2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.

Abstract

HomeCirculation: Cardiovascular Quality and OutcomesVol. 11, No. 42018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUB2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures Randal J. Thomas, MD, MS, MAACVPR, FACC, FAHA, Gary Balady, MD, FAHA, Gaurav Banka, MD, Theresa M. Beckie, PhD, FAHA, Jensen Chiu, MHA, Sana Gokak, MPH, P. Michael Ho, MD, PhD, FACC, FAHA, Steven J. Keteyian, PhD, FAACVPR, Marjorie King, MD, FACC, MAACVPR, Karen Lui, RN, MS, MAACVPR, Quinn Pack, MD, MS, Bonnie K. Sanderson, PhD, RN and Tracy Y. Wang, MD, MHS, MSc, FACC, FAHA Randal J. ThomasRandal J. Thomas Search for more papers by this author , Gary BaladyGary Balady Search for more papers by this author , Gaurav BankaGaurav Banka Search for more papers by this author , Theresa M. BeckieTheresa M. Beckie Search for more papers by this author , Jensen ChiuJensen Chiu Search for more papers by this author , Sana GokakSana Gokak Search for more papers by this author , P. Michael HoP. Michael Ho *, † Search for more papers by this author , Steven J. KeteyianSteven J. Keteyian *, † Search for more papers by this author , Marjorie KingMarjorie King Search for more papers by this author , Karen LuiKaren Lui Search for more papers by this author , Quinn PackQuinn Pack Search for more papers by this author , Bonnie K. SandersonBonnie K. Sanderson Search for more papers by this author and Tracy Y. WangTracy Y. Wang Search for more papers by this author Originally published29 Mar 2018https://doi.org/10.1161/HCQ.0000000000000037Circulation: Cardiovascular Quality and Outcomes. 2018;11:e000037Table of ContentsPreamble 21.Introduction 21.1.Scope of the Problem 31.2.Disclosure of Relationships With Industry and Other Entities 42.Methodology 42.1.Literature Review 42.2.Definition and Selection of Measures 43.ACC/AHA CR Measure Set Performance Measures 63.1.Discussion of Changes to 2007 and 2010 CR Measure Set 63.1.1.Retired Measures 63.1.2.Revised Measures 63.1.3.New Measures 74.Areas for Further Research 7References 9Appendix A. Cardiac Rehabilitation Measure Set 12Performance Measures for Cardiac Rehabilitation 12Short Title: PM-1: Referral From Inpatient Setting 12Short Title: PM-2: Exercise Training Referral for HFrEF From Inpatient Setting 14Short Title: PM-3: Referral From Outpatient Setting 16Short Title: PM-4: Exercise Training Referral for HFrEF From Outpatient Setting 18Short Title: PM-5A: Enrollment (Claims-Based) 20Short Title: PM-5B: Enrollment (Medical Records and/or Databases/Registries) 21Quality Measures for Cardiac Rehabilitation 22Short Title: QM-1: Time to Enrollment 22Short Title: QM-2: Cardiac Rehabilitation Adherence (≥36 sessions) 24Short Title: QM-3: Cardiac Rehabilitation Outcomes Communication 26Appendix B. Author Listing of Relationships With Industry and Other Entities (Relevant) 28Appendix C. Peer Reviewer Relationships With Industry and Other Entities 29PreambleThe American College of Cardiology (ACC)/American Heart Association (AHA) performance measurement sets serve as vehicles to accelerate translation of scientific evidence into clinical practice. Measure sets developed by the ACC/AHA are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement.Writing committees are instructed to consider the methodology of performance measure development1 and to ensure that the measures developed are aligned with ACC/AHA clinical guidelines. The writing committees also are charged with constructing measures that 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 hospitals, practices, and/or practitioners.Potential challenges from measure implementation may lead to unintended consequences. The manner in which challenges are addressed is dependent on several factors, including the measure design, data collection method, performance attribution, baseline performance rates, reporting methods, and incentives linked to these reports.The ACC/AHA Task Force on Performance Measures (Task Force) distinguishes quality measures from performance measures. Quality measures are those metrics that may be useful for local quality improvement but are not yet appropriate for public reporting or pay for performance programs (uses of performance measures). New measures are initially evaluated for potential inclusion as performance measures. In some cases, a measure is insufficiently supported by the guidelines. In other instances, when the guidelines support a measure, the writing committee may feel it is necessary to have the measure tested to identify the consequences of measure implementation. Quality measures may then be promoted to the status of performance measures as supporting evidence becomes available.Gregg C. Fonarow, MD, FACC, FAHAChair, ACC/AHA Task Force on Performance Measures1. IntroductionIn 2016, the Task Force convened the writing committee to begin the process of revising the existing performance measures set for cardiac rehabilitation (CR) that was released in 20072 and for which a focused update was issued in 2010.3 The writing committee also was charged with the task of developing new measures to benchmark and improve the quality of care for patients eligible for CR.The performance measures for CR included in the measure set are briefly summarized in Table 1, which provides information on the measure number, measure title, and care setting. The detailed measure specifications (Appendix A) provide not only the information included in Table 1 but also provide more detailed information including the measure description, numerator, denominator (including denominator exclusions and exceptions), rationale for the measure, guidelines that