New Quality and Performance Measures to Support Atrial Fibrillation Guidelines

The American College of Cardiology (ACC) and American Heart Association (AHA) have released new clinical performance and quality measures designed to speed the adoption of guidelines issued last year for the treatment of atrial fibrillation (AF).

There are three performance measures for inpatient facilities and three nearly identical performance measures for outpatient care, all which are designed both to help providers improve their own performance and to create a basis for evaluation by patients, payers, and other stakeholders:

• CHA₂DS₂-VASc risk score documented before discharge (inpatient)
• Anticoagulation prescribed before discharge (inpatient)
• Prothrombin/international normalized ratio (INR) follow-up planned before discharge for warfarin treatment (inpatient)
• CHA₂DS₂-VASc risk score documented (outpatient)
• Anticoagulation prescribed (outpatient)
• Monthly INR for warfarin treatment (outpatient)

The 18 quality measures, on the other hand, are designed strictly for care providers who want to evaluate and improve their own operations. The ACC and AHA regard them as preliminary standards that may eventually evolve into full performance measures.

The first 10 are aimed at inpatient facilities:

• Beta blocker prescribed prior to discharge
• Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) prescribed prior to discharge
• Antiarrhythmic drugs not prescribed to patients with permanent AF
• Dofetilide or sotalol not prescribed to dialysis patients or those with end-stage kidney disease
• Thrombin or factor Xa inhibitor not prescribed to patients with mechanical heart valves
• Thrombin, factor Xa inhibitor, rivaroxaban or edoxaban not prescribed to dialysis patients or those with end-stage kidney disease
• Antiplatelet and anticoagulation not prescribed together for patients who do not have coronary artery disease or vascular disease
• Nondihydropyridine calcium channel blocker not prescribed to patients with reduced ejection fraction
• Anticoagulation given during and after catheter ablation
• Patient and physician share decision about anticoagulation agent

The remaining 8, which are aimed at outpatient facilities, are the same — minus the measures concerning ACE inhibitors and ablation.

The goal, in writing the measures, was to capture as much information about the quality of care while minimizing the reporting burden placed on caregivers.

“Particular attention was given to assessments, therapies, and interventions that could improve the quality of life for patients with AF. Effective clinical care, patient safety, and care coordination measures were developed. The writing committee believes that these measures have the potential to improve the patient care and thereby improve the quality of life,” the authors of the new document wrote in the Journal of the American College of Cardiology.

The new document updates and expands upon an older set of measures that was published in 2008. Those earlier measures applied only to outpatient care, so all measures related to inpatient care are entirely new, as are all 18 of the quality measures. The main change to the 3 performance measurements for outpatient care was to use CHA₂DS₂-VASc instead of CHADS₂.

“Although the writing committee did note that the data needed for the monthly International Normalized Ratio Warfarin Treatment measure have proved difficult to collect for some institutions, it was noted that some healthcare systems, such as the US Department of Veterans Affairs, may be able to collect this information. The writing committee hopes that by maintaining this as a performance measure, health systems will encourage sites to improve data collection. The writing committee also anticipates that increased interoperability of healthcare data in general, and across inpatient and outpatient records in particular, will facilitate reporting of this measure.”