ACCF/AHA/AMA–PCPI 2011 Performance Measures for AdultsWith Coronary Artery Disease and HypertensionA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and theAmerican Medical Association–Physician Consortium for Performance ImprovementDeveloped in Collaboration With the American Academy of Family Physicians,American Association of Cardiovascular and Pulmonary Rehabilitation, American Association ofClinical Endocrinologists, American College of Emergency Physicians, American College of Radiology,American Nurses Association, American Society of Health-System Pharmacists, Society of HospitalMedicine, and Society of Thoracic Surgeons
Joseph V. Messer, MD, MACC, FAHA, FACP, Co-Chair*;John Spertus, MD, MPH, FACC, FAHA, Co-Chair*†; Bruce Abramowitz, MD, FACC;
Karen Alexander, MD, FACC‡; Craig T. Beam, CRE§;Robert O. Bonow, MD, MACC, FAHA, FACP*; Jill S. Burkiewicz, PharmD, BCPS�;
Michael Crouch, MD, MSPH¶; David C. Goff, Jr., MD, PhD, FAHA, FACP#;Richard Hellman, MD, FACP, FACE**; Thomas James III, MD, FACP, FAAP;
Marjorie L. King, MD, FACC, MAACVPR††; Edison A. Machado, Jr., MD, MBA‡‡;Eduardo Ortiz, MD, MPH; Michael O’Toole, MD, FACC; Stephen D. Persell, MD, MPH;
Jesse M. Pines, MD, MBA, MSCE, FAAEM§§; Frank J. Rybicki, MD, PhD��; Lawrence B. Sadwin;Joanna D. Sikkema, MSN, ANP-BC, FAHA¶¶; Peter K. Smith, MD##;Patrick J. Torcson, MD, FACP, MMM***; John B. Wong, MD, FACP
*ACCF/AHA Representative; †Recused from voting on Measures 3 and 4; ‡American Geriatrics Society Representative; §American Heart AssociationConsumer Council Representative; �American Society of Health-System Pharmacists Representative; ¶American Academy of Family Physicians
epresentative; #ACCF/AHA Task Force on Performance Measures Liaison; **American Association of Clinical Endocrinologists Representative;†American Association of Cardiovascular and Pulmonary Rehabilitation Representative; ‡‡Involved in measure development, but not in this documentor publication; §§American College of Emergency Physicians Representative; � �American College of Radiology Representative; ¶¶American Nurses
Association Representative; ##Society of Thoracic Surgeons Representative; ***Society of Hospital Medicine Representative. †††Former Task ForceChair during this writing effort.
This document was approved by the American College of Cardiology Foundation Board of Trustees in January 2011, the American Heart AssociationScience Advisory and Coordinating Committee in January 2011, and the American Medical Association-Physician Consortium for PerformanceImprovement in January 2011.
The American College of Cardiology requests that this document be cited as follows: Drozda J. Jr., Messer JV, Spertus J, Abramowitz B, Alexander K, BeamT, Bonow RO, Burkiewicz JS, Crouch M, Goff DC Jr., Hellman R, James T 3rd, King ML, Machado EA Jr., Ortiz E, O’Toole M, Persell SD, Pines JM, RybickiJ, Sadwin LB, Sikkema JD, Smith PK, Torcson PJ, Wong JB. ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery diseasend hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and themerican Medical Association-Physician Consortium for Performance Improvement. J Am Coll Cardiol 2011;58:316–36.This article has been copublished in Circulation.Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American
eart Association (my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, [email protected].
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the expressermission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at [email protected] Physician Performance Measurement Set (PPMS) and related data specifications were developed by the Physician Consortium for Performance Improvement
the Consortium) including the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), and the American Medical AssociationAMA) to facilitate quality-improvement activities by physicians. The performance measures contained in this PPMS are not clinical guidelines, do not establish atandard of medical care, and have not been tested for all potential applications. While copyrighted, they can be reproduced and distributed, without modification, foroncommercial purposes—for example, use by healthcare providers in connection with their practices. Commercial use is defined as the sale, license, or distribution ofhe performance measures for commercial gain, or incorporation of the performance measures into a product or service that is sold, licensed, or distributed for commercialain. Commercial uses of the PPMS require a license agreement between the user and the AMA (on behalf of the Consortium) or the ACCF or the AHA. Neither theMA, ACCF, AHA, the Consortium, nor its members shall be responsible for any use of this PPMS.The measures and specifications are provided “as is” without warranty of any kind.Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary
icenses from the owners of these code sets. The AMA, the ACCF, the AHA, the Consortium, and its members disclaim all liability for use or accuracyf any Current Procedural Terminology (CPT®) or other coding contained in the specifications.
CPT® contained in the measures specifications is copyright 2008 American Medical Association. LOINC® copyright 2004 Regenstrief Institute, Inc.® ®
Published by Elsevier Inc. doi:10.1016/j.jacc.2011.05.002
NOMED CLINICAL TERMS (SNOMED CT ) copyright 2004 College of American Pathologists (CAP). All Rights Reserved. Use of SNOMED CTis only authorized within the United States.
ver the past decade, there has been an increasing awarenessat the quality of medical care delivered in the United States,fined as the delivery of effective, timely, safe, equitable,
ficient, and patient-centered medical care, has the potentialr improvement (1).Consistent with this focus on healthcare quality, the Amer-
an College of Cardiology Foundation (ACCF) and themerican Heart Association (AHA) have taken a leadershiple in defining “what works in medicine” with their ACCF/HA guidelines statements, as well as in developing perfor-ance measures that define what should or should not bene in the care of patients with cardiovascular diseaseable 1).The ACCF/AHA Task Force on Performance Measures
as originally formed in February 2000 and was chargedith identifying the clinical topics appropriate for the devel-ment of performance measures and with assembling writ-g committees composed of clinical and methodologicalperts. When appropriate, these writing committees havecluded representation from other organizations involved ine care of patients with the condition of focus. The writingmmittees are informed about the methodology of perfor-ance measure development (2) and are instructed to con-ruct measures for broad use that meet these criteria. The
riting committees also are directed to strive to create
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318 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
easures that minimize responder burdens and that areigned with national standards so as to promote harmonyong measures.Performance measures can include structural, process, ortcome measures (11). Although implementation of mea-res of outcomes and efficiency is currently not as welltablished as that of process measures, it is expected thatch measures will become more pervasive over time.Performance measures also vary in the degree of evidencepporting their use and in the information available aboutw their implementation may affect provider behaviors.
herefore, it is within the scope of the writing committee’ssk to comment, when appropriate, on the strengths andmitations of external reporting for a particular cardiovascu-r disease state or patient population. Thus, the metricsntained within this document are categorized as eithererformance measures” or “quality measures.” Performanceeasures are those metrics that the writing committee desig-tes as appropriate for use for both quality improvement andternal reporting. In contrast, quality measures are thosepropriate for the purposes of quality improvement but notr external reporting until further validation and testing arerformed.All measures have limitations and pose challenges toplementation that could result in unintended consequences.
he manner in which these issues are addressed is dependentseveral factors, including the data collection method,
rformance attribution, baseline performance rates, incen-ves, reporting methods used, and the incentives linked toese reports. The ACCF/AHA encourages those interested inplementing these measures for purposes beyond qualityprovement to work with the ACCF/AHA to consider thesemplex issues in pilot implementation projects, to assess
mitations and confounding factors, and to guide refinementsthe measures to enhance their utility for these additionalrposes.By facilitating measurements of cardiovascular healthcareality, ACCF/AHA performance measurement sets mayrve as vehicles to accelerate appropriate translation ofientific evidence into clinical practice. These documents aretended to provide practitioners and institutions that deliverre with tools to measure the quality of their care andentify opportunities for improvement. It is our hope thatplication of these performance measures will provide aechanism through which the quality of medical care can beeasured and improved.The present set of measures breaks important ground forrformance measurement: First, as opposed to many measurescused on acute disease treatment in the hospital setting, thesee focused on primary and secondary prevention in the ambu-tory setting. Second, the present measures address not onlyhether important cardiac risk factors such as hypertension andids are “treated” but whether these are “controlled” to targetals. Achieving such control requires both clinicians and theirtients to fulfill their respective roles. The clinician mustentify a risk, implement appropriate intervention, monitor thesponse, and then further modify care to reach target goals. Thetient too has an important part in reaching success, including
eping appointments, modifying his or her lifestyle, and adher- ta
g to prescribed therapies. Finally, these performance measuresphasize patient-focused functional outcomes. They stress the
ed to assess patient angina and functional symptoms but alsodevelop treatment plans to improve these outcomes.
Eric D. Peterson, MD, MPH, FACC, FAHAChair, ACCF/AHA Task Force on Performance Measures
. Introduction
he ACCF/AHA/American Medical Association–Physicianonsortium for Performance Improvement (AMA–PCPI)oronary Artery Disease and Hypertension Performanceeasures Writing Committee (the writing committee) wasarged with revising the ACCF/AHA/AMA–PCPI Chronic
oronary Artery Disease and Hypertension performanceeasures sets, which were published in 2005 (4,5). Therpose of the present effort is to provide updated measuresat can be used to improve care for patients with coronarytery disease (CAD) and hypertension.Recognizing that each measure may impose a burden onoviders, the writing committee sought to focus on those areasith the most potential for impact, where there was the strongestnsensus about the best practice, and where the likelihood forintended harm was lowest. Moreover, the group sought asuch as possible to keep the measures straightforward, alignedhen appropriate with measures developed by others, andinically sensible, giving the clinician the latitude for judgmentout the appropriateness of an intervention when such latitudejustified. Finally, the writing committee sought to adhere to theganizations’ previously published methodology for creatingrformance measures (2,12).This updated measure set addresses care in the outpatienttting exclusive of the emergency department. Manyideline-recommended processes were not translated intoeasures. Decisions about measures to include were based onany factors. Common considerations were the complexity
the guideline recommendations on which the measuresere based (potentially making translation difficult) and theasibility of collecting the required data. This document istended to supersede the prior CAD and hypertensionrformance measures set (4,5).The members of the writing committee included cliniciansecializing in cardiology, internal medicine, family medi-ne, hospital medicine, and advanced practice nursing, asell as individuals with expertise in performance measurevelopment, implementation, and testing. The writing com-ittee also included patient/consumer representatives and ayer representative. The writing committee had representa-
on from the American Academy of Clinical Endocrinolo-sts, the American Association of Cardiovascular and Pul-onary Rehabilitation, American Academy of Familyhysicians, the American College of Emergency Physicians,e American College of Radiology, the American Geriatricsociety, the American Nurses Association, the Americanociety of Health-System Pharmacists, the Society of Hospi-
l Medicine, and the Society for Thoracic Surgeons.
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319JACC Vol. 58, No. 3, 2011 Drozda Jr. et al.July 12, 2011:316–36 Performance Measures for CAD and Hypertension
In this updated measure set, the writing committee presentsmeasures, including 2 new measures and 5 revised
easures, all of which are intended only for the ambulatoryutpatient) setting. A summary of the new measures set isesented in Table 2.
.1. Scope of the ProblemAD and hypertension are major and growing public healthoblems in the United States. See the ACCF/AHA/AMA–
CPI 2011 chronic stable coronary artery disease (4a) andpertension (5a) performance measurement sets, which areth available on the PCPI Web site at http://www.ama-sn.org/apps/listserv/x-check/qmeasure.cgi?submit�PCPI,r a detailed discussion of the scope of the problem andportunities for improving the quality of care provided totients with these conditions.
