2017 AHA/ACC Clinical Performance and Quality Measures

43 Pages·2017·1.22 MB·English

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO. -, 2017
ª2017 AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION AND ISSN 0735-1097/$36.00
AMERICAN HEART ASSOCIATION, INC. http://dx.doi.org/10.1016/j.jacc.2017.06.032
PERFORMANCE MEASURE
2017 AHA/ACC Clinical Performance
and Quality Measures for Adults With
ST-Elevation and Non–ST-Elevation
Myocardial Infarction
AReportoftheAmericanCollegeofCardiology/AmericanHeartAssociation
TaskForceonPerformanceMeasures
DevelopedinCollaborationWiththeSocietyforCardiovascularAngiographyandInterventions
EndorsedbytheAmericanAssociationofCardiovascularandPulmonaryRehabilitation
Writing HaniJneid,MD,FACC,FAHA,Chair P.MichaelHo,MD,PhD,FACC,FAHA
Committee CorrineY.Jurgens,PhD,RN,ANP-BC,FAHA
Members DanielAddison,MD MarjorieL.King,MD,FACC
DeepakL.Bhatt,MD,MPH,FACC,FAHA DharamJ.Kumbhani,MD,SM,FACC,FAHA
GreggC.Fonarow,MD,FACC,FAHA SamirPancholy,MD,FACCy
SanaGokak,MPH
KathleenL.Grady,PhD,FAHA
LeeA.Green,MD,MPH *ACC/AHATaskForceonPerformanceMeasuresLiaison.ySocietyfor
CardiovascularAngiographyandInterventionsRepresentative.
PaulA.Heidenreich,MD,MS,FACC,FAHA*
ACC/AHA GreggC.Fonarow,MD,FACC,FAHA,Chair PaulS.Chan,MD,MSc,FACCx
TaskForceon PaulA.Heidenreich,MD,MS,FACC,FAHA, LesleyH.Curtis,PhDx
Performance ImmediatePastChair LaurenGilstrap,MDx
Measures MichelleGurvitz,MD,FACCz
NancyM.Albert,PhD,CCNS,CCRN,FAHAz P.MichaelHo,MD,PhD,FACC,FAHAx
GeoffreyD.Barnes,MD,MSc,FACCx CorrineY.Jurgens,PhD,RN,ANP-BC,FAHAx
ThisdocumentunderwentpeerreviewbetweenDecember7,2016,andDecember31,2016,anda30-daypubliccommentperiodbetweenDecember7,
2016,andJanuary6,2017.
ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyClinicalPolicyApprovalCommitteeonMay22,2017,theAmericanHeartAs-
sociationScienceAdvisoryandCoordinatingCommitteeonJune7,2017,theAmericanHeartAssociationExecutiveCommitteeonAugust11,2017,and
theSocietyforCardiovascularAngiographyandInterventionsonJuly17,2017.
TheAmericanCollegeofCardiologyrequeststhatthisdocumentbecitedasfollows:JneidH,AddisonD,BhattDL,FonarowGC,GokakS,GradyKL,
GreenLA,HeidenreichPA,HoPM,JurgensCY,KingML,KumbhaniDJ,PancholyS.2017AHA/ACCclinicalperformanceandqualitymeasuresforadults
withST-elevationandnon–ST-elevationmyocardialinfarction:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForce
onPerformanceMeasures.JAmCollCardiol.2017;xx:xxx–xxx.
ThisarticlehasbeencopublishedinCirculation:CardiovascularQualityandOutcomes.
Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmericanCollegeofCardiology(www.acc.org)andtheAmericanHeart
Association(professional.heart.org).Forcopiesofthisdocument,pleasecontactElsevierReprintDepartmentviafax(212-633-3820)oremail(reprints@
elsevier.com).
Permissions:Multiplecopies,modification,alteration,enhancement,and/ordistributionofthisdocumentarenotpermittedwithouttheexpress
permissionoftheAmericanCollegeofCardiology.PleasecontactElsevier’[email protected].
2 Jneidetal. JACC VOL. -, NO. -, 2017
2017AHA/ACCSTEMI/NSTEMIMeasureSet -, 2017:-–-
SeanO’Brien,PhDz RobertYeh,MD,FACCz
JeffreyOlin,DO,FACC,FAHAx SamadZaheeruddin,MDz
TiffanyRandolph,MDz
AndreaM.Russo,MD,FACCx
RandalJ.Thomas,MD,FACC,FAHAz zAmericanCollegeofCardiologyRepresentative.xAmericanHeart
PaulD.Varosy,MD,FACCz AssociationRepresentative.
TABLE OF CONTENTS
PREAMBLE...................................... - ShortTitle:PM-11:TimetoPrimaryPCIAmong
TransferredPatients...................... -
ShortTitle:PM-12:CardiacRehabilitation
1.INTRODUCTION ............................... -
Referral ............................... -
1.1. ScopeoftheProblem .........................- ShortTitle:PM-13:P2Y12Inhibitorat
Discharge .............................. -
1.2. DisclosureofRelationshipsWithIndustryand
ShortTitle:PM-14:ImmediateAngiography
OtherEntities ...............................- AfterCardiacArrest ...................... -
ShortTitle:PM-15:StressTestinConservatively
2.METHODOLOGY ............................... - TreatedPatients......................... -
ShortTitle:PM-16:EarlyTroponinMeasurement
2.1. LiteratureReview ........................... -
AfterNSTEMI ........................... -
2.2. DefinitionandSelectionofMeasures ........... - ShortTitle:PM-17:AMIRegistry
Participation............................ -
3.AHA/ACCSTEMIANDNSTEMIMEASURESET QualityImprovementMeasuresforInpatient
PERFORMANCEMEASURES ..................... - STEMIandNSTEMIPatients...................-
InpatientMeasures ........................ -
3.1. DiscussionofChangesto2008STEMIandNSTEMI ShortTitle:QM-1:RiskScoreStratificationfor
MeasureSet................................ - NSTEMI ............................... -
3.1.1.RetiredMeasures .......................- ShortTitle:QM-2:EarlyInvasiveStrategyfor
3.1.2.RevisedMeasures.......................- High-RiskNSTEMI ....................... -
ShortTitle:QM-3:TherapeuticHypothermiafor
3.1.3.NewMeasures..........................-
STEMIPatients.......................... -
ShortTitle:QM-4:AldosteroneAntagonistat
4.AREASFORFURTHERRESEARCH ............... - Discharge .............................. -
ShortTitle:QM-5:InappropriateIn-HospitalUse
APPENDIXA ofNSAIDs.............................. -
ShortTitle:QM-6:InappropriatePrasugrelat
STEMIandNSTEMIPerformanceMeasures.......... - DischargeinTIA/StrokePatients ............ -
PerformanceMeasuresforUseinPatientsWith ShortTitle:QM-7:InappropriateHigh-Dose
InpatientSTEMIandNSTEMI ..................- AspirinWithTicagreloratDischarge ......... -
InpatientMeasures ........................ -
ShortTitle:PM-1:AspirinatArrival .......... - APPENDIXB
ShortTitle:PM-2:AspirinatDischarge ....... -
AuthorListingofRelationshipsWithIndustryand
ShortTitle:PM-3:BetaBlockerat
Discharge .............................. - OtherEntities(Relevant)—2017AHA/ACCClinical
PerformanceandQualityMeasuresforAdultsWith
ShortTitle:PM-4:High-IntensityStatinat
ST-ElevationandNon–ST-ElevationMyocardial
Discharge .............................. -
Infarction ..................................... -
ShortTitle:PM-5:EvaluationofLVEF ........ -
ShortTitle:PM-6:ACEIorARBforLVSD...... -
APPENDIXC
ShortTitle:PM-7:Door-to-NeedleTime ...... -
ShortTitle:PM-8:FirstMedical PeerReviewerRelationshipsWithIndustryandOther
Contact-DeviceTime ..................... - Entities—2017AHA/ACCClinicalPerformanceand
ShortTitle:PM-9:ReperfusionTherapy....... - QualityMeasuresforAdultsWithST-Elevationand
ShortTitle:PM-10:Door-in-Door-OutTime.... - Non–ST-ElevationMyocardialInfarction ............ -
JACC VOL. -, NO. -, 2017 Jneidetal. 3
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PREAMBLE waschargedwiththetaskofdevelopingnewmeasuresto
benchmark and improve the quality of care for patients
The American College of Cardiology (ACC)/American withSTEMIandNSTEMI.
