Major medical societies update performance measures for coronary artery disease, hypertension

New performance measures for adults with coronary artery disease (CAD) and hypertension are meant to provide a patient-centered focus and give practitioners and institutions tools to measure and improve care quality.

The new measures from the American College of Cardiology Foundation (ACCF), the American Heart Association, and the American Medical Association's Physician Consortium for Performance Improvement (AMA-PCPI) update a set released by the three groups in 2005, and are a significant departure from them. Specifically, the new measures consider not just whether cardiac risk factors are treated but whether they are controlled to target levels. The measures appeared online June 13 at the Journal of the American College of Cardiology.

Screening for diabetes in patients with CAD was retired as a measure. While the writing committee recognized the significance of diabetes in patients with CAD, the measure was found to be difficult to implement and was not widely used. Another work group is expected to release new diabetes screening guidelines that could be a significant change from the current ones.

The 10 performance measures comprise both revisions of five measures from the 2005 set and five new measures. Measures in the updated set for coronary artery disease include:

Blood pressure control. Prescribe at least two antihypertensive medications in patients who have not reached a target blood pressure of less than 140/90 mm Hg.

Lipid control. Document a plan of care, which includes at minimum the prescription of a statin, for patients who cannot lower their LDL cholesterol below 100 mg/dL.

Symptom and activity assessment. Evaluate patients' activity level and the corresponding presence or absence of angina symptoms.

Symptom management. Document a plan of care to manage angina symptoms.

Tobacco use, screening, cessation and intervention. Screen patients for tobacco use, and provide tobacco-cessation counseling for users.

Antiplatelet therapy. Prescribe aspirin or clopidogrel for patients.

Beta-blocker therapy. Physicians should prescribe beta-blocker therapy for patients with prior myocardial infarction or a left ventricular ejection fraction of less than 40%.

ACE inhibitor/ARB therapy. Physicians should prescribe an ACE inhibitor or ARB for patients with diabetes or left ventricular ejection fraction of less than 40%.

Cardiac rehabilitation patient referral. Refer patients who have had an acute heart attack, a coronary artery bypass graft surgery, stenting, cardiac valve surgery or cardiac transplantation to an early outpatient cardiac rehabilitation program.

To treat hypertension, the new measures call for a target of under 140/90 mm Hg, and prescription of at least two antihypertensive medications for patients who have not met that.

These measures are meant to resolve some of the methodological issues associated with performance measures at the individual practitioner or practice level resulting from the socioeconomic and clinical heterogeneity of patient populations and the relatively small number of patients treated by any one practitioner or group. This measures set attempts to resolve those issues with the blood pressure and lipid control measures, as well as the symptom assessment and management measures.

The performance measures were based on updated practice guidelines and were designed to harmonize with other national measure sets. Before being used in accountability programs, including public reporting or pay-for-performance programs, they will undergo testing developed by the AMA-PCPI and by the ACCF PINNACLE Registry.