B-3.

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs51 (no class of recommendation or level of evidence given)

All cardiac patients entering exercise rehabilitation should be stratified according to the risk for the occurrence of cardiac events during exercise.

Exercise Standards for Testing and Training: A statement for healthcare professionals from the American Heart Association52 (no class of recommendation or level of evidence given)

Screening procedures can be used that identify an individual who is at risk for an exercise-related cardiac event, which may be helpful in reducing these occurrences.

After the medical evaluation is complete, subjects can be classified by risk on the basis of their characteristics. This classification is used to determine the need for subsequent supervision and the level of monitoring required.

Back to Top | Article Outline
PERFORMANCE MEASURE B-3
Back to Top | Article Outline
Individualized Assessment and Evaluation of Modifiable Cardiovascular Risk Factors, Development of Individualized Interventions, and Communication With Other HealthCare Providers

This performance measure includes 10 individual submeasures for the evaluation of modifiable cardiovascular risk factors, development of individualized interventions, and communication with other healthcare providers concerning these risk factors and interventions.

The rationale for including both recognition and intervention for satisfactory fulfillment of these measures is predicated upon the belief that high-quality cardiovascular care requires both the identification and treatment of known cardiovascular risk factors.

An important component of this performance measure is the expectation that the CR staff communicates with appropriate primary care providers and treating physicians in order to help coordinate risk factor management and to promote life-long adherence to lifestyle and pharmacological therapies. (See Performance Measure B-3j for more specific coverage of communication with the patient's primary healthcare provider.)

Back to Top | Article Outline
PERFORMANCE MEASURE B-3A: INDIVIDUALIZED ASSESSMENT OF TOBACCO USE

For each eligible patient enrolled in the CR program, there is documentation that the following criteria have been met:

1. An assessment is made of current and past tobacco use.

2. If current tobacco use is identified, an intervention plan is recommended to the patient and communicated to the primary care provider and/or cardiologist. This plan may include individual education, counseling, and/or referral to a tobacco cessation program.

3. Prior to completion of the CR program, the patient's tobacco use status and tobacco avoidance treatment plan are reassessed and communicated to the patient as well as to the primary care provider and/or cardiologist.

Numerator: Number of patients in the healthcare system's CR program(s) who meet the performance measure for tobacco use

Denominator: Number of patients in the healthcare system's CR program(s)

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Electronic or paper-based prospective flow sheet (preferred) or retrospective medical record review

Back to Top | Article Outline
Rationale

Cessation of tobacco use is most successful when healthcare providers work together with patients to identify and implement effective treatment strategies. Persons with CVD who stop smoking reduce their cardiovascular risk by approximately 35%.56,57

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2006 Update39

Class I:

Goal: Complete cessation (level of evidence: B).

AHA/AACVPR Scientific Statement: Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update57 (no class of recommendation or level of evidence given)

Class I:

Short-term Goal: Patient will demonstrate readiness to change by initially expressing decision to quit and selecting a quit date. Subsequently, patient will quit smoking and all tobacco use, adhere to pharmacological therapy (if prescribed), and practice relapse prevention strategies; patient will resume cessation plan as quickly as possible when temporary relapse occurs.

Long-term Goal: Complete abstinence from smoking and use of all tobacco products for at least 12 months (maintenance) from quit date.

AHA Scientific Statement: Diet and Lifestyle Recommendations Revision 200658 (no class of recommendation or level of evidence given)

Long-term Goal: Avoid use of (and exposure to) tobacco products from quit date.

Back to Top | Article Outline
Related Performance Measurement Sets

Clinical Performance Measures: Chronic Stable Coronary Artery Disease. Tools Developed by Physicians for Physicians. Physician Consortium for Performance Improvement59

Percentage of patients queried 1 or more times during the reporting year about cigarette smoking.

Percentage of patients identified as cigarette smokers who received smoking cessation intervention during the reporting year.

Back to Top | Article Outline
Challenges to Implementation

This measure relies on patient self-report.

Back to Top | Article Outline
PERFORMANCE MEASURE B-3B: INDIVIDUALIZED ASSESSMENT OF BLOOD PRESSURE CONTROL

For each eligible patient enrolled in the CR program, there is documentation that the following criteria have been met:

1. An assessment is made of blood pressure (BP) control, with target goals defined by the AHA/ACC secondary prevention guidelines.

