2017 AHA/ACC Clinical Performance and Quality Measures ......STEMI/NSTEMI measure set that includes 24 total mea-sures of which 17 are performance measures and 7 are quality measures

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PERFORMANCE MEASURE

2017 AHA/ACC Clinical Performanceand Quality Measures for Adults WithST-Elevation and Non–ST-ElevationMyocardial InfarctionA Report of the American College of Cardiology/American Heart AssociationTask Force on Performance Measures

Developed in Collaboration With the Society for Cardiovascular Angiography and Interventions

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation

Writing Hani Jneid, MD, FACC, FAHA, Chair

CommitteeMembers
Daniel Addison, MD
Deepak L. Bhatt, MD, MPH, FACC, FAHAGregg C. Fonarow, MD, FACC, FAHASana Gokak, MPHKathleen L. Grady, PhD, FAHALee A. Green, MD, MPHPaul A. Heidenreich, MD, MS, FACC, FAHA*

This document underwent peer review between December 7, 2016, and Dec

2016, and January 6, 2017.

This document was approved by the American College of Cardiology Clin

sociation Science Advisory and Coordinating Committee on June 7, 2017, the

the Society for Cardiovascular Angiography and Interventions on July 17, 20

The American College of Cardiology requests that this document be cited

Green LA, Heidenreich PA, Ho PM, Jurgens CY, King ML, Kumbhani DJ, Panc

with ST-elevation and non–ST-elevation myocardial infarction: a report of th

on Performance Measures. J Am Coll Cardiol. 2017;xx:xxx–xxx.

This article has been copublished in Circulation: Cardiovascular Quality a

Copies: This document is available on the World Wide Web sites of the

Association (professional.heart.org). For copies of this document, please con

elsevier.com).

Permissions: Multiple copies, modification, alteration, enhancement, and

permission of the American College of Cardiology. Please contact Elsevier’s

P. Michael Ho, MD, PhD, FACC, FAHACorrine Y. Jurgens, PhD, RN, ANP-BC, FAHAMarjorie L. King, MD, FACCDharam J. Kumbhani, MD, SM, FACC, FAHASamir Pancholy, MD, FACCy

*ACC/AHA Task Force on Performance Measures Liaison. ySociety forCardiovascular Angiography and Interventions Representative.

ACC/AHATask Force onPerformanceMeasures

Gregg C. Fonarow, MD, FACC, FAHA, Chair

Paul A. Heidenreich, MD, MS, FACC, FAHA,

Immediate Past Chair

Nancy M. Albert, PhD, CCNS, CCRN, FAHAz

Geoffrey D. Barnes, MD, MSc, FACCx

Paul S. Chan, MD, MSc, FACCxLesley H. Curtis, PhDxLauren Gilstrap, MDxMichelle Gurvitz, MD, FACCzP. Michael Ho, MD, PhD, FACC, FAHAxCorrine Y. Jurgens, PhD, RN, ANP-BC, FAHAx

ember 31, 2016, and a 30-day public comment period between December 7,

ical Policy Approval Committee on May 22, 2017, the American Heart As-

American Heart Association Executive Committee on August 11, 2017, and

17.

as follows: Jneid H, Addison D, Bhatt DL, Fonarow GC, Gokak S, Grady KL,

holy S. 2017 AHA/ACC clinical performance and quality measures for adults

e American College of Cardiology/American Heart Association Task Force

nd Outcomes.

American College of Cardiology (www.acc.org) and the American Heart

tact Elsevier Reprint Department via fax (212-633-3820) or email (reprints@

/or distribution of this document are not permitted without the express

permission department at [email protected].

http://www.acc.org/http://professional.heart.org/mailto:[email protected]:[email protected]:[email protected]://dx.doi.org/10.1016/j.jacc.2017.06.032

In

Jneid et al. J A C C V O L . - , N O . - , 2 0 1 7

2017 AHA/ACC STEMI/NSTEMI Measure Set - , 2 0 1 7 :- –-2

Sean O’Brien, PhDzJeffrey Olin, DO, FACC, FAHAxTiffany Randolph, MDzAndrea M. Russo, MD, FACCxRandal J. Thomas, MD, FACC, FAHAzPaul D. Varosy, MD, FACCz

Robert Yeh, MD, FACCzSamad Zaheeruddin, MDz

zAmerican College of Cardiology Representative. xAmerican HeartAssociation Representative.

TABLE OF CONTENTS

Inp

PREAMBLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

1.1. Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . -

1.2. Disclosure of Relationships With Industry andOther Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

2. METHODOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

2.1. Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . -

2.2. Definition and Selection of Measures . . . . . . . . . . . -

3. AHA/ACC STEMI AND NSTEMI MEASURE SET

PERFORMANCE MEASURES . . . . . . . . . . . . . . . . . . . . . -

3.1. Discussion of Changes to 2008 STEMI and NSTEMIMeasure Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

3.1.1. Retired Measures . . . . . . . . . . . . . . . . . . . . . . . -

3.1.2. Revised Measures . . . . . . . . . . . . . . . . . . . . . . . -

3.1.3. New Measures . . . . . . . . . . . . . . . . . . . . . . . . . . -

4. AREAS FOR FURTHER RESEARCH . . . . . . . . . . . . . . . -

APPENDIX A

STEMI and NSTEMI Performance Measures . . . . . . . . . . -

Performance Measures for Use in Patients WithInpatient STEMI and NSTEMI . . . . . . . . . . . . . . . . . . -

patient Measures . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-1: Aspirin at Arrival . . . . . . . . . . -Short Title: PM-2: Aspirin at Discharge . . . . . . . -Short Title: PM-3: Beta Blocker atDischarge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-4: High-Intensity Statin atDischarge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-5: Evaluation of LVEF . . . . . . . . -Short Title: PM-6: ACEI or ARB for LVSD . . . . . . -Short Title: PM-7: Door-to-Needle Time . . . . . . -Short Title: PM-8: First MedicalContact-Device Time . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-9: Reperfusion Therapy . . . . . . . -Short Title: PM-10: Door-in-Door-Out Time . . . . -

