AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services: A Report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation)

Thomas, Randal J. MD, MS, FAACVPR, FACC, FAHA, Chair; King, Marjorie MD, FAACVPR, FACC; Lui, Karen RN, MS, FAACVPR; Oldridge, Neil PhD, FAACVPR, FACSM; Piña, Ileana L. MD, FACC; Spertus, John MD, MPH, FACC; ACCFAHA Task Force on Performance Measures

Journal of Cardiopulmonary Rehabilitation & Prevention: September/October 2010 - Volume 30 - Issue 5 - p 279–288
doi: 10.1097/HCR.0b013e3181f5e36f
Aacvpr/Acc/Aha 2010 Statement

This article is copublished in Circulation and the Journal of the American College of Cardiology.

Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org), the American Heart Association (my.americanheart.org), and the American Association of Cardiovascular and Pulmonary Rehabilitation (http://www.aacvpr.org). For commercial reprints and all quantities of 500 or more, e-mail reprintsolutions@wolterskluwer.com. For quantities of 500 or less, e-mail reprints@lww.com or call 1-866-903-6951.

Permissions: Multiple copies, 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; permission requests can be submitted electronically from the article listing on the JCRP Web site (www.jcrpjournal.com).

ACCF/AHA Task Force on Performance Measures members are as follows: Frederick A. Masoudi, MD, MSPH, FACC, FAHA, Chair; Elizabeth DeLong, PhD; John P. Erwin, III, MD, FACC; David C. Goff, Jr, MD, PhD, FAHA, FACP; Kathleen Grady, PhD, RN, FAHA, FAAN; Lee A. Green, MD, MPH; Paul A. Heidenreich, MD, FACC; Kathy J. Jenkins, MD, MPH, FACC; Ann R. Loth, RN, MS, CNS; Eric D. Peterson, MD, MPH, FACC, FAHA; and David M. Shahian, MD, FACC.

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

This document was approved by the American College of Cardiology Foundation Executive Committee in April 2010, by the American Heart Association Science Advisory and Coordinating Committee in April 2010, and by the AACVPR Document Oversight Committee and Board of Directors in June 2010. When citing this document, please use the following format: Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/ secondary prevention services. J Cardiopulom Rehabil Prev. 2010;30:279–288.

These measures and specifications are provided “as is” without warranty of any kind. Neither the AACVPR, the ACCF, nor the AHA shall be responsible for any use of these performance measures.

Limited proprietary coding is contained in the measure specifications (online data supplement available at http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.06.006/DC1) for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AACVPR, the ACCF, and the AHA disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT™) or other coding contained in the specifications.

CPT™ contained in the online data supplement is © 2010 American Medical Association.

Copyright © 2010 American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Cardiology, and American Heart Association.

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PREAMBLE

Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality “chasm.”1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability.

Consistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas (Table 1). The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate, incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements of cardiovascular care. The writing committees are also instructed to evaluate the extent to which existing nationally recognized performance measures conform to the attributes of performance measures described by the ACCF/AHA and to strive to create measures aligned with acceptable existing measures when this is feasible.

The initial measure sets published by the ACCF/AHA focused primarily on processes of medical care or actions taken by healthcare providers, such as the prescription of a medication for a condition. These process measures are founded on the strongest recommendations contained in the ACCF/AHA clinical practice guidelines, delineating actions taken by clinicians in the care of patients, such as the prescription of a particular drug for a specific condition. Specifically, the writing committees consider as candidates for measures those processes of care that are recommended by the guidelines either as Class I, which identifies procedures/treatments that should be administered, or Class III, which identifies procedures/treatments that should not be administered (Table 2). Class II recommendations are not considered as candidates for performance measures. The methodology guiding the translation of guideline recommendations into process measures has been explicitly delineated by the ACCF/AHA, providing guidance to the writing committees.10

Although they possess several strengths, processes of care are limited as the sole measures of quality. Thus, current ACCF/AHA performance measures writing committees are instructed to consider measures of structures of care, outcomes, and efficiency as complements to process measures. In developing such measures, the committees are guided by methodology established by the ACCF/AHA.11 Although implementation of measures of outcomes and efficiency is currently not as well established as that of process measures, it is expected that such measures will become more pervasive over time.

