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)

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.

Table 1: ACCF/AHA Performance Measure Sets

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

Table 2: Applying Classification of Recommendations and Level of Evidence

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

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.

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.

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.

Corresponding Guidelines and Clinical Recommendations:

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

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.

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.

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.

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