HeartAssociation(AHA)performancemeasuresetsserve Allthemeasuresincludedinthemeasuresetarebriefly
asvehiclestoacceleratetranslationofscientificevidence summarizedinTable1,whichprovidesinformationonthe
into clinical practice. Measure sets developed by the measure number, title, care setting, attribution, and
ACC/AHA are intended to provide practitioners and in- domain.Thedetailedmeasurespecifications(availablein
stitutions that deliver cardiovascular services with tools AppendixA)providenotonlytheinformationincludedin
to measure the quality of care provided and identify Table1,butalsomoredetailedinformationincludingthe
opportunitiesforimprovement. measuredescription,numerator,denominator(including
Writing committees are instructed to consider the denominatorexclusionsandexceptions),rationaleforthe
methodology of performance measure development (1) measure, guideline recommendations that support the
and to ensure that the measures developed are aligned measure,measurementperiod,andsourcesofdata.
with ACC/AHA clinical practice guidelines. The writing Thewritingcommitteehasdevelopedacomprehensive
committeesalsoarechargedwithconstructingmeasures STEMI/NSTEMI measure set that includes 24 total mea-
thatmaximallycaptureimportantaspectsofcarequality, sures of which 17 are performance measures and 7 are
including timeliness, safety, effectiveness, efficiency, qualitymeasures(asreflectedinTable1andAppendixA).
equity, and patient-centeredness, while minimizing, The writing committee believes that implementation of
when possible, the reporting burden imposed on hospi- this measure set by healthcare providers, physician
tals,practices,and/orpractitioners. practices, and hospital systems will enhance the quality
Potential challenges from measure implementation of care and likely improve outcomes of patients with
may lead to unintended consequences. The manner in STEMIandNSTEMI.
which challenges are addressed is dependent on several
1.1. ScopeoftheProblem
factors, including the measure design, data collection
method, performance attribution, baseline performance Acute myocardial infarction (AMI) is a frequent cause of
rates, reporting methods, and incentives linked to these hospitaladmissionintheUnitedStatesandisassociated
reports. with significant short- and long-term mortality and
The ACC/AHA Task Force on Performance Measures morbidity. Every 42 seconds, approximately 1 American
(Task Force) distinguishesqualitymeasuresfromperfor- willsufferanAMI,andtheestimatedannualincidencesof
mancemeasures.Qualitymeasuresarethosemetricsthat new and recurrent MI events are 550,000 and 200,000
may be useful for local quality improvement but are not events,respectively(3).
yet appropriate for public reporting or pay for perfor- Fortunately, the rates of hospitalization and 30-day
mance programs (uses of performance measures). New mortality for AMI have been on the decline (4,5). This
measuresareinitiallyevaluatedforpotentialinclusionas reduction in mortality is likely related to the shift in the
performance measures. In some cases, a measure is pattern of clinical presentation of AMI as well as to
insufficiently supported by the guidelines. In other in- improved acute treatments and long-term care. Yeh and
stances, when the guidelines support a measure, the colleagues examined age- and sex-adjusted incidence
writing committee may feel it is necessary to have rates for STEMI and NSTEMI from a community-based
themeasuretestedtoidentifytheconsequencesofmea- population (Northern California) between 1999 and
sure implementation. Quality measures may then be 2008,anddemonstratedanoverallsignificantdecreasein
promotedto the status ofperformance measuresassup- AMIincidencerateafter2000(6).Althoughtheadjusted
portingevidencebecomesavailable. 30-day mortality rate after AMI decreased significantly
GreggC.Fonarow,MD,FACC,FAHA (driven by a significant reduction in NSTEMI mortality),
Chair,ACC/AHATaskForceonPerformanceMeasures the overall mortality rate in 2008 after an AMI was still
7.8%at30days(6).