Although the focus of the performance measures writing committees is on measures intended for quality improvement efforts, other organizations may use these measures for external review or public reporting of provider performance. Therefore, it is within the scope of the writing committee task to comment, when appropriate, on the strengths and limitations of such external reporting for a particular CVD state or patient population. Thus, the metrics contained within this document are categorized as either performance measures or test measures. Performance measures are those metrics that the committee designates as appropriate for use for both quality improvement and external reporting. In contrast, test measures are those appropriate for the purposes of quality improvement but not for external reporting until further validation and testing are performed.

All measures have limitations and pose challenges to implementation that could result in unintended consequences when used for accountability. The implementation of measures for purposes other than quality improvement requires field testing to address issues related but not limited to sample size, frequency of use of an intervention, comparability, and audit requirements. The manner in which these issues are addressed is dependent on several factors, including the method of data collection, performance attribution, baseline performance rates, incentives, and public reporting methods. The ACCF/AHA encourages those interested in implementing these measures for purposes beyond quality improvement to work with the ACCF/AHA to consider these complex issues in pilot implementation projects, to assess limitations and confounding factors, and to guide refinements of the measures to enhance their utility for these additional purposes.

By facilitating measurements of cardiovascular healthcare quality, ACCF/AHA performance measurement sets may serve as vehicles to accelerate appropriate translation of scientific evidence into clinical practice. These documents are intended to provide practitioners and institutions that deliver care with tools to measure the quality of their care and identify opportunities for improvement. It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved.

—Frederick A. Masoudi, MD, MSPH, FACC, FAHA Chair, ACCF/AHA Task Force on Performance Measures

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UPDATE OF PERFORMANCE MEASURES FOR REFERRAL TO CARDIAC REHABILITATION

Background

The AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services were published in October 2007.7 This document updates the 2 measures that articulate the opportunities to improve referrals to outpatient Cardiac Rehabilitation that were embodied in Measure Set A from that 2007 paper (Appendix A in Reference 7). Measure A-1 (Cardiac Rehabilitation Patient Referral From an Inpatient Setting) and measure A-2 (Cardiac Rehabilitation Patient Referral From an Outpatient Setting) have been revised to clarify several aspects of the measures and to facilitate their implementation. The updated measures (Appendix B) have been revised as described in the following text. The measures in Measure Set B from the 2007 paper related to the structure and processes of care for cardiac rehabilitation programs remain unchanged and are not included in this update.

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Measure A-1. Cardiac Rehabilitation Patient Referral From an Inpatient Setting

Numerator Exclusion Criteria:

* “Patient-oriented barriers” was revised to “patient-oriented factors,” and the example provided was changed. Patient refusal, which was listed as an example in the 2007 paper, should not be considered a reason not to provide a referral. Whether the patient chooses to act upon the referral or not is beyond the provider control. The example provided in this update clarifies that patients discharged to a nursing care facility for long-term care can be excluded.

* “Provider-oriented barriers” was revised to “medical factors,” and the examples provided were changed. The 2007 measures listed “patient deemed to have a high-risk condition or a contraindication to exercise” as an example. This was revised to specify “medically unstable, life-threatening condition” as an example of an appropriate medical exclusion. The rationale reflects the capacity of cardiac rehabilitation programs to modify their program to the medical needs of individual patients and that, other than life-threatening conditions, there are no a priori reasons to presume that a patient might not be able to participate in a rehabilitation and secondary prevention program.

* “Health care system barriers” was revised to “healthcare system factors,” and the examples provided were changed. “Financial barriers” was deleted and “lack of CR programs near a patient's home” was clarified to specify no cardiac rehabilitation program available within 60 minutes of travel time from the patient's home.

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Denominator:

A note was added to clarify that patients with a qualifying event who are to be discharged for a short-term stay in an inpatient medical rehabilitation facility are still expected to be referred to an outpatient cardiac rehabilitation program by the inpatient team during the index hospitalization. This referral should be reinforced by the care team at the medical rehabilitation facility.

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Corresponding Guidelines and Clinical Recommendations:

The recommendations in this section were updated to reflect the most recent iterations of the guidelines cited.

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Measure A-2. Cardiac Rehabilitation Patient Referral From an Outpatient Setting

Numerator:

* The note describing what constitutes a referral has been expanded to clarify that standards of practice for cardiac rehabilitation programs require care coordination communications to be sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new nonemergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program.

