New performance measures refine tools for improving care of heart attack patients

Jointly developed by the American College of Cardiology and the American Heart Association, the performance measures appear in the December 9, 2008, issue of the Journal of the American College of Cardiology and the December 9, 2008, issue of Circulation. They identify some of the most important steps in helping patients return to a healthy life after surviving a heart attack—steps that sometimes are missed even by well-intentioned doctors.

"We all do our best for our patients. Performance measures are extraordinarily important in helping us learn how well we are doing and in providing targets for improving quality," said Harlan M. Krumholz, M.D., chair of the writing committee that developed the heart attack performance measures and a professor of medicine at Yale University, New Haven, CT. "They guide us to areas of opportunity where we can do better—and our patients benefit from that."

The new performance measures have been endorsed by the American Academy of Family Physicians, American College of Emergency Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation, Society of Hospital Medicine, and Society for Cardiovascular Angiography and Interventions. They update a previous version published in 2006.

Performance measures are derived from clinical guidelines but serve a different purpose. Clinical guidelines make recommendations that physicians should consider when managing patients, and describe how strong the evidence is to support each recommendation. Performance measures distill from the guidelines key therapies that so clearly improve patient outcomes they literally define high-quality care.

"A performance measure is more than a recommendation. It's a mandate. It defines high-quality care and sets the expectation that doctors should either treat patients according to the best evidence, or explain why not," Dr. Krumholz said. In addition, performance measures must be quantifiable, so that data can be collected in a reliable way. Performance measures also identify areas where there is likely to be room for improvement in the quality of care.

Hospitals and doctors can begin using the new performance measures to benchmark the quality of heart attack care in several areas, including:

-- The prescription of statins before patients are discharged from the hospital. The previous performance measures were more general, calling for "lipid lowering therapy." The new performance measures acknowledge that the evidence for benefit is primarily related to statins.

-- The timeliness of percutaneous coronary intervention (PCI)—a term that includes angioplasty and stenting—when the patient must be transferred from a hospital without a cardiac catheterization laboratory to a PCI-capable hospital. Previous performance measures did not track transferred heart attack patients. The new performance measures call for collecting data not only on how much time elapses from arrival at the first hospital to departure to the second hospital, but also from arrival at the first hospital to PCI at the second hospital.

-- Referral to a cardiac rehabilitation program. Studies have shown that cardiac rehab markedly improves survival after a heart attack, but only about one in three patients participate in such programs. The new performance measures call for hospitals to track referral to such programs. It is hoped these data may also shed light on the obstacles to referral.

-- Elimination of a performance measure on treatment with beta blockers within 24 hours of hospitalization for a heart attack. New scientific evidence has made the clinical decision to give or withhold beta blockers more complex, thereby making measurement difficult.

-- Evaluation of the heart's pumping function, or left ventricular systolic function, during hospitalization. This measurement is essential for subsequent decisions about care.

-- Several "test" performance measures that are intended for internal use by hospitals and doctors, including evaluation of blood levels of low-density-lipoprotein (LDL, or so-called "bad") cholesterol, dosage of several types of blood-thinning medications, and prescription at hospital discharge of the anti-clotting medication clopidogrel.

As in their previous version, the new performance measures continue to track use of aspirin therapy, both at hospital arrival and as a discharge medication; beta blocker prescription at discharge; prescription of an angiotensin-converting-enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at discharge for patients with reduced pump function; time to delivery of clot-busting medications or PCI (in patients who are not transferred to another hospital); and counseling to stop smoking.

"We have made a commitment to continually update, refine, and improve these performance measures, so that they represent the very best and most recent science," Dr. Krumholz said. "We want to ensure that what we are measuring is meaningful and relevant and is going to make a difference for patients."

Source: American College of Cardiology