03-0052 cad

Clinical Performance Measures
Chronic Stable Coronary Artery Disease
Tools Developed by Physicians for Physicians American College of Cardiology
American Heart Association
Physician Consortium for Performance Improvement
Purpose
This measurement tool provides physicians with evidence-based1 clinical performance measures, including a data collection flowsheet, that may be useful for quality improvement activities within physician practices.
The measures and flowsheet are intended for prospective data collection only. The ability to track changesover time is integral to the concept of continuous quality improvement in patient care. Evidence-based clinicalperformance measures have been identified as a means for tracking these changes.
These measures are provided for physicians by the American College of Cardiology (ACC), the American Heart
Association (AHA), and the Physician Consortium for Performance Improvement (The Consortium). The ACC,
formance Improvement
a professional society of over 25,000 cardiovascular physicians and scientists committed to providing optimalcardiovascular care, and the AHA, a national voluntary health organization with over 30,000 scientist andphysician volunteers dedicated to reducing disability and death from cardiovascular diseases and stroke, havejoined with The Consortium to ensure that the cardiovascular community speaks with one voice on clinicalperformance measurement. The ACC and the AHA have a long-standing partnership in publishing clinicalpractice guidelines and are now developing physician-level performance measures for implementation in boththe inpatient and outpatient setting.
The Consortium is a physician-led initiative that includes methodological experts, clinical experts representingmore than 50 national medical specialty societies, state medical societies, the Agency for Healthcare Researchand Quality, and the Centers for Medicare and Medicaid Services. The Consortium’s vision is to fulfill theresponsibility of physicians to patient care, public health, and safety by becoming the leading source tium for Per
organization for evidence-based clinical performance measures and outcomes reporting tools for physicians.
Performance measures must be designed based on their intended purpose.2,3 The measures presented hereare intended to facilitate individual physician quality improvement. Therefore, there are no minimum samplesize requirements, and the suggested feedback is sufficiently detailed to pinpoint areas of concern for thephysician (eg, lipid profile test values per patient). The measures defined in this measurement tool are notintended, and should not be used, for physician comparison.4 Performance measures are not clinical guidelines; rather, measures are derived from evidence-based clinicalguidelines and indicate whether or not or how often a process or outcome of care occurs.2 Performancemeasures provide important information to a physician, allowing him or her to enhance the quality of caredelivered to patients.
This Physician Performance Measurement Set (PPMS) was developed by the Physician Consortium for Performance Improvement (TheConsortium) to facilitate quality improvement activities by physicians. The performance measures contained in this PPMS are not clinicalguidelines and do not establish a standard of medical care. This PPMS is intended to assist physicians in enhancing quality of care and is not intended for comparing individual physicians to each other or for individual physician accountability by comparing physician performance against the measure or guideline. The Consortium has not tested this PPMS.
Physician Consor
This PPMS is subject to review and may be revised or rescinded at any time by The Consortium. The PPMS may not be altered without theprior written approval of The Consortium. A PPMS developed by The Consortium, while copyrighted, can be reproduced and distributed,without modification, for noncommercial purposes. Any other use is subject to the approval of The Consortium. Neither The Consortium nor its members shall be responsible for any use of this PPMS. Clinical measures and data are being provided in accordance with the DataRights Agreement between the Centers for Medicare & Medicaid Services and the American Medical Association.
Statistics on Chronic Stable Coronary
Selected Evidence-Based Clinical Guidelines
Artery Disease
Evidence-based clinical practice guidelines are available for the Chronic stable coronary artery disease (CAD) is the leading management of CAD. This measurement set is based on clinical cause of mortality in the United States, accounting for almost • American College of Cardiology/American Heart Association • Approximately 13 million Americans are living with CAD.5 • More than 1 million Americans had a new or recurrent • American College of Cardiology/American Heart Association/ American College of Physicians-American Society of InternalMedicine7 • Within the past 2 decades, the number of short-stay hospital discharges for individuals with CAD increased • The total annual cost of CAD in the United States is • National Heart, Lung, and Blood Institute11,17 The performance measures found in this document have been For individuals with CAD, the risk of another heart attack, developed in agreement with these guidelines, enabling the stroke, and other serious complications is substantial.