Short Title: PM-11: Time to Primary PCI AmongTransferred Patients . . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-12: Cardiac RehabilitationReferral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-13: P2Y12 Inhibitor atDischarge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-14: Immediate AngiographyAfter Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-15: Stress Test in ConservativelyTreated Patients . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-16: Early Troponin MeasurementAfter NSTEMI . . . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: PM-17: AMI RegistryParticipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

Quality Improvement Measures for InpatientSTEMI and NSTEMI Patients . . . . . . . . . . . . . . . . . . . -

atient Measures . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: QM-1: Risk Score Stratification forNSTEMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: QM-2: Early Invasive Strategy forHigh-Risk NSTEMI . . . . . . . . . . . . . . . . . . . . . . . -Short Title: QM-3: Therapeutic Hypothermia forSTEMI Patients . . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: QM-4: Aldosterone Antagonist atDischarge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: QM-5: Inappropriate In-Hospital Useof NSAIDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -Short Title: QM-6: Inappropriate Prasugrel atDischarge in TIA/Stroke Patients . . . . . . . . . . . . -Short Title: QM-7: Inappropriate High-DoseAspirin With Ticagrelor at Discharge . . . . . . . . . -

APPENDIX B

Author Listing of Relationships With Industry andOther Entities (Relevant)—2017 AHA/ACC ClinicalPerformance and Quality Measures for Adults WithST-Elevation and Non–ST-Elevation MyocardialInfarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

APPENDIX C

Peer Reviewer Relationships With Industry and OtherEntities—2017 AHA/ACC Clinical Performance andQuality Measures for Adults With ST-Elevation andNon–ST-Elevation Myocardial Infarction . . . . . . . . . . . . -

J A C C V O L . - , N O . - , 2 0 1 7 Jneid et al.- , 2 0 1 7 :- –- 2017 AHA/ACC STEMI/NSTEMI Measure Set

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PREAMBLE

The American College of Cardiology (ACC)/AmericanHeart Association (AHA) performance measure sets serveas vehicles to accelerate translation of scientific evidenceinto clinical practice. Measure sets developed by theACC/AHA are intended to provide practitioners and in-stitutions that deliver cardiovascular services with toolsto measure the quality of care provided and identifyopportunities for improvement.

Writing committees are instructed to consider themethodology of performance measure development (1)and to ensure that the measures developed are alignedwith ACC/AHA clinical practice guidelines. The writingcommittees also are charged with constructing measuresthat maximally capture important aspects of care quality,including timeliness, safety, effectiveness, efficiency,equity, and patient-centeredness, while minimizing,when possible, the reporting burden imposed on hospi-tals, practices, and/or practitioners.

Potential challenges from measure implementationmay lead to unintended consequences. The manner inwhich challenges are addressed is dependent on severalfactors, including the measure design, data collectionmethod, performance attribution, baseline performancerates, reporting methods, and incentives linked to thesereports.

The ACC/AHA Task Force on Performance Measures(Task Force) distinguishes quality measures from perfor-mance measures. Quality measures are those metrics thatmay be useful for local quality improvement but are notyet appropriate for public reporting or pay for perfor-mance programs (uses of performance measures). Newmeasures are initially evaluated for potential inclusion asperformance measures. In some cases, a measure isinsufficiently supported by the guidelines. In other in-stances, when the guidelines support a measure, thewriting committee may feel it is necessary to havethe measure tested to identify the consequences of mea-sure implementation. Quality measures may then bepromoted to the status of performance measures as sup-porting evidence becomes available.

Gregg C. Fonarow, MD, FACC, FAHAChair, ACC/AHA Task Force on Performance Measures

1. INTRODUCTION

In the summer of 2015, the Task Force convened thewriting committee to begin the process of revising theexisting set of performance measures for adult patientshospitalized with ST-Elevation and Non–ST-ElevationMyocardial Infarction (STEMI and NSTEMI, respectively),that was last updated in 2008 (2). The writing committee

was charged with the task of developing new measures tobenchmark and improve the quality of care for patientswith STEMI and NSTEMI.

All the measures included in the measure set are brieflysummarized in Table 1, which provides information on themeasure number, title, care setting, attribution, anddomain. The detailed measure specifications (available inAppendix A) provide not only the information included inTable 1, but also more detailed information including themeasure description, numerator, denominator (includingdenominator exclusions and exceptions), rationale for themeasure, guideline recommendations that support themeasure, measurement period, and sources of data.

The writing committee has developed a comprehensiveSTEMI/NSTEMI measure set that includes 24 total mea-sures of which 17 are performance measures and 7 arequality measures (as reflected in Table 1 and Appendix A).The writing committee believes that implementation ofthis measure set by healthcare providers, physicianpractices, and hospital systems will enhance the qualityof care and likely improve outcomes of patients withSTEMI and NSTEMI.