.2. Disclosure of Relationshipsith Industry and Other Entities
he work of the writing committee was sponsored exclu-vely by the ACCF, the AHA, and the AMA–PCPI, withoutmmercial support. Writing committee members volun-ered their time for this effort. Meetings of the writingmmittee were confidential and attended only by committeeembers and staff from the ACCF, AHA, AMA–PCPI, Theint Commission, and the National Committee on Qualityssurance (NCQA) to promote harmonization across similareasure sets, as described further in later sections. Writingmmittee members were required to declare in writing alllationships with industry relevant to this topic. Less than% of the writing committee membership has relationships
ith industry relevant to this topic, in accordance withandard requirements of the ACCF and AHA. Please seeppendix A for relevant writing committee relationships withdustry. In addition, Appendix B includes relevant relation-
ble 1. ACCF/AHA Performance Measure Sets
Topic Original Publication Date
ronic heart failure (3) 2005 ACC/A
ACC/A
ronic stable coronary arterysease (4)
2005 ACC/A
pertension (5) 2005 ACC/A
-elevation and non–ST-elevationyocardial infarction (6)
2006 ACC/A
rdiac rehabilitation (7) 2007 AACVP
rial fibrillation (8) 2008 ACC/A
imary prevention of CVD (9) 2009 ACCF/
ripheral artery disease (10) 2010 ACCF/
rcutaneous coronary intervention 2012* ACCF/
rdiac imaging 2012* ACCF/
AACVPR indicates American Association of Cardiovascular and Pulmonary Rehaundation; ACR, American College of Radiology; AHA, American Heart Assocsociation–Physician Consortium for Performance Improvement; SCAI, SocietyM, Society for Vascular Medicine; SVN, Society for Vascular Nursing; and SV*Planned publication date.
ips with industry for all peer reviewers of this document. op
.3. Review and Endorsementetween February 9, 2010, and March 13, 2010, the ACCF/HA/AMA–PCPI 2011 Performance Measures for Adultsith Coronary Artery Disease and the 2011 Performanceeasures for Adults With Hypertension underwent a 30-dayblic comment period. During this time, ACCF, AHA, and
MA–PCPI members, as well as other health professionalsd members of the general public, had an opportunity toview and comment on the draft document in advance of itsnal approval and publication. An official peer and contentview of the full document was also conducted, with 2 peerviewers nominated by the ACCF and 1 reviewer nominatedthe AHA. Additional comments were sought from clinical
ntent experts and performance measurement experts.The ACCF/AHA/AMA–PCPI 2011 Performance Mea-res for Adults With Coronary Artery Disease and Hyper-nsion was adopted by the respective boards of the ACCFd AHA and approved by the AMA–PCPI in January 2011.
hese measures will be reviewed for currency once annuallyd updated as needed. They should be considered valid untilther updated or rescinded by the ACCF/AHA Task Force onerformance Measures and the AMA–PCPI.
. Methodology
he development of performance measures involves identifi-tion of a set of measures targeted toward a particular patientpulation, observed over a particular time period. Tohieve this goal, the ACCF/AHA Task Force on Perfor-ance Measures has outlined and published a methodologysequential tasks required for the development of process-
-care measures as well as for outcomes measures suitabler public reporting (2,11). In addition, the AMA–PCPI hasveloped a Work Group Charge that outlines the process
eps that should be followed by writing committees devel-
ring Organizations Status
patient measures Currently undergoing update
I—outpatient measures Currently undergoing update
I Updated 2011 (4a)
I Updated 2011 (5a)
Updated 2008 (6a)
AHA Updated 2010 (referral measures only) (7a)
I . . .
. . .
R/SCAI/SIR/SVM/SVN/SVS . . .
AI/PCPI/NCQA . . .
R/PCPI/NCQA . . .
; ACC, American College of Cardiology; ACCF, American College of CardiologyCQA, National Committee for Quality Assurance; PCPI, American Medical
iac Angiography and Interventions; SIR, Society for Interventional Radiology;ty for Vascular Surgery.
Partne
HA—in
HA/PCP
HA/PCP
HA/PCP
HA
R/ACC/
HA/PCP
AHA
AHA/AC
AHA/SC
AHA/AC
bilitationiation; Nfor CardS, Socie
ing performance measures (13). The following sections
320 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
tline how these methodologies were applied by the presentriting committee.
.1. Identifying Clinically Important Outcomeso guide the selection of measures for inclusion in the measuret, the writing committee sought to identify outcomes that areeaningful to patients with CAD or hypertension and theructures or processes recommended by practice guidelines thate most strongly associated with those outcomes. The processes
which measures were based include management of riskctors, identification of effective therapeutic options in eligibletients, and accurate and appropriate evaluation of symptoms to
ble 2. 2011 ACCF/AHA/AMA–PCPI Coronary Artery Disease and
Measure
ronary artery disease
1. Blood pressure control Percentage of patients aged �18 years wita blood pressure �140/90 mm Hg, OR wh�2 antihypertensive medications during the
2. Lipid control Percentage of patients aged �18 years witan LDL cholesterol result �100 mg/dL, ORcare to achieve LDL cholesterol �100 mg/
3. Symptom and activityassessment
Percentage of patients aged �18 years witthere are documented results of an evaluatsymptoms‡ in the medical record
4. Symptommanagement†
Percentage of patients aged �18 years witresults of an evaluation of level of activity,appropriate management of anginal symptosymptoms, OR evaluation of level of activitydocumented to achieve control of anginal s
All patients evaluated in an outpatient settininfarction, coronary artery bypass graft surgstable angina and have not already participevent/diagnosis and are referred to such a
pertension
1. Blood pressure control Percentage of patients aged �18 years witpressure �140/90 mm Hg, OR who have amedications during their most recent office
*Please refer to the complete measures for comprehensive information, inclu†New measure.‡Includes assessment of anginal equivalents.ACCF indicates American College of Cardiology Foundation; ACE, angiotensin-sociation–Physician Consortium for Performance Improvement; ARB, angioten
w-density lipoprotein; LVEF, left ventricular ejection fraction; and PCI, percuta
ide treatments. A complete list of the desirable outcomes C
entified by the writing committee and how they relate to theoposed process measures is included in the measure specifi-tions, which are available on the PCPI Web site at http://ww.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit�PI (4a,5a).
.2. Dimensions of Careiven the multiple measurable domains of providing care, theriting committee identified and explicitly articulated thelevant dimensions of care that should be evaluated. As partthe methodology, each potential performance measure wastegorized into its relevant dimension of care (Table 3).
rtension Measurement
Description*
nosis of coronary artery disease seen within a 12-month period who haveblood pressure �140/90 mm Hg and were prescribed
ecent office visit
nosis of coronary artery disease seen within a 12-month period who haveve an LDL cholesterol result �100 mg/dL and have a documented plan ofding, at a minimum, the prescription of a statin
nosis of coronary artery disease seen within a 12-month period for whomvel of activity AND an evaluation of presence or absence of anginal
nosis of coronary artery disease seen within a 12-month period and withh an evaluation of presence or absence of anginal symptoms‡, withluation of level of activity and symptoms includes no report of anginalmptoms includes report of anginal symptoms, and a plan of care iss)
nosis of coronary artery disease seen within a 12-month period who weressation counseling if identified as tobacco users
nosis of coronary artery disease seen within a 12-month period who were
nosis of coronary artery disease seen within a 12-month period who alsor LVEF �40% who were prescribed beta-blocker therapy
nosis of coronary artery disease seen within a 12-month period who alsod who were prescribed ACE-inhibitor or ARB therapy
within the previous 12 months have experienced an acute myocardialI, cardiac valve surgery, or cardiac transplantation, or who have chronican early outpatient CR or secondary prevention program for the qualifying
nosis of hypertension seen within a 12-month period who have a bloodressure �140/90 mm Hg and were prescribed �2 antihypertensive
easure exceptions (4a,5a).
ng enzyme; AHA, American Heart Association; AMA–PCPI, American Medicaleptor blocker; CAD, coronary artery disease; CR, cardiac rehabilitation; LDL,oronary intervention.
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321JACC Vol. 58, No. 3, 2011 Drozda Jr. et al.July 12, 2011:316–36 Performance Measures for CAD and Hypertension
on of areas in which evidence was lacking and preventedplication of measures within the set. Diagnostics, patientucation (including prognosis and etiology), treatment, self-anagement, and monitoring of disease status were selectedthe relevant dimensions of care for CAD and hypertensionrformance measures.In addition, to ensure the measure set is as comprehensivepossible, the writing committee also evaluated the potential
easures against the Institute of Medicine domains of health-re quality (safety, effectiveness, patient-centeredness, time-
ness, efficiency, and equity) (1). While focusing primarilyprocesses of care, the writing committee also considered
easures of structures of care and outcomes for CAD (e.g.,mptom management and lipid management) and for hyper-nsion (e.g., blood pressure control). Although the writingmmittee does not endorse any particular measure devel-ed by others and believes that all measures should be usedquantify the full spectrum of relevant healthcare dimen-
ons, the measures proposed in this set are intended tomplement existing National Quality Forum (NQF)–en-rsed CAD outcome measures, such as the HealthPartnerstimally managed modifiable cardiac risk factor measure4), and NQF-endorsed hypertension outcome measures,ch as the NCQA hypertension control measure (15,16).
.3. Literature Reviewhe writing committee developed this revised measurement set
the basis of several clinical practice guidelines and did notrform an independent assessment of the evidence itself.
urthermore, the writing committee followed the methodologyecified in the ACC/AHA document on developing processeasures (2) and in the PCPI position statement on the evidencese required for measures development (17). The practiceidelines and statements that provided the basis for these
ble 3. 2011 ACCF/AHA/AMA–PCPI Coronary Artery Disease andimensions of Care Measures Matrix
Measure Name Diagnostics
ronary artery disease
1. Blood pressure control ✓
2. Lipid control ✓
3. Symptom and activity assessment
4. Symptom management
5. Tobacco use: screening, cessation, and intervention ✓
9. Cardiac rehabilitation patient referral from an outpatientsetting
pertension
1. Blood pressure control ✓
*Although no current measures exist for this dimension, future developmentACCF indicates American College of Cardiology Foundation; ACE, angiotensin-sociation–Physician Consortium for Performance Improvement; ARB, angioten
easures can be seen in Table 4. re
To avoid duplication of efforts and to harmonize with othertional measures as much as possible, the writing committeeso reviewed existing CAD measures, including those devel-ed by HealthPartners, the Agency for Health Research and
uality (30), the Institute for Clinical Systems Improvement6,31), and the Veterans Health Administration (32), as well aspertension outcome measures developed by Institute for
linical Systems Improvement (33), NCQA (15,16), and theeterans Health Administration (32).
.4. Definition and Selection of Measuresxplicit criteria exist for the development of process perfor-ance measures so that they accurately reflect the quality ofre, including a strong evidence base; quantification of themerator and denominators of potential measures; andaluation of the interpretability, applicability, and feasibilitythe proposed measure (2). The writing committee sought to
entify measures for which there was strong evidence ford clear consensus about their importance in the care of
AD and hypertension patients and that is linked to improvedtcomes.In addition to analyzing the updated guideline recommen-tions, the writing committee reviewed other clinical guid-ce documents, as detailed below, as well as all availableformation on gaps in care and unexplained variations inre for CAD and hypertension patients. The writing com-ittee also reviewed data on feasibility, reliability, andception reporting available from implementation of a sub-t of the 2005 measures (34–38). The writing committeeplied a patient-centric approach to identify areas wherew measures or revisions to the 2005 measures might beeded. As part of this process, the writing committee alsonsidered whether any of the 2005 measures should betired. After extensive discussion and additional literature
rtension Performance Measurement Sets:
Patientducation* Treatment Self-Management*
Monitoring ofDisease Status
✓
✓
✓
✓ ✓
✓ ✓ ✓
✓
✓
✓
✓ ✓
✓
mine how to address this dimension of care.ng enzyme; AHA, American Heart Association; AMA–PCPI, American Medicalceptor blockers; and LVEF, left ventricular ejection fraction.
