New performance measures issued on CAD, hypertension

The growing number of patients affected by coronary artery disease (CAD) and hypertension has sparked three societies, the American College of Cardiology Foundation (ACCF), American Heart Association and American Medical Association (AMA) to modify performance measures, to improve quality of care.

The societies, part of the Physician Consortium for Performance Improvement (PCPI) initiative, upgraded and added five performance measures to the 2005 performance measures. The committee said that the measures “break new ground” and examine whether cardiac risk factors are treated and controlled to target levels by more patient-focused outcomes.

The 2005 measures focused on proper screening for diabetes in patients with CAD, which were replaced and updated to include 10 CAD and hypertension measures.

The updated performance measures for CAD include:

• Blood pressure (BP) control: Patients should reach a target BP goal of less than 140/90 mm Hg. If patients do not reach this goal, patients should receive at least two antihypertensive medications;
• Lipid control: Patients should have LDL cholesterol that is less than 100 mg/mL. If not reached, physicians should attempt to focus on lowering this LDL level, which could include—at minimum—a statin;
• Symptom and activity assessment: Physicians must evaluate patient activity level and examine the patients' presence or absence of angina symptoms;
• Symptom management: Physicians should document a plan of care to manage angina symptoms;
• Tobacco use, screening, cessation and intervention: Patients should be screened for tobacco use and should receive smoking cessation counseling if they smoke;
• Antiplatelet therapy: Physicians should prescribe aspirin or clopidogrel;
• Beta-blocker therapy: This therapy should be prescribed in patients with a prior incidence of MI or a left ventricular ejection fraction of less than 40 percent;
• ACE inhibitor/ARB therapy: This should be prescribed to patients with diabetes or a left ventricular ejection fraction of less than 40 percent;
• Cardiac rehabilitation patient referral: Physicians should refer patients who experienced an acute MI, CABG, stenting, cardiac valve surgery or cardiac transplantation to an outpatient cardiac rehab program.

The hypertension measure includes:

• Blood pressure control: Patients should achieve a target BP of less than 140/90 mm Hg. If not, physicians should administer at least two antihypertension medications.

“The current measures represent an attempt to resolve some of the methodological issues associated with creating performance measures at the individual practitioner or practice level,” said writing committee co-chair Joseph P. Drozda, Jr., MD, director of outcomes research at Sisters of Mercy Health System in St. Louis. “These issues arise because of the socioeconomic and clinical heterogeneity of patient populations and the relatively small number of patients treated by any one practitioner or group, prohibiting risk adjustment.”

Before the performance measures are used in accountability programs—pay-for-performance programs or public reporting—they will undergo testing developed by PCPI and ACCF’s PINNACLE Registry.

“These measures are primarily intended for the use of individual practitioners and group practices in their efforts to improve the care of patients with hypertension and those with stable coronary disease,” Drozda said. “By adhering to the specifications called for in this measures set, entities operating such accountability programs can be assured of having high quality and clinically meaningful measures.”