1.1. Scope of the Problem

Acute myocardial infarction (AMI) is a frequent cause ofhospital admission in the United States and is associatedwith significant short- and long-term mortality andmorbidity. Every 42 seconds, approximately 1 Americanwill suffer an AMI, and the estimated annual incidences ofnew and recurrent MI events are 550,000 and 200,000events, respectively (3).

Fortunately, the rates of hospitalization and 30-daymortality for AMI have been on the decline (4,5). Thisreduction in mortality is likely related to the shift in thepattern of clinical presentation of AMI as well as toimproved acute treatments and long-term care. Yeh andcolleagues examined age- and sex-adjusted incidencerates for STEMI and NSTEMI from a community-basedpopulation (Northern California) between 1999 and2008, and demonstrated an overall significant decrease inAMI incidence rate after 2000 (6). Although the adjusted30-day mortality rate after AMI decreased significantly(driven by a significant reduction in NSTEMI mortality),the overall mortality rate in 2008 after an AMI was still7.8% at 30 days (6).

Importantly, AMI patients who survive the initial eventhave substantial risk for future cardiovascular events,including recurrent MI, death, heart failure, and stroke. Inthe PLATO (Platelet Inhibition and Patient Outcomes)trial, the rate of the combined cardiovascular endpoint(vascular death, MI, or stroke) was 11.7% at 12 monthsamong AMI patients treated with aspirin and clopidogrel(7). This included a 6.9% rate of recurrent MI at 12 months

TABLE 1 2017 AHA/ACC STEMI and NSTEMI Myocardial Infarction Clinical Performance and Quality Measures

No. Measure Title Care Setting Attribution Measure Domain

Performance Measures

PM-1 Aspirin at Arrival Inpatient Facility or Provider Level Effective Clinical Care

PM-2 Aspirin Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care

PM-3 Beta Blocker Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care

PM-4 High-Intensity Statin Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care

PM-5 Evaluation of LVEF Inpatient Facility or Provider Level Effective Clinical Care

PM-6 ACEI or ARB Prescribed for LVSD Inpatient Facility or Provider Level Effective Clinical Care

PM-7 Time to Fibrinolytic Therapy* Inpatient Facility or Provider Level Communication and Care Coordination

PM-8 Time to Primary PCI* Inpatient Facility or Provider Level Communication and Care Coordination

PM-9 Reperfusion Therapy* Inpatient Facility or Provider Level Effective Clinical Care

PM-10 Time From ED Arrival at STEMI Referral Facility toED Discharge From STEMI Referral Facility inPatients Transferred for Primary PCI*

Inpatient Facility Level Communication and Care Coordination

PM-11 Time From FMC (At or Before ED Arrival at STEMIReferral Facility) to Primary PCI at STEMIReceiving Facility Among Transferred Patients*

Inpatient Facility Level Communication and Care Coordination

PM-12 Cardiac Rehabilitation Patient Referral From anInpatient Setting

Inpatient Facility or Provider Level Communication and Care Coordination

PM-13 PY12 Receptor Inhibitor Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care

PM-14 Immediate Angiography for Resuscitated Out-of-Hospital Cardiac Arrest in STEMI Patients*

Inpatient Facility or Provider Level Effective Clinical Care

PM-15 Noninvasive Stress Testing Before Discharge inConservatively Treated Patients

Inpatient Facility or Provider Level Efficiency and Cost Reduction

PM-16 Early Cardiac Troponin Measurement† (Within6 Hours of Arrival)

Inpatient Facility or Provider Level Efficiency and Cost Reduction

PM-17 Participation in $1 Regional or National RegistriesThat Include Patients With Acute MyocardialInfarction Registry

Inpatient Facility Level Community, Population, and Public Health

Quality Measures

QM-1 Risk Stratification of NSTEMI Patients With a RiskScore†


QM-2 Early Invasive Strategy (Within 24 Hours) in High-Risk NSTEMI Patients†


QM-3 Therapeutic Hypothermia for Comatose STEMIPatients With Out-of-Hospital Cardiac Arrest*


QM-4 Aldosterone Antagonist Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care

QM-5 Inappropriate In-Hospital Use of NSAIDs Inpatient Facility or Provider Level Patient Safety

QM-6 Inappropriate Prescription of Prasugrel at Dischargein Patients With a History of Prior Stroke or TIA

Inpatient Facility or Provider Level Patient Safety

QM-7 Inappropriate Prescription of High-Dose AspirinWith Ticagrelor at Discharge

Inpatient Facility or Provider Level Patient Safety

*These measures apply only to patients with STEMI. †These measures apply only to patients with NSTEMI.

ACC indicates American College of Cardiology; ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; ED, emergencydepartment; FMC, first medical contact; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; NSAIDs, nonsteroidal anti-inflammatory drugs; NSTEMI,non–ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; PM, performance measures; QM, quality measures; STEMI, ST-elevation myocardial infarction; andTIA, transient ischemic attack.



(7). In 2010 alone, about 595,000 inpatient hospital dis-charges were attributed to AMI (3). AMI is also associatedwith a substantial direct and indirect cost burden, and isclassified among the top 10 most expensive hospitalprincipal discharge diagnoses (3).