2. For patients with a diagnosis of hypertension, an intervention plan is developed. This should include education about target BP goals, medication compliance, lifestyle modification for optimal dietary and physical activity habits, and weight control.

3. During the CR program, BP control is reassessed and communicated to the patient as well as to the primary care provider and/or cardiologist.

Numerator: Number of patients in the healthcare system's CR program(s) who meet the performance measure for BP control

Denominator: Number of patients in the healthcare system's CR program(s)

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Electronic- or paper-based prospective flow sheet (preferred) or retrospective medical record review

Back to Top | Article Outline
Rationale

The BP levels represent a strong, consistent, continuous, independent, and etiologically relevant risk factor for cardiovascular and renal disease. Optimal control of BP has a beneficial impact on lowering cardiovascular risk.39,57

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2006 Update39

Class I:

Goal: <140/90 mm Hg or <130/80 mm Hg if patient has diabetes or chronic kidney disease (level of evidence: B, for lifestyle modification; A, for pharmacological treatment).

AHA/AACVPR Scientific Statement: Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update58 (no class of recommendation or level of evidence given)

Goal: Continued assessment and modification of intervention until normalization of BP.

AHA Scientific Statement: Diet and Lifestyle Recommendations Revision 200658 (no class of recommendation or level of evidence given).

Goal: Aim for a normal BP.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National High Blood Pressure Education Program60 (no class of recommendation or level of evidence given)

Treating systolic BP and diastolic BP to targets that are lower than 140/90 mm Hg is associated with a decrease in CVD complications. In patients with hypertension with diabetes or renal disease, the BP goal is lower than 130/80 mm Hg.

Back to Top | Article Outline
Related Performance Measurement Sets

Clinical Performance Measures: Chronic Stable Coronary Artery Disease. Tools Developed by Physicians for Physicians. Physician Consortium for Performance Improvement58

Percentage of patients who had a BP measurement during the last office visit.

Back to Top | Article Outline
PERFORMANCE MEASURE B-3C: INDIVIDUALIZED ASSESSMENT OF OPTIMAL LIPID CONTROL

For each eligible patient enrolled in the CR program, there is documentation that the following criteria have been met:

1. An assessment of blood lipid control and use of lipid-lowering medications, with target goals defined by the AHA/ACC secondary prevention guidelines.

2. For patients with a diagnosis of hyperlipidemia, an intervention plan has been recommended to the patient. This should include education about target lipid goals, importance of medication compliance, lifestyle modification for optimal dietary and regular physical activity habits, and weight control.

3. Prior to completion of the CR program, lipid control and the lipid management plan, including lifestyle modification, are reassessed and communicated to the patient as well as to the primary care provider and/or cardiologist.

Numerator: Number of patients in the healthcare system's CR program(s) who meet the performance measure for lipid control

Denominator: Number of patients in the healthcare system's CR program(s)

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Electronic- or paper-based prospective flow sheet (preferred) or retrospective medical record review

Back to Top | Article Outline
Rationale

Multiple clinical trials have shown the benefit of lipid-lowering agents and lifestyle modification for patients with documented CVD.39 A more aggressive low-density lipoprotein target goal of <70 mg/dL should be considered for persons with multiple cardiovascular risk factors, particularly when they are under suboptimal control (eg, a patient with coronary artery disease who continues to smoke).

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update39

Class I:

Goal: Low-density lipoprotein cholesterol <100 mg/dL. If triglycerides are higher than 200 mg/dL, non–high-density lipoprotein cholesterol should be lower than 130 mg/dL (level of evidence: B, for lifestyle modification; A, for pharmacological treatment).

AHA/AACVPR Scientific Statement: Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update57 (no class of recommendation or level of evidence given)

Short-term Goal: Continued assessment and modification of intervention until the low-density lipoprotein level is lower than 100 mg/dL (further reduction to a goal (70 mg/dL is considered reasonable).