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322 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
easures included in the 2005 CAD and hypertension out-tient measure sets. The comparison of the 2005 and 2011easures is shown in Table 5.All measures were designed to assess quality of care inpropriate patients across a variety of outpatient care settingsd care teams and to support achievement of the desirabletcomes identified. The measures also were designed to allowr the exclusion of patients with contraindications to the processcare or other valid reasons for not including them in the
easure. In defining the measure exceptions, the writing com-ittee was guided by the AMA–PCPI Recommendations forpecification and Categorization of Measure Exclusions (17), asscussed further below.The writing committee evaluated the potential new andvised measures against the ACCF/AHA attributes of per-rmance measures (Table 6) to reach consensus on whicheasures should advance for inclusion in the final measuret and whether to designate any of the measures as testeasures (appropriate for internal quality improvement only)the final set (2). After the peer review and public commentriod, the writing committee reviewed and discussed themments received, and further refinements were made in the
ble 4. Associated Guidelines and Statements
ird Report of the National Cholesterol Education Program (NCEP), Expertnel on Detection, Evaluation, and Treatment of High Blood Cholesterol inults (ATP III) (18)
e National Institutes of Health: National Heart, Lung, and Blood Institute:tional High Blood Pressure Education Program (19)
C/AHA 2002 Guideline Update for the Management of Patients Withronic Stable Angina (20)
blic Health Service: Treating Tobacco Use and Dependence Clinicalactice Guideline 2008 Update (21)
C/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery2)
C/AHA 2007 Focused Update of the Guidelines for the Management oftients With ST-Elevation Myocardial Infarction (23)
C/AHA 2007 Guidelines for the Management of Patients With Unstablegina and Non–ST-Segment–Elevation Myocardial Infarction (24)
A Evidence-Based Guidelines for Cardiovascular Disease Prevention inomen: 2007 Update (25)
A/SCAI 2007 Focused Update of the Guidelines for Percutaneous Coronarytervention (26)
CF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria forrdiac Computed Tomography and Cardiac Magnetic Resonance Imaging (29)
ACC indicates American College of Cardiology; ACCF, American College ofrdiology Foundation; ACEP, American College of Emergency Physicians; ACR,erican College of Radiology; AHA, American Heart Association; ASE,erican Society of Echocardiography; ASNC, American Society of Nuclear
rdiology; NASCI, North American Society for Cardiovascular Imaging; SCAI,ciety for Cardiac Angiography and Interventions; SCCT, Society of Cardio-scular Computer Tomography; SCMR, Society for Cardiovascular Magneticsonance; and SIR, Society for Interventional Radiology.
.1. Target Population and Care Periodhe target population for the outpatient measures consists oftients with diagnoses of either CAD or hypertension. Forrposes of this document, the outpatient care period isfined as the care provided in an outpatient setting within the
me period under evaluation—usually 1 year. These mea-res are intended to assess the management of the care fortients with CAD or hypertension at the practitioner level inambulatory-care setting for the primary purpose of qualityprovement.
.2. Alignment With Existingeasure Sets and National Guidelines
he writing committee made every effort to harmonize theserformance measures with similar metrics in other ACCF/HA/AMA–PCPI performance measures sets. An examplethis is the harmonization of the lipid-lowering measure in
is set with that in the ST-elevation myocardial infarction/n–ST-elevation myocardial infarction set that specifies thee of statin drugs as opposed to any lipid-lowering agenta). In addition, the writing committee was aware that the 3inical practice guidelines on which these measures arergely based were also at various stages of being updated,t the writing committee decided to proceed with thisvised measures set without waiting for the final release ofe guideline updates. The guidelines in question are theighth Report of the Joint National Committee on Prevention,etection, Evaluation, and Treatment of High Blood PressureNC 8), a forthcoming ACCF/AHA practice guideline onable ischemic heart disease, and the guidelines of theholesterol Education Project’s Adult Treatment Panel IV.he writing committee’s decision to proceed was based one following considerations:
The CAD and hypertension performance measures setoriginally was developed in 2005 and was due for updatingin 2008. Because the ACCF/AHA stable ischemic heartdisease practice guideline, the Cholesterol Education Proj-ect’s Adult Treatment Panel IV, and the JNC 8 guidelinesare projected to be published in late 2011 or early 2012, thewriting committee felt that waiting would result in anundue delay in the release of the present update. Thewriting committee believed that a pragmatic approach tothis situation was needed, even though the more linearapproach of waiting for the guidelines to be publishedbefore developing the measures had methodological appeal.Members of the writing committees, who are developingthe guideline updates, were selected as members of thiswriting committee to informally facilitate alignment of theguidelines and the measures. These members are EduardoOrtiz (JNC 8), John Spertus (ACCF/AHA stable ischemicheart disease practice guideline), and David Goff (Choles-
323JACC Vol. 58, No. 3, 2011 Drozda Jr. et al.July 12, 2011:316–36 Performance Measures for CAD and Hypertension
The writing committee focused on developing measures inareas where the level of evidence was the strongest, thusminimizing the risk that the measures would be out ofalignment with updated guidelines.
.3. Measures Related to Medication Usehe writing committee gave careful consideration to the types of
ble 5. Comparison of 2005 and 2011 Coronary Artery Disease
2011 Measure 2005 Measure Change
ronaryeryease
1. Blood pressurecontrol
Blood pressuremeasurement
It is now anintermediate outmeasure.
2. Lipid control ● Lipid profile● Drug therapy for
lowering LDLcholesterol
New measure clipid profile withtherapy for loweLDL cholesterol.
3. Symptom andactivityassessment
Symptom and activityassessment
This measure norequires simultaassessment.
4. Symptommanagement
No measure for 2005 This is a new m
5. Tobaccocessation andintervention
Smoking cessation(assessment)
The new measurequires 2 actionassessment andintervention.
6. Antiplatelettherapy
Antiplatelet therapy The descriptionnumerator havemodified.
7. Beta-blockertherapy: prior MI
Beta-blocker therapy:prior MI
The descriptiondenominator havmodified.
8. ACE inhibitor/ARBtherapy: diabetesor left ventricularsystolicdysfunction (LVEF�40%)
Both original mewere combinedsingle measurebecome an interoutcome measu
ACE indicates angiotensin-converting enzyme; ARB, angiotensin II receptorntricular ejection fraction; and MI, myocardial infarction.
edication use measures that would be developed for the as
easures set. The discussion centered on whether to includely measures of prescription of medications or to developeasures of optimal dosing and patient adherence as well.
.3.1. Prescription Alone Versus Optimal Dosingdeveloping its blood pressure measures, the writing com-
ittee recognized the need to strike a balance between
ypertension Performance Measures
Rationale
The writing committee believed that the original measure, which relied on a plan ofcare, failed to account for an adequate “intensity” of effort to control bloodpressure. The current measure therefore targets established goals and makesaccommodations for patients with refractory hypertension by specifying that�2 medications be used. The management plan may include the prescription of�2 antihypertensive medications, referral for consideration of coronaryrevascularization, or referral for additional evaluation or treatment of anginalsymptoms.
The writing committee believed that the evidence favoring the use of statins as aspecific intervention was sufficient to explicitly recommend this treatment. This wasbased on the higher risk associated with this population and the demonstratedeffectiveness of statins in reducing risk of adverse outcomes.
The control of symptoms at patients’ desired level of activity is the primary reasonpatients with chronic stable angina often seek care and is a highly relevantoutcome. Simultaneous assessment of symptoms and activity provides a morecomprehensive view of patient status and improves on the previous version of themeasure(s) in that it requires the evaluation of both level of activity and presenceof anginal symptoms, because patients may accommodate increasing angina bydecreasing their physical activities.
The writing committee recognized a significant gap in measures addressing criticalpatient-centric outcomes for chronic stable CAD care and effective management ofischemic symptoms.
There is good evidence that tobacco screening and brief cessation intervention(including counseling and pharmacotherapy) in the primary-care setting issuccessful in helping tobacco users quit.
Use of antiplatelet therapy has been shown to reduce the occurrence of vascularevents in patients with CAD, including MI and death.
ACCF/AHA guidelines have shown that for hospitalized patients with reducedejection fraction, ACE inhibitors or ARBs and beta-blocker therapy should becontinued.
Recent national registry data indicate that the use of ACE inhibitors or ARBs ineligible patients without documented contraindications or intolerance remainssuboptimal, especially in the outpatient setting.
Cardiac rehabilitation programs remain underused. The writing committeerecognized a significant gap in this area.
Although screening for diabetes in the chronic stable CAD patient population isimportant, the measure was found to be difficult to implement and therefore wasnot widely used. Additionally, new screening guidelines are forthcoming, in whichthe recommendations for screening may change significantly. The Diabetes WorkGroup met in 2009, and the Chronic Stable Coronary Artery Disease WritingCommittee defers this measure to that group for their consideration.
The measures were combined to capture both patients who have their bloodpressure controlled and those who do not have their blood pressure controlled buthave their treatment regimen adjusted as a result. The management plan mayinclude either the prescription of �2 antihypertensive medications, referral forconsideration of coronary revascularization, or referral for additional evaluation ortreatment of anginal symptoms.
rs; CAD, coronary artery disease; LDL, low-density lipoprotein; LVEF, left
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324 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
izing the likelihood that promoting a strict standard fortimal dosing would lead to adverse, unintended conse-ences related to overtreatment. Overtreatment can result inisodes of hypotension with associated orthostatic symp-ms, frank syncope, and injuries from falls. The writingmmittee also considered the difficulties of capturing spe-fic doses of medications and of assessing whether dosingas optimal. The writing committee also was concernedout broadly implementing measures of medication dosingcause of the challenges of capturing large numbers oftential contraindications and adverse effects of individualedications.In addition, requiring optimal dosing could decrease sometients’ access to care and create or worsen healthcare dispar-es. With the requirement that only patients attaining bloodessure targets would successfully meet the measure, physi-ans would have an incentive not to accept into their practicestients with refractory blood pressure or with difficult-to-ntrol CAD symptoms. This was a concern because thesulting “lower scores” would reflect poorly on the physician,using some to dismiss such patients from their practices. Theriting committee also recognized that using medication pre-ription alone, as opposed to patients’ filling their prescriptions,
a performance measure could potentially be viewed asndoning undertreatment. Nevertheless, current healthcare re-rds, which often do not link to pharmacy data, render data ontient pharmacy refills impractical to collect. Finally, theriting committee recognized that physicians could use multipleedications at suboptimal doses and that the current measureould give those physicians “credit” for meeting the measure,en if patients’ blood pressures remained elevated. Neverthe-ss, balancing these considerations with concerns about feasi-lity, unintended consequences such as adverse selection, and
ble 6. ACCF/AHA Attributes of Performance Measures
Consideration Attribute
eful in improving patienttcomes
Evidence basedInterpretableActionable
easure design Denominator precisely definedNumerator precisely definedValidity type
● Face*● Content†● Construct‡
Reliability
easure implementation Feasibility● Reasonable effort● Reasonable cost● Reasonable time period for collection
erall assessment Overall assessment of measure for inclusionin measurement set
*The measure intuitively seems to capture what it is intended to capture.†The extent to which the items comprehensively capture the domain they
e intended to measure.‡The extent to which the measures correlate with other methods ofantifying the underlying construct.Adapted from Normand et al. (39).
ethodological difficulties, the writing committee ultimately cl
cided to measure the medication prescription but not optimalsing.
.3.2. Medication Adherencehe writing committee debated whether physician qualityas better assessed through measures of medication prescrip-on or patient adherence to prescribed medication. The majorjection to the use of patient adherence as a measure ofysician quality is that, although prescribing physiciansve some influence on patient choices, adherence is largelyt in the individual physician’s locus of control. Healthsurance pharmacy benefit designs, including formulariesd copays, play important roles in patient decisions tohere to prescribed drug regimens (40,41). Ultimately,cause patient autonomy is the overriding ethical andagmatic principle governing the patient-physician relation-ip, the patient is free to decide whether to take medicationsprescribed. Similar to the above concern with optimal
sing, a measure of patient adherence could cause physi-ans to avoid caring for patients with a history of nonadher-ce or a perceived likelihood of being nonadherent. This, inrn, could reduce access to care for such patients, withlnerable populations being at particular risk.Another major concern is that reliable information ontient adherence is often difficult and expensive to obtain.ewer methods of electronic transfer of information fromarmacies may make measurement of adherence moreasible in the future. Once these linkages are standardactice, adherence measurement may become a valuableality-improvement and patient-management tool for theysician, but, because of the difficulty of capturing medica-
on sampling and low-cost, generic prescriptions that arelled outside of a pharmacy benefit plan, the data may neverhieve the level of quality required for a publicly reportedeasure.Although the writing committee decided that medicationherence would not be included as a measure of individualysician performance, it believed that measures of adher-ce, such as those included in HEDIS (Healthcare Effective-ss Data and Information Set), could be used at the healthan, employer, or health system levels as effective quality-provement tools. The writing committee believed thatalth plans and employers have more potential influence onherence, through improved mechanisms to follow up onfilled prescriptions and through economic incentives—forample, removing copays for antihypertensive medications.addition, these larger organizations have the resources to
eate effective disease management and case managementograms (40,42–44), which have appeared to improve med-ation adherence.
