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It’s hard enough to figure out how to change your daily practice in keeping with the ever-present new advances in heart failure treatment, much less measure whether those changes are improving the quality of care for your patients. But take heart — a panel of experts convened by the American Heart Association and the American College of Cardiology is worrying about that for you.
The panel, including providers, researchers, payers, managed care companies, industry representatives, and assessors of health care quality, published its first report on devising reliable performance measures for cardiovascular disease and stroke in the March issue of Circulation.1
In addition to that report, a separate paper on evaluating quality of care for CHF patients was published in the on-line edition of the journal (http://circ.ahajournals.org). The group also held a conference, the Second Scientific Forum on Assessment of Healthcare Quality in Cardiovas-cular Disease and Stroke, in April in Washington, DC, for which abstracts are available at www. americanheart.org.
"There is evidence of great variation in care," says Harlan Krumholz, MD, chairman of the conference and associate professor of medicine at Yale School of Medicine in New Haven, CT. "Similar patients can be treated very differently in different towns and regions of the country. We need to be able to measure what we do in order to ensure that all patients get the very best care."
The panel said in its report that clinicians must be involved in the entire process of quality assessment because they are the only people with the knowledge and experience to make judgments based on the clinical realities of medical care. The report cites the need to link development of the clinical guidelines providers use in their daily practice with development of performance measures or quality indicators since they are both dependent on the same body of scientific evidence.
"Not only will such a process allow experts to suggest measures for quality-assessment efforts that reflect the realities of clinical care, but these indicators may also become a vehicle for more rapid translation of strong new evidence into clinical practice," the report says.
Getting new evidence-based information into daily practice is exactly what’s needed to improve cardiovascular care, Krumholz says. The medical community has reached the point where it needs to accept greater accountability for the quality of care it delivers."
The panel issued strong warnings against the use of simplistic methods to measure the quality of care being provided by physicians and hospitals. "Report cards" published by various organizations and the recent proliferation of health care rankings available on the Internet are not necessarily valid because they rely more on administrative claims data than on actual patient care information, says John Spertus, MD. Spertus is director of cardiovascular education at the Mid America Heart Institute and associate professor of medicine at the University of Missouri in Kansas City. He was the co-chair of the conference and a member of the CHF work group.
"The problem with a lot of the report cards out there is that they measure quality of care by how long patients are in the hospital and whether they died or not," Spertus says. "A lot of what constitutes good care is did the patients get the right medications and how are they doing. A more accurate representation of quality is achieved by assessing clinical data that is adjusted to the variability of patients."
Guidelines can be converted to performance measures, Spertus says, but care must be taken to select treatments where the consensus would say nonadherence equals poor quality. "You have to be able to measure accurately. For example, beta-blockers might be good for heart failure patients, but not if they have asthma. It’s not bad care if you don’t get a beta-blocker because you have a contraindication."
One of the most urgent areas for improving performance measurement is heart failure, says Marvin Konstam, MD, chief of cardiology at New England Medical Center in Boston and a member of the CHF work group.
"There are new advances taking place all the time in the management of heart failure," he says. "There is still a considerable amount of variability in the way patients are managed, and this variability is very likely to influence clinical outcomes. In addition, heart failure is the single most costly disease entity for HCFA [Health Care Financing Administration]. There is a consensus building that it’s important to develop standardized quality measures that reflect guidelines as they are being developed."
Konstam says the kinds of measures that are needed don’t really exist except in the report from the panel. But more ideas will be forthcoming from this group and from the Heart Failure Society of America, which has initiated a partnership with HCFA to develop standardized quality measures based on up-to-date treatment guidelines.
Konstam and colleagues around the country are participating in monthly teleconferences to discuss quality improvement. A session will be held on this topic at the society’s conference in September in Boca Raton, FL. (See www.hfsa.org for more information.)
The paper from the CHF work group emphasizes quality measures such as implementation of ACE inhibitors and beta-blockers, and measurement of ventricular function. The work group endorsed four specific structural measures for consideration as quality indicators:
1. Clinicians at a care facility should have a document that endorses the best practice for its patients based on clear, evidence-based heart failure guidelines.
2. Clinicians should have a mechanism to systematically monitor patient care and outcomes in alignment with the guidelines and should review this information at least annually.
3. Clinicians should recognize that patients may require different levels of care and that there must be an organizational structure to move patients to the appropriate level of care.
4. Clinicians could benefit patients by having specific programs to address the end-of-life needs of many patients with heart failure.
The CHF work group also endorsed four items as quality measures:
1. The medical record of patients with heart failure should have clear documentation of left ventricular systolic function.
2. Patients with heart failure, left ventricular systolic dysfunction, and no contraindications to ACE inhibitors should be prescribed ACE inhibitors.
3. Patients hospitalized with heart failure and left ventricular systolic dysfunction should be treated with digoxin.
4. Patients with NYHA class II and III heart failure, left ventricular systolic dysfunction, and no contraindication to beta-blockers should be prescribed beta-blockers.
Spertus says the whole point of this work is to determine what constitutes state-of-the-art care for heart patients and to develop measures to make sure it’s actually being delivered. "If quality measurement is not done right, it will set the whole field back because a lot of erroneous conclusions will be made," he says.
1. Krumholz H, et al. Measuring and improving quality of care: A report from the American Heart Association/ American College of Cardiology First Scientific Forum on Assessment of Healthcare Quality in Cardiovascular Disease and Stroke. Circulation 2000; 101:e122-e144.