physician to track his or her performance in individual patientcare and across patient populations. Please note that treatmentmust be based on individual patient needs and professional Statistics on Current Practice
Despite potential risks and established clinical guidelines, For more information and updates, including a list of practicing recent data suggest that some patients are not being physicians and other experts who developed this measurement managed optimally for this disease. It has been reported set, please visit The Consortium’s Web site www.ama-assn.org/go/quality
• Less than 50% of Medicare patients hospitalized for acute myocardial infarction (AMI) received counseling forsmoking cessation.6 Relevant Physician Specialties, Patient
• Only 79% of Medicare patients hospitalized for AMI were Population, and Settings of Care
These performance measures are designed for: • Only 74% of Medicare patients hospitalized for AMI were prescribed angiotensin-converting enzyme (ACE) inhibitor • Use by any physician who manages the ongoing care of • Prospective data collection in the office-based practice American College of Cardiology, American Heart Association, and
Physician Consortium for Performance Improvement
Chronic Stable Coronary Artery Disease Core Physician Performance Measurement Set a
Clinical Recommendations
Clinical Performance Measures Per Reporting Year
Blood Pressure
Percentage of patients who had a blood pressure measurement during the last office visit Measurement
Numerator = Patients who had a blood pressure measurement during the last office visit
Denominator = All patients with CAD
management targets are ≤130 mm Hg systolic (Class I Percentage of patients who had a blood pressure Percentage of patients with last blood pressure Distribution of most recent blood pressure values Systolic: <120, 120-129, 130-139, 140-149,
150-159, 160-169, 170-179, ≥180, undocumented
Diastolic: <75, 75-79, 80-89, 90-99, 100-109,
≥110, undocumented
Lipid Profile
Percentage of patients who received at least one lipid profile (or ALL component tests) Numerator = Patients who received at least one lipid profile (or ALL component tests)
Denominator = All patients with CAD
lipoprotein cholesterol (HDL-C),low-density lipoprotein Whether or not a lipid profile was obtained Percentage of patients who received at least one Most recent total cholesterol, HDL-C, LDL-C, Distribution of percentage of patients with themost recent test results in the following ranges:Total cholesterol: ≥240, 200-239, <200,undocumentedLDL-C: ≥160, 130-159, 100-129, <100,undocumentedHDL-C: <40, 40-49, 50-59, ≥60, undocumentedTriglycerides: ≥400, 200-399, <200, 150-199, <150,undocumented Symptom & Activity
Percentage of patients who were evaluated for both level of activity and anginal Assessment
symptoms during one or more office visits Numerator = Patients evaluated for both level of activity and anginal symptoms during one or
Denominator = All patients with CAD
Whether or not patient’s level of activity and Percentage of patients who were evaluated for both level of activity and anginal symptoms during Smoking Cessation
Percentage of patients who were queried one or more times about cigarette smoking Numerator = Patients who were queried one or more times about cigarette smoking
Denominator = All patients with CAD
Percentage of patients identified as cigarette smokers who received smoking cessation Numerator = Patients who received smoking cessation intervention
Denominator = All patients with CAD identified as cigarette smokers
Whether or not patient was queried one or Percentage of patients who were queried one or Whether or not patient identified as cigarette Percentage of patients identified as cigarette smokers who received intervention for smoking American College of Cardiology, American Heart Association, and
Physician Consortium for Performance Improvement
Chronic Stable Coronary Artery Disease Core Physician Performance Measurement Set a
Clinical Recommendations
Clinical Performance Measures Per Reporting Year
Antiplatelet Therapy
Percentage of patients who were prescribed antiplatelet therapyd Numerator = Patients who were prescribed antiplatelet therapy
Denominator = All patients with CAD
Percentage of all patients who were prescribed reason(s)c for notprescribing antiplatelet Percentage of patients who were prescribed antiplatelet therapy, with all denominatorexclusions applied Drug Therapy
Percentage of patients who were prescribed a statin (based on current ACC/AHA guidelines) for Lowering
Numerator = Patients who were prescribed a statin
LDL-Cholesterol
Denominator = All patients with CAD
Percentage of all patients who were prescribed Percentage of patients who were prescribed a statin, with all denominator exclusions applied Beta-Blocker Therapy –