1. INTRODUCTION Importantly,AMIpatientswhosurvivetheinitialevent
have substantial risk for future cardiovascular events,
In the summer of 2015, the Task Force convened the includingrecurrentMI,death,heartfailure,andstroke.In
writing committee to begin the process of revising the the PLATO (Platelet Inhibition and Patient Outcomes)
existing set of performance measures for adult patients trial, the rate of the combined cardiovascular endpoint
hospitalized with ST-Elevation and Non–ST-Elevation (vascular death, MI, or stroke) was 11.7% at 12 months
MyocardialInfarction(STEMIandNSTEMI,respectively), amongAMIpatientstreatedwithaspirinandclopidogrel
thatwaslastupdatedin2008(2).Thewritingcommittee (7).Thisincludeda6.9%rateofrecurrentMIat12months
4 Jneidetal. JACC VOL. -, NO. -, 2017
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TABLE 1 2017AHA/ACCSTEMIandNSTEMIMyocardialInfarctionClinicalPerformanceandQualityMeasures
No. MeasureTitle CareSetting Attribution MeasureDomain
PerformanceMeasures
PM-1 AspirinatArrival Inpatient FacilityorProviderLevel EffectiveClinicalCare
PM-2 AspirinPrescribedatDischarge Inpatient FacilityorProviderLevel EffectiveClinicalCare
PM-3 BetaBlockerPrescribedatDischarge Inpatient FacilityorProviderLevel EffectiveClinicalCare
PM-4 High-IntensityStatinPrescribedatDischarge Inpatient FacilityorProviderLevel EffectiveClinicalCare
PM-5 EvaluationofLVEF Inpatient FacilityorProviderLevel EffectiveClinicalCare
PM-6 ACEIorARBPrescribedforLVSD Inpatient FacilityorProviderLevel EffectiveClinicalCare
PM-7 TimetoFibrinolyticTherapy* Inpatient FacilityorProviderLevel CommunicationandCareCoordination
PM-8 TimetoPrimaryPCI* Inpatient FacilityorProviderLevel CommunicationandCareCoordination
PM-9 ReperfusionTherapy* Inpatient FacilityorProviderLevel EffectiveClinicalCare
PM-10 TimeFromEDArrivalatSTEMIReferralFacilityto Inpatient FacilityLevel CommunicationandCareCoordination
EDDischargeFromSTEMIReferralFacilityin
PatientsTransferredforPrimaryPCI*
PM-11 TimeFromFMC(AtorBeforeEDArrivalatSTEMI Inpatient FacilityLevel CommunicationandCareCoordination
ReferralFacility)toPrimaryPCIatSTEMI
ReceivingFacilityAmongTransferredPatients*
PM-12 CardiacRehabilitationPatientReferralFroman Inpatient FacilityorProviderLevel CommunicationandCareCoordination
InpatientSetting
PM-13 PY12ReceptorInhibitorPrescribedatDischarge Inpatient FacilityorProviderLevel EffectiveClinicalCare
PM-14 ImmediateAngiographyforResuscitatedOut-of- Inpatient FacilityorProviderLevel EffectiveClinicalCare
HospitalCardiacArrestinSTEMIPatients*
PM-15 NoninvasiveStressTestingBeforeDischargein Inpatient FacilityorProviderLevel EfficiencyandCostReduction
ConservativelyTreatedPatients
PM-16 EarlyCardiacTroponinMeasurement†(Within Inpatient FacilityorProviderLevel EfficiencyandCostReduction
6HoursofArrival)
PM-17 Participationin$1RegionalorNationalRegistries Inpatient FacilityLevel Community,Population,andPublicHealth
ThatIncludePatientsWithAcuteMyocardial
InfarctionRegistry
QualityMeasures
QM-1 RiskStratificationofNSTEMIPatientsWithaRisk Inpatient FacilityorProviderLevel EffectiveClinicalCare
Score†
QM-2 EarlyInvasiveStrategy(Within24Hours)inHigh- Inpatient FacilityorProviderLevel EffectiveClinicalCare
RiskNSTEMIPatients†
QM-3 TherapeuticHypothermiaforComatoseSTEMI Inpatient FacilityorProviderLevel EffectiveClinicalCare
PatientsWithOut-of-HospitalCardiacArrest*
QM-4 AldosteroneAntagonistPrescribedatDischarge Inpatient FacilityorProviderLevel EffectiveClinicalCare
QM-5 InappropriateIn-HospitalUseofNSAIDs Inpatient FacilityorProviderLevel PatientSafety
QM-6 InappropriatePrescriptionofPrasugrelatDischarge Inpatient FacilityorProviderLevel PatientSafety
inPatientsWithaHistoryofPriorStrokeorTIA
QM-7 InappropriatePrescriptionofHigh-DoseAspirin Inpatient FacilityorProviderLevel PatientSafety
WithTicagreloratDischarge
*ThesemeasuresapplyonlytopatientswithSTEMI.†ThesemeasuresapplyonlytopatientswithNSTEMI.
ACCindicatesAmericanCollegeofCardiology;ACEI,angiotensin-convertingenzymeinhibitor;AHA,AmericanHeartAssociation;ARB,angiotensinreceptorblocker;ED,emergency
department;FMC,firstmedicalcontact;LVEF,leftventricularejectionfraction;LVSD,leftventricularsystolicdysfunction;NSAIDs,nonsteroidalanti-inflammatorydrugs;NSTEMI,
non–ST-elevationmyocardialinfarction;PCI,percutaneouscoronaryintervention;PM,performancemeasures;QM,qualitymeasures;STEMI,ST-elevationmyocardialinfarction;and
TIA,transientischemicattack.
(7). In 2010 alone, about 595,000 inpatient hospital dis- 2012 (8),AMIisdefinedby thedetectionofariseand/or
chargeswereattributedtoAMI(3).AMIisalsoassociated fall of cardiac biomarkers (preferably cardiac troponin
withasubstantialdirectandindirectcostburden,andis levels) with at least 1 value above the 99th percentile
classified among the top 10 most expensive hospital upper reference limit and with at least one of the
principaldischargediagnoses(3). following:(a)symptomsofischemia;(b)neworpresumed
As indicated in the Third Universal Definition of new significant ST-segment–T wave changes or new left
Myocardial Infarction consensus document published in bundle branch block; (c) development of pathological Q
JACC VOL. -, NO. -, 2017 Jneidetal. 5
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waves in the electrocardiogram (ECG); (d) imaging evi- III guideline recommendations) of patients with STEMI/
denceofnew lossofviablemyocardium or new regional NSTEMI and that satisfy the attributes of performance
wall motion abnormality; (e) identification of an intra- measures(e.g.,feasible,reliable,actionable).Thiswriting
coronarythrombusbyangiographyorautopsy.TheThird committee developed the measures in this document
Universal Definition of Myocardial Infarction consensus after comprehensive examination of the most current
document, published in 2012, classifies MI into 5 types, relevant guidelines, internal discussion and internal
based on pathological, clinical, and prognostic differ- voting,peerreview,andpubliccomment.
ences, along with different treatment strategies (8). The
1.2. DisclosureofRelationshipsWithIndustryand
performance and quality measures described in the cur-
OtherEntities
rent document are predominantly pertinent to patients
withspontaneousMI,orMItype1.MItype1isanevent The Task Force makes every effort to avoid actual, po-
relatedtoatheroscleroticplaquedisruption(e.g.,rupture, tential, or perceived conflicts of interest that could arise
ulceration,erosion)withsuperimposedthrombusforma- asaresultofrelationshipswithindustryorotherentities
tion in a coronary artery, resulting in acute reduction in (RWI). Detailed information on the ACC/AHA policy on
myocardialbloodsupplyand/ordistalembolizationwith RWI can be found online. All members of the writing
subsequent myonecrosis. MI type 2 is myocardial injury committee, as well as those selected to serve as peer re-
caused by conditions other than coronary artery disease viewers of this document, were required to disclose all
that results in an imbalance between myocardial oxygen current relationships and those existing within the 12
supplyand/ordemand(e.g.,coronaryarteryembolismor months before the initiation of this writing effort. ACC/
spasm, tachyarrhythmias, anemia, respiratory failure, AHA policy also requires that the writing committee
profoundhypotension). chairsandatleast50%ofthewritingcommitteehaveno
The measure set developed by our writing committee relevantRWI.