.4. Outcome Measureshe outcome measures selected were the subject of intensebate within the writing committee, which sought to ad-nce the utility of the measures and to maintain consistencyith our existing standards for public reporting (2,11).easures were selected by writing committee consensus andere carefully judged, with the goals of moving toward more
inically important outcomes (e.g., symptom control for
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325JACC Vol. 58, No. 3, 2011 Drozda Jr. et al.July 12, 2011:316–36 Performance Measures for CAD and Hypertension
AD) and adding process measures (e.g., referral to cardiachabilitation [CR]), given that evidence of the relationship ofocess measures to important clinical outcomes has accrued.he writing committee was also sensitive to the pitfalls ofing “intermediate outcomes,” such as blood pressure andw-density lipoprotein cholesterol goals, in isolation, aseasures of quality (45–47). The writing committee evalu-ed the inclusion of measures related to death, cerebrovas-lar accident, and other life-altering events but believed thateir low incidence, variability, or uncertain relationship toeexisting risk factors (i.e., inadequate risk adjustment)ecluded their inclusion at this time (48). The measureslected are based on existing guidelines, and the majority aresociated with Class I recommendations (e.g., CR, antiplate-t therapy) and with Level A evidence (e.g., angiotensin-nverting enzyme inhibitor/angiotensin II receptor blockererapy, beta-blocker therapy).The writing committee designed individual measures topture unique information that allows independent analysist developed combined measures when independent report-g of outcomes could lead to misinterpretation given therrent state of understanding of the impact on these out-mes of variables such as risk factors, case mix, andidence. It is hoped that the current set of measures willovide contemporaneous information as the evidence basevelops and thus permit future measure enhancement in thisea. The writing committee continued to support denomina-r exceptions for many of the measures with appropriatelytegorized documentation of the reason for the exception.
he development of large databases of appropriate exceptionsessential and will be promoted by use of these measures assigned. This information will be critically important, whened with risk-adjustment models, to enable public reportingindependent, clinically important outcome measures that
ovide an interpretable and accurate description of individ-l practice.
. Discussion of Changes to the005 Measures Set
he current measures sets (Table 2) represent significantpartures from the first ACC/AHA/AMA–PCPI CAD/hy-rtension performance measures. The writing committeeamined the 9 CAD measures and 2 hypertension measuresthe original 2005 set and considered updated guideline
commendations, field-testing data, and implementation ex-riences to determine whether any of the measures should bevised or retired. The writing committee also discussedhether measures with very high rates of compliance shouldmain in the measure set to emphasize their clinical impor-nce, even though provider performance on them appears tove “topped out.”Changes in the current measures set include both revisionsprior measures and the addition of new measures. In
dition, one measure from the CAD set is being retired. Theriting committee’s rationale for making these changes andr not adding certain measures of perceived importance will
discussed in the following sections of this document. re
.1. Retirement of 2005 Coronaryrtery Disease and Hypertension Measuresnly one measure (the CAD measure “screening for diabe-s”) from the CAD and hypertension measures set is beingtired, and none was believed to have topped out.
.1.1. Retirement of Coronary Artery Disease Measure:creening for Diabeteshe writing committee decided to retire the CAD measurecreening for diabetes” because of several factors:
The logistical difficulty in screening for diabetes, requiringthe patient to return for laboratory testing for either afasting blood glucose test or a postchallenge 2-hour glu-cose tolerance testLack of clarity about the evidence supporting a 1-yearinterval for testing for diabetes in patients with CAD, withthe American Association of Clinical Endocrinologistsguideline in diabetes (2007) rating the evidence as Level CUser reports of challenges in implementing the diabetesscreening measure
The writing committee recognized the significance ofabetes as a comorbidity in patients with CAD and alsocognized that the validity of the diabetes-related measure ine current set (angiotensin-converting enzyme inhibitor orgiotensin II receptor blocker therapy—diabetes or leftntricular systolic dysfunction) depends on the accurateentification of the prevalence of diabetes in the denominatorpulation. Additionally, the writing committee noted thate 2010 American Diabetes Association “Standards of Med-al Care in Diabetes” addressed the difficulty in screening forabetes in that they now state that a properly validatedmoglobin A1c assay can be used to diagnose diabetes at alue �6.5% (49). The use of the hemoglobin A1c as areening test for diabetes could also be expected to make itgnificantly easier to identify such screening in the medicalcord—a major challenge faced during efforts to implemente original measure.After a thorough discussion of all of these considerations,
e writing committee decided to remove this measure frome CAD set and to defer further discussion of diabetesreening measures to the NCQA/AMA–PCPI Joint Diabetesxpert Panel.
.2. New Performance Measures inhis Updateew performance measures were created to reflect the newestideline recommendations and address significant gaps inre. In addition, the writing committee explored the devel-ment of outcome, group- or system-level, overuse, com-site, and bundled measures.
.2.1. Coronary Artery Disease: Symptom Managementreatment of CAD has 2 complementary objectives: toduce the risk of death and to control anginal symptoms.linical events such as death or myocardial infarction are rarelative to the frequency of daily symptoms and functionalmitations experienced by many patients. Because of the
lationship between symptoms of ischemic heart disease and
326 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
e level of patient activity, the writing committee requiredmultaneous activity and angina assessment as a patient-ntered process measure that is directly related to a mean-gful outcome. This pairing of symptom and activity assess-ent is necessary because patients may modify their activitylessen anginal symptoms. Thus, a worsening in symptomntrol might manifest itself as more angina at a similarount of activity, similar or less angina at a lower level of
tivity, or both. Moreover, patients’ CAD can change overme, and the sequential evaluation of symptoms is a neces-ry means of optimizing patients’ treatment plans. Theriting committee considered the challenges inherent ineasuring patient-reported outcomes, including the limitedter-rater reliability of physician-performed functional as-ssments such as the Canadian Cardiovascular Societylassification. Patient-centered, disease-specific health statusestionnaires can overcome this problem, but such methodse not used routinely in patient care because of the redesignpatient workflow that would be required and the fact that
e current reimbursement system does not incentivize suchforts. Nevertheless, systems for administration and scoringist and could be further refined to meet a perceived need fore systematic collection of these data. Several commonlyed and validated tools are provided as examples of howgina could be evaluated and documented. A narrativesessment of symptom and activity status documented in theart can also satisfy the numerator for this measure but willake extraction from electronic medical records systemsfficult.Extensive discussion of the frequency of assessment was
so undertaken by the writing committee, and, although it isear that it might be appropriate to assess symptoms andtivity for every visit in which a CAD diagnosis was billed,e writing committee felt most comfortable requiring thatis be reported at least once within a 12-month period.The writing committee recognized a significant gap in
easures addressing patient-centered outcomes of chronicable CAD care. The symptom management measure helps
close this gap by requiring the collection of informationcessary to assess the patient’s functional status and byomoting intensification of therapeutic interventions whenmptoms are not adequately controlled. In choosing thiseasure, the writing committee recognized that patients whove frequent anginal symptoms report worse quality of life,ve worse survival rates, incur higher costs, and are moressatisfied with their care than those with less severemptoms (50–56). Given the challenges in documentationlated to the measure, the writing committee consideredaking symptom management a quality-improvement–onlyeasure. The writing committee believed this was not appro-iate, however, because of the importance of effectiveanagement of ischemic symptoms. Accordingly, whenmptom changes are identified during a visit, a plan todress the change in status should be documented. Thatanagement plan may include the prescription of �2 anti-pertensive medications, referral for consideration of coro-ry revascularization, or referral for additional evaluation or
eatment of anginal symptoms. If a plan for control of angina
nnot be implemented, then a medical-, system-, or patient- sh
lated reason should be noted as outlined in the PCPI’sceptions methodology (17). The writing committee realizesat complete elimination of symptoms is not always possi-e, so this measure prioritizes symptom management and thetient’s experience as the primary goal of the therapeuticcounter. In addition, there was discussion of other aspectsmanaging chronic CAD patients who report a change in
mptoms, including lifestyle interventions, assessment ofedication adherence, patient education, and evaluation forrdiac or noncardiac contributors (arrhythmias, depression,d heart failure). The writing committee believed, however,at these other aspects of care, though important parts of theerapeutic approach, are so broad or complex as to precludeclusion as measures for the chronic management of CAD.
.2.2. Coronary Artery Disease: Cardiac Rehabilitationatient Referral From an Outpatient SettingR is underutilized, despite evidence that it improves quality
life, reduces modifiable cardiovascular risk factors, en-nces adherence to preventive medications, and lowers the
sks of morbidity and mortality (57–74). Suaya et al (70)alyzed outcomes from 601,099 Medicare beneficiaries andund that only 13.9% of eligible patients enrolled in CR afteryocardial infarction, noting significant geographic variationreferral rates and lower use in women, nonwhites, oldertients, and those also receiving Medicaid, despite a 21% to% reduction in 5-year mortality rate in those who partici-ted when compared with nonparticipants (71). More re-ntly, the PINNACLE Program of the American College ofardiology’s National Cardiovascular Data Registry (NCDR)und that only 18.1% of eligible patients were referred to CR7). For these many reasons, the writing committee recog-zed a significant opportunity for improvement and includede NQF-endorsed referral to CR measure in this set.During the public comment period, reviewers asked that
e writing committee consider adding an accompanyingeasure that captures whether the referral to CR is followed
enrollment in CR, the ultimate desired outcome. Theriting committee recognized that factors affecting enroll-ent and completion of CR are complex and involve issuesyond the control of referring practitioners, such as inade-ate insurance coverage (including benefit design featuresch as high copayments), lack of available programs inany urban and rural areas, transportation problems, andmited patient education and motivation to participate. Per-rmance measures tracking enrollment and completion ofR are included in the 2007 American Association ofardiovascular Pulmonary Rehabilitation/AHA Performanceeasures on Cardiac Rehabilitation (7) and were written tocourage performance-improvement activities by CR pro-ams. In addition, during the NQF endorsement process, themerator statement for the CR measure was revised topand standards of practice for CR programs (7a). Importantong these is care coordination, which recognizes that CR
ograms should communicate with referring providers notly about medical issues, but also about completion of the
R program. Future iterations of CR performance measures
ould include enrollment and completion measures, after
327JACC Vol. 58, No. 3, 2011 Drozda Jr. et al.July 12, 2011:316–36 Performance Measures for CAD and Hypertension
rther studies have clarified responsibilities, defined excep-ons, and evaluated feasibility.
.3. Revised Measures in This Updateour measures from the CAD set and 1 measure from thepertension set were modified to incorporate results from
eld-testing projects and to address inadequacies in theiginal measures.
.3.1. Combining Hypertension Measures:lood Pressure Measurement and Plan of Carehe writing committee concluded that the ACCF/AHA/MA–PCPI hypertension measures should be modified andmbined into one measure that would reflect not only bloodessure measurement, but also an evidence-based, clinicallyportant intermediate outcome that would be correlated withture reductions of clinical morbidity, complication, hospi-lization, and mortality rates. This intermediate outcomeflects the writing committee’s recognition that blood pres-re targets for specific populations are still being refined5). For the hypertension measure set, the writing committeeose a denominator statement of all patients aged �18 yearsith hypertension; for the CAD set, the denominator is alltients aged �18 years with a diagnosis of CAD. Themerator was defined as all patients with a blood pressure140/90 mm Hg, or all patients with a blood pressure of140/90 mm Hg who were prescribed �2 antihypertensiveedications during the most recent office visit during theeatment period. The writing committee considered modify-g the target blood pressure for patients with diabetes.lthough earlier guidelines—JNC 7 2004 (19), Americanssociation of Clinical Endocrinologists 2007 (75), andmerican Diabetes Association 2010 (49)—have suggested aood pressure target �140/90 mm Hg for patients withabetes, evidence from the ACCORD (Action to Controlardiovascular Risk in Diabetes) trial (45) and INVESTnternational Verapamil SR/Trandolapril Study) (76) indi-tes that a blood pressure target �140/90 mm Hg mayovide a less favorable benefit-risk ratio in patients withabetes than had been previously thought. The writingmmittee defers further consideration of blood pressurergets in patients with diabetes to the NCQA/AMA–PCPIint Diabetes Expert Panel for further clarification.The writing committee emphasizes the importance of theality of the data used to make clinical decisions. In the casethe hypertension performance measure, proper technique
d preparation for obtaining the blood pressure value used ine measure are most important. Validated blood pressureonitors, whether used for home monitoring or in theedical office setting, and when used with proper technique,cluding an appropriate period of rest beforehand (5 to 10in), will yield blood pressure readings that correlate wellith the standard manual technique.
