John A. Spertus

ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Heart Failure A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association–Physician Consortium for Performance Improvement

Developed in Collaboration With the American Academy of Family Physicians, American Academy of Hospice and Palliative Medicine, American Nurses Association, American Society of Health-System Pharmacists, Heart Rhythm Society, and Society of Hospital Medicine Endorsed by the Heart Failure Society of America WRITING COMMITTEE MEMBERS Robert O. Bonow, MD, MACC, FAHA, MACP,* Co-Chair; Theodore G. Ganiats, MD, Co-Chair; Craig T. Beam, CRE†; Kathleen Blake, MD, MPH, FACC, FHRS†; Donald E. Casey, JR, MD, MPH, MBA, FACP, FAHA§; Sarah J. Goodlin, MD, FACC, FAAHPM ; Kathleen L. Grady, PhD, APN, FAHA, FAAN*; Randal F. Hundley, MD, FACC; Mariell Jessup, MD, FACC, FAHA*; Thomas E. Lynn, MD; Frederick A. Masoudi, MD, MSPH, FACC¶; David Nilasena, MD, MSPH, MS; Ileana L. Piña, MD, MPH, FACC, FAHA*; Paul D. Rockswold, MD, MPH, FAAFP#; Lawrence B. Sadwin†; Joanna D. Sikkema, MSN, ANP-BC, FAHA**; Carrie A. Sincak, PharmD, BCPS††; John Spertus, MD, MPH, FACC, FAHA*; Patrick J. Torcson, MD, FACP††; Elizabeth Torres, MD§§; Mark V. Williams, MD, FHM; John B. Wong, MD

ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement.

Eric D. Peterson, MD, MPH, FACC, FAHA, Chair; Frederick A. Masoudi, MD, MSPH, FACC, FAHA[†††][1]; Elizabeth DeLong, PhD; John P. Erwin III, MD, FACC; Gregg C. Fonarow, MD, FACC, FAHA; David C. Goff, Jr., MD, PhD, FAHA, FACP; Kathleen Grady, PhD, RN, FAHA, FAAN; Lee A. Green, MD, MPH; Paul A.

ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain. In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally, percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

Modest Associations Between Electronic Health Record Use and Acute Myocardial Infarction Quality of Care and Outcomes Results From the National Cardiovascular Data Registry

Background—In 2009, national legislation promoted wide-spread adoption of electronic health records (EHRs) across US hospitals; however, the association of EHR use with quality of care and outcomes after acute myocardial infarction (AMI) remains unclear. Methods and Results—Data on EHR use were collected from the American Hospital Association Annual Surveys (2007–2010) and data on AMI care and outcomes from the National Cardiovascular Data Registry Acute Coronary Treatment and Interventions Outcomes Network Registry-Get With The Guidelines. Comparisons were made between patients treated at hospitals with fully implemented EHR (n=43 527), partially implemented EHR (n=72 029), and no EHR (n=9270). Overall EHR use increased from 82.1% (183/223) hospitals in 2007 to 99.3% (275/277) hospitals in 2010. Patients treated at hospitals with fully implemented EHRs had fewer heparin overdosing errors (45.7% versus 72.8%; P<0.01) and a higher likelihood of guideline-recommended care (adjusted odds ratio, 1.40 [confidence interval, 1.07–1.84]) compared with patients treated at hospitals with no EHR. In non–ST-segment–elevation AMI, fully implemented EHR use was associated with lower risk of major bleeding (adjusted odds ratio, 0.78 [confidence interval, 0.67–0.91]) and mortality (adjusted odds ratio, 0.82 [confidence interval, 0.69–0.97]) compared with no EHR. In ST-segment–elevation MI, outcomes did not significantly differ by EHR status. Conclusions—EHR use has risen to high levels among hospitals in the National Cardiovascular Data Registry. EHR use was associated with less frequent heparin overdosing and modestly greater adherence to acute MI guideline-recommended therapies. In non–ST-segment–elevation MI, slightly lower adjusted risk of major bleeding and mortality were seen in hospitals implemented with full EHRs; however, in ST-segment–elevation MI, differences in outcomes were not seen.

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness Criteria for Stress Echocardiography

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Health Status Variation Across Practices in Outpatients With Heart Failure: Insights From the CHAMP-HF (Change the Management of Patients With Heart Failure) Registry

Background: Although a key treatment goal for patients with heart failure with reduced ejection fraction is to optimize their health status (their symptoms, function, and quality of life), the variability across outpatient practices in achieving this goal is unknown. Methods and Results: In the CHAMP-HF (Change the Management of Patients With Heart Failure) registry, associations between baseline practice characteristics and Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary (OS) and Symptom Frequency (SF) scores were assessed in 3494 patients across 140 US practices using hierarchical regression after accounting for 23 patient and 11 treatment characteristics. We then calculated an adjusted median odds ratio to quantify the average difference in likelihood that a patient would have excellent (KCCQ-OS, ≥75) health status or minimal (monthly or fewer) symptoms (KCCQ-SF, ≥75) when treated at one practice versus another, at random. The mean (±SD) KCCQ-OS and KCCQ-SF were 64.2±24 and 68.9±25.6, with 40% (n=1380) and 50% (n=1760) having KCCQ scores ≥75, respectively. The adjusted median odds ratio across practices, for KCCQ-OS ≥75, was 1.70 (95% confidence interval, 1.54–1.99; P<0.001) indicating a median 70% higher odds of a patient having good-to-excellent health status when treated at one random practice versus another. In regard to KCCQ-SF, the adjusted median odds ratio for KCCQ-SF ≥75 was 1.54 (95% confidence interval, 1.41–1.76; P=0.001). Conclusions: In a large, contemporary registry of outpatients with chronic heart failure with reduced ejection fraction, we observed significant practice-level variability in patients’ health status. Quantifying patients’ health status as a measure of quality should be explored as a foundation for improving care. Clinical Trial Registration: URL: https://www.centerwatch.com. Unique identifier: TX144901.Background nWhile a key treatment goal for patients with heart failure and reduced ejection fraction (HFrEF) is to optimize their health status (their symptoms, function, and quality of life), the variability across outpatient practices in achieving this goal is unknown.

HEART FAILURE WITH REDUCED EJECTION FRACTION CARE PATTERNS IN THE OUTPATIENT PRACTICE SETTING: INITIAL FINDINGS FROM CHAMP-HF

Background: Few data exist regarding contemporary care patterns for heart failure with reduced ejection fraction (HFrEF) in the outpatient setting. Change the Management of Patients with Heart Failure (CHAMP-HF) is a prospective cohort study designed to characterize current management of patients