appliesonlytoMItype1anddoesnotuniformlyapplyto Any writing committee member who develops new
the other 4 types of MI. In fact, some of those measures RWIduringhisorhertenureonthewritingcommitteeis
are even contraindicated with certain MI type, such as required to notify staff in writing. These statements are
aspirin or P2Y receptor inhibitor therapies, which are reviewedperiodicallybytheTaskForceandbymembers
12
contraindicated in patients with a MI type 2 resulting ofthewritingcommittee.AuthorandpeerreviewerRWI
from severe hemorrhage and anemia. Given the wide- which are relevant to the document are included in the
spread use of very sensitive assays for markers of appendixes: Please see Appendix B for relevant writing
myocardialnecrosis(e.g.,thehighlysensitiveandspecific committee RWI and Appendix C for relevant peer
cardiactroponin[cTn]biomarkers)andadvancedimaging reviewer RWI. Additionally, to ensure complete trans-
modalities,verysmallamountsofmyonecrosisunrelated parency,thewritingcommitteemembers’comprehensive
to ischemia can be detected (e.g., heart failure, renal disclosureinformation,includingRWInotrelevanttothe
failure,myocarditis,pulmonaryembolism).Ourmeasures present document, is available online. Disclosure infor-
alsodonotapplytothesemyocardialinjuryevents,which mationfortheTaskForceisalsoavailableonline.
shouldbedifferentiatedfromtrueAMIevents. The work of the writing committee was supported
For the sake of immediate treatment strategies (e.g., exclusivelybytheACCandtheAHAwithoutcommercial
reperfusion therapy), AMI is differentiated into STEMI support. Members of the writing committee volunteered
and NSTEMI, depending on the existence of ST-segment their time for this effort. Meetings of the writing com-
elevation in $2 contiguous leads on the presenting ECG. mittee were confidential and attended only by writing
Acute STEMI equivalent can, however, manifest as: committeemembersandstafffromtheACC,AHA,andthe
hyperacuteT-wavechanges,trueposteriorMI,multilead SocietyforCardiovascularAngiographyandInterventions
ST depression with coexistent ST elevation in lead aVR, whoservedasacollaboratoronthisproject.
characteristic diagnostic criteria in the setting of left
2. METHODOLOGY
bundle branch block. The proportion of STEMI versus
NSTEMIeventsvariesindifferentregistriesanddepends
ontheageofpatients,theirgeographiclocation,andthe 2.1. LiteratureReview
type of surveillance used. In general, STEMI patients In developing the updated STEMI/NSTEMI measure set,
accountfor29%to47%ofallAMIpatients(9,10). the writing committee reviewed evidence-based guide-
UpdatingtheexistingSTEMI/NSTEMImeasuresetwas lines and statements that would potentially impact the
a priority for the ACC and AHA. Particular attention was construct of the measures. The practice guidelines and
giventoevidence-baseddiagnostic andtherapeutic stra- statements that most directly contributed to the devel-
tegiesthathavehighimpactonoutcomes(e.g.,ClassIor opmentofthesemeasuresaresummarizedinTable2.
6 Jneidetal. JACC VOL. -, NO. -, 2017
2017AHA/ACCSTEMI/NSTEMIMeasureSet -, 2017:-–-
All measures were designed to assess quality of care
AssociatedGuidelinesandOtherClinical
TABLE 2
GuidanceDocuments experiencedbyindividualswhohaveSTEMIorNSTEMIin
theinpatientsetting.Eachmeasurewasdesignedtolimit
CLINICALPRACTICEGUIDELINES
performance measurement to patients without a valid
1. 2014AHA/ACCGuidelinefortheManagementofPatientsWith
Non–ST-ElevationAcuteCoronarySyndromes(11) reason for exclusion from the measure. Measure exclu-
2. 2013ACCF/AHAGuidelinefortheManagementofST-Elevation sions were those reasonsthat remove apatient from the
MyocardialInfarction(12) denominator, regardless of whether they would be
3. AHA/ACCFSecondaryPreventionandRiskReductionTherapyforPatients included in the numerator. For example, all measures
WithCoronaryandOtherAtheroscleroticVascularDisease:2011
Update(13) excludedpatientswhowere<18yearsofage,whoreceived
comfortcaremeasuresonly,orinhospice.Incontrastto
4. 2013ACC/AHAGuidelineontheTreatmentofBloodCholesterolto
ReduceAtheroscleroticCardiovascularRiskinAdults(14) exclusions,denominatorexceptionswerethoseconditions
5. 2015ACC/AHA/SCAIFocusedUpdateonPrimaryPercutaneousCoronary thatremovedapatientfromthedenominatoronlyifthe
InterventionforPatientsWithST-ElevationMyocardialInfarction:An
numeratorcriteriawerenotmet.Denominatorexceptions
Updateofthe2011ACCF/AHA/SCAIGuidelineforPercutaneous
CoronaryInterventionandthe2013ACCF/AHAGuidelineforthe wereusedinselectcasestoallowforafairermeasurement
ManagementofST-ElevationMyocardialInfarction(15)
ofqualityforthoseproviderswithhigherriskpopulations.
6. 2016ACC/AHAGuidelineFocusedUpdateonDurationofDual Exceptionswerealsousedtodefertotheclinicaljudgment
AntiplateletTherapyinPatientsWithCoronaryArteryDisease(16)
oftheprovider.Severalofthemeasuresincludedexcep-
7. 2016ACC/AHA/HFSAFocusedUpdateonNewPharmacologicalTherapy
forHeartFailure:AnUpdateofthe2013ACCF/AHAGuidelineforthe tions. For example, in the case of the “P2Y12 Inhibitor at
ManagementofHeartFailure(17) Discharge” measure, a care provider may write a pre-
STATEMENTS/PERFORMANCEMEASURES scriptionforanoralP2Y receptorinhibitor(clopidogrel,
12
1. 2015ACC/AHAFocusedUpdateofSecondaryPreventionLipid ticagrelor,or prasugrel) even if the patient revealed that
PerformanceMeasures(18)
he/she will not take the medication due to a number of
2. ThirdUniversalDefinitionofMyocardialInfarction(8)
reasons(e.g.,concernsaboutitsbleedingrisk).Inthiscase,
3. ACC/AHA2008PerformanceMeasuresforAdultsWithST-Elevationand the provider wouldreceive credit for the measure. How-
Non–ST-ElevationMyocardialInfarction(2)
ever,ifthepatienthadexplicitlyexpressedtotheprovider
4. ACC/AHA2008StatementonPerformanceMeasurementand
ReperfusionTherapy(19) thathe/shedidnotwishtohavethemedicationprescribed,
noprescriptionwillbewrittenandtheprovidercanthen
ACCindicatesAmericanCollegeofCardiology;ACCF,AmericanCollegeofCardiology
Foundation;AHA,AmericanHeartAssociation;ESCindicatesEuropeanSocietyofCar- document in the medical record patient’s refusal of the
diology;HFSA,HeartFailureSocietyofAmerica;andSCAI,SocietyforCardiovascular medication. In this scenario, the provider will not be
AngiographyandInterventions.
