ACC/AHA: New quality measures for cardiac care detail construction, collection

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To help ensure that performance measures—the current standard for measuring quality—keep pace with the evolving science of quality improvement, a guidance document outlining new insights into the methodology for the development and use of performance measures in cardiac care will be published in the Nov. 16 issue of the Journal of the American College of Cardiology.

The report was developed by the American College of Cardiology and American Heart Association.

Due to the inherent delay between the collection of new evidence and its adoption into routine clinical care, existing performance measures do not always take the emerging body of evidence into account. The report, which updates the initial 2005 document, addresses this and seeks to insure that only the processes of care associated with the strongest evidence of an association with meaningful outcomes are endorsed, according to John A. Spertus, MD, cardiology chair at the University of Missouri Kansas City and chair of the 12-person writing committee

"As performance measures have grown in importance, we must constantly be sure that they are created in the most sound scientific manner so that the goal of using these measures—to improve care—is most likely to be achieved," Spertus said.

Although initially intended to help physicians improve the quality of care and patient outcomes, performance measures are, in fact, more often used as tools for accountability and performance-based reimbursement.

"As we use performance measures, we have learned how to make them more accurate, meaningful and actionable," said Spertus. "Recently, insurers are starting to pay more for practices that more often comply with performance measures and major payors, such as Medicare, are increasingly publishing providers' performances for the public to review."

The updated report identifies challenges and critical opportunities to improve the selection, construction, implementation and interpretation of performance measurement as a means to provide a higher quality of cardiovascular care.

When constructing a performance measure, it's important to evaluate the strength of evidence supporting a potential performance measure, define the clinical significance of the outcome most likely to be achieved by adherence to a performance measure, and assess the magnitude of the association between adherence to the potential performance measure and a clinically important outcome, according to the document.

The authors noted there must be a clearly articulated approach to the selection of performance measures because manufacturers can have strong financial incentives for their diagnostic or therapeutic products to be included in a performance measure.

Additionally, when selecting performance measures, there should be confidence that they will "meaningfully improve the health—either survival or health status (patients' symptoms, function and quality of life)—of the population to whom the measures are applied."

The writing committee reinforced the importance of considering both the cost effectiveness and total cost burden of potential performance measures before selection. "Although these may change over time, explicitly quantifying the cost effectiveness of treatments at the time that performance measures are created ... will minimize the likelihood that unintended economic consequences for society and hospitals emerge from adopting a measure," they wrote.

Spertus and colleagues emphasized the importance of preliminary testing of proposed measures in local, regional, or national projects before application for purposes of accountability.

To make performance measurement implementation easier and more meaningful, the authors suggested "elevating the evidentiary threshold for endorsing a performance measure, simplifying the inclusion/exclusion criteria, limiting the number of measures and retiring measures" that are outdated.

"Professional societies have learned a lot about new challenges and opportunities since the original recommendations for the methodology of performance measure development were written five years ago," Spertus said. "Since performance measures, once developed, almost always become mandatory clinical actions, it is very important that the issues raised in this paper be considered so that adverse consequences can be avoided."