support the measure, measurement period, source of data, and attribution.Table 1. ACC/AHA 2018 Clinical Performance and Quality Measures for Cardiac RehabilitationNo.Measure TitleCare SettingAttributionMeasure DomainPerformance Measures PM-1CR Patient Referral From an Inpatient SettingInpatientFacility LevelCommunication and Care Coordination PM-2Exercise Training Referral for HF From Inpatient SettingInpatientFacility LevelCommunication and Care Coordination PM-3CR Patient Referral From an Outpatient SettingOutpatientFacility or Provider LevelCommunication and Care Coordination PM-4Exercise Training Referral for HF From Outpatient SettingOutpatientFacility or Provider LevelCommunication and Care Coordination PM-5aCR Enrollment–Claims BasedOutpatientProvider LevelEffective Clinical Care PM-5bCR Enrollment–Registry/Electronic Health Records BasedInpatientProvider LevelEffective Clinical CareQuality Measures QM-1CR Time to EnrollmentOutpatientFacility or Provider LevelEffective Clinical Care QM-2CR Adherence (≥36 sessions)OutpatientFacility or Provider LevelEffective Clinical Care QM-3CR Communication: Patient Enrollment, Adherence, and Clinical OutcomesOutpatientFacility or Provider LevelCommunication and Care CoordinationACC indicates American College of Cardiology; AHA, American Heart Association; CR, cardiac rehabilitation; HF, heart failure; PM, performance measure; and QM, quality measure.The writing committee developed a comprehensive CR measure set that includes 9 measures, including 6 performance measures and 3 quality measures as reflected in Table 1 and Appendix A. The writing committee believes that implementation of this measure set by healthcare systems, healthcare providers, health insurance carriers, chronic disease management organizations, CR programs, and other groups who have responsibility for the delivery of care to persons with cardiovascular disease will enhance the structure, process, and outcomes of care provided to patients who are eligible for CR services.1.1. Scope of the ProblemThe 2017 AHA Heart Disease and Stroke Statistics report highlights the large number of patients who need CR each year, including 625 000 patients discharged from US hospitals after an acute coronary syndrome, 954 000 patients who underwent percutaneous coronary interventions (PCI), 500 000 patients discharged with a new diagnosis of heart failure (HF), and 397 000 who underwent coronary artery bypass graft surgery (CABG).4 Furthermore, data from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project statistics show that >608 000 patients were discharged with a primary diagnosis of acute myocardial infarction (AMI) in 2012 with a length of stay (mean) of 4.6 days, charges (mean) of >$72 000 per patient stay, and an in-hospital death rate of 5.16%.5 More than half a million patients with coronary atherosclerosis and other heart diseases were treated in hospitals in 2012 with a mean length of stay of 3.7 days and associated charges of almost $69 000.5CR is a multidisciplinary, systematic approach to applying secondary prevention therapies of known benefit. After a myocardial infarction (MI), CR decreases recurrent MI and mortality rates based on a meta-analysis of 34 randomized trials.6 Participation in CR programs can also improve a patient’s quality of life and ability to return to work more quickly.7,8 One observational study within a community demonstrated a 10-year absolute risk reduction in all-cause mortality of >12% in patients with CABG who participated in a CR program.9 Studies have also found that CR participation is associated with a 20% to 30% reduction in hospital readmission during the year after a cardiac event.8,10,11Even with the underlying evidence demonstrating the benefits of CR, most eligible patients are still not receiving this therapy. Analyses show that:Just under 35% of patients surveyed in the Behavioral Risk Factor Surveillance System, who had an AMI, received CR.12Certain subpopulations, including ethnic minorities, women, and those with caregiver-related responsibilities, multiple comorbidities, limited program access, and inadequate health insurance coverage, are less likely to receive CR.13,14Data from the ACTION-Get With The Guidelines registry (2014)4 on the current ST-elevation myocardial infarction/non–ST-elevation myocardial infarction measures related to CR continue to demonstrate an opportunity for improvement with 75.9% of patients with non–ST-elevation myocardial infarction receiving this referral and 84.5% for those with ST-elevation myocardial infarction. Rates of CR referral are even lower (approximately 60%) for patients who undergo PCI.15 Similarly, data from the Get With The Guidelines-Heart Failure registry showed that, in patients hospitalized for HF, only 10.4% (12.2% with HF with reduced ejection fraction [HFrEF] and 8.8% with HF with preserved ejection fraction [HFpEF]) received CR referral at discharge.16Furthermore, in addition to a referral gap, an enrollment gap also exists in CR, with only about 50% of patients referred to CR actually enrolling and participating in CR.17–19 In addition, completion rates of CR are suboptimal.13,19 If CR participation rates were improved to at least 70%, it is estimated that approximately 25 000 deaths and 180 000 hospitalizations could be prevented each year.20 For all of the previously mentioned reasons, updating the existing CR measure set has been recognized as a high priority for the ACC and AHA. Particular attention has been given to the infrastructure and processes that are most likely to improve CR participation by eligible patients and ultimately improve patient outcomes. This document