penalized for this performance measure because a valid
patient reason is documented. The writing committee
2.2. DefinitionandSelectionofMeasures closelydeliberatedtheexceptionstobeincludedwitheach
The writing committee reviewed recent clinical practice measureand,insomecases,determinednottoincludeany
guidelines and other clinical guidance documents exceptions(asinthecaseofthepatientsafetymeasures).
(Table2).Thewritingcommitteealsoexaminedavailable During the course of developing the measure set, the
information on disparities in care to address which new writing committee evaluated the potential measures
measures might be appropriate as performance versus againsttheACC/AHAattributesofperformancemeasures
qualitymeasuresforthismeasuresetupdate.Tothisef- (Table3)toreachconsensusonwhichmeasuresshouldbe
fect, an extensive environmental scan of the published advancedforinclusioninthefinalmeasureset.Afterthe
literaturewasperformed.Inalargeretrospectiveanalysis peer review and public comment period, the writing
of STEMI patients transferred to primary percutaneous committee reviewed and discussed the comments
coronary intervention (PCI) centers in the ACTION-Get received,andfurtherrefinedthemeasureset.Thewriting
With The Guidelines registry (2007-2010), only 11% had committee acknowledges that the new measures created
timely door-in-door-out time #30 minutes (20). In inthissetwillneedtobetestedandvalidatedovertime.
another cohort of STEMI patients transferred from By publishingthisperformanceandquality measure set,
non–PCI-capable hospitals to STEMI receiving centers the writing committee hopes to encourage their wide-
(2008-2012),timelyprimaryPCI(#120minutes)wasach- spreadandexpeditiousadoption,aswellasfacilitatethe
ieved in 65% of transferred patients (21). Another report collection and analysis of data that are needed to
showedthatonly41%ofpatientswerereferredtocardiac continuously assess their relevance over time. In the
rehabilitation after AMI (22,23). These reports highlight future,thewritingcommitteemembersanticipatehaving
but a few examples of the persistent disparities in care. data that will allow them to reassess whether any of
Importantly, it appears guideline-directed care can the measures included in this set should be revised
greatlyreducealargeproportionofdisparitiespreviously (e.g., modified, deleted, or potentially upgraded from a
notedinwomen(24,25). qualitymeasuretoaperformancemeasure).
JACC VOL. -, NO. -, 2017 Jneidetal. 7
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TABLE 3 ACC/AHATaskForceonPerformanceMeasures:AttributesforPerformanceMeasures(26)
1.EvidenceBased
High-impactareathatisusefulinimproving a)Forstructuralmeasures,thestructureshouldbecloselylinkedtoameaningfulprocessofcarethatinturnis
patientoutcomes linkedtoameaningfulpatientoutcome.
b)Forprocessmeasures,thescientificbasisforthemeasureshouldbewellestablished,andtheprocessshouldbe
closelylinkedtoameaningfulpatientoutcome.
c)Foroutcomemeasures,theoutcomeshouldbeclinicallymeaningful.Ifappropriate,performancemeasures
basedonoutcomesshouldadjustforrelevantclinicalcharacteristicsthroughtheuseofappropriate
methodologyandhigh-qualitydatasources.
2.MeasureSelection
Measuredefinition a)Thepatientgrouptowhomthemeasureapplies(denominator)andthepatientgroupforwhomconformanceis
achieved(numerator)areclearlydefinedandclinicallymeaningful.
Measureexceptionsandexclusions b)Exceptionsandexclusionsaresupportedbyevidence.
Reliability c)Themeasureisreproducibleacrossorganizationsanddeliverysettings.
Facevalidity d)Themeasureappearstoassesswhatitisintendedto.
Contentvalidity e)Themeasurecapturesmostmeaningfulaspectsofcare.
Constructvalidity f)Themeasurecorrelateswellwithothermeasuresofthesameaspectofcare.
3.MeasureFeasibility
Reasonableeffortandcost a)Thedatarequiredforthemeasurecanbeobtainedwithreasonableeffortandcost.
Reasonabletimeperiod b)Thedatarequiredforthemeasurecanbeobtainedwithintheperiodallowedfordatacollection.
4.Accountability
Actionable a)Thoseheldaccountablecanaffectthecareprocessoroutcome.
Unintendedconsequencesavoided b)Thelikelihoodofnegativeunintendedconsequenceswiththemeasureislow.
ACCindicatesAmericanCollegeofCardiology;AHA,AmericanHeartAssociation.
3. AHA/ACC STEMI AND NSTEMI MEASURE SET test measures in the 2008 measure set, were retired for
PERFORMANCE MEASURES thereasonsspecifiedinTable4.
3.1.2. RevisedMeasures
3.1. DiscussionofChangesto2008STEMIandNSTEMI
MeasureSet The writing committee reviewed and made changes to 4
After reviewing the existing guidelines, and the 2008 measures, which are summarized in Table 5. Most the
performance and quality measure set (2), the writing changes were made to reflect the new evidence and
committee discussed which measures should be revised updated guideline recommendations, to strengthen the
to reflect the updated science, and worked to identify measureconstruct,ortoexpandthemeasurestoinclude
which guideline recommendations could serve as the newprovenpharmacotherapies.
basis for new performance or quality measures. The
3.1.3. NewMeasures
writing committee also reviewed existing measure sets
thatwerepubliclyavailable. The new measure set includes 4 performance measures
The following subsections serve as a synopsis of the and7qualitymeasures.Table6includesalistofthenew
revisions that were made to previous measures, and a measuresandtheirrationale.
description of why the new inpatient measures were Fourofthequalitymeasuresarestructuredinatypical
created. format in which the goal is to seek a score of 100%.