Percentage of CAD patients with prior MI who were prescribed beta-blocker therapy Prior Myocardial
Numerator = Patients who were prescribed beta-blocker therapy
Infarction (MI)
Denominator = All patients with CAD who also have prior MI
Percentage of all patients with prior MI who Percentage of patients with prior MI who were prescribed beta-blocker therapy, with all of medical reason(s)bfor not prescribing a beta-blocker; documentation of patient reason(s)cfor not prescribing a beta-blocker American College of Cardiology, American Heart Association, and
Physician Consortium for Performance Improvement
Chronic Stable Coronary Artery Disease Core Physician Performance Measurement Set a
Clinical Recommendations
Clinical Performance Measures Per Reporting Year
ACE Inhibitor Therapy
Percentage of CAD patients who also have diabetes and/or LVSD who were prescribed Numerator = Patients who were prescribed ACE inhibitor therapy
Denominator = All patients with CAD who also have diabetes and/or LVSD
Whether or not patient with diabetes and/or Percentage of all (including patients on ARBs) LVSD was prescribed ACE inhibitor therapy patients with diabetes and/or LVSD who were ACE inhibitor was notindicated (eg, patients on angiotensin receptorblockers [ARB]);documentation of medical reason(s)b for not prescribing ACEinhibitor; documentationof patient reason(s)cfor not prescribing ACE inhibitor Screening for
Percentage of patients who were screened for diabetes Diabetesf
Numerator = Patients who were screened for diabetesg
Denominator = All patients with CAD who do not have documented diabetes
Percentage of patients who were screened Refers to all patients diagnosed with CAD. Medical reasons for not prescribing antiplatelet therapy (aspirin, clopidogrel, or combination of aspirin and dipyridamole): active bleeding in the previous
six months which required hospitalization and/or transfusion(s), patient on other antiplatelet therapy, etc.
Medical reasons for not prescribing a statin: clinical judgment, documented LDL-C <130, etc.
Medical reasons for not prescribing a beta-blocker: bradycardia (defined as heart rate <50 bpm without beta-blocker therapy), history of Class IV
(congestive) heart failure, history of second- or third-degree atrioventricular (AV) block without permanent pacemaker, etc.
Medical reasons for not prescribing ACE inhibitor (ACEI): allergy, angioedema due to ACEI, anuric renal failure due to ACEI, pregnancy, moderate or
severe aortic stenosis, etc.
Patient reasons for not prescribing antiplatelet therapy, statin, beta-blocker, or ACEI: economic, social, and/or religious, etc.
Antiplatelet therapy may include aspirin, clopidogrel, or combination of aspirin and dipyridamole.
Not indicated for a statin refers to LDL-C <100.
Test measure.
Screening for diabetes is usually done by fasting blood glucose or 2-hour glucose tolerance testing. Clinical recommendations indicate screening should be considered at 3-year intervals.
American College of Cardiology, American Heart Association, and
Physician Consortium for Performance Improvement
Chronic Stable Coronary Artery Disease Core Physician Performance Measurement Set
Prospective Data Collection Flowsheet
Provider No. ___________ Patient Name or Code __________________________________ Birth Date ____ / ____ / ______ Gender M ❑ F ❑
(mm / dd / yyyy)
Medical History (Select all that apply):
Allergies:
moderately or severelydepressed LV systolic function) Date
(mm/dd/yyyy)
Weight (lb/kg)
Monitoring
Blood Pressure
Lipid Profile (mg/dl):
Total Cholesterol
Triglycerides
Laboratory
Screening for Diabetesa
Level of Activity
Anginal Symptoms
AND/OR
Grading of Angina by the
CCSC Systemc AND/OR
Patient Completed
Symptom and/or Activity
Questionnaired
Symptom & Activity Assessment
Test measure
Screening for diabetes is usually done by fasting blood glucose or 2-hour glucose tolerance testing. Clinical recommendations indicate screening should beconsidered at 3-year intervals.
Grading of Angina Pectoris by the Canadian Cardiovascular Society Classification (CCSC) System7
Class I: Ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina (occurs) with strenuous, rapid or prolonged exertion at work orrecreation Class II: Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, orin wind, or under emotional stress, or only during the few hours after awakening. Angina occurs on walking more than 2 blocks on the level and climbing more thanone flight of ordinary stairs at a normal pace and in normal conditions Class III: Marked limitations of ordinary physical activity. Angina occurs on walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at a normal pace Class IV: Inability to carry on any physical activity without discomfort – anginal symptoms may be present at rest Questionnaire may include Seattle Angina Questionnaire (SAQ)12 This flowsheet is intended for prospective data collection only.