serves to reflect those measures that were developed by the writing committee after comprehensive internal discussion, peer review, and public comment.1.2. Disclosure of Relationships With Industry and Other EntitiesThe Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that could arise as a result of relationships with industry or other entities (RWI). Detailed information on the ACC/AHA policy on RWI can be found online. All members of the writing committee, as well as those selected to serve as peer reviewers of this document, were required to disclose all current relationships and those existing within the 12 months before the initiation of this writing effort. ACC/AHA policy also requires that the writing committee chair and at least 50% of the writing committee have no relevant RWI.Any writing committee member who develops new RWI during his or her tenure on the writing committee is required to notify staff in writing. These statements are reviewed periodically by the Task Force and by members of the writing committee. Author and peer reviewer RWI that are relevant to the document are included in the appendixes: Appendix B for relevant writing committee RWI and Appendix C for relevant peer reviewer RWI. Additionally, to ensure complete transparency, the writing committee members’ comprehensive disclosure information, including RWI not relevant to the present document, is available online. Disclosure information for the Task Force is also available online.The work of the writing committee was supported exclusively by the ACC and the AHA without commercial support. Members of the writing committee volunteered their time for this effort. Meetings of the writing committee were confidential and attended only by writing committee members and staff from the ACC, AHA, and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), which served as a collaborator on this project.2. Methodology2.1. Literature ReviewIn developing the updated CR measure set, the writing committee reviewed evidence-based guidelines and statements that would potentially impact the construct of the measures. The clinical practice guidelines and scientific statements that most directly contributed to the development of these measures are shown in Table 2.Table 2. Associated Clinical Practice Guidelines and Other Clinical Guidance DocumentsClinical Practice Guidelines 1.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes21 2.2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction22 3.2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction23 4.2013 ACCF/AHA Guideline for the Management of Heart Failure24 5.2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk25 6.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease26 7.Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update: a guideline from the American Heart Association27 8.AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary Artery and Other Atherosclerotic Vascular Disease: 2011 update28 9.2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery29 10.2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention30Performance Measures and Scientific Statements 1.ACCF/AHA/AMA–PCPI 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension31 2.ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction32 3.Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association33 4.Preventing and Experiencing Ischemic Heart Disease as a Woman: State of the Science: A Scientific Statement From the American Heart Association34 5.ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Heart Failure35 6.2012 ACCF/AATS/SCAI/STS Expert Consensus Document on Transcatheter Aortic Valve Replacement36AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; ACP, American College of Physicians; AHA, American Heart Association; AMA, American Medical Association; PCPI, Physician Consortium for Performance Improvement; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; and STS, Society of Thoracic Surgeons.2.2. Definition and Selection of MeasuresThe writing committee reviewed both recent clinical practice guidelines and other clinical guidance documents (Table 2). The writing committee also examined available information on gaps in care to address which new measures might be appropriate as performance measures or quality measures for this measure set update.The writing committee took into consideration a number of additional factors, including:Previous feedback from the National Quality Forum endorsement process and from the Centers for Medicare & Medicaid Services (CMS) has included suggestions to incorporate enrollment in the next version of the CR performance measures.CMS approved HFrEF as a covered indication for CR beginning in February 2014. Other insurance carriers have also approved coverage for patients with HF. In addition, the “2013 ACCF/AHA Guideline for the Management of Heart Failure” included a Class I recommendation for exercise training for patients with HF.24 These factors highlighted the need to incorporate such patients in the updated version of the CR measures.As ACC and AHA have recently worked with CMS to establish a consensus core set of cardiovascular performance measures, the writing committee decided to not include the CR referral performance measure as a separate measure because of concerns about the difficulty for some centers to collect the measure. However, the writing committee did include the CR referral measure as a component of the composite “defect free care” measure for MI.37 This suggests that a goal of the updated version of the CR performance measures should be to improve the ease of collection, while maintaining high-quality