However,3ofthenewqualitymeasures(QM-5,QM-6,and
QM-7)aresafetymeasuresand,inthose,thegoalistoseek
3.1.1. RetiredMeasures
ascoreof0%(e.g.,0%useorprescriptionofaninappro-
The writing committee decided to retire 1 performance priatetreatmentreflectsanoptimalqualityofcare).
measureforsmokingcessationcounselingbecauseofthe For more detailed information on the measure
consistently high levels of performance achieved construct,pleaserefer tothe detailedmeasure specifica-
(Table4).Otherqualitymeasures,previouslyincludedas tionssummarizedinAppendixA.
8 Jneidetal. JACC VOL. -, NO. -, 2017
2017AHA/ACCSTEMI/NSTEMIMeasureSet -, 2017:-–-
TABLE 4 RetiredSTEMIandNSTEMIMeasuresFromthe2008Set
# CareSetting MeasureTitle RationaleforRetiringtheMeasure
PM-12 Inpatient AdultSmoking Thismeasureisbeingretiredbecauseperfectscoresareconsistentlyachievedandthemeasureappearstohave
CessationAdvice/ reachedaceilingeffect.Therefore,givenabsenceofroomforfurtherimprovement,thewritingcommittee
Counseling optedtoomitthismeasurefromtheinpatientperformancemeasuresetforAMI(realizingalsothataseparate
outpatientCADmeasuresetwilllikelyaddresssmokingcessationadvice/counseling).Thewritingcommittee
alsorecognizestheimportanceoftheAmericanMedicalAssociation/PhysicianConsortiumforPerformance
ImprovementTobaccoUse:ScreeningandCessationInterventionmeasurethatalreadyexists(27).
QM-1 Inpatient LDLCholesterol ThismeasureisbeingretiredtobeconcordantwiththenewlipidguidelinesthatnolongerrecommendLDL
Assessment measurementstotargetstatinprescriptionand/ordosing.
QM-2 Inpatient ExcessiveInitial Thismeasureisbeingretiredbecauseitcoversonlyoneaspectofmedicationuse(e.g.,overdosing)andmisses
HeparinDose otheraspectssuchasunder-dosingandinappropriateuse.Inaddition,thisisnotadirectstand-aloneClassIor
IIIrecommendationintheguidelinesandhasshortcomingspertinenttomeasurefeasibilityandaccountability.
QM-3 Inpatient ExcessiveInitial Thismeasureisbeingretiredbecauseitcoversonlyoneaspectofmedicationuse(e.g.,overdosing)andmisses
EnoxaparinDose otheraspectssuchasunderdosingandinappropriateuse.Inaddition,thisisnotadirectstand-aloneClassIorIII
recommendationintheguidelinesandhasshortcomingspertinenttomeasurefeasibilityandaccountability.
QM-4 Inpatient ExcessiveInitial Thismeasureisbeingretiredbecauseitcoversonlyoneaspectofmedicationuse,(e.g.,overdosing)andmisses
AbciximabDose otheraspectssuchasunderdosingandinappropriateuse.Inaddition,thisisnotadirectstand-aloneClassIorIII
recommendationintheguidelinesandhasshortcomingspertinenttomeasurefeasibilityandaccountability.
QM-5 Inpatient ExcessiveInitial Thismeasureisbeingretiredbecauseitcoversonlyoneaspectofmedicationuse(e.g.,overdosing)andmisses
EptifibatideDose otheraspectssuchasunderdosingandinappropriateuse.Inaddition,thisisnotadirectstand-aloneClassIorIII
recommendationintheguidelinesandhasshortcomingspertinenttomeasurefeasibilityandaccountability.
QM-6 Inpatient ExcessiveInitial Thismeasureisbeingretiredbecauseitcoversonlyoneaspectofmedicationuse(e.g.,overdosing)andmisses
TirofibanDose otheraspectssuchasunderdosingandinappropriateuse.Inaddition,thisisnotadirectstand-aloneClassIorIII
recommendationintheguidelinesandhasshortcomingspertinenttomeasurefeasibilityandaccountability.
QM-7 Inpatient AnticoagulantDosing Thismeasureisbeingretiredbecauseitcoversonlyoneaspectofmedicationuseandmissesotheraspectssuchas
Protocol inappropriateuse.Inaddition,thisisnotadirectstand-aloneClassIorIIIrecommendationintheguidelinesand
hasshortcomingspertinenttomeasurefeasibilityandaccountability.
QM-8 Inpatient AnticoagulantError Thismeasureisbeingretiredbecauseitcoversonlylimitedaspectsofmedicationuseandmissesotheraspectssuch
TrackingSystem asinappropriateuse.Inaddition,thisisnotadirectstand-aloneClassIorIIIrecommendationintheguidelines.
AMIindicatesacutemyocardialinfarction;LDL,low-densitylipoprotein;NSTEMI,non–ST-elevationmyocardialinfarction;PM,performancemeasure;QM,qualitymeasure;and
STEMI,ST-elevationmyocardialinfarction.
TABLE 5 RevisedSTEMIandNSTEMIMeasures
# CareSetting MeasureTitle RationaleforRevisionoftheMeasure
PM-4 Inpatient StatinforAMI Thismeasureisbeingrevisedtoreflectthe2013ACC/AHAGuidelineontheTreatmentofBlood
CholesteroltoReduceAtheroscleroticCardiovascularRiskinAdults(14),whichrecommendedstatin
useforallpatientswithestablishedatheroscleroticcardiovasculardisease,includingpatientswithAMI.
PM-5 Inpatient EvaluationofLVEF Thetitleofthismeasureisbeingrevisedfrom“EvaluationofLeftVentricularSystolicFunction”to
“EvaluationofLeftVentricularEjectionFraction.”Thetreatmentrecommendationsregardingtheuse
ofguideline-directedmedicationtherapiesarebasedonLVEF,notqualitativeestimatesofleft
ventricularsystolicfunction.The2013ACCF/AHASTEMIguideline(12)explicitlyrecommended
measuringLVEF.The2014AHA/ACCNSTE-ACSguidelines(11)likewisehavemedication
recommendationsbasedonknowledgeoftheejectionfraction.
PM-12 Inpatient CardiacRehabilitation ThismeasureisbeingadaptedfromtheAACVPR/ACCF/AHA2010Update:PerformanceMeasureson
Referral CardiacRehabilitationforReferraltoCardiacRehabilitation/SecondaryPreventionServices(28).
Onemodificationsincethepublicationofthat2010measurementsetwastheremovalofpatientreasons
fromthelistofmeasureexceptions.Specifically,patientrefusaldoesnotconstituteajustifiablereason
foracliniciannotofferingareferraltoapatient.
Ifdocumentationinthemedicalrecordexistsnotingthattheproviderhasinformedanddiscussedreferral
tocardiacrehabilitation/secondarypreventionprogramwiththepatient,butthatthepatientrefusesa
referral,thenthehealthcareproviderwouldnotbeexpectedtosendcommunicationaboutthepatient
tothecardiacrehabilitation/secondarypreventionprogram.ThisisconsistentwithHIPAA
confidentialityregulationsandshareddecisionmaking,andperformancewouldthenbeconsidered
metbytheprovider(preventingunjustpenalizationoftheprovider).