.3.2. Coronary Artery Disease: Smoking Cessationhe writing committee agreed that tobacco use remains agnificant modifiable risk factor for CAD and that evidenceows that screening and brief cessation intervention (coun-
ling, pharmacotherapy, or both) at the point of care can C
crease overall tobacco abstinence rates (21,77,78). Further-ore, an opportunity exists to improve present levels ofreening and intervention. The writing committee discussede frequency of measurement, with some advocating thatreening and intervention be treated as a vital sign and berformed at every visit, whereas others were concerned thatcessive documentation requirements would minimize theportance of screening and intervention, with tobaccoreening devolving to just another activity for the physician
check off in the medical record (21,78). The writingmmittee also recognized the difficulty of measuring theality of specific types of interventions and their influencetobacco abstinence rates. The writing committee, there-
re, elected to keep the requirement to 1 screening andtervention per 1-year measuring period.Eventually, the writing committee believes this process
easure could be replaced by documentation of tobacco-freetes. The writing committee decided that developing aeasure of tobacco-free rates was premature at this juncturecause of socioeconomic and geographic disparities and thefficulty of actually determining ongoing rates of tobacco useiven the high recidivism rate after smoking cessation).
.3.3. Coronary Artery Disease: Lipid Controlhe lipid control measure also underwent significant revision.he original measure, which emphasized achieving a low-nsity lipoprotein target and was indifferent to the drugsed to achieve it, was retired. It was replaced with a measureat emphasizes statin use. This decision was predicated onerging insights that statin therapy specifically results in a
latively constant relative risk reduction that is clinicallyportant in a high-risk population, such as those withtablished CAD. In contrast, the data supporting specific
pid targets (a distinct concept from higher-dose statins thate associated with additional clinical benefits) are mucheaker. Given the absence of data on the clinical benefit ofme nonstatin medications that reduce cholesterol (46,47),e writing committee believed that the weight of evidencepported a specific, statin-based performance measure.
.3.4. Hypertension and Coronary Artery Disease:lood Pressure Controlhe link between hypertension and the development ofrdiovascular events is well substantiated. Individuals withgh underlying cardiovascular risk (e.g., those with estab-shed atherosclerotic disease, diabetes mellitus, chronic kid-y disease, or multiple cardiovascular risk factors) have theeatest absolute risk of new cardiovascular events attribut-le to uncontrolled hypertension.We chose 140/90 mm Hg as the threshold for hypertensionntrol in these performance measures because it is thecommended blood pressure goal in JNC 7 both for individ-ls with and without established cardiovascular disease (19).s noted previously, the status of specific blood pressurergets for patients with diabetes and hypertension is cur-ntly in flux despite the JNC 7 recommendation of �130/80m Hg as a goal (19). Arguments also have been made topport a general goal of �130/80 mm Hg for patients withgh cardiovascular risk, including patients with established
AD (79,80). Nevertheless, no clinical trial directly com-
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328 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
res the clinical outcomes of large populations of coronarysease patients treated to different blood pressure targets.ome clinical trials in which specific antihypertensive drugerapies were given to individuals with CAD or highrdiovascular disease risk who had blood pressures �140/90m Hg have shown beneficial results (81–83), but other trialsve had negative or equivocal findings (84–87). Althoughis heterogeneity in the published literature justifies the usethe less strict �140/90 mm Hg threshold in these perfor-
ance measures, lower blood pressure targets may be appro-iate for some patients with CAD or other conditions. At thisint, however, it is unclear how such patients could beliably identified for purposes of performance measurement.The writing committee recognized that hypertension treat-
ent decisions generally should be based on the average ofultiple readings and that for many patients there is a role forood pressure measurement outside the clinician’s office.g., home blood pressure monitoring or ambulatory bloodessure monitoring). Whether different goals should be usedinterpreting blood pressures obtained at home is an issue
at has not been clearly resolved, so the writing committeed not specify a different blood pressure threshold foreasurements obtained outside the office (79).The writing committee engaged in a protracted and de-
iled discussion of the blood pressure value to be used inlculating this measure because the clinician may be lookingmultiple home readings, the results of ambulatory blood
essure monitoring, values obtained in the office, or somembination of all of these. It is difficult to provide oneerational definition for use in a performance measure thatdicates whether blood pressure measurements that may beailable within a patient’s medical record should be aver-ed to indicate how well the blood pressure is controlled.ltimately, the writing committee settled on requiring theovider to specify at each visit the blood pressure readingat was used in clinical decision making. When a clinicianes the mean of multiple readings to determine whether atient has controlled blood pressure, this value can be usedthe specified value in the performance measure.Achievement of the hypertension performance measures
quires that the blood pressure decrease to �140/90-mm Hgreshold or that �2 antihypertensive medications are pre-ribed in the absence of a medical-, patient-, or healthcarestem–related reason that justifies not doing so. (For pur-ses of this measure, the individual components of combi-tion medications are counted separately.) The drug-escription measure was selected with the recognition thateasures used for accountability and reporting that are solelysed on outcomes—here, blood pressure control—may noteld informative comparisons when risk adjustment is notrformed and that it is not feasible to develop and broadlyply robust risk-adjustment models at this time. (The writingmmittee nevertheless believed that the proportion of pa-
ents with controlled blood pressure remains of interest andould be tracked by providers separately for quality-provement purposes.) In addition, the trials that demon-
rated the cardiovascular benefits of blood pressure lowering
ve typically used �2 medications in the more intensively st
eated groups, especially in participants who did not meet theial-specific blood pressure control goals.A limitation to the hypertension performance measuresesented here is that their scope includes only blood pressurentrol or the prescription of �2 drugs. The writing commit-e recognizes that many other necessary aspects of hyper-nsion care are not part of these measures. These include bute not limited to counseling and other interventions toomote dietary modification, weight loss, physical activity,lf-monitoring, care plan adherence, and appropriate follow-. The writing committee did not leave these topics out ofe measures because we viewed them as less important thanug therapy. Rather, they are less readily measured withisting data sources, and the satisfaction of counselingquirements for a performance measure does not provide anydication about the quality of the counseling interactionsovided by clinicians. We also recognize that appropriatecognition and treatment of concomitant risk factors (e.g.,oking, dyslipidemia, related comorbidities such as kidney
sease) are important components of the care of patients withpertension, but they are not within the scope of theseeasures.
.3.5. Coronary Artery Disease: Antiplatelet Therapyhe writing committee chose to revise the 2005 antiplateleterapy measure to include only the prescription of clopi-grel or aspirin in the numerator. The prior measure allowedr prescription of any antiplatelet agent to be counted in themerator. The rationale for the change is that the guidelineswhich this measurement set is based (88) state that aspirin
ould be started at 75 to 162 mg per day and continueddefinitely in all patients unless contraindicated (Class I,evel of Evidence: A) and that clopidogrel can be used whenpirin is absolutely contraindicated (Class IIa, Level ofvidence: B). No other antiplatelet agents are recommended.The writing committee recognizes that a new antiplateletent, prasugrel, has been approved by the U.S. Food andrug Administration for use in acute coronary syndromes andat some patients with chronic stable coronary disease willon this agent. The writing committee concluded, however,
at prasugrel could not be added to the antiplatelet measuretil such time as the drug is recommended in the pertinentactice guideline. In the interim, patients on this agent can becluded from the denominator as a medical exception. Theme reasoning will hold for other antiplatelet agents cur-ntly under development that may receive Food and Drugdministration approval in the future.
.4. Potential Measures Considered But Notcluded in This Update
he writing committee considered several other potentialeasures. For various reasons they were determined to beappropriate for inclusion in the measure set.
.4.1. Coronary Artery Disease:veruse of Stress Testingan attempt to address efficiency in the management of
AD, the writing committee considered a measure of �1
ress test per year in patients with stable CAD. This measure
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329JACC Vol. 58, No. 3, 2011 Drozda Jr. et al.July 12, 2011:316–36 Performance Measures for CAD and Hypertension
as selected because of a belief among some of the writingmmittee members that excessive stress testing in patientshose symptom status had not changed was a significantsue. To investigate this hypothesis, AMA–PCPI staff re-ewed Medicare claims data and found that, in the absencean acute coronary syndrome, few patients with CAD had
1 stress test in a given year. This information is available atttp://www.ama-assn.org/apps/listserv/x-check/qmeasure.i?submit�PCPI (4a).Additionally, the writing committee took note of the
CCF’s separate efforts to develop appropriate use criteriar diagnostic imaging (89). Furthermore, in a study per-rmed with United Healthcare, gaps were identified in thepropriate application of diagnostic imaging as measured byese criteria (29). As the current measures set was beingveloped, the ACCF submitted imaging efficiency measuresNQF that were based on its appropriate use criteria and thatd been successfully piloted in the United Healthcare study0). Finally, the writing committee is aware that the ACCFpreparing a document that will delineate the methodologyis using in developing measures of quality and appropri-eness in the use of technology and that will incorporate thesults of its efficiency measures work. The writing commit-e agrees with the observation made in the ACCF/AHAatement on efficiency measures that appropriate use criteriae well suited as the basis of such measures because theycorporate quality and appropriateness (91). Because of thefficulty encountered in constructing an efficiency measured because of the work being done by ACCF in thisportant area, the writing committee decided to defer forw the further development of diagnostic efficiency mea-res, pending the results of the ACCF’s efforts.
.4.2. Measures Related to Appropriate Use ofercutaneous Coronary Intervention,hysiological Testing Before Percutaneousoronary Intervention, and Treatmentelection for Revascularizationhe writing committee determined that addressing appropri-e use of percutaneous coronary intervention (PCI) is beyonde scope of this document. The ACCF/AHA/AMA–PCPI/CQA PCI Writing Committee will specifically addresspropriate use of PCI and physiological testing before PCId will evaluate both overuse and underuse of PCI. Al-ough overuse will most readily be assessed through proce-ral registries, such as the ACC’s NCDR CathPCI Registry,deruse will require the assessment of symptoms amongtients with stable ischemic heart disease. With more expe-
ence from the currently proposed symptom managementeasure and the input from the ACCF/AHA/AMA–PCPI/ociety for Cardiovascular Angiography and Interventions/CQA PCI Writing Committee, we anticipate being able toovide measures for the appropriate use of PCI in subse-ent measurement sets.
.4.3. Measures Related to Shared Decision Makinghared decision-making approaches have been advocated as aay to potentially increase patient commitment to long-term
herence to cardiovascular medications such as statins and m
tihypertensive agents (92,93). Shared decision making,cilitated by the use of structured decision aids, does appear
improve patients’ confidence in and satisfaction withhatever decision they make about taking chronic medication4). Nevertheless, the limited published data on the effects ofe use of decision aids on decisional outcomes, includingedication acceptance and adherence, have shown mixedsults (95–99), partly because of inconsistent implementa-on of the decision aid (100).Patients’ perceptions of untreated risk severity and poten-
al benefits and harms of treatment depend heavily on theays in which risk information is conveyed (94). Expressingtential treatment benefit in terms of relative (versus abso-te) risk reduction has been associated with higher accep-nce of and adherence to statin therapy (101). Detailedformation about potential adverse side effects of medica-ons may tend to decrease initial medication acceptance, noatter how it is expressed. Accuracy of patients’ risk percep-ons may be best improved by using naturalistic frequenciesd graphic illustrations (93,102).Thus far, no care guidelines policy groups have set forthidence-based recommendations or proposed any metricsr evaluating shared decision making, although internationalandards are under development (103,104). For these rea-ns, the writing committee is not including any provisionlated to shared decision making for the management ofAD and hypertension.