standards for data that are collected.Input from CMS has also requested the e-specification of the performance measures, a process that is difficult given that electronic health records generally do not include CR referral as a discrete data field, making it necessary to use manual chart abstraction or local electronic health record systems to collect data on CR referral. The CR referral measure is currently included in ACC and AHA registries, an important step that may serve as an example for ways in which vendors of electronic health records can include the CR referral measure, as well as other measures included in the updated CR measure set.Growing evidence suggests that alternative models of CR delivery (eg, home-based, electronic/mobile technology-based) are both feasible and potentially helpful for increasing the reach of CR services, suggesting that the updated CR measure set should be broad enough in scope to allow for the inclusion of alternative models of CR delivery that are supported by published evidence.CR measures were designed to cover 2 specific aspects of CR services: 1) referral of eligible patients to a CR program and 2) delivery of CR services through multidisciplinary CR programs. The measures also were designed to include all eligible patients who did not have a valid reason for exclusion from the measure. Measure exclusions are those reasons that remove a patient automatically from the denominator. For example, all measures excluded patients who were <18 years of age. In contrast to exclusions, denominator exceptions are those conditions that remove a patient from the denominator only if the numerator criteria are not met. Denominator exceptions are used in select cases to allow for a fairer measurement of quality for those providers with higher risk populations. Exceptions are also used to defer to the clinical judgment of the provider. Exceptions have been listed in several of the measures. For example, in the case of the CR referral from an inpatient setting, a physician who recommends CR referral to an eligible patient is considered to have met performance even if the patient refuses, at the time of referral, because of ≥1 reasons (eg, lack of transportation, patient preference). In such a case, the physician would receive credit for the measure. If the patient has told the physician that he/she does not wish to enroll in a CR program, the physician can document in the medical record that he/she has recommended referral but that the patient has refused CR. This is important because, in this scenario, the provider should not be penalized for the lack of a completed CR program referral as long as the CR referral recommendation and the patient refusal are documented. The writing committee closely examined which exceptions should be included for each measure.For the purposes of this document, a CR program is defined as a systematic, medically supervised program that helps patients recuperate from their cardiac event; adopt and adhere to healthy lifestyle habits; address comorbid conditions (eg, depression, diabetes mellitus, sleep apnea); monitor for safety issues, including new or recurrent signs or symptoms; and, adhere to evidence-based medical therapies. A CR program may include a traditional center-based CR program that incorporates face-to-face interactions and supervised exercise training sessions or, importantly, may include other alternative CR delivery models that meet all criteria for a safe and effective CR program, as specified by AACVPR CR practice guidelines.38 Such alternative CR program models are defined as hospital outpatient-based programs. These programs may include traditional and/or novel delivery options (eg, home-based CR models, remote monitoring, or mobile health strategies to link patients with CR professionals, either alone or in combination with center-based CR) as part of the program. The programs may also incorporate the core clinical and operational components of an industry-standard service that provides, tracks, and reports on safe and effective exercise. Lastly, the programs provide patient-centered disease management education aimed to progress patients toward improved outcomes in the clinical, functional, and behavioral domains.During the course of developing the measure set, the writing committee evaluated the potential measures against the ACC/AHA attributes of performance measures (Table 3) to reach consensus on which measures should be advanced for inclusion in the final measure set. After the peer review and public comment period, the writing committee reviewed and discussed the comments received and further refined the measure set. The writing committee acknowledges that the new measures created in this set will need to be tested and validated over time. By publishing this measure set, the writing committee encourages adoption of these performance measures, which will facilitate the collection and analysis of data needed to assess the validity of these measures. In the future, the writing committee anticipates having data that will allow it to reassess whether any measures included in this set should be modified, or potentially promoted from a quality measure to a performance measure.Table 3. ACC/AHA Task Force on Performance Measures: Attributes for Performance Measures391. Evidence Based High-impact area that is useful in improving patient outcomesa) For structural measures, the structure should be closely linked to a meaningful process of care that in turn is linked to a meaningful patient outcome.b) For process measures, the scientific basis for the measure should be well established, and the process should be closely