PM-13 Inpatient P2Y12ReceptorInhibitor Inthe2008ACC/AHASTEMI/NSTEMImeasureset(2),atestmeasureentitled“ClopidogrelatDischarge”
Prescribedat wasincluded.Sincethen,2newerFDA-approvedmedications—ticagrelorandprasugrel—haveemerged
Discharge anddemonstratedsafety,efficacy,andclinicaleffectivenessafterAMI.All3medicationsareinhibitors
oftheP2Y12receptorandarerecommendedinadditiontoaspirin(aspartofadualantiplatelet
regimen)toreducerecurrentischemiceventsafterAMI.
AACVPRindicatesAmericanAssociationofCardiovascularandPulmonaryRehabilitation;ACC,AmericanCollegeofCardiology;ACCF,AmericanCollegeofCardiologyFoundation;AHA,
AmericanHeartAssociation;AMI,acutemyocardialinfarction;FDA,U.S.FoodandDrugAdministration;HIPAA,theHealthInsurancePortabilityandAccountabilityAct;LVEF,left
ventricularejectionfraction;NSTEMI,non–ST-elevationmyocardialinfarction;NSTE-ACS,non–ST-segmentelevationacutecoronarysyndromes;PM,performancemeasure;andSTEMI,
ST-elevationmyocardialinfarction.
JACC VOL. -, NO. -, 2017 Jneidetal. 9
-, 2017:-–- 2017AHA/ACCSTEMI/NSTEMIMeasureSet
TABLE 6 NewSTEMI/NSTEMIMeasures
RationaleforDesignatingasaQuality
MeasureasOpposedtoaPerformance
No. CareSetting MeasureTitle RationaleforCreatingNewMeasure Measure(IfApplicable)
PM-14 Inpatient ImmediateAngiography ThismeasureseekstoimplementaClassI(Levelof NotApplicable
forResuscitatedOut- EvidenceB)recommendationinthe2013
of-HospitalCardiac ACCF/AHASTEMIguideline(12)thatimmediate
ArrestinSTEMI angiographywithPCIwhenindicatedshouldbe
Patients performedinresuscitatedout-of-hospitalcardiac
arrestpatientswhoseinitialECGshowsSTEMI.The
writingcommitteeoptedtoincludeangiography
only,whichiseasilymeasurable,andnotPCI
becauseofthedifficultyassociatedwith
ascertainingPCIappropriatenessoritslack
thereof.
PM-15 Inpatient NoninvasiveStress ThismeasureseekstoimplementClassI(Levelof NotApplicable
TestingBefore EvidenceB)recommendationsinboththe2013
Dischargein STEMI(12)and2014AHA/ACCNSTE-ACS(11)
Conservatively guidelinestoperformnoninvasivestresstestingto
TreatedPatients detectinducibleischemiainmedicallytreated
STEMIandNSTEMIpatients.
PM-16 Inpatient EarlyCardiacTroponin ThismeasureseekstoimplementClassI(Levelof NotApplicable
Measurement(Within EvidenceA)recommendationsinthe2014AHA/
6HoursofArrival) ACCNSTE-ACSguideline(11)tomeasureserial
cardiactroponinlevels(atpresentationand3to6
haftersymptomonsetinallpatients).
PM-17 Inpatient ParticipationinRegional ThismeasureseekstoimplementClassI(Levelof NotApplicable
orNationalAcute EvidenceB)andClassIIa(LevelofEvidenceB)
MyocardialInfarction recommendationsinthe2013STEMI(12)and2014
Registry AHA/ACCNSTE-ACSguidelines(11),respectively.
Thewritinggroupfeltthatparticipationina
regionalornationalAMIregistrywillhelptrack
andassesstheoutcomes,complications,and
qualityofcareforpatientswithAMI,andis
supportedbyevidence.
QM-1 Inpatient RiskScoreStratification ThismeasureseekstoimplementaClassI(Levelof Thewritingcommitteefeltitwasbesttokeepthis
forNSTEMIPatients EvidenceA)recommendationinthe2014 asaqualitymeasurebecauseofissuesrelatedto
AHA/ACCNSTE-ACS(11)guidelinethatriskscores themeasurefeasibility.Mostregistriesdonot
shouldbeusedtoassessprognosisinpatientswith includeriskscores,andmostriskscores(e.g.,
NSTE-ACS.Thewritingcommitteerealizesthe GRACE,TIMI,PURSUIT)aredifficulttocompute
importanceofthismeasuretodictatethe retrospectivelyfromtheirrespective
appropriatestrategy(invasiveversusischemic- components,andarelikelytocauseasignificant
guided)andthetimingofthestrategy(early abstractionburden.
versuslateinvasive)inpatientswithNSTEMI.
QM-2 Inpatient EarlyInvasiveStrategy ThismeasureseekstoimplementaClassI(Levelof Thewritingcommitteefeltitwasbesttokeepthis
(Within24Hours)in EvidenceA)recommendationinthe2014 asaqualitymeasureformanyreasons.The
High-RiskNSTEMI AHA/ACCNSTE-ACSguideline(11)thatanearly writinggroupacknowledgesthatearlyinvasive
Patients invasivestrategyshouldbeperformedininitially strategy(comparedwithadelayedinvasive
stabilizedhigh-riskpatientswithNSTE-ACS. strategy)inhigh-riskNSTE-ACSpatients
predominantlyreducesrecurrentischemia
(ratherthanthehardoutcomesofrecurrentMI
ordeath).Althoughthisstrategyadditionally
reduceslengthofstayandcosts,itcreatesa
logisticalburdenoncardiaccatheterizationlabs,
especiallyduringweekends.Finally,objective
riskstratificationbyriskscoresisusuallynot
availableincurrentregistries;thus,ascertaining
whichpatientsbenefitfromearlyinvasive
strategymaynotbereadilyfeasible.
QM-3 Inpatient TherapeuticHypothermia ThismeasureseekstoimplementaClassI(Levelof Thewritingcommitteefeltitwasbesttokeepthis
forComatoseSTEMI EvidenceB)recommendationinthe2013 asaqualitymeasurebecauseofnewer
PatientsWithOut-of- ACCF/AHASTEMIguideline(12)thattherapeutic controversialdatapertinenttothe
HospitalCardiac hypothermiashouldbestartedassoonaspossible effectiveness,timing,andimplementationof
Arrest incomatosepatientswithSTEMIandout-of- therapeutichypothermia.
hospitalcardiacarrestcausedbyVForVT.