Long-term Goal: Low-density lipoprotein cholesterol level is lower than 100 mg/dL (further reduction to a goal <70 mg/dL is considered reasonable). Secondary Goal: Non–high-density lipoprotein cholesterol level is lower than 130 mg/dL (further reduction to a goal of <100 mg/dL is considered reasonable).

AHA Scientific Statement: Diet and Lifestyle Recommendations Revision 200658 (no class of recommendation or level of evidence given)

Goal: Aim for recommended levels of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides.

Back to Top | Article Outline
Related Performance Measurement Sets

Clinical Performance Measures. Chronic Stable Coronary Artery Disease. Tools Developed by Physicians for Physicians. Physician Consortium for Performance Improvement59

Percentage of patients receiving at least 1 lipid profile during the reporting year. Percentage of patients who are receiving a statin (based on current ACC/AHA guidelines).

Back to Top | Article Outline
PERFORMANCE MEASURE B-3d: INDIVIDUALIZED ASSESSMENT OF PHYSICAL ACTIVITY HABITS

For each eligible patient enrolled in the CR program, there is documentation that the following criteria have been met:

1. An assessment of current physical activity habits.

2. If physical activity habits at time of program entry do not meet suggested guidelines as defined by the AHA/ACC secondary prevention guidelines, then recommendations to improve physical activity habits are given to the patient.

3. Prior to completion of the CR program, physical activity habits and the physical activity intervention plan are reassessed and communicated to the patient as well as to the primary care provider and/or cardiologist.

Numerator: Number of patients in the healthcare system's CR program(s) who meet the performance measure for physical activity habits

Denominator: Number of patients in the healthcare system's CR program(s)

Period of Assessment: Per reporting year

Method of Reporting: A standardized method for assessing physical activity is to be used, with results entered into an inclusive data collection tracking sheet

Sources of Data: Electronic- or paper-based prospective flow sheet (preferred) or retrospective medical record review

Back to Top | Article Outline
Rationale

Adherence to regular physical activity has been associated with a 20% to 30% reduction in all-causes mortality in patients with CVD.9

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update39

Class I:

Goal: 30 minute, 7 days per week (minimum 5 days per week) (level of evidence: B).

AHA/AACVPR Scientific Statement: Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update56 (no class of recommendation or level of evidence given)

Goal: 30 to 60 minute per day of moderate-intensity physical activity on 5 or more (preferably most) days of the week.

Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease: A statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity)61 (no class of recommendation or level of evidence given)

Health professionals should prescribe physical activity programs commensurate with those recommended by the Centers for Disease Control and Prevention and the American College of Sports Medicine, that is, 30 minutes or more of moderate-intensity physical activity such as brisk walking on most, and preferably all, days of the week.

Back to Top | Article Outline
Challenges to Implementation

Community-based exercise may not utilize modalities designed for elderly patients and those with neurological and musculoskeletal disease, making continued regular physical activity a challenge for some patients.

Back to Top | Article Outline
PERFORMANCE MEASURE B-3e: INDIVIDUALIZED ASSESSMENT OF WEIGHT MANAGEMENT

For each eligible patient enrolled in the CR program, there is documentation that the following criteria have been met:

1. An assessment of body weight/composition, including the measurement of either body mass index or waist circumference, with targets as defined by the AHA/ACC secondary prevention guidelines.39

2. If the body weight/composition measure(s) is (are) above recommended goal(s), then an intervention plan is recommended to the patient. This should include education about target goals and lifestyle modification including a healthy diet, behavior change, and regular physical activity and/or referral to a weight management program.

3. Prior to completion of the CR program, body weight/composition and the intervention plan are reassessed and communicated to the patient as well as the primary care provider and/or cardiologist.

Numerator: Number of patients in the healthcare system's CR program(s) who meet the performance measure for assessment of weight management

Denominator: Number of patients in the healthcare system's CR program(s)

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Electronic- or paper-based prospective flow sheet (preferred) or retrospective medical record review

Back to Top | Article Outline
Rationale

Obesity is an independent risk factor for CVD and adversely affects CVD risk factors. By adhering to diet and lifestyle recommendations, patients can substantially reduce their risk of CVD.58

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update39

Class I

Goal: Body mass index: 18.5–24.9 kg/m2; waist circumference: men <40 in.; women <35 in. (level of evidence: B).