linked to a meaningful patient outcome.c) For outcome measures, the outcome should be clinically meaningful. If appropriate, performance measures based on outcomes should adjust for relevant clinical characteristics through the use of appropriate methodology and high-quality data sources.2. Measure Selection Measure definitiona) The patient group to whom the measure applies (denominator) and the patient group for whom conformance is achieved (numerator) are clearly defined and clinically meaningful. Measure exceptions and exclusionsb) Exceptions and exclusions are supported by evidence. Reliabilityc) The measure is reproducible across organizations and delivery settings. Face validityd) The measure appears to assess what it is intended to. Content validitye) The measure captures most meaningful aspects of care. Construct validityf) The measure correlates well with other measures of the same aspect of care.3. Measure Feasibility Reasonable effort and costa) The data required for the measure can be obtained with reasonable effort and cost. Reasonable time periodb) The data required for the measure can be obtained within the period allowed for data collection.4. Accountability Actionablea) Those held accountable can affect the care process or outcome. Unintended consequences avoidedb) The likelihood of negative unintended consequences with the measure is low.ACC indicates American College of Cardiology, and AHA, American Heart Association.3. ACC/AHA CR Measure Set Performance Measures3.1. Discussion of Changes to 2007 and 2010 CR Measure SetAfter reviewing the existing guidelines, the 2007 measure set,2 and the 2010 focused update,3 the writing committee discussed which measures required revision to reflect updated science in the field of CR and identified which guideline recommendations could serve as the basis for new performance or quality measures. The writing committee also reviewed existing publicly available measure sets.These subsections serve as a synopsis of the revisions that were made to previous measures and a description of why the new measures were created for both the inpatient and outpatient setting.3.1.1. Retired MeasuresThe writing committee decided to retire the “Set B” CR performance measures (CR program measures) included in the original 2007 CR measure set. This was done to avoid duplication of effort, because the “Set B” measures are currently being updated, tested, and implemented through a separate process by the AACVPR. The measures, along with a brief rationale for retiring the measures, are included in Table 4.Table 4. Retired CR Measures From the 2007 SetNo.Care SettingMeasure TitleRationale for Retiring the MeasureB-1N/AStructure-Based Measurement SetThis measure will be considered for revision and/or maintenance by the AACVPR, because elements of this measure are currently used within AACVPR Program Certification.B-2N/AAssessment of Risk for Adverse Cardiovascular EventsThis measure will be considered for revision and/or maintenance by the AACVPR, because it is specific to CR programming and outcomes and is used within the AACVPR CR Registry and Program Certification.B-3N/AIndividualized Assessment and Evaluation of Modifiable Cardiovascular Risk Factors, Development of Individualized Interventions, and Communication With Other Health Care ProvidersThis measure is being replaced by AACVPR with patient-related outcomes measures, which currently include improvement in functional capacity, blood pressure control, and depression, as well as a process measures related to intervention for tobacco use. AACVPR will continue to evaluate and develop new measures related to CR programming and outcomes to use within the AACVPR CR Registry and Program Certification.B-4N/AMonitor Response to Therapy and Document Program EffectivenessThis measure will be considered for revision and/or maintenance by AACVPR as elements are used within the AACVPR CR Registry and Program Certification.AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; CR, cardiac rehabilitation; and N/A, not applicable.3.1.2. Revised MeasuresThe writing committee reviewed and made changes to the inpatient and outpatient CR referral measures, as summarized in Table 5. Minimal changes were made, primarily to those that improve ease of use of the measures and strengthen the construct of the measures. Table 5 provides information on the updated measures including the care setting, title, and a brief rationale for revisions made to the measures.Table 5. Revised CR MeasuresNo.Measure TitleDescriptionRationale for RevisionPM-1CR Referral From an Inpatient SettingAll patients hospitalized with a CR-eligible diagnosis or procedure should be referred to an outpatient CR program prior to hospital dischargeIf patient refuses CR referral, referral order and patient materials should not be sent to the receiving CR program against the patient’s wishes. CR referral would still be met as long as other aspects of CR referral have been met (CR referral recommended and documented).PM-3CR Referral From an Outpatient SettingAll outpatients who are eligible for CR and have not yet participated in CR should be referred to an outpatient CR program.If patient refuses CR referral, referral order and patient materials should not be sent to the receiving CR program against the patient’s wishes. CR referral would still be met as long as other aspects of CR referral have been met (CR referral recommended and documented).CR indicates cardiac rehabilitation; and PM, performance measure.3.1.3. New MeasuresThe writing committee created a comprehensive list of measures that can be used for patients who are eligible to participate in CR. This set