QM-4 Inpatient AldosteroneAntagonist ThismeasureseekstoimplementClassI Thewritingcommitteefeltitisbesttokeepthisasa
atDischarge recommendationsinthe2013ACCF/AHASTEMI qualitymeasurebecauseofissuesrelatedtothe
(12)and2014AHA/ACCNSTE-ACS(11)guidelines measureconstruct.Thismeasureislikelyto
supportingtheuseofaldosteroneantagonistsin presentasignificantabstractionburdenandmay
eligiblepatientswithSTEMIandNSTEMI, berelevantonlytoasmallfractionofAMI
respectively. patients(giventheelaborateinclusion/exclusion
criteriaintheEPHESUS(29)clinicaltrial).
Continuedonthenextpage
10 Jneidetal. JACC VOL. -, NO. -, 2017
2017AHA/ACCSTEMI/NSTEMIMeasureSet -, 2017:-–-
TABLE 6 Continued
RationaleforDesignatingasaQuality
MeasureasOpposedtoaPerformance
No. CareSetting MeasureTitle RationaleforCreatingNewMeasure Measure(IfApplicable)
QM-5 Inpatient InappropriateIn-Hospital ThismeasureseekstoimplementClassIII Thewritingcommitteefeltitisbesttokeepthisasa
UseofNSAIDs recommendations(ClassIIIHarm,Levelof qualitymeasuregiventhelowimpactassociated
Evidence:B)inboththe2013ACCF/AHASTEMI withtheuseofNSAIDsduringthebrief
(12)and2014AHA/ACCNSTE-ACS(11)guidelines, hospitalizationperiod(thisislikelymore
cautioningagainsttheuseofthesedrugsafter relevantintheoutpatientsetting).The
AMI. existenceofanextensiveandevolvinglistof
NSAIDsmayalsocreatesignificantabstraction
burden.
QM-6 Inpatient InappropriatePrescription ThismeasureseekstoimplementClassIII Thewritingcommitteefeltitisbesttokeepthisasa
ofPrasugrelat recommendations(ClassIIIHARM,Levelof qualitymeasureonlyforthetimebeinguntil
DischargeinPatients Evidence:B)inboththe2013ACCF/AHASTEMI moredatabecomeavailablepertinenttothis
WithaHistoryofPrior (12)and2014AHA/ACCNSTE-ACS(11)guidelines, measureanditsimpactinreal-worldpatients.
StrokeorTIA cautioningagainsttheuseofprasugrelinpatients
withpriorTIA/stroke,becauseofnetclinicalharm
inthesepatients.TheFDAalsoissuedablackbox
warningonthis.
QM-7 Inpatient InappropriatePrescription ThismeasureseekstoimplementClassIII Thewritingcommitteefeltitisbesttokeepthisasa
ofHigh-DoseAspirin recommendations(ClassIIIHARM,Levelof qualitymeasureonlyforthetimebeinguntil
WithTicagrelorat Evidence:B)inboththe2013ACCF/AHASTEMI moredatabecomeavailablepertinenttothis
Discharge (12)and2014AHA/ACCNSTE-ACS(11)guidelines, measureanditsimpactinreal-worldpatients.
cautioningagainsttheuseofhigh-doseaspirin
>100mgamongpatientsreceivingticagrelor.The
FDAalsoissuedablackboxwarningonthis.
ACCindicatesAmericanCollegeofCardiology;ACCF,AmericanCollegeofCardiologyFoundation;AHA,AmericanHeartAssociation;EPHESUS,EplerenonePost–AcuteMyocardial
InfarctionHeartFailureEfficacyandSurvivalStudy;FDA,U.S.FoodandDrugAdministration;GRACE,GlobalRegistryofAcuteCoronaryEvents;NSAIDs,nonsteroidalanti-
inflammatorydrugs;NSTE-ACS,non–ST-segmentelevation-acutecoronarysyndrome;NSTEMI,non–ST-elevationmyocardialinfarction;PM,performancemeasure;PCI,percuta-
neouscoronaryintervention;PURSUIT,PlateletGlycoproteinIIb/IIIainUnstableAngina:ReceptorSuppressionUsingIntegrilin;QM,qualitymeasure;STEMI,ST-segmentelevation
myocardialinfarction;TIA,transientischemicattack;TIMI,ThrombolysisinMyocardialInfarction;VF,ventricularfibrillation;andVT,ventriculartachycardia.
4. AREAS FOR FURTHER RESEARCH Guidelines implemented a “Defect-Free Care” measure
for AMI patients, which was endorsed by the National
The writing committee recognizes that the ultimate QualityForum.Ourwritingcommitteedidnotadoptthis
measure of performance lies in the assessment of out- measureinthecurrentdocumenttoavoidtheadditional
comes, such as mortality (in-hospital or 30-day), health burden of data abstraction and reporting. This is espe-
status, and other outcomes (recurrent MI, urgent repeat cially important given that we have expanded the per-
revascularization). However, the complexity associated formance measure set to include a larger and more
with adjustment for the large number of patient charac- comprehensive set of 17 performance measures than
teristics that both influence treatment decisions and previouslyadopted.Ourwritingcommitteeacknowledges
impact mortality make these measures less attractive to the importance of the “Defect-Free Care” measure and
use.Thirty-dayrisk-adjustedAMImortalityhasbeenused wouldliketoevaluateitsperformanceandimpactinreal
by CMS for payment incentives and in public reporting. world before considering it in the future. We also
The impact of these and other measures on hospital emphasize the importance of assessing the impact of
quality should be the focus of future research. The com- compliance (or lack thereof) to some or all performance
mittee also realizes that many measures are already measuresonshort-andlong-termclinicaloutcomes.Our
“topped-out” and can be retired to minimize abstraction writing committee also recognizes that all performance
burden. Additional research should examine the impact measures and quality measures are dynamic and can be
of dropping such measures. Furthermore, continuous revised or retired based on the emergence of scientific
researchtoexaminetemporaltrendsanddisparities(i.e., evidenceandnewguidelinerecommendations.
withrespecttosex,age,ethnicity)intheachievementof
performanceandqualitymeasureswillhelpguidefuture
revisionsaswellastheimplementationofthecurrentset. STAFF
While the majority of current measures are binary (for
example, yes or no for medication prescription), the AmericanCollegeofCardiology
next frontier in performance evaluation may be also to MaryNorineWalsh,MD,FACC,President
measure doses of prescribed pharmacotherapies and ShalomJacobovitz,ChiefExecutiveOfficer
comparethemtodosesusedinrandomizedtrialsshowing William J. Oetgen, MD, MBA, FACC, Executive Vice
benefit.Finally,theACCACTIONRegistry–GetWithThe President,Science,Education,Quality,andPublishing