* Exclusion criteria: The same revisions made to the patient, medical, and health system factors described for Measure A-1 in Section 1.2 were made to this measure.

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Denominator:

The denominator statement was clarified to specify that only patients who have had a qualifying event/diagnosis during the previous 12 months and have not participated in an outpatient cardiac rehabilitation program since the qualifying event/diagnosis should be included.

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Attribution/Aggregation:

This section was added to clarify that 1) the measure should be reported by the clinician who provides the primary cardiovascular-related care for the patient (In general, this would be the patient's cardiologist, but in some cases it might be a family physician, internist, nurse practitioner, or other healthcare provider.); and 2) the level of aggregation (clinician versus practice) will depend upon the availability of adequate sample sizes to provide stable estimates of performance.

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Administrative Codes to Identify Denominator-Eligible Populations

To facilitate implementation of these measures in a variety of systems, we have included administrative codes that may be useful in identifying the population of patients who are eligible for inclusion in the denominator for each of the updated measures. See the online data supplement at http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.06.006/DC1 for details.

Staff

American Association of Cardiovascular and Pulmonary Rehabilitation

P. Joanne Ray, CFRE, Executive Director

Abigail Lynn, Senior Coordinator

American College of Cardiology Foundation

John C. Lewin, MD, Chief Executive Officer

Charlene May, Senior Director, Clinical Policy and Documents

Melanie Shahriary, RN, BSN, Associate Director, Performance Measures and Data Standards

Jensen S. Chiu, MHA, Specialist, Clinical Performance Measurement

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

American Heart Association

Nancy Brown, Chief Executive Officer

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

Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations

Dorothea K. Vafiadis, MS, Science and Medicine Advisor

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References

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
2. Bonow RO, Bennett S, Casey DE Jr. ACC/AHA clinical performance measures for adults with chronic heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart Failure Clinical Performance Measures). J Am Coll Cardiol- 2005; 46:1144–1178.
3. American Medical Association. Physician Consortium for Performance Improvement. Clinical Performance Measures: Chronic Stable Coronary Artery Disease. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/370/cadminisetjune06.pdf. Accessed January 5, 2010.
4. American Medical Association. Physician Consortium for Performance Improvement. Clinical Performance Measures: Hypertension. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/370/hypertension-8-05.pdf. Accessed January 5, 2010.
5. Krumholz HM, Anderson JL, Brooks NH. 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.
6. Krumholz HM, Anderson JL, Bachelder BL. ACC/AHA 2008 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 for ST-Elevation and Non-ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008; 52:2046–2099.
7. Thomas RJ, King M, Lui K. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol. 2007; 50:1400–1433.
8. Estes NA III, Halperin JL, Calkins H. ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation). J Am Coll Cardiol. 2008; 51:865–884.
9. Redberg RF, Benjamin EJ, Bittner V. ACCF/AHA 2009 performance measures for primary prevention of cardiovascular disease in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for Primary Prevention of Cardiovascular Disease). J Am Coll Cardiol. 2009; 54:1364–1405.
10. Spertus JA, Eagle KA, Krumholz HM. 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.
11. Krumholz HM, Brindis RG, Brush JE. Standards for statistical models used for public reporting of health outcomes: an American Heart Association Scientific Statement from the Quality of Care and Outcomes Research Interdisciplinary Writing Group: cosponsored by the Council on Epidemiology and Prevention and the Stroke Council Endorsed by the American College of Cardiology Foundation. Circulation. 2006; 113:456–462.
12. Eagle KA, Guyton RA, Davidoff R. 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). J Am Coll Cardiol. 2004; 44:e213–310.
13. Antman EM, Hand M, Armstrong PW. 2007 focused update of the ACC/AHA 2004 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. J Am Coll Cardiol. 2008; 51:210–247.
14. Anderson JL, Adams CD, Antman EM. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2007; 50:e1–e157.
15. Fraker TD Jr, Fihn SC, Gibbons RJ. 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Group to Develop the Focused Update of the 2002 Guidelines for the Management of Patients With Chronic Stable Angina). J Am Coll Cardiol. 2007; 50:2264–2274.
16. 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.
17. Mosca L, Banka CL, Benjamin EJ. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007; 115:1481–1501.
18. King SB III, Smith SC Jr, Hirshfeld JW Jr. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008; 51:172–209.
19. 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.
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Appendix A Cited Here...