.5. Testing and Researchesting is a requirement for all performance measures beforeeir use in public reporting or pay-for-performance programs05,106), and NQF will not fully endorse measures that havet been comprehensively tested (78). The AMA–PCPI hasblished a document delineating the thorough testing proto-l to which all of its measures will be subjected (107). All ofe new measures in this set will be tested according to thatotocol. The writing committee recommends that theseeasures not be broadly used for accountability purposestil this testing is complete.Additionally, the writing committee recommends thate process measures in this set be systematically studiedith respect to their effects on clinical, financial, andtient satisfaction outcomes. Of particular note in thisgard is the blood pressure control measure in thepertension set, which was the subject of much discus-
on during the writing committee deliberations and duringe public comment period. The writing committee encour-es research into the effect of this measure on theescription of optimal or maximally tolerated doses oftihypertensive medications and on ultimately achievingood pressure control targets; such research should usepropriate risk adjustment and evaluate both desiredtcomes and unintended consequences. All argumentsout these issues remain highly theoretical until theserts of objective data are obtained.Another measure of particular interest with respect to itstential impact on outcomes is the symptom and activitysessment measure in the CAD set. Implementation of this
easure is likely to identify patients whose angina symptoms
330 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
e not adequately controlled, leading to additional diagnosticd therapeutic interventions. These interventions, in turn,ay have a positive impact on angina-related quality of life,well as morbidity rate, mortality rate, and costs. Under-
anding the balance of these various outcomes in differentpulations will have obvious utility for policy makers,ysicians, and especially patients.
taff
merican College of Cardiology Foundation
alph G. Brindis, MD, MPH, FACC, FSCAI, President
hn C. Lewin, MD, Chief Executive Officer
net Wright, MD, FACC, Senior Vice President,Science and Quality
harlene May, Senior Director, Science and Clinical Policy
elanie Shahriary, RN, BSN, Director, Performance Mea-sures and Data Standards
merican College of Cardiology Foundation/merican Heart Association
nsen S. Chiu, MHA, Specialist, Clinical Performance Measures
merican Heart Association
alph L. Sacco, MS, MD, FAAN, FAHA, President
ancy Brown, Chief Executive Officer
ose Marie Robertson, MD, FACC, FAHA, FESC, ChiefScience Officer
ppendix A. Author Relationships With Industry and Other Entitiith Coronary Artery Disease and Hypertension
CommitteeMember Employment Consultant
seph Drozda,, Co-chair
Sisters of Mercy Health System—Director of Outcomes Research
None Non
seph V.sser, Co-chair
Rush University Medical Center—Professor of Medicine; CardiovascularAssociates of Glenbrook andEvanston
None Non
hn Spertus†,-chair
Saint Luke’s Hospital of KansasCity—Clinical Director, OutcomesResearch
● Amgen● Novartis● PRISM
Technology● St. Jude Medical● UnitedHealth
Non
uceramowitz
University of Illinois at Chicago—Associate Professor of Medicine;Advocate Christ Medical Center—Director, Interventional Cardiology
None Non
ren Alexander Duke University Medical CenterDCRI—Associate Professor
● Gilead Non
aig T. Beam Medical Development Specialists—Senior Vice President
None Non
ayle R. Whitman, PhD, RN, FAHA, FAAN, Senior VicePresident, Office of Science Operations
ark D. Stewart, MPH, Science and Medicine Advisor,Office of Science Operations
heryl L. Perkins, MD, RPh, Science and Medicine Advisor,Office of Science Operations
dy Hundley, Production Manager, Scientific Publishing,Office of Science Operations
merican Medical Association–Physicianonsortium for Performance Improvement
arjorie Rallins, DPM, Director, Measure Specifications,Standards, and Informatics
avid Small, MS, MPP, Policy Analyst I
amantha Tierney, MPH, Project Manager II, Measure De-velopment Operations
CF/AHA/AMA-PCPI 2011 Performance Measures for Adults
Ownership/Partnership/
Principal Research
Institutional,Organizational, orOther Financial
BenefitExpert
Witness
None Novartis ● Boston ScientificRhythm (son)*
● UnitedHealth
None
None None None None
● Health OutcomesSciences
● Kansas CityCardiomyopathyQuestionnaire*
● Peripheral ArteryQuestionnaire*
● Seattle AnginaQuestionnaire*
● Atherotect*● Bristol-Myers
Squibb/Sanofi-aventis*
● Eli Lilly*● Johnson &
Johnson*● Roche
Diagnostics*
● CV Outcomes‡ None
None None None None
None ● POZEN● Sanofi-aventis
None None
None None None None
(Continued)
es—AC
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e
e
e
e
e
A
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331JACC Vol. 58, No. 3, 2011 Drozda Jr. et al.July 12, 2011:316–36 Performance Measures for CAD and Hypertension
ppendix A. Continued
CommitteeMember Employment Consultant Speaker
Ownership/Partnership/
Principal Research
Institutional,Organizational, orOther Financial
BenefitExpert
Witness
bert O. Bonow Northwestern University FeinbergSchool of Medicine—GoldbergDistinguished Professor and Chief,Division of Cardiology
None None None None None None
l S. Burkiewicz Midwestern University ChicagoCollege of Pharmacy—AssociateProfessor and Pharmacy Practice andPGY1 Residency Program Director
None None None None None None
chael Crouch Memorial Family Medicine ResidencyProgram—Residency Director
None None None None None None
vid C. Goff, Jr. Wake Forest University of School ofMedicine—Professor, Department ofMedicine; Professor and Chair,Department of Epidemiology andPrevention
None None None ● Merck*● Takeda
None None
hard Hellman University of Missouri–Kansas CitySchool of Medicine—ClinicalProfessor of Medicine
None None None None None None
omas James III Humana, Inc—Medical Director,National Network Operations
None None None None None None
rjorie L. King Columbia University (Helen HayesHospital)—Director, Cardiac Services
None None None None None None
ison A.chado, Jr.
IPRO–Chief Quality Officer and VicePresident, Strategy Division
None None None None None None
uardo Ortiz National Heart, Blood and LungInstitute—Senior Medical Officer
Northwestern University—AssistantProfessor, Department of Medicineand Institute for Healthcare Studies
None None None None None None
sse M. Pines University of Pennsylvania—AssistantProfessor of Emergency Medicineand Associate Director, EmergencyCare Policy and Research Division
None None None None None None
nk J. Rybicki Brigham and Women’s Hospital—Director, Cardiac CT and VascularCT/MRI
● BraccoDiagnostics
● Siemens Medical● Toshiba Medical
● BraccoDiagnostics
● Siemens Medical● Toshiba Medical
None ● BraccoDiagnostics
● SiemensMedical
● ToshibaMedical
None None
wrence B.dwin
Torbot Group, Inc. None None None None None None
anna D.kema
University of Miami—Director, AcuteCare Nurse Practitioner Program
None None None None None None
ter K. Smith Duke University Medical Center—Professor and Chief, ThoracicSurgery
● BaxterCorporation*
None None None None None
trick J.rcson
St. Tammany ParishHospital—Director of HospitalMedicine
None None None None None None
hn B. Wong Tufts Medical Center—Chief, Divisionof Clinical Decision Making
None None None None None None
This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. Theselationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process.e table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interestpresents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10 000 or more of the fair market value of the businesstity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship is considered to beodest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency.lationships in this table are modest unless otherwise noted.*Significant relationship.†Recused from voting on Measures 3 and 4.‡No financial relationship.
DCRI indicates Duke Clinical Research Institute.
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JaDo
GoFu
KaGr
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BeCh
JuGa
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RoHe
JuHo
HaKr
332 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
ppendix B. Reviewer Relationships With Industry and Other Entities—ACCF/AHA/AMA-PCPI 2011 Performance Measures fordults With Coronary Artery Disease and Hypertension
Peereviewer Representation Consultant Speaker
Ownership/Partnership/
Principal Personal Research
Institutional,Organizational
or OtherFinancial Benefit
ExpertWitness
mes T.ve
Official Reviewer—ACCF Board ofTrustees
None None None ● Baxter● GlaxoSmithKline�
● Medtronic
None ● Plaintiff,PCI, 2008
rdon L.ng
Official Reviewer—ACCF Board ofGovernors
● NovartisPharmaceuticals
● AbbottCardiovascular
● GlaxoSmithKline
None ● Roche None None
thleen L.ady
Official Reviewer—ACCF/AHA TaskForce on Performance MeasuresLead Reviewer
None None None None None None
de W.ncy
Official Reviewer—AHA None None None None None None
eferences1. Institute of Medicine. Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington, DC: National AcademiesPress; 2001.
2. Spertus JA, Eagle KA, Krumholz HM, et al. American College ofCardiology and American Heart Association methodology for theselection and creation of performance measures for quantifying thequality of cardiovascular care. J Am Coll Cardiol. 2005;45:1147–56.
3. Bonow RO, Bennett S, Casey DE Jr., et al. ACC/AHA clinicalperformance measures for adults with chronic heart failure: a report ofthe American College of Cardiology/American Heart Association TaskForce on Performance Measures (Writing Committee to Develop HeartFailure Clinical Performance Measures). J Am Coll Cardiol. 2005;46:1144–78.
4. American College of Cardiology Foundation/American Heart Associa-tion/American Medical Association–Physician Consortium for Perfor-mance Improvement. Clinical performance measures. Chronic stablecoronary artery disease. Chicago, IL: American Medical Association;
Content Reviewer—Formation ofOptimal Cardiovascular UtilizationStrategies (FOCUS) Group
● Astellas ● Astellas*
hn R.ndle
Content Reviewer—ACCF ClinicalQuality Committee
None None
chael J.lk
Content Reviewer—ACCF/AHA TaskForce on Appropriate Use Criteria
None None
This table represents the relevant relationships with industry and other entilationships with industry at the time of publication. A person is deemed to haore of the voting stock or share of the business entity, or ownership of $10 0e person from the business entity exceed 5% of the person’s gross income for tder the preceding definition. Relationships that exist with no financial benefiodest unless otherwise noted.*Significant relationship.†No financial relationship.ACCF indicates American College of Cardiology Foundation; AHA, American Hetcomes Research in Cardiovascular Disease and Stroke Scientific Sessions; SIHd UA, unstable angina.
2005.
4a.American College of Cardiology Foundation/American Heart Associa-tion/American Medical Association–Physician Consortium for Perfor-mance Improvement Clinical Performance Measures. Chronic stablecoronary artery disease performance measurement set. 2011. Availableat: http://www.ama-assn.org/ama1/pub/upload/mm/pcpi/cadminisetjune06.pdf. American Medical Association. Accessed April 27, 2011.
5. American College of Cardiology Foundation/American Heart Associa-tion/American Medical Association–Physician Consortium for Perfor-mance Improvement. Clinical performance measures. Hypertension.Chicago, IL: American Medical Association; 2005.
5a.American College of Cardiology Foundation/American Heart Associa-tion/American Medical Association–Physician Consortium for Perfor-mance Improvement Clinical Performance Measures. Hypertensionperformance measurement set. 2011. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/pcpi/hypertension-8-05. American Med-ical Association. Accessed April 27, 2011.
6. Krumholz HM, Anderson JL, Brooks NH, et al. ACC/AHA clinicalperformance measures for adults with ST-elevation and non–STelevation myocardial infarction: a report of the American College ofCardiology/American Heart Association Task Force on PerformanceMeasures (Writing Committee to Develop Performance Measures onST-Elevation and Non–ST-Elevation Myocardial Infarction). J Am Coll
Ownership/Partnership/
Principal Personal Research
Institutional,Organizational
or OtherFinancial Benefit
ExpertWitness
● Bristol-MyersSquibb
● Merck● Pfizer● Roche
● Daiichi-Sankyo● Novartis Pharmaceuticals
None None
None None None None
None ● Bristol-Myers Squibb● Eli Lilly● Sanofi-aventis● Schering-Plough*● The Medicines Company*
None None
None ● Astellas Pharma● Bracco Diagnostics
None None
None None None None
None None None None
None None None None
None None None None
None ● Bristol-Myers Squibb● PGx
None None
None None None None
None None None None
were disclosed at the time of peer review. It does not necessarily reflectnificant interest in a business if the interest represents ownership of 5% orore of the fair market value of the business entity; or if funds received by
ous year. A relationship is considered to be modest if it is less than significanto included for the purposes of transparency Relationships in this table are
ciation; PCI, percutaneous coronary intervention; QCOR, Quality of Care ande ischemic heart disease; STEMI, ST-segment elevation myocardial infarction;
334 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
6a.Krumholz HM, Anderson JL, Bachelder BL, et al. ACC/AHA 2008performance measures for adults with ST-elevation and non–ST-elevation myocardial infarction: a report of the American College ofCardiology/American Heart Association Task Force on PerformanceMeasures (Writing Committee to Develop Performance Measures forST-Elevation and Non–ST-Elevation Myocardial Infarction). J Am CollCardiol. 2008;52:2046–99.