American College of Cardiology, American Heart Association, and
Physician Consortium for Performance Improvement
Chronic Stable Coronary Artery Disease Core Physician Performance Measurement Set
Prospective Data Collection Flowsheet
Provider No. ___________ Patient Name or Code _________________________________
Adverse Drug Reactions:
Date of Visit
(mm/dd/yyyy)
Intervention:
Counseling
Pharmacologic
Antiplatelet Therapy
LDL-C Lowering Therapy
Beta-Blocker Therapy
Medication Management
ACE Inhibitor Therapy
*Specify medical (eg, allergy, contraindication) or patient (eg, economic, social, religious) reasons for not prescribing therapy: Other Medications
This flowsheet is intended for prospective data collection only.
PD24:03-0158:1.7M:4/03 2003 American Medical Association References
Sackett DL, Straus SE, Richardson WS, et al. Evidence-based Medicine: 10 Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA guidelines for coronary How to Practice & Teach EBM. 2nd edition. London:Churchill artery bypass graft surgery: A report of the American College of Cardiology/American Heart Association task force on practice guidelines Performance Measurement Coordinating Council. Desirable Attributes of (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Performance Measures. A Consensus Document from the AMA, JCAHO, Surgery). J Am Coll Cardiol. 1999;34:1262-1347.
11 National Heart, Lung, and Blood Institute. National Cholesterol Education http://www.ama-assn.org/ama/pub/category/2946.html.
Program (NCEP). Third report of the NCEP on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Solberg LI, Mosser G, McDonald S. The three faces of performance measurement: improvement, accountability, and research.
12 Spertus JA, Winder JA, Dewhurst TA, et al. Development and evaluation Jt Comm J Qual Improv. 1997;23:135-147.
of the Seattle Angina Questionnaire: a new functional status measure for Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH, Manning WG.
coronary artery disease. J Am Coll Cardiol. 1995;25:333-341. The unreliability of individual physician “report cards” for assessing the 13 American Diabetes Association: Clinical Practice Recommendations 2003.
costs and quality of care of a chronic disease. JAMA. 1999;28:2098-2105.
Screening for Type 2 Diabetes (Position Statement). Diabetes Care. 2003; American Heart Association. Heart Disease and Stroke Statistics — 2003 Update. Dallas, Tex.: American Heart Association; 2002.
14 American College of Endocrinology Consensus Statement on Guidelines for Jencks SF, Huff ED, Cuerdon T. Change in the Quality of Care Delivered to Glycemic Control. Endocrine Practice. 2002;8(suppl 1):6-11.
Medicare Beneficiaries, 1998-1999 to 2000-2001. JAMA. 2003;289:305-312.
15 Communication from American Association of Clinical Endocrinologists, Gibbons RJ, Chatterjee K, Daley J, et al. American College of Cardiology/American Heart Association/American College of 16 Gibbons RJ, Abrams J, Chatterjee K, et al. American College of Physicians-American Society of Internal Medicine guidelines for the Cardiology/American Heart Association 2002 Guideline Update for the management of patients with chronic stable angina: A report of the Management of Patients with Chronic Stable Angina-Summary Article. American College of Cardiology/American Heart Association task force on A Report of the American College of Cardiology/American Heart Association practice guidelines (Committee on the Management of Patients with Task Force on Practice Guidelines (Committee on the Management of Patients with Chronic Stable Angina). JACC. 2003;41(1):159-68.
J Am Coll Cardiol. 1999;33:2092-2197.
17 National Heart, Lung, and Blood Institute. National High Blood Pressure Brunwald E, Antman EM, Beasley JW, et al. ACC/AHA guidelines for Education Program. The sixth report of the Joint National Committee on the management of patients with unstable angina and non-ST-segment Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association task force on practice guidelines(Committee on the Management of Patients with Unstable Angina). J Am Coll Cardiol. 2000;36:970-1062.
Ryan RJ, Antman EM, Brooks NH, et al. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report ofthe American College of Cardiology/American Heart Association task forceon practice guidelines (Committee on Management of Acute MyocardialInfarction). J Am Coll Cardiol. 1999;34:890-911.

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