ACC/AHA Issue Revised Performance and Quality Measures for Atrial Fibrillation

ACC AHA Atrial Fibrillation Flutter Guidelines
ACC AHA Atrial Fibrillation Flutter Guidelines
New ACC/AHA performance and quality measures for atrial fibrillation/flutter include metrics for outpatient care.

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Performance Measures issued a new report on treating adults with atrial fibrillation or atrial flutter, published in the Journal of the American College of Cardiology.

Measures now include quality measures that apply to inpatient treatment, whereas previous measures only applied to the outpatient setting. ACC/AHA expanded the quality measures to “further improve the continuity of care for these patients by addressing the multiple settings in which they receive care.”

The writing committee reviewed evidence-based guidelines and statements to develop the measures, including the 2014 AHA/ACC/HRS (Heart Rhythm Society) Guidelines for the Management of Patients With Atrial Fibrillation and the 2012 HRS/EHRA/ECAS (European Heart Rhythm Association; European Cardiac Arrhythmia Society) Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation Recommended for Patient Selection, Procedural Techniques, Patient Management and Follow-Up, Definitions, End Points, and Research Trial Design. They added 3 new performance measures and 18 new quality measures, and revised the 3 previous performance measures.

As defined by the task force, performance measures are appropriate for potential use in public reporting, while quality measures are metrics that may be useful for local quality improvement but are not yet appropriate for public reporting or pay-for-performance programs. New measures are usually introduced as quality measures for potential inclusion as performance measures, and can rise to the level performance measures as supporting evidence becomes available.

“Certainly we think that all organizations are not going to be able to look at all of these measures,” said Joseph Marine, MD, vice-director for operations and associate professor of medicine in the Division of Cardiology at Johns Hopkins Hospital, and a member of the ACA/AHA writing committee. “Measuring and reporting quality is burdensome and requires administrative effort, so individual organizations will probably choose which measures they feel are more important and more feasible for them to measure and report. The document is kind of a menu of options for healthcare organizations to look at and consider whether they want to adopt them or not.”

The 3 new inpatient performance measures (PM) include:

  • PM-1—Documentation of the CHA2DS2VASC risk score for stroke prior to discharge or at outpatient encounter.
  • PM-2—Prescribe anticoagulation based on the above risk score.
  • PM-3—Establish a plan to check INR monthly, and document monthly INR if the patient will be taking warfarin.

Chethan Gangireddy, MD, MPH, assistant professor of medicine at the Lewis Katz School of Medicine at Temple University, said in an email that the new and revised measures likely won’t require institutions to make major changes to clinical practice. The measures are “generally already pretty well accepted” and most hospitals and medical centers have already incorporated these practices.

“However, by defining the performance measure in the context of things that might ultimately be used for public reporting, I think the goal of these guidelines is to encourage compliance with these basic concepts which if followed could significantly reduce the number of strokes caused by atrial fibrillation annually,” he added.

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The writing committee decided to revise the previous performance measures—PM-4, PM-5, and PM-6—rather than remove them. The measures were updated to reflect guideline recommendations and strengthen the “measure construct.” PM-4 and PM-5, for example, were revised to incorporate the 2014 AHA/ACC/HRS Guideline for Management of Patients With Atrial Fibrillation, which recommends using the CHA2DS2-VASc score to calculate risk for stroke patients with atrial fibrillation instead of the CHA2DS2.

PM-6, titled “Monthly INR for Warfarin Treatment,” was changed to facility or provider level instead of being limited to physician level. The writing committee acknowledged that this measure has been difficult to implement in registries, but concluded that PM-6 helps improve patient care and can be implemented in some settings, such as integrated healthcare systems.

“It is the hope of the writing committee that with increased interoperability and common data standards, this measure may be more readily adopted by more systems in the future,” they wrote.

Dr Gangireddy took note of several key quality measures (QM) including QM-4/QM-13, “Inappropriate Prescription of Dofetilide or Sotalol Prior to Discharge in Patients With Atrial Fibrillation and End-Stage Kidney Disease or on Dialysis;” QM-8/QM-17, “Inappropriate Prescription of Nondihydropyridine Calcium Channel Antagonist Prior to Discharge in Patients With Reduced Ejection Fraction;” and QM-18, “Shared Decision Making Between Physician and Patient in Anticoagulation Prescription.” The outpatient version, QM-10, encourages shared decision making between physician and patient in anticoagulation prescription prior to discharge.

Dr Marine said that one of the committee’s goals was to codify quality of care, a difficult process that has been ongoing for years.

“These are measures the group felt would lend themselves most readily to being measured and codified,” he said. “Much of this information is in electronic medical records, which almost all healthcare providers are using now, and because the evidence for the usefulness of the therapy being measured is fairly clear and uncontroversial in the medical literature.”

QM-18, for example, reflects a recommendation made in the 2014 Atrial Fibrillation Guideline that anticoagulation should be a shared decision-making effort between the patient and physician. Dr Marine added that the measure is being introduced as a quality measure because the committee recognizes that it is difficult to provide documentation in the medical records showing that shared decision-making has taken place.

“Really, all decision-making in medical care is shared decision making, so one could ask why this is specifically necessary,” he said. “This was called out in the document because an emphasis was made on this in the Atrial Fibrillation guidelines so the committee decided to codify this as a quality measure. It is a complicated decision—there are a lot of choices to be made, there are a lot of risks and benefits, and there are a lot of factors that go into decided the best anticoagulant and how to monitor treatment. Calling it out in a quality document like this is to emphasize to the community that this is an important issue.”


Heidenreich PA, Solis P, Estes NA, et al. 2016 ACC/AHA clinical performance and quality measures for adults with atrial fibrillation or atrial flutter. A report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Coll Amer Cardiol. 2016.  doi:10.1016/j.jacc.2016.03.521.