As indicated in the Third Universal Definition ofMyocardial Infarction consensus document published in

2012 (8), AMI is defined by the detection of a rise and/orfall of cardiac biomarkers (preferably cardiac troponinlevels) with at least 1 value above the 99th percentileupper reference limit and with at least one of thefollowing: (a) symptoms of ischemia; (b) new or presumednew significant ST-segment–T wave changes or new leftbundle branch block; (c) development of pathological Q


5

waves in the electrocardiogram (ECG); (d) imaging evi-dence of new loss of viable myocardium or new regionalwall motion abnormality; (e) identification of an intra-coronary thrombus by angiography or autopsy. The ThirdUniversal Definition of Myocardial Infarction consensusdocument, published in 2012, classifies MI into 5 types,based on pathological, clinical, and prognostic differ-ences, along with different treatment strategies (8). Theperformance and quality measures described in the cur-rent document are predominantly pertinent to patientswith spontaneous MI, or MI type 1. MI type 1 is an eventrelated to atherosclerotic plaque disruption (e.g., rupture,ulceration, erosion) with superimposed thrombus forma-tion in a coronary artery, resulting in acute reduction inmyocardial blood supply and/or distal embolization withsubsequent myonecrosis. MI type 2 is myocardial injurycaused by conditions other than coronary artery diseasethat results in an imbalance between myocardial oxygensupply and/or demand (e.g., coronary artery embolism orspasm, tachyarrhythmias, anemia, respiratory failure,profound hypotension).

The measure set developed by our writing committeeapplies only to MI type 1 and does not uniformly apply tothe other 4 types of MI. In fact, some of those measuresare even contraindicated with certain MI type, such asaspirin or P2Y12 receptor inhibitor therapies, which arecontraindicated in patients with a MI type 2 resultingfrom severe hemorrhage and anemia. Given the wide-spread use of very sensitive assays for markers ofmyocardial necrosis (e.g., the highly sensitive and specificcardiac troponin [cTn] biomarkers) and advanced imagingmodalities, very small amounts of myonecrosis unrelatedto ischemia can be detected (e.g., heart failure, renalfailure, myocarditis, pulmonary embolism). Our measuresalso do not apply to these myocardial injury events, whichshould be differentiated from true AMI events.

For the sake of immediate treatment strategies (e.g.,reperfusion therapy), AMI is differentiated into STEMIand NSTEMI, depending on the existence of ST-segmentelevation in $2 contiguous leads on the presenting ECG.Acute STEMI equivalent can, however, manifest as:hyperacute T-wave changes, true posterior MI, multileadST depression with coexistent ST elevation in lead aVR,characteristic diagnostic criteria in the setting of leftbundle branch block. The proportion of STEMI versusNSTEMI events varies in different registries and dependson the age of patients, their geographic location, and thetype of surveillance used. In general, STEMI patientsaccount for 29% to 47% of all AMI patients (9,10).

Updating the existing STEMI/NSTEMI measure set wasa priority for the ACC and AHA. Particular attention wasgiven to evidence-based diagnostic and therapeutic stra-tegies that have high impact on outcomes (e.g., Class I or

III guideline recommendations) of patients with STEMI/NSTEMI and that satisfy the attributes of performancemeasures (e.g., feasible, reliable, actionable). This writingcommittee developed the measures in this documentafter comprehensive examination of the most currentrelevant guidelines, internal discussion and internalvoting, peer review, and public comment.

1.2. Disclosure of Relationships With Industry andOther Entities

The Task Force makes every effort to avoid actual, po-tential, or perceived conflicts of interest that could ariseas a result of relationships with industry or other entities(RWI). Detailed information on the ACC/AHA policy onRWI can be found online. All members of the writingcommittee, as well as those selected to serve as peer re-viewers of this document, were required to disclose allcurrent relationships and those existing within the 12months before the initiation of this writing effort. ACC/AHA policy also requires that the writing committeechairs and at least 50% of the writing committee have norelevant RWI.

Any writing committee member who develops newRWI during his or her tenure on the writing committee isrequired to notify staff in writing. These statements arereviewed periodically by the Task Force and by membersof the writing committee. Author and peer reviewer RWIwhich are relevant to the document are included in theappendixes: Please see Appendix B for relevant writingcommittee RWI and Appendix C for relevant peerreviewer RWI. Additionally, to ensure complete trans-parency, the writing committee members’ comprehensivedisclosure information, including RWI not relevant to thepresent document, is available online. Disclosure infor-mation for the Task Force is also available online.

The work of the writing committee was supportedexclusively by the ACC and the AHA without commercialsupport. Members of the writing committee volunteeredtheir time for this effort. Meetings of the writing com-mittee were confidential and attended only by writingcommittee members and staff from the ACC, AHA, and theSociety for Cardiovascular Angiography and Interventionswho served as a collaborator on this project.

2. METHODOLOGY

2.1. Literature Review

In developing the updated STEMI/NSTEMI measure set,the writing committee reviewed evidence-based guide-lines and statements that would potentially impact theconstruct of the measures. The practice guidelines andstatements that most directly contributed to the devel-opment of these measures are summarized in Table 2.

http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policyhttp://jaccjacc.acc.org/Clinical_Document/Comprehensive_STEMI_NSTEMI_PM_RWI_6_9_17.pdfhttp://www.acc.org/guidelines/about-guidelines-and-clinical-documents/guidelines-and-documents-task-forces

TABLE 2Associated Guidelines and Other ClinicalGuidance Documents

CLINICAL PRACTICE GUIDELINES

1. 2014 AHA/ACC Guideline for the Management of Patients WithNon–ST-Elevation Acute Coronary Syndromes (11)

2. 2013 ACCF/AHA Guideline for the Management of ST-ElevationMyocardial Infarction (12)

3. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for PatientsWith Coronary and Other Atherosclerotic Vascular Disease: 2011Update (13)

4. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol toReduce Atherosclerotic Cardiovascular Risk in Adults (14)

5. 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous CoronaryIntervention for Patients With ST-Elevation Myocardial Infarction: AnUpdate of the 2011 ACCF/AHA/SCAI Guideline for PercutaneousCoronary Intervention and the 2013 ACCF/AHA Guideline for theManagement of ST-Elevation Myocardial Infarction (15)

6. 2016 ACC/AHA Guideline Focused Update on Duration of DualAntiplatelet Therapy in Patients With Coronary Artery Disease (16)

7. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapyfor Heart Failure: An Update of the 2013 ACCF/AHA Guideline for theManagement of Heart Failure (17)

STATEMENTS/PERFORMANCE MEASURES

1. 2015 ACC/AHA Focused Update of Secondary Prevention LipidPerformance Measures (18)

2. Third Universal Definition of Myocardial Infarction (8)

3. ACC/AHA 2008 Performance Measures for Adults With ST-Elevation andNon–ST-Elevation Myocardial Infarction (2)

4. ACC/AHA 2008 Statement on Performance Measurement andReperfusion Therapy (19)

ACC indicates American College of Cardiology; ACCF, American College of CardiologyFoundation; AHA, American Heart Association; ESC indicates European Society of Car-diology; HFSA, Heart Failure Society of America; and SCAI, Society for CardiovascularAngiography and Interventions.



2.2. Definition and Selection of Measures

The writing committee reviewed recent clinical practiceguidelines and other clinical guidance documents(Table 2). The writing committee also examined availableinformation on disparities in care to address which newmeasures might be appropriate as performance versusquality measures for this measure set update. To this ef-fect, an extensive environmental scan of the publishedliterature was performed. In a large retrospective analysisof STEMI patients transferred to primary percutaneouscoronary intervention (PCI) centers in the ACTION-GetWith The Guidelines registry (2007-2010), only 11% hadtimely door-in-door-out time #30 minutes (20). Inanother cohort of STEMI patients transferred fromnon–PCI-capable hospitals to STEMI receiving centers(2008-2012), timely primary PCI (#120 minutes) was ach-ieved in 65% of transferred patients (21). Another reportshowed that only 41% of patients were referred to cardiacrehabilitation after AMI (22,23). These reports highlightbut a few examples of the persistent disparities in care.Importantly, it appears guideline-directed care cangreatly reduce a large proportion of disparities previouslynoted in women (24,25).

All measures were designed to assess quality of careexperienced by individuals who have STEMI or NSTEMI inthe inpatient setting. Each measure was designed to limitperformance measurement to patients without a validreason for exclusion from the measure. Measure exclu-sions were those reasons that remove a patient from thedenominator, regardless of whether they would beincluded in the numerator. For example, all measuresexcluded patients whowere

TABLE 3 ACC/AHA Task Force on Performance Measures: Attributes for Performance Measures (26)

1. Evidence Based

High-impact area that is useful in improvingpatient outcomes

a) For structural measures, the structure should be closely linked to a meaningful process of care that in turn islinked to a meaningful patient outcome.

b) For process measures, the scientific basis for the measure should be well established, and the process should beclosely linked to a meaningful patient outcome.

c) For outcome measures, the outcome should be clinically meaningful. If appropriate, performance measuresbased on outcomes should adjust for relevant clinical characteristics through the use of appropriatemethodology and high-quality data sources.

2. Measure Selection

Measure definition a) The patient group to whom the measure applies (denominator) and the patient group for whom conformance isachieved (numerator) are clearly defined and clinically meaningful.

Measure exceptions and exclusions b) Exceptions and exclusions are supported by evidence.

Reliability c) The measure is reproducible across organizations and delivery settings.

Face validity d) The measure appears to assess what it is intended to.

Content validity e) The measure captures most meaningful aspects of care.

Construct validity f) The measure correlates well with other measures of the same aspect of care.

3. Measure Feasibility

Reasonable effort and cost a) The data required for the measure can be obtained with reasonable effort and cost.

Reasonable time period b) The data required for the measure can be obtained within the period allowed for data collection.

4. Accountability

Actionable a) Those held accountable can affect the care process or outcome.

Unintended consequences avoided b) The likelihood of negative unintended consequences with the measure is low.

ACC indicates American College of Cardiology; AHA, American Heart Association.


7

3. AHA/ACC STEMI AND NSTEMI MEASURE SET

PERFORMANCE MEASURES

3.1. Discussion of Changes to 2008 STEMI and NSTEMIMeasure Set

After reviewing the existing guidelines, and the 2008performance and quality measure set (2), the writingcommittee discussed which measures should be revisedto reflect the updated science, and worked to identifywhich guideline recommendations could serve as thebasis for new performance or quality measures. Thewriting committee also reviewed existing measure setsthat were publicly available.

The following subsections serve as a synopsis of therevisions that were made to previous measures, and adescription of why the new inpatient measures werecreated.

3.1.1. Retired Measures

The writing committee decided to retire 1 performancemeasure for smoking cessation counseling because of theconsistently high levels of performance achieved(Table 4). Other quality measures, previously included as

test measures in the 2008 measure set, were retired forthe reasons specified in Table 4.