AHA/AACVPR Scientific Statement: Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update57 (no class of recommendation or level of evidence given)

Short-term Goal: Continued assessment and modification of interventions until progressive weight loss is achieved. Provide referral to specialized, validated nutrition weight loss programs if weight goals are not achieved.

Long-term Goal: Adherence to diet and physical activity/exercise program aimed toward attainment of established weight goal.

AHA Scientific Statement: Diet and Lifestyle Recommendations Revision 200658 (no class of recommendation or level of evidence given)

Goal: Aim for a healthy body weight.

(No class of recommendation or level of evidence given)

Goals: Balance energy intake and physical activity to achieve and maintain a healthy body weight; consume a diet rich in vegetables and fruits; choose whole-grain, high-fiber foods; consume fish, especially oily fish, at least twice a week; limit intake of saturated fat to less than 7% of energy, trans fat to less than 1% of energy, and cholesterol to less than 300 mg/d by choosing lean meats and vegetable alternatives, fat-free (skim) or low-fat (1% fat) dairy products and minimize intake of partially hydrogenated fats; minimize intake of beverages and foods with added sugars; choose and prepare foods with little or no salt; if you consume alcohol, do so in moderation; and when you eat food prepared outside of the home, follow these diet and lifestyle recommendations.

Back to Top | Article Outline
Challenges to Implementation

Weight management relies on patient compliance with diet and lifestyle recommendations.

Back to Top | Article Outline
PERFORMANCE MEASURE B-3f: INDIVIDUALIZED ASSESSMENT OF THE DIAGNOSIS OF DIABETES MELLITUS OR IMPAIRED FASTING GLUCOSE

For each eligible patient enrolled in the CR program, there is documentation that the following criteria have been met:

1. Assessment of the diagnosis of impaired fasting glucose (IFG) and diabetes mellitus (DM), with definitions as described in the most recent American Diabetes Association (ADA) Standards of Medical Care in Diabetes Position Statement.62

2. If the patient has a diagnosis of IFG or DM, then an intervention plan is recommended to the patient for glycemic monitoring during exercise, for glycemic goals, and for recommendations concerning medical nutrition therapy (MNT) and/or skill training sessions (if not previously attended).

3. Prior to completion of the CR program, DM/IFG status and the DM/IFG intervention plan are reassessed and communicated to the patient as well as to the primary care provider and/or cardiologist.

Numerator: Number of patients in the healthcare system's CR program(s) who meet the performance measure for DM/IFG

Denominator: Number of patients in the healthcare system's CR program(s)

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Electronic- or paper-based prospective flow sheet (preferred) or retrospective medical record review

Back to Top | Article Outline
Rationale

The presence of DM or IFG has been linked to unfavorable long-term cardiovascular outcomes. Because improved glycemic control has been shown to favorably affect cardiovascular morbidity and mortality,61 the CR program setting is an ideal environment to educate patients about the implications of DM or IFG and to initiate the behavior patterns that foster improved glycemic control.56

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

Physical Activity/Exercise and Type 2 Diabetes: A consensus statement from the American Diabetes Association63 (no class of recommendation given)

Those who take insulin or secretagogues should check capillary blood glucose before, after, and several hours after completing a session of physical activity, at least until they know their usual glycemic responses to such activity (level of evidence: E, from the ADA classification system, in which level of evidence E is based on expert consensus or clinical experience).

American Diabetes Association Standards of Medical Care in Diabetes–200662 (no class of recommendation given)

Lowering HbA1C has been associated with a reduction of microvascular and neuropathic complications of diabetes (level of evidence: A, from the ADA classification system, in which level A is based on clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered).

People with DM should receive individualized medical nutrition therapy (MNT) as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT (level of evidence: B, from the ADA classification system, in which level B is based on supportive evidence from well-conducted cohort studies).

People with DM should receive DM self-management education according to national standards when their DM is diagnosed and as needed thereafter (level of evidence: B, see above).

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update39

Class I

Initiate lifestyle and pharmacotherapy to achieve near-normal HbA1C (level of evidence: B). Begin vigorous modification of other risk factors (level of evidence: B). Coordinate diabetic care with patient's primary care physician or endocrinologist (level of evidence: C).

