ACC/AHA Clinical Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction
A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures on ST-Elevation and Non–ST-Elevation Myocardial Infarction)
TABLE OF CONTENTS
I. Introduction 735
A. Scope of the Problem 735
B. Writing Committee Structure/Members 735
C. Independence/Relationships With Industry Disclosure 735
D. Review/Endorsement 735
II. Methodology 735
A. Definition of STEMI/NSTEMI 735
B. Dimensions of Care 736
C. Literature Review 736
D. Definition and Selection of Measures 736
III. STEMI/NSTEMI Performance Measures 737
A. Inpatient Population and Care Period 737
B. Brief Summary of the Measurement Set 737
C. Data Collection 738
IV. Discussion 738
A. Addition of ARBs to ACEI Measure 738
B. Median Versus Mean—Time to Fibrinolytic Therapy and Time to Primary PCI Measures 739
C. New Standard for Time to Primary PCI Measure 739
D. New Reperfusion Therapy Measure 739
Appendix A: ACC/AHA STEMI/NSTEMI Measurement Set Specifications 740
Appendix B: Sample Rating Form and Guide 754
Appendix C: Relationships With Industry—Writing Committee 756
Appendix D: Relationships With Industry—Peer Reviewers 757
Medicine is experiencing an unprecedented focus on quantifying and improving health care quality. The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multi-faceted strategy to facilitate the process of improving clinical care. The initial phase of this effort was to create clinical practice guidelines that carefully review and synthesize available evidence to better guide patient care. Such guidelines are written in a spirit of suggesting diagnostic or therapeutic interventions for patients in most circumstances. Accordingly, significant judgment by clinicians is required to adapt these guidelines to the care of individual patients, and these guidelines can be generated with varying degrees of confidence based upon available evidence. Occasionally, the evidence supporting a particular structural aspect or process of care is so strong that failure to perform such actions reduces the likelihood that optimal patient outcomes will occur. Creating a mechanism for quantifying these opportunities to improve the outcomes of care is an important and pressing challenge.
In the next phase of its quality improvement efforts, the ACC and the AHA created the ACC/AHA Task Force on Performance Measures in February 2000 to spearhead the development of performance measures that allow the quality of cardiovascular care to be assessed and improved. Three nominees from each organization were charged with the task of assembling teams of clinical and methodological experts, both from within the sponsoring organizations and from other organizations dedicated to the care of patients covered by the performance measurement set. These writing committees were given careful guidance with respect to the necessary attributes of good performance measures and the process of identifying, constructing, and refining these measures so that they can accurately achieve their desired goals (1).
The role of performance measurement writing committees is not to perform a primary evaluation of the medical literature; this is undertaken by ACC/AHA guidelines committees. However, performance measurement writing committees work collaboratively with guidelines committees so that the guideline recommendations are written with a degree of specificity that supports performance measurement and so that new knowledge can be rapidly incorporated into performance measurement. Development of ACC/AHA guidelines includes a detailed review of and ranking of the evidence available for the diagnosis and treatment of specific disease areas. Published guideline recommendations employ the ACC/AHA classification system I, IIa, IIb, and III (Fig. 1).
So as not to duplicate performance measure development efforts, writing committees were also instructed to evaluate existing nationally recognized performance measures using the ACC/AHA “attributes of good performance measures.” The measure specifications were adopted for those performance measures that meet these criteria. Such measures have established validity, reliability, and feasibility and will form the foundation of the ACC/AHA measurement sets. Furthermore, writing committees are encouraged to identify additional performance measures that correspond to those key areas of quality proven to improve patient outcomes.
ACC/AHA Performance Measurement Sets are to be applied in either the inpatient and/or outpatient setting depending upon the topic. Although inpatient measures have traditionally been captured by retrospective data collection, the increased use of electronic medical records allows for prospective collection in the inpatient and outpatient settings. Prospective data collection is itself a continuous quality improvement process. The performance measures quantify explicit actions performed in carefully specified patients for whom adherence should be advocated in all but the most unusual circumstances. In addition, the measures are constructed with the intent to facilitate both retrospective and prospective data collection using explicit administrative and/or easily documented clinical criteria. Furthermore, the data elements required to construct the performance measures are identified and linked to existing ACC/AHA Clinical Data Standards to encourage the standardization of cardiovascular measurement.
While the focus of the performance measures writing committees is to develop measures for internal quality improvement, it is appreciated that other organizations may use these measures for external reporting of provider performance.⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓
↵*Immediate past Task Force Chair.
†Former Task Force Member.
This document was approved by the American College of Cardiology Board of Trustees in October 2005 and the American Heart Association Science Advisory and Coordinating Committee in October 2005.
When citing this document, the American Heart Association would appreciate the following citation format: Krumholz HM, Anderson JL, Brooks NH, Fesmire FM, Lambrew CT, Landrum MB, Weaver WD, Whyte J. ACC/AHA clinical performance measures for adults with ST-elevation and non–ST-elevation myocardial infarction: a report of the ACC/AHA Task Force on Performance Measures (ST-Elevation and Non–ST-Elevation Myocardial Infarction Performance Measures Writing Committee). Circulation. 2006;113:732–761. Published online before print January 3, 2006. DOI: 10.1161/CIRCULATIONAHA.106.172860.
This document has been copublished in the January 3, 2006, issue of the Journal of the American College of Cardiology.
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