3.1.2. Revised Measures

The writing committee reviewed and made changes to 4measures, which are summarized in Table 5. Most thechanges were made to reflect the new evidence andupdated guideline recommendations, to strengthen themeasure construct, or to expand the measures to includenew proven pharmacotherapies.

3.1.3. New Measures

The new measure set includes 4 performance measuresand 7 quality measures. Table 6 includes a list of the newmeasures and their rationale.

Four of the quality measures are structured in a typicalformat in which the goal is to seek a score of 100%.However, 3 of the new quality measures (QM-5, QM-6, andQM-7) are safety measures and, in those, the goal is to seeka score of 0% (e.g., 0% use or prescription of an inappro-priate treatment reflects an optimal quality of care).

For more detailed information on the measureconstruct, please refer to the detailed measure specifica-tions summarized in Appendix A.

TABLE 5 Revised STEMI and NSTEMI Measures

# Care Setting Measure Title Rationale for Revision of the Measure

PM-4 Inpatient Statin for AMI This measure is being revised to reflect the 2013 ACC/AHA Guideline on the Treatment of BloodCholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults (14), which recommended statinuse for all patients with established atherosclerotic cardiovascular disease, including patients with AMI.

PM- 5 Inpatient Evaluation of LVEF The title of this measure is being revised from “Evaluation of Left Ventricular Systolic Function” to“Evaluation of Left Ventricular Ejection Fraction.” The treatment recommendations regarding the useof guideline-directed medication therapies are based on LVEF, not qualitative estimates of leftventricular systolic function. The 2013 ACCF/AHA STEMI guideline (12) explicitly recommendedmeasuring LVEF. The 2014 AHA/ACC NSTE-ACS guidelines (11) likewise have medicationrecommendations based on knowledge of the ejection fraction.

PM-12 Inpatient Cardiac RehabilitationReferral

This measure is being adapted from the AACVPR/ACCF/AHA 2010 Update: Performance Measures onCardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services (28).

One modification since the publication of that 2010 measurement set was the removal of patient reasonsfrom the list of measure exceptions. Specifically, patient refusal does not constitute a justifiable reasonfor a clinician not offering a referral to a patient.

If documentation in the medical record exists noting that the provider has informed and discussed referralto cardiac rehabilitation/secondary prevention program with the patient, but that the patient refuses areferral, then the healthcare provider would not be expected to send communication about the patientto the cardiac rehabilitation/secondary prevention program. This is consistent with HIPAAconfidentiality regulations and shared decision making, and performance would then be consideredmet by the provider (preventing unjust penalization of the provider).

PM-13 Inpatient P2Y12 Receptor InhibitorPrescribed atDischarge

In the 2008 ACC/AHA STEMI/NSTEMI measure set (2), a test measure entitled “Clopidogrel at Discharge”was included. Since then, 2 newer FDA-approved medications—ticagrelor and prasugrel—have emergedand demonstrated safety, efficacy, and clinical effectiveness after AMI. All 3 medications are inhibitorsof the P2Y12 receptor and are recommended in addition to aspirin (as part of a dual antiplateletregimen) to reduce recurrent ischemic events after AMI.

AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA,American Heart Association; AMI, acute myocardial infarction; FDA, U.S. Food and Drug Administration; HIPAA, the Health Insurance Portability and Accountability Act; LVEF, leftventricular ejection fraction; NSTEMI, non–ST-elevation myocardial infarction; NSTE-ACS, non–ST-segment elevation acute coronary syndromes; PM, performance measure; and STEMI,ST-elevation myocardial infarction.

TABLE 4 Retired STEMI and NSTEMI Measures From the 2008 Set

# Care Setting Measure Title Rationale for Retiring the Measure

PM-12 Inpatient Adult SmokingCessation Advice/Counseling

This measure is being retired because perfect scores are consistently achieved and the measure appears to havereached a ceiling effect. Therefore, given absence of room for further improvement, the writing committeeopted to omit this measure from the inpatient performance measure set for AMI (realizing also that a separateoutpatient CAD measure set will likely address smoking cessation advice/counseling). The writing committeealso recognizes the importance of the American Medical Association/Physician Consortium for PerformanceImprovement Tobacco Use: Screening and Cessation Intervention measure that already exists (27).

QM-1 Inpatient LDL CholesterolAssessment

This measure is being retired to be concordant with the new lipid guidelines that no longer recommend LDLmeasurements to target statin prescription and/or dosing.

QM-2 Inpatient Excessive InitialHeparin Dose

This measure is being retired because it covers only one aspect of medication use (e.g., overdosing) and missesother aspects such as under-dosing and inappropriate use. In addition, this is not a direct stand-alone Class I orIII recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability.

QM-3 Inpatient Excessive InitialEnoxaparin Dose

This measure is being retired because it covers only one aspect of medication use (e.g., overdosing) and missesother aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or IIIrecommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability.

QM-4 Inpatient Excessive InitialAbciximab Dose

This measure is being retired because it covers only one aspect of medication use, (e.g., overdosing) and missesother aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or IIIrecommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability.

QM-5 Inpatient Excessive InitialEptifibatide Dose


QM-6 Inpatient Excessive InitialTirofiban Dose


QM-7 Inpatient Anticoagulant DosingProtocol

This measure is being retired because it covers only one aspect of medication use and misses other aspects such asinappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines andhas shortcomings pertinent to measure feasibility and accountability.

QM-8 Inpatient Anticoagulant ErrorTracking System

This measure is being retired because it covers only limited aspects of medication use and misses other aspects suchas inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines.