AHA/AACVPR Scientific Statement: Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update57 (no class of recommendation or level of evidence given)

Educate patient and staff to be alert for signs/symptoms of hypoglycemia or hyperglycemia and provide appropriate assessment and interventions.

Teach and practice self-monitoring skills for use during unsupervised exercise. Refer to registered dietitian for MNT. Consider referral to certified diabetic educator for skill training, medication instruction, and support groups.

Back to Top | Article Outline
Challenges to Implementation

Patients may not be aware that they have IFG or DM. In addition, it may be difficult for CR staff to obtain medical records to verify or refute the diagnosis. Given the latter, either patient self-report or medical records, if available, may be used to meet these criteria.

Back to Top | Article Outline
PERFORMANCE MEASURE B-3g: INDIVIDUALIZED ASSESSMENT OF THE PRESENCE OR ABSENCE OF DEPRESSION

For each eligible patient enrolled in the CR program, there is documentation that the following criteria have been met:

1. Assessment of the presence or absence of depression, using a valid and reliable screening tool.

2. If clinical depression is suspected as a result of screening, this has been discussed with the patient.

3. If clinical depression is suspected as a result of screening, the primary care provider and/or mental healthcare provider have been notified.

Numerator: Number of patients in the healthcare system's CR program(s) who meet the performance measure for depression

Denominator: Number of patients in the healthcare system's CR program(s)

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Electronic- or paper-based prospective flow sheet (preferred) or retrospective medical record review

Back to Top | Article Outline
Rationale

Depression is highly prevalent among patients following acute cardiac events, with 20% to 45% of patients suffering significant levels of depressive symptoms after an acute MI.64,65 Depression has been shown to be a powerful, independent risk factor for cardiac mortality after an acute MI or unstable angina.66,67 Several studies suggest that depressed patients with CVD benefit from CR programs by improving coping skills and self-image, reducing biological risk factors such as social isolation and smoking, providing emotional support, and improving quality-of-life scores.68

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

Depression Screening in Cardiac Rehabilitation: AACVPR Task Force Report69 (no class of recommendation or level of evidence given)

The AACVPR recommends that appropriately trained healthcare professionals in the CR setting assess for depression using a valid and reliable screening tool and ask specific questions about depression as a part of the intake assessment and/or clinical interview. They also recommend that cardiac rehabilitation professionals communicate findings indicating possible clinical depression to referring physicians, facilitate referral of patients for appropriate treatment, and periodically reassess therapeutic progress.

Back to Top | Article Outline
Challenges to Implementation

Depression screening includes patient self-report, but validated self-report tools are available to help facilitate screening for depression.

Back to Top | Article Outline
PERFORMANCE MEASURE B-3h: INDIVIDUALIZED ASSESSMENT OF EXERCISE CAPACITY

For each eligible patient enrolled in the CR program, there is documentation that the following criteria have been met:

1. Assessment of maximal or submaximal exercise capacity, using at least 1 of several possible assessment methods that has standard end points as defined by groups such as the American College of Sports Medicine and ACC/AHA practice guidelines and scientific statements.52,70

2. An individualized exercise prescription, based on the assessment of exercise capacity, is recommended to the patient and communicated to the primary care provider and/or cardiologist.

3. Prior to completion of the CR program, change in exercise capacity is reassessed and communicated to the patient as well as to the primary care provider and/or cardiologist.

Numerator: Number of patients in the healthcare system's CR program(s) who meet the performance measure for assessment of exercise capacity

Denominator: Number of patients in the healthcare system's CR program(s)

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Electronic- or paper-based prospective flow sheet (preferred) or retrospective medical record review

Back to Top | Article Outline
Rationale

Meta-analyses and systematic reviews have concluded that comprehensive, exercise-based CR reduces mortality rates in patients with CVD.2,3,5–7,9–11

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

ACC/AHA 2002 Guidelines Update for Exercise Testing: Summary Article.71

Class I: Assessment of symptom-limited exercise tolerance for activity prescription.