7. Thomas RJ, King M, Lui K, et al. AACVPR/ACC/AHA 2007 perfor-mance measures on cardiac rehabilitation for referral to and delivery ofcardiac rehabilitation/secondary prevention services. J Am Coll Cardiol.2007;50:1400–33.
7a.Thomas RJ, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 update:performance measures on cardiac rehabilitation for referral to cardiacrehabilitation/secondary prevention services: a report of the AmericanAssociation of Cardiovascular and Pulmonary Rehabilitation and theAmerican College of Cardiology Foundation/American Heart Associa-tion Task Force on Performance Measures (Writing Committee toDevelop Clinical Performance Measures for Cardiac Rehabilitation).J Am Coll Cardiol. 2010;56:1159–67.
8. Estes NA III, Halperin JL, Calkins H, et al. ACC/AHA/PhysicianConsortium 2008 clinical performance measures for adults with nonval-vular atrial fibrillation or atrial flutter: a report of the American Collegeof Cardiology/American Heart Association Task Force on PerformanceMeasures and the Physician Consortium for Performance Improvement(Writing Committee to Develop Clinical Performance Measures forAtrial Fibrillation). J Am Coll Cardiol. 2008;51:865–84.
9. Redberg RF, Benjamin EJ, Bittner V, et al. ACCF/AHA 2009 perfor-mance measures for primary prevention of cardiovascular disease inadults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures(Writing Committee to Develop Performance Measures for PrimaryPrevention of Cardiovascular Disease). J Am Coll Cardiol. 2009;54:1364–405.
0. Olin JW, Allie DE, Belkin M, et al. ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 performance measures for adults with peripheral arterydisease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, theAmerican College of Radiology, the Society for Cardiac Angiographyand Interventions, the Society for Interventional Radiology, the Societyfor Vascular Medicine, the Society for Vascular Nursing, and theSociety for Vascular Surgery (Writing Committee to Develop Perfor-mance Measures for Peripheral Artery Disease). J Am Coll Cardiol.2010;56:2147–81.
1. Krumholz HM, Brindis RG, Brush JE, et al. Standards for statisticalmodels used for public reporting of health outcomes: an American HeartAssociation scientific statement from the Quality of Care and OutcomesResearch Interdisciplinary Writing Group: cosponsored by the Councilon Epidemiology and Prevention and the Stroke Council. Circulation.2006;113:456–62.
2. Spertus JA, Bonow RO, Chan P, et al. ACCF/AHA new insights into themethodology of performance measurement: a report of the AmericanCollege of Cardiology Foundation/American Heart Association TaskForce on Performance Measures. J Am Coll Cardiol. 2010;56:1767–82.
3. Physician Consortium for Performance Improvement. PCPI WorkGroup Charge. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/370/pcpi-work-group-charge.pdf. American Medical Asso-ciation. Accessed August 19, 2010.
5. National Committee for Quality Assurance. The State of HealthcareQuality. Available at: http://www.ncqa.org/tabid/836/Default.aspx. Ac-cessed March 21, 2011.
6. National Committee for Quality Assurance. HEDIS. 2010. HealthcareEffectiveness Data & Information Set.Vol. 2, Technical Specifications:Controlling Blood Pressure. Available at: http://www.ncqa.org/tabid/78/Default.aspx. Accessed August 19, 2010.
7. Physician Consortium for Performance Improvement. Specification andcategorization of measure exclusions: recommendations to PCPI workgroups. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/370/exclusions053008.pdf. American Medical Association. AccessedApril 5, 2010.
8. National Heart, Lung, and Blood Institute, National Institutes of Health.National Cholesterol Education Program: third report of the National
Cholesterol Education Program (NCEP) Expert Panel on detection,
evaluation, and treatment of high blood cholesterol in adults (AdultTreatment Panel II). NIH Publication No. 02-5212. Available at:http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf. AccessedApril 1, 2010.
9. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of theJoint National Committee on Prevention, Detection, Evaluation, andTreatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–72.
0. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guidelineupdate for the management of patients with chronic stable angina—summary article: a report of the American College ofCardiology/American Heart Association Task Force on Practice Guidelines (Com-mittee on the Management of Patients With Chronic Stable Angina).J Am Coll Cardiol. 2003;41:159–68.
1. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence:2008 Update. Available at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf. US Department of Health and Human ServicesPublic Health Service. Accessed March 21, 2011.
2. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guidelineupdate for coronary artery bypass graft surgery: summary article: areport of the American College of Cardiology/American Heart Associ-ation Task Force on Practice Guidelines (Committee to Update the 1999Guidelines for Coronary Artery Bypass Graft Surgery). J Am CollCardiol. 2004;44:1146–54.
3. Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of theACC/AHA 2004 guidelines for the management of patients withST-elevation myocardial infarction: a report of the American College ofCardiology/American Heart Association Task Force on Practice Guide-lines. J Am Coll Cardiol. 2008;51:210–47.
4. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guide-lines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College ofCardiology/American Heart Association Task Force on Practice Guide-lines (Writing Committee to Revise the 2002 Guidelines for theManagement of Patients With Unstable Angina/Non–ST-ElevationMyocardial Infarction). J Am Coll Cardiol. 2007;50:e1–157.
5. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines forcardiovascular disease prevention in women: 2007 update. Circulation.2007;115:1481–501.
6. King SB III, Smith SC Jr., Hirshfeld JW Jr., et al. 2007 Focused updateof the ACC/AHA/SCAI 2005 guideline update for percutaneous coro-nary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J AmColl Cardiol. 2008;51:172–209.
7. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria forstress echocardiography: a report of the American College of CardiologyFoundation Appropriateness Criteria Task Force, American Society ofEchocardiography, American College of Emergency Physicians, Amer-ican Heart Association, American Society of Nuclear Cardiology,Society for Cardiovascular Angiography and Interventions, Society ofCardiovascular Computed Tomography, and Society for CardiovascularMagnetic Resonance. J Am Coll Cardiol. 2008;51:1127–47.
8. Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriate-ness criteria for single-photon emission computed tomography myocar-dial perfusion imaging (SPECT MPI): a report of the American Collegeof Cardiology Foundation Quality Strategic Directions CommitteeAppropriateness Criteria Working Group and the American Society ofNuclear Cardiology. J Am Coll Cardiol. 2005;46:1587–605.
9. Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac com-puted tomography and cardiac magnetic resonance imaging: a report ofthe American College of Cardiology Foundation Quality StrategicDirections Committee Appropriateness Criteria Working Group, Amer-ican College of Radiology, Society of Cardiovascular Computed To-mography, Society for Cardiovascular Magnetic Resonance, AmericanSociety of Nuclear Cardiology, North American Society for CardiacImaging, Society for Cardiovascular Angiography and Interventions,and Society of Interventional Radiology. J Am Coll Cardiol. 2006;48:1475–97.
0. Agency for Healthcare Research and Quality. Prevention quality indi-cators overview. July 2004. Available at: http://www.qualityindicator-s.ahrq.gov/Modules/pqi_overview.aspx. Accessed August 19, 2010.
1. Institute for Clinical Systems Improvement. Health Care Guideline:
Lipid Management in Adults. 11th ed. 2009. Available at:
335JACC Vol. 58, No. 3, 2011 Drozda Jr. et al.July 12, 2011:316–36 Performance Measures for CAD and Hypertension
http://www.icsi.org/lipid_management_3/lipid_management_in_adults_4.html. Accessed August 19, 2010.
2. Office of Quality and Performance. FY2008, Q1 technical manual for theVHA measurement system. Available at: http://qualitymeasures.ahrq.gov/browse/by-organization-indiv.aspx?orgid�3. Agency for Health-care Research and Quality. Accessed March 21, 2011.
3. Institute for Clinical Systems Improvement. Health Care Guideline: hyper-tension diagnosis and treatment. 13th ed. 2010. Available at: http://www.icsi.org/guidelines_and_more/gl_os_prot/cardiovascular/hypertension_4/hypertension_diagnosis_and_treatment__11.html. Accessed August19, 2010.
4. Electronic Health Records (EHR) Demonstration. Available at:http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/EHR_DemoSummary.pdf. Centers for Medicare & Medicaid Services, De-partment of Health and Human Services. Accessed April 5, 2010.
5. Medicare Physician Group Practice Demonstration. Available at:http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/PGP_Fact_Sheet.pdf. Centers for Medicare & Medicaid Services, Departmentof Health and Human Services. Accessed April 5, 2010.
6. DOQ and DOQ-IT measure specifications. Available at:http://www.qualitynet.org/dcs/ContentServer?cid�1143577171055&pagename�QnetPublic%2FPage%2FQnetTier2%26c�Page. Centersfor Medicare & Medicaid Services, Department of Health and HumanServices. Accessed April 5, 2010.
7. Chan PS, Oetgen WJ, Buchanan D, et al. Cardiac performance measurecompliance in outpatients: the American College of Cardiology andNational Cardiovascular Data Registry’s PINNACLE (Practice Inno-vation And Clinical Excellence) program. J Am Coll Cardiol. 2010;56:8–14.
8. Chan PS, Oetgen WJ, Spertus JA. The Improving Continuous CardiacCare (IC3) program and outpatient quality improvement. Am J Med.2010;123:217–9.
9. Normand SL, McNeil BJ, Peterson LE, et al. Eliciting expert opinionusing the Delphi technique: identifying performance indicators forcardiovascular disease. Int J Qual Health Care. 1998;10:247–60.
0. Chernew ME, Shah MR, Wegh A, et al. Impact of decreasing copay-ments on medication adherence within a disease management environ-ment. Health Aff (Millwood). 2008;27:103–12.
1. Mojtabai R, Olfson M. Medication costs, adherence, and health out-comes among Medicare beneficiaries. Health Aff (Millwood). 2003;22:220–9.
2. Faxon DP, Schwamm LH, Pasternak RC, et al. Improving quality of carethrough disease management: principles and recommendations from theAmerican Heart Association’s Expert Panel on Disease Management.Circulation. 2004;109:2651–4.
3. Fonarow GC, Gawlinski A, Moughrabi S, Tillisch JH. Improvedtreatment of coronary heart disease by implementation of a CardiacHospitalization Atherosclerosis Management Program (CHAMP). Am JCardiol. 2001;87:819–22.
4. Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge educa-tion improves clinical outcomes in patients with chronic heart failure.Circulation. 2005;111:179–85.
5. Cushman WC, Evans GW, Byington RP, et al. Effects of intensiveblood-pressure control in type 2 diabetes mellitus. N Engl J Med.2010;362:1575–85.
6. Kastelein JJ, Akdim F, Stroes ES, et al. Simvastatin with or withoutezetimibe in familial hypercholesterolemia. N Engl J Med. 2008;358:1431–43.
7. Taylor AJ, Villines TC, Stanek EJ, et al. Extended-release niacin orezetimibe and carotid intima-media thickness. N Engl J Med. 2009;361:2113–22.
8. Thomas JW, Hofer TP. Accuracy of risk-adjusted mortality rate as ameasure of hospital quality of care. Med Care. 1999;37:83–92.
9. Standards of medical care in diabetes–2010. Diabetes Care. 2010;33Suppl 1:S11–61.
0. Arnold SV, Morrow DA, Lei Y, et al. Economic impact of angina afteran acute coronary syndrome: insights from the MERLIN-TIMI 36 trial.Circ Cardiovasc Qual Outcomes. 2009;2:344–53.
1. Maddox TM, Reid KJ, Rumsfeld JS, Spertus JA. One-year health statusoutcomes of unstable angina versus myocardial infarction: a prospective,observational cohort study of ACS survivors. BMC Cardiovasc Disord.2007;7:28.