AMI indicates acute myocardial infarction; LDL, low-density lipoprotein; NSTEMI, non–ST-elevation myocardial infarction; PM, performance measure; QM, quality measure; andSTEMI, ST-elevation myocardial infarction.



TABLE 6 New STEMI/NSTEMI Measures

No. Care Setting Measure Title Rationale for Creating New Measure

Rationale for Designating as a QualityMeasure as Opposed to a Performance

Measure (If Applicable)

PM-14 Inpatient Immediate Angiographyfor Resuscitated Out-of-Hospital CardiacArrest in STEMIPatients

This measure seeks to implement a Class I (Level ofEvidence B) recommendation in the 2013ACCF/AHA STEMI guideline (12) that immediateangiography with PCI when indicated should beperformed in resuscitated out-of-hospital cardiacarrest patients whose initial ECG shows STEMI. Thewriting committee opted to include angiographyonly, which is easily measurable, and not PCIbecause of the difficulty associated withascertaining PCI appropriateness or its lackthereof.

Not Applicable

PM-15 Inpatient Noninvasive StressTesting BeforeDischarge inConservativelyTreated Patients

This measure seeks to implement Class I (Level ofEvidence B) recommendations in both the 2013STEMI (12) and 2014 AHA/ACC NSTE-ACS (11)guidelines to perform noninvasive stress testing todetect inducible ischemia in medically treatedSTEMI and NSTEMI patients.

Not Applicable

PM-16 Inpatient Early Cardiac TroponinMeasurement (Within6 Hours of Arrival)

This measure seeks to implement Class I (Level ofEvidence A) recommendations in the 2014 AHA/ACC NSTE-ACS guideline (11) to measure serialcardiac troponin levels (at presentation and 3 to 6h after symptom onset in all patients).

Not Applicable

PM-17 Inpatient Participation in Regionalor National AcuteMyocardial InfarctionRegistry

This measure seeks to implement Class I (Level ofEvidence B) and Class IIa (Level of Evidence B)recommendations in the 2013 STEMI (12) and 2014AHA/ACC NSTE-ACS guidelines (11), respectively.The writing group felt that participation in aregional or national AMI registry will help trackand assess the outcomes, complications, andquality of care for patients with AMI, and issupported by evidence.

Not Applicable

QM-1 Inpatient Risk Score Stratificationfor NSTEMI Patients

This measure seeks to implement a Class I (Level ofEvidence A) recommendation in the 2014AHA/ACC NSTE-ACS (11) guideline that risk scoresshould be used to assess prognosis in patients withNSTE-ACS. The writing committee realizes theimportance of this measure to dictate theappropriate strategy (invasive versus ischemic-guided) and the timing of the strategy (earlyversus late invasive) in patients with NSTEMI.

The writing committee felt it was best to keep thisas a quality measure because of issues related tothe measure feasibility. Most registries do notinclude risk scores, and most risk scores (e.g.,GRACE, TIMI, PURSUIT) are difficult to computeretrospectively from their respectivecomponents, and are likely to cause a significantabstraction burden.

QM-2 Inpatient Early Invasive Strategy(Within 24 Hours) inHigh-Risk NSTEMIPatients

This measure seeks to implement a Class I (Level ofEvidence A) recommendation in the 2014AHA/ACC NSTE-ACS guideline (11) that an earlyinvasive strategy should be performed in initiallystabilized high-risk patients with NSTE-ACS.

The writing committee felt it was best to keep thisas a quality measure for many reasons. Thewriting group acknowledges that early invasivestrategy (compared with a delayed invasivestrategy) in high-risk NSTE-ACS patientspredominantly reduces recurrent ischemia(rather than the hard outcomes of recurrent MIor death). Although this strategy additionallyreduces length of stay and costs, it creates alogistical burden on cardiac catheterization labs,especially during weekends. Finally, objectiverisk stratification by risk scores is usually notavailable in current registries; thus, ascertainingwhich patients benefit from early invasivestrategy may not be readily feasible.

QM-3 Inpatient Therapeutic Hypothermiafor Comatose STEMIPatients With Out-of-Hospital CardiacArrest

This measure seeks to implement a Class I (Level ofEvidence B) recommendation in the 2013ACCF/AHA STEMI guideline (12) that therapeutichypothermia should be started as soon as possiblein comatose patients with STEMI and out-of-hospital cardiac arrest caused by VF or VT.

The writing committee felt it was best to keep thisas a quality measure because of newercontroversial data pertinent to theeffectiveness, timing, and implementation oftherapeutic hypothermia.

QM-4 Inpatient Aldosterone Antagonistat Discharge

This measure seeks to implement Class Irecommendations in the 2013 ACCF/AHA STEMI(12) and 2014 AHA/ACC NSTE-ACS (11) guidelinessupporting the use of aldosterone antagonists ineligible patients with STEMI and NSTEMI,respectively.

The writing committee felt it is best to keep this as aquality measure because of issues related to themeasure construct. This measure is likely topresent a significant abstraction burden and maybe relevant only to a small fraction of AMIpatients (given the elaborate inclusion/exclusioncriteria in the EPHESUS (29) clinical trial).

Continued on the next page


9

TABLE 6 Continued

No. Care Setting Measure Title Rationale for Creating New Measure

Rationale for Designating as a QualityMeasure as Opposed to a Performance

Measure (If Applicable)

QM-5 Inpatient Inappropriate In-HospitalUse of NSAIDs

This measure seeks to implement Class IIIrecommendations (Class III Harm, Level ofEvidence: B) in both the 2013 ACCF/AHA STEMI(12) and 2014 AHA/ACC NSTE-ACS (11) guidelines,cautioning against the use of these drugs afterAMI.