AHA/AACVPR Scientific Statement: Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update57 (no class of recommendation or level of evidence given)

Develop a documented individualized exercise prescription for aerobic and resistance training that is based on evaluation findings, risk stratification, patient and program goals, and resources. Exercise prescription should specify frequency, intensity, duration, and modalities.

Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology Position Paper15 (no class of recommendation or level of evidence given)

Moderate- to high-risk cardiac patients must undergo an individualized exercise program and receive an exercise prescription within the limits imposed by their disease.

Back to Top | Article Outline
Challenges to Implementation

In some cases, results of recent stress tests are available to assess exercise capacity, but this is not universal. The CR program may use an alternative assessment of exercise capacity, such as submaximal treadmill testing or a 6-minute walk.

Back to Top | Article Outline
PERFORMANCE MEASURE B-3I: INDIVIDUALIZED ADHERENCE TO PREVENTIVE MEDICATIONS

For each eligible patient with coronary artery disease enrolled in the CR program, there is documentation that the following criterion has been met:

The patient has received individual or group education concerning the importance of adherence to preventive medications that are described in the AHA/ACC secondary prevention guidelines. (Note: Patients should be encouraged to discuss questions or concerns about prescribed preventive medications with their healthcare providers.)

Numerator: Number of patients in the healthcare system's CR program(s) who meet the performance measure for adherence to preventive medications

Denominator: Number of patients in the healthcare system's CR program(s)

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Electronic- or paper-based prospective flow sheet (preferred) or retrospective medical record review

Back to Top | Article Outline
Rationale

The use of preventive medications that may or may not be tied to a specific risk factor (aspirin, omega-3 fatty acids, β-blockers, and angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker agents, for instance) are also critically important in reducing recurrent cardiovascular events in patients enrolled in a CR program. A gap in their usage is common, but can be corrected with the help of systematic programs, such as CR programs, that can promote the appropriate use of preventive medications and thereby improve patient outcomes.26

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update39

Class I: Use of antiplatelet agents, renin-angiotensin-aldosterone system blockers, and β-blockers (level of evidence: B).

Back to Top | Article Outline
Related Performance Measurement Sets

Clinical Performance Measures: Chronic Stable Coronary Artery Disease. Tools Developed by Physicians for Physicians. Physician Consortium for Performance Improvement59

Percentage of patients receiving antiplatelet therapy, drug therapy for lowering cholesterol, or β-blocker therapy post-MI.

ACC/AHA STEMI/NSTEMI Clinical Performance Measures72

Patients with acute MI without contraindications who are prescribed the following drug at discharge: (1) aspirin, (2) β-blocker, (3) lipid-lowering therapy, or (4) angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker for left ventricular systolic dysfunction.

Back to Top | Article Outline
Challenges to Implementation

Rehabilitation teams need to understand how current clinical practice guidelines relate to individual patients in order to optimize education.

Back to Top | Article Outline
PERFORMANCE MEASURE B-3J: COMMUNICATION WITH HEALTHCARE PROVIDERS

There is a policy in place to ensure communication with healthcare providers, including individual patient status related to each modifiable risk factor at entrance to and completion of the CR program, as well as when thresholds are met for more frequent or urgent communication concerning suboptimal risk factor control.

Numerator: The number of CR programs in the healthcare system that meet the performance measure for communication with healthcare providers

Denominator: The number of CR programs in the healthcare system

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Written program policies

Back to Top | Article Outline
Rationale

Optimal communication between the CR team and appropriate healthcare providers will promote timely adjustments in a patient's medical regimen, leading to improved risk factor modification.

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

AHA/AACVPR Scientific Statement: Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update57 (no class of recommendation or level of evidence given)

It is essential to the success of any program that each of these interventions is performed in concert with the patient's primary care provider and/or cardiologist, who will subsequently supervise and refine these interventions over the long term.

Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs43 (no class of recommendation or level of evidence given)

By working closely with referring physicians, the cardiac rehabilitation team can assist the patient in reaching target goals more effectively.

Back to Top | Article Outline
Challenges to Implementation

CR programs may not have access to all data related to risk factor control, such as most recent lipid profile, HbA1C, or patient-specific contraindications to preventive medications.