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Appendix B: AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services PERFORMANCE MEASURE A-1

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A-1. 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.

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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 written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient's enrollment 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 (eg, the patient's cardiovascular history, testing, and treatments). All communications must maintain appropriate confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA).

Exclusion criteria:

* Patient factors (eg, patient to be discharged to a nursing care facility for long-term care).

* Medical factors (eg, patient deemed by provider to have a medically unstable, life-threatening condition).

* Health care system factors (eg, no cardiac rehabilitation program available within 60 minutes of travel time from the patient home).

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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 in the Numerator section

(Note: Patients with a qualifying event who are to be discharged for a short-term stay in an inpatient medical rehabilitation facility are still expected to be referred to an outpatient cardiac rehabilitation program by the in-patient team during the index hospitalization. This referral should be reinforced by the care team at the medical rehabilitation facility.)

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Period of Assessment

Inpatient hospitalization.

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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.

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Sources of Data

Administrative data and/or medical records.

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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 surgery, 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.

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Corresponding Guidelines and Clinical Recommendations

ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery.12

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Class I

Cardiac rehabilitation should be offered to all eligible patients after CABG surgery (Level of Evidence: B).

ACC/AHA 2007 Update of the Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction.13

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Class I

Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (eg, recent acute coronary syndrome or revascularization, heart failure) is recommended (Level of Evidence: B).

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction.14

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Class I

Cardiac rehabilitation/secondary prevention programs are recommended for patients with unstable angina/non–ST-segment elevation MI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is particularly warranted (Level of Evidence: B).

Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with unstable angina/non–ST-segment elevation MI, particularly those with multiple modifiable risk factors and those moderate- to high-risk patients in whom supervised or monitored exercise training is warranted (Level of Evidence: B).

ACC/AHA 2007 Chronic Angina Focused Update of the Guidelines for the Management of Patients With Chronic Stable Angina.15

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Class I

Medically supervised programs (cardiac rehabilitation) are recommended for at-risk patients (eg, recent acute coronary syndrome or revascularization, heart failure) (Level of Evidence: B).

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult.16

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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 (LVEF) (Level of Evidence: B).

AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update.17

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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 an LVEF <40% (Level of Evidence: B).

ACC/AHA/SCAI 2007 Focused Update of the Guidelines for Percutaneous Coronary Intervention.18

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Class I

Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (eg, recent acute coronary syndrome or revascularization, heart failure) is recommended (Level of Evidence: B).

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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.

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PERFORMANCE MEASURE A-2

A-2. 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, 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.

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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 written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient's enrollment 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 (eg, patient cardiovascular history, testing, and treatments). According to standards of practice for cardiac rehabilitation programs, care coordination communications are sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new nonemergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program. All communications must maintain an appropriate level of confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA).

Exclusion criteria:

* Patient factors (eg, patient resides in a long-term nursing care facility).

* Medical factors (eg, patient deemed by provider to have a medically unstable, life-threatening condition).

* Health care system factors (eg, no cardiac rehabilitation program available within 60 min of travel time from home).

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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, and who have not participated in an outpatient cardiac rehabilitation program since the qualifying event/diagnosis.

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Period of Assessment

Twelve months following a qualifying event/diagnosis.

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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.

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Sources of Data

Administrative data and/or medical records.

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Attribution/Aggregation

This measure should be reported by the clinician who provides the primary cardiovascular-related care for the patient. In general, this would be the patient's cardiologist, but in some cases it might be a family physician, internist, nurse practitioner, or other health-care provider. The level of “aggregation” (clinician versus practice) will depend upon the availability of adequate sample sizes to provide stable estimates of performance.

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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 (19). A key component to CR utilization is the appropriate and timely referral of patients to an outpatient CR program. While referral takes place generally while the patient is hospitalized for a qualifying event (MI, CSA, CABG, 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 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.

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.

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Corresponding Guidelines and Clinical Recommendations

See Clinical Recommendations section from Performance Measure A-1.

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Challenges to Implementation

Identification 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...

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