The writing committee felt it is best to keep this as aquality measure given the low impact associatedwith the use of NSAIDs during the briefhospitalization period (this is likely morerelevant in the outpatient setting). Theexistence of an extensive and evolving list ofNSAIDs may also create significant abstractionburden.

QM-6 Inpatient Inappropriate Prescriptionof Prasugrel atDischarge in PatientsWith a History of PriorStroke or TIA

This measure seeks to implement Class IIIrecommendations (Class III HARM, Level ofEvidence: B) in both the 2013 ACCF/AHA STEMI(12) and 2014 AHA/ACC NSTE-ACS (11) guidelines,cautioning against the use of prasugrel in patientswith prior TIA/stroke, because of net clinical harmin these patients. The FDA also issued a black boxwarning on this.

The writing committee felt it is best to keep this as aquality measure only for the time being untilmore data become available pertinent to thismeasure and its impact in real-world patients.

QM-7 Inpatient Inappropriate Prescriptionof High-Dose AspirinWith Ticagrelor atDischarge

This measure seeks to implement Class IIIrecommendations (Class III HARM, Level ofEvidence: B) in both the 2013 ACCF/AHA STEMI(12) and 2014 AHA/ACC NSTE-ACS (11) guidelines,cautioning against the use of high-dose aspirin>100 mg among patients receiving ticagrelor. TheFDA also issued a black box warning on this.

The writing committee felt it is best to keep this as aquality measure only for the time being untilmore data become available pertinent to thismeasure and its impact in real-world patients.

ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; EPHESUS, Eplerenone Post–Acute MyocardialInfarction Heart Failure Efficacy and Survival Study; FDA, U.S. Food and Drug Administration; GRACE, Global Registry of Acute Coronary Events; NSAIDs, nonsteroidal anti-inflammatory drugs; NSTE- ACS, non–ST-segment elevation-acute coronary syndrome; NSTEMI, non–ST-elevation myocardial infarction; PM, performance measure; PCI, percuta-neous coronary intervention; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin; QM, quality measure; STEMI, ST-segment elevationmyocardial infarction; TIA, transient ischemic attack; TIMI, Thrombolysis in Myocardial Infarction; VF, ventricular fibrillation; and VT, ventricular tachycardia.



4. AREAS FOR FURTHER RESEARCH

The writing committee recognizes that the ultimatemeasure of performance lies in the assessment of out-comes, such as mortality (in-hospital or 30-day), healthstatus, and other outcomes (recurrent MI, urgent repeatrevascularization). However, the complexity associatedwith adjustment for the large number of patient charac-teristics that both influence treatment decisions andimpact mortality make these measures less attractive touse. Thirty-day risk-adjusted AMI mortality has been usedby CMS for payment incentives and in public reporting.The impact of these and other measures on hospitalquality should be the focus of future research. The com-mittee also realizes that many measures are already“topped-out” and can be retired to minimize abstractionburden. Additional research should examine the impactof dropping such measures. Furthermore, continuousresearch to examine temporal trends and disparities (i.e.,with respect to sex, age, ethnicity) in the achievement ofperformance and quality measures will help guide futurerevisions as well as the implementation of the current set.While the majority of current measures are binary (forexample, yes or no for medication prescription), thenext frontier in performance evaluation may be also tomeasure doses of prescribed pharmacotherapies andcompare them to doses used in randomized trials showingbenefit. Finally, the ACC ACTION Registry– Get With The

Guidelines implemented a “Defect-Free Care” measurefor AMI patients, which was endorsed by the NationalQuality Forum. Our writing committee did not adopt thismeasure in the current document to avoid the additionalburden of data abstraction and reporting. This is espe-cially important given that we have expanded the per-formance measure set to include a larger and morecomprehensive set of 17 performance measures thanpreviously adopted. Our writing committee acknowledgesthe importance of the “Defect-Free Care” measure andwould like to evaluate its performance and impact in realworld before considering it in the future. We alsoemphasize the importance of assessing the impact ofcompliance (or lack thereof) to some or all performancemeasures on short- and long-term clinical outcomes. Ourwriting committee also recognizes that all performancemeasures and quality measures are dynamic and can berevised or retired based on the emergence of scientificevidence and new guideline recommendations.

STAFF

American College of Cardiology

Mary Norine Walsh, MD, FACC, PresidentShalom Jacobovitz, Chief Executive OfficerWilliam J. Oetgen, MD, MBA, FACC, Executive Vice

President, Science, Education, Quality, and Publishing


11

Lara Slattery, MHS, Senior Director, ACC ScientificReporting

Esteban Perla, MPH, Team Lead, Quality MeasurementAmelia Scholtz, PhD, Publications Manager, Science,

Education, Quality, and PublishingAmericanCollegeofCardiology/AmericanHeartAssociation

Katherine Sheehan, PhD, Director, Guideline Strategy andOperations

Sana Gokak, MPH, Associate, Quality Measurement

American Heart Association

Steven R. Houser, PhD, FAHA, PresidentNancy Brown, Chief Executive OfficerRose Marie Robertson, MD, FAHA, Chief Science and

Medicine OfficerGayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice

President, Office of Science OperationsJody Hundley, Production Manager, Scientific Publishing,

Office of Science Operations

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