Back to Top | Article Outline
PERFORMANCE MEASURE B-4
Back to Top | Article Outline
Monitor Response to Therapy and Document Program Effectiveness

For each CR program in a healthcare system, a written policy is in place to:

1. Document the percentage of patients for whom the CR program has received a formal referral request who actually enroll in the program.

2. Document for each patient a standardized plan to assess completion of the prescribed course of CR as defined on entrance to the program.

3. Document for each patient a standardized plan to assess outcome measurements at the initiation and again at the completion of CR, including at least 1 outcome measure for the core program components as outlined in the Cardiac Rehabilitation/Secondary Prevention Performance Measure Set B, Performance Measure 3.

4. Describe the program's methodology to document program effectiveness and initiate QI strategies.

Numerator: Number of CR programs in the healthcare system that meet this performance measure for monitoring response to therapy and documenting program effectiveness

Denominator: Number of CR programs in the healthcare system

Period of Assessment: Per reporting year

Method of Reporting: Inclusive data collection tracking sheet

Sources of Data: Written program policies

Back to Top | Article Outline
Rationale

Continuous QI relies on collecting information about individual response to therapy as well as analysis of aggregate data to assess program effectiveness. The recommendation is that each CR program provides evidence of a standardized method to document individual patient outcomes on completion of the course of CR as defined on intake to the CR program which, in aggregate, will permit documentation of program effectiveness and QI initiative success.

Outcome assessment and evaluation provides evidence of effectiveness of therapeutic interventions. According to a recent report of the National Heart, Lung, and Blood Institute, this enhances the migration of best practice to clinical practice, improves decision making and the quality of care provided, and supports the optimal allocation of healthcare resources for all patients.73

The 2004 AACVPR consensus statement document suggests that “no single form [or] assessment protocol… will fit the needs of all programs.”74 The document gives examples of outcome measures for evaluating program effectiveness and communicating with other healthcare professionals, providing the basis for a flexible “structural framework…that will guide programs in the development of standardized assessment protocols that fit their specific needs.”74

Initiation and completion of the prescribed course of CR, as defined on admission assessment, are keys to promoting both life-long behavior change as well as physiologic adaptations from regular exercise. Comprehensive CR programs include core components designed to address secondary prevention issues that can improve with patient self-management. Reassessment of outcome measures after completion of CR can help programs assess their performance in each of these core components. It is anticipated that programs would assess different core components outcomes over time, using aggregate results to assess issues such as overall program performance, alternative approaches to programming, and programming in underserved populations such as minorities, women, and the elderly.

Back to Top | Article Outline
Corresponding Guidelines and Clinical Recommendations

AACVPR Consensus Statement. Outcomes Evaluation in Cardiac Rehabilitation/Secondary Prevention Programs: Improving Patient Care and Program Effectiveness74 (no class of recommendation or level of evidence given)

Cardiac rehabilitation programs need to establish a standardized method of data collection and maintain effective communication with other healthcare providers who also provide care for the referred patient.

Core Components of Cardiac Rehabilitation/ Secondary Prevention Programs: 2007 Update57 (no class of recommendation or level of evidence given)

The assessment and evaluation of at least 1 of the expected outcome measures is recommended for each of the core cardiac rehabilitation components. Cited Here...

Back to Top | Article Outline

Appendix C Cited Here...

Back to Top | Article Outline

Appendix D Cited Here...

Table. No caption av...

Cited By:

This article has been cited 2 time(s).

Journal of Cardiovascular Nursing
Improving Utilization of Cardiac Rehabilitation Services: Where to Start?
Comoss, P
Journal of Cardiovascular Nursing, 23(6): 480-481.
10.1097/01.JCN.0000317463.33391.ce
PDF (365) | CrossRef
Journal of Cardiopulmonary Rehabilitation and Prevention
Outpatient Cardiac Rehabilitation Attendance in England: VARIABILITY BY REGION AND CLINICAL CHARACTERISTICS
Bethell, H; Lewin, R; Evans, J; Turner, S; Allender, S; Petersen, S
Journal of Cardiopulmonary Rehabilitation and Prevention, 28(6): 386-391.
10.1097/HCR.0b013e31818c3b44
PDF (664) | CrossRef
Back to Top | Article Outline
© 2007 Lippincott Williams & Wilkins, Inc.