2. Mozaffarian D, Bryson CL, Spertus JA, et al. Anginal symptomsconsistently predict total mortality among outpatients with coronary
artery disease. Am Heart J. 2003;146:1015–22.
3. Plomondon ME, Magid DJ, Masoudi FA, et al. Association betweenangina and treatment satisfaction after myocardial infarction. J GenIntern Med. 2008;23:1–6.
4. Spertus JA, Jones P, McDonell M, et al. Health status predicts long-termoutcome in outpatients with coronary disease. Circulation. 2002;106:43–9.
5. Spertus JA, Salisbury AC, Jones PG, et al. Predictors of quality-of-lifebenefit after percutaneous coronary intervention. Circulation. 2004;110:3789–94.
6. Spertus JA. Evolving applications for patient-centered health statusmeasures. Circulation. 2008;118:2103–10.
7. Artham SM, Lavie CJ, Milani RV. Cardiac rehabilitation programsmarkedly improve high-risk profiles in coronary patients with highpsychological distress. South Med J. 2008;101:262–7.
8. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiacrehabilitation/secondary prevention programs: 2007 update: a scientificstatement from the American Heart Association Exercise, CardiacRehabilitation, and Prevention Committee, the Council on ClinicalCardiology; the Councils on Cardiovascular Nursing, Epidemiology andPrevention, and Nutrition, Physical Activity, and Metabolism; and theAmerican Association of Cardiovascular and Pulmonary Rehabilitation.Circulation. 2007;115:2675–82.
9. Canyon S, Meshgin N. Cardiac rehabilitation: reducing hospital read-missions through community based programs. Aust Fam Physician.2008;37:575–7.
0. Centers for Disease Control and Prevention. Receipt of outpatientcardiac rehabilitation among heart attack survivors–United States, 2005.MMWR Morb Mortal Wkly Rep. 2008;57:89–94.
1. Curnier DY, Savage PD, Ades PA. Geographic distribution of cardiacrehabilitation programs in the United States. J Cardiopulm Rehabil.2005;25:80–4.
2. Egger E, Schmid JP, Schmid RW, et al. Depression and anxietysymptoms affect change in exercise capacity during cardiac rehabilita-tion. Eur J Cardiovasc Prev Rehabil. 2008;15:704–8.
3. Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationshipbetween cardiac rehabilitation and long-term risks of death and myo-cardial infarction among elderly Medicare beneficiaries. Circulation.2010;121:63–70.
4. Jolliffe JA, Rees K, Taylor R, et al. Exercise-based rehabilitation forcoronary heart disease. Cochrane Database Syst Rev. 2001;(1):CD001800.
5. Lavie CJ, Milani RV. Effects of cardiac rehabilitation on exercisecapacity, coronary risk factors, behavioral characteristics, and quality oflife in a large elderly cohort. Am J Cardiol. 1995;76:177–9.
6. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation andsecondary prevention of coronary heart disease: an American HeartAssociation scientific statement from the Council on Clinical Cardiology(Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) andthe Council on Nutrition, Physical Activity, and Metabolism (Subcom-mittee on Physical Activity), in collaboration with the AmericanAssociation of Cardiovascular and Pulmonary Rehabilitation. Circula-tion. 2005;111:369–76.
7. Milani RV, Lavie CJ. Impact of cardiac rehabilitation on depression andits associated mortality. Am J Med. 2007;120:799–806.
8. O’Connor GT, Buring JE, Yusuf S, et al. An overview of randomizedtrials of rehabilitation with exercise after myocardial infarction. Circu-lation. 1989;80:234–44.
9. Shah ND, Dunlay SM, Ting HH, et al. Long-term medication adherenceafter myocardial infarction: experience of a community. Am J Med.2009;122:961-e7–13.
0. Suaya JA, Shepard DS, Normand SL, et al. Use of cardiac rehabilitationby Medicare beneficiaries after myocardial infarction or coronary bypasssurgery. Circulation. 2007;116:1653–62.
1. Suaya JA, Stason WB, Ades PA, et al. Cardiac rehabilitation andsurvival in older coronary patients. J Am Coll Cardiol. 2009;54:25–33.
2. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation forpatients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682–92.
3. Taylor RS, Unal B, Critchley JA, Capewell S. Mortality reductions inpatients receiving exercise-based cardiac rehabilitation: how much canbe attributed to cardiovascular risk factor improvements? Eur J Cardio-vasc Prev Rehabil. 2006;13:369–74.
4. Thomas RJ, Miller NH, Lamendola C, et al. National survey on genderdifferences in cardiac rehabilitation programs: patient characteristics and
336 Drozda Jr. et al. JACC Vol. 58, No. 3, 2011Performance Measures for CAD and Hypertension July 12, 2011:316–36
5. Rodbard HW, Blonde L, Braithwaite SS, et al. American Association ofClinical Endocrinologists medical guidelines for clinical practice for themanagement of diabetes mellitus. Endocr Pract. 2007;13(Suppl 1):1–68.
6. Cooper-Dehoff RM, Gong Y, Handberg EM, et al. Tight blood pressurecontrol and cardiovascular outcomes among hypertensive patients withdiabetes and coronary artery disease. JAMA. 2010;304:61–8.
7. Agency for Healthcare Research and Quality. Counseling to PreventTobacco Use and Tobacco-Caused Disease, Topic Page. November2003. US Preventive Services Task Force. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac.htm. AccessedNovember 17, 2008.
8. National Quality Forum. National Voluntary Consensus Standards forthe Treatment of Substance Use Conditions: Evidence-Based TreatmentPractices. 2007. Available at: http://www.rwjf.org/files/research/nqrconsensusreport2007.pdf. Accessed April 21, 2010.
9. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for themanagement of arterial hypertension: the Task Force for the Manage-ment of Arterial Hypertension of the European Society of Hypertension(ESH) and of the European Society of Cardiology (ESC). Eur Heart J.2007;28:1462–536.
0. Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertensionin the prevention and management of ischemic heart disease: a scientificstatement from the American Heart Association Council for High BloodPressure Research and the Councils on Clinical Cardiology and Epide-miology and Prevention. Circulation. 2007;115:2761–88.
1. Fox KM. Efficacy of perindopril in reduction of cardiovascular eventsamong patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lan-cet. 2003;362:782–8.
2. Nissen SE, Tuzcu EM, Libby P, et al. Effect of antihypertensive agentson cardiovascular events in patients with coronary disease and normalblood pressure: the CAMELOT study: a randomized controlled trial.JAMA. 2004;292:2217–25.
3. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk pa-tients. The Heart Outcomes Prevention Evaluation Study Investigators.N Engl J Med. 2000;342:145–53.
4. Braunwald E, Domanski MJ, Fowler SE, et al. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med.2004;351:2058–68.
5. McMurray JJ, Holman RR, Haffner SM, et al. Effect of valsartan on theincidence of diabetes and cardiovascular events. N Engl J Med.2010;362:1477–90.
6. Poole-Wilson PA, Lubsen J, Kirwan BA, et al. Effect of long-actingnifedipine on mortality and cardiovascular morbidity in patients withstable angina requiring treatment (ACTION trial): randomised con-trolled trial. Lancet. 2004;364:849–57.
7. Yusuf S, Teo K, Anderson C, et al. Effects of the angiotensin-receptorblocker telmisartan on cardiovascular events in high-risk patients intol-erant to angiotensin-converting enzyme inhibitors: a randomised con-trolled trial. Lancet. 2008;372:1174–83.
8. Fraker TD Jr., Fihn SD, Gibbons RJ, et al. 2007 Chronic angina focusedupdate of the ACC/AHA 2002 guidelines for the management ofpatients with chronic stable angina: a report of the American College ofCardiology/American Heart Association Task Force on Practice Guide-lines Writing Group to Develop the Focused Update of the 2002Guidelines for the Management of Patients With Chronic Stable Angina.J Am Coll Cardiol. 2007;50:2264–74.
9. Patel MR, Spertus JA, Brindis RG, et al. ACCF proposed method forevaluating the appropriateness of cardiovascular imaging. J Am CollCardiol. 2005;46:1606–13.
0. National Quality Forum. National Voluntary Consensus Standards forImaging Efficiency: A Consensus Report. 2010. Available at:http://www.qualityforum.org/projects/imaging_efficiency.aspx#t�2%
26s�%26p�7%7C. ou
1. Krumholz HM, Keenan PS, Brush JE Jr., et al. Standards for measuresused for public reporting of efficiency in health care: a scientificstatement from the American Heart Association Interdisciplinary Coun-cil on Quality of Care and Outcomes Research and the AmericanCollege of Cardiology Foundation. Circulation. 2008;118:1885–93.
2. Edwards A, Elwyn G, Hood K, et al. The development of COMRADE:a patient-based outcome measure to evaluate the effectiveness of riskcommunication and treatment decision making in consultations. PatientEduc Couns. 2003;50:311–22.
3. Montori VM, Breslin M, Maleska M, Weymiller AJ. Creating aconversation: insights from the development of a decision aid. PLoSMed. 2007;4:e233.
4. O’Connor AM, Bennett CL, Stacey D, et al. Decision aids for peoplefacing health treatment or screening decisions. Cochrane Database SystRev. 2009;(3):CD001431.
5. Casebeer L, Huber C, Bennett N, et al. Improving the physician-patientcardiovascular risk dialogue to improve statin adherence. BMC FamPract. 2009;10:48.
6. Jones LA, Weymiller AJ, Shah N, et al. Should clinicians deliverdecision aids? Further exploration of the statin choice randomized trialresults. Med Decis Making. 2009;29:468–74.
7. Mann DM, Ponieman D, Montori VM, et al. The Statin Choice decisionaid in primary care: a randomized trial. Patient Educ Couns. 2010;80:138–40.
8. Weymiller AJ, Montori VM, Jones LA, et al. Helping patients with type2 diabetes mellitus make treatment decisions: statin choice randomizedtrial. Arch Intern Med. 2007;167:1076–82.
9. Yilmaz MB, Pinar M, Naharci I, et al. Being well-informed about statinis associated with continuous adherence and reaching targets. Cardio-vasc Drugs Ther. 2005;19:437–40.
0. Abadie R, Weymiller AJ, Tilburt J, et al. Clinician’s use of the StatinChoice decision aid in patients with diabetes: a videographic studynested in a randomized trial. J Eval Clin Pract. 2009;15:492–7.
1. Carling C, Kristoffersen DT, Herrin J, et al. How should the impact ofdifferent presentations of treatment effects on patient choice be evalu-ated? A pilot randomized trial. PLoS One. 2008;3:e3693.
2. Trevena LJ, Davey HM, Barratt A, et al. A systematic review oncommunicating with patients about evidence. J Eval Clin Pract. 2006;12:13–23.
3. Burton D, Blundell N, Jones M, et al. Shared decision-making incardiology: do patients want it and do doctors provide it? Patient EducCouns. 2010;80:173–9.
4. Elwyn G, Edwards A, Wensing M, et al. Shared decision making:developing the OPTION scale for measuring patient involvement. QualSaf Health Care. 2003;12:93–9.
5. Brush JE Jr., Krumholz HM, Wright JS, et al. American College ofCardiology 2006 principles to guide physician pay-for-performanceprograms: a report of the American College of Cardiology Work Groupon Pay for Performance (A Joint Working Group of the ACC QualityStrategic Direction Committee and the ACC Advocacy Committee).J Am Coll Cardiol. 2006;48:2603–9.
6. Drozda JP Jr., Hagan EP, Mirro MJ, et al. ACCF 2008 health policystatement on principles for public reporting of physician performancedata: a report of the American College of Cardiology FoundationWriting Committee to Develop Principles for Public Reporting ofPhysician Performance Data. J Am Coll Cardiol. 2008;51:1993–2001.
7. Measure Implementation and Evaluation Advisory Committee of thePhysician Consortium for Performance Improvement Performance Mea-sures (PCPI). Measure Testing Protocol for Physician Consortium forPerformance Improvement Performance Measures. 2010. Available at:http://www.ama-assn.org/resources/doc/cqi/pcpi-testing-protocol.pdf.Accessed April 21, 2011.
EY WORDS: ACCF/AHA/AMA–PCPI performance measures �bulatory-level quality � coronary artery disease � health policy and
tcome research � hypertension � quality indicators.
