The American College of Cardiology (ACC) and American Heart Association (AHA) have jointly issued their 2020 Clinical Performance and Quality Measures for Adults With Heart Failure regarding care for inpatient and outpatient settings.

Critical Evidence-Based Updates

The update, which was published in the Journal of the American College of Cardiology and Circulation: Cardiovascular Quality and Outcomes, includes 10 new heart failure measures (7 performance measures, 2 quality measures, and 1 structural measure) and is a revision of the performance measures for heart failure that were issued in 2011. The report was written by the ACC/AHA Task Force on Performance Measures and developed in collaboration with the Heart Failure Society of America (HFSA).


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The task force reviewed evidence-based guidelines and statements that would potentially affect the construct of the measures. The performance measures are from the 2017 ACC/AHA/HFSA heart failure guideline update and were selected from the strongest recommendations (class 1 or 3). The update includes quality measures that are not yet ready for public reporting or pay for performance but might be useful for clinicians and healthcare organizations for quality improvement.

Safety, Treatment, Performance, and Quality Measures

A new safety measure was developed regarding laboratory monitoring for patients treated with mineralocorticoid receptor antagonists (MRA) that was paired with a new treatment measure for MRA in patients who have heart failure with reduced left ventricular ejection fraction (LVEF).

Other additions involve measures regarding sacubitril/valsartan and use of cardiac resynchronization therapy (CRT). To address the frequent lack of titration of heart failure medications, the task force included 2 new performance measures based on dose, achieving 50% of the recommended dose (eg, beta blocker or angiotensin-converting enzyme [ACE] inhibitor/angiotensin receptor antagonist/angiotensin receptor neprilysin inhibitor [ARNI]) or documenting that such a dose was not tolerated or otherwise inappropriate.

The update has also added 2 patient-reported outcome quality measures that use heart failure patient-reported outcome questionnaires accepted by the US Food and Drug Administration.

How Measures Were Selected

“Ultimately, we selected measures based on their importance for health, existing gaps in care, ease of implementation, potential duplication with other performance measure lists, and risk for unintended consequences,” according to the task force.

The 2020 update includes 18 measures: 13 performance measures, 4 quality measures, 1 structural measure, and 2 rehabilitation performance measures (from the 2018 ACC/AHA performance measures for cardiac rehabilitation).

“Although all the measures are considered valuable in improving care, we recognize that organizations may only be able to focus on a limited number of measures,” stated the task force. “When implementing any measure that involves patient input, it is important to consider the patient’s health literacy and adapt data collection accordingly. Performance measures are a critical step in addressing disproportionately lower quality of care and potentially worse health status and outcomes among an underserved population.”

Measures Retired, Revised, or Added

The task force retired the LVEF assessment measure used in the inpatient setting because it is documented as being used more than 97% of the time. The group retained the LVEF assessment in the outpatient setting.

The task force also reviewed and revised measures on patient self-care education, ACE inhibitor or angiotensin receptor blocker (ARB) therapy for left ventricular systolic dysfunction, and postdischarge appointment.

Among the 7 new performance measures, 6 were based on class 1 guideline recommendations for therapies known to prolong patient survival. An additional performance measure (measurement of potassium after a mineralocorticoid receptor antagonist prescription) is also guideline recommended and included as a safety measure to accompany a prescription for a mineralocorticoid receptor antagonist.

The task force also developed 2 new measures based on dose. “These were chosen because of the gap between doses used in practice and those shown to provide survival benefit in clinical trials,” noted the task force. “They were designed to apply only to those patients without demonstrated intolerance at higher doses.”

Key Heart Failure Measures

The new heart failure measures with their descriptions are as follows:

  • PM-6: Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting). Measure Description: Percentage of patients aged 18 years or older with a diagnosis of heart failure with a current or prior LVEF of up to 40% who remained symptomatic at New York Heart Association (NYHA) functional class II or class III despite ACE inhibitor or ARB therapy for at least 3 months and were prescribed ARNI therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge.
  • PM-7: Dose of Beta-Blocker Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient Setting). Measure Description: Percentage of patients aged 18 years or older with a diagnosis of heart failure with a current or prior LVEF of up to 40% who were prescribed a guideline-recommended beta blocker (eg, bisoprolol, carvedilol, or sustained-release metoprolol succinate) at a dose that is at least 50% of the target dose.
  • PM-8: Dose of ACE Inhibitor, ARB, or ARNI Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient Setting). Measure Description: Percentage of patients aged 18 years or older with a diagnosis of heart failure with a current or prior LVEF of up to 40% who were prescribed an ACE inhibitor, ARB, or ARNI at a dose that is at least 50% of the target dose.
  • PM-9: Mineralocorticoid Receptor Antagonist Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting). Measure Description: Percentage of patients aged 18 years or older with a diagnosis of heart failure with a current or prior LVEF of up to 35% who are NYHA class II through class IV despite attempts at treatment with beta blockers and ACE inhibitors, ARB, or ARNI.
  • PM-10: Laboratory Monitoring in New Mineralocorticoid Receptor Antagonist Therapy (Outpatient and Inpatient Setting). Measure Description: Percentage of patients aged 18 years or older with a diagnosis of heart failure who were started on MRA therapy and had potassium and renal function checked within 1 week of the patient initiation of the MRA prescription.
  • PM-11: Hydralazine/Isosorbide Dinitrate Therapy for Heart Failure With Reduced Ejection Fraction in Those Self-Identified as Black or African American (Outpatient and Inpatient Setting). Measure Description: Percentage of patients aged 18 years or older with a diagnosis of heart failure and a current or prior ejection fraction of up to 40% who are self-identified as Black or African American and receiving ACE inhibitor, ARB, or ARNI therapy and beta-blocker therapy who were prescribed a combination of hydralazine and isosorbide dinitrate.
  • PM-13: Cardiac Resynchronization Therapy Implantation for Patients With Heart Failure With Reduced Ejection Fraction on Guideline-Directed Medical Therapy (Outpatient Setting). Measure Description: Percentage of patients aged 18 years or older with a diagnosis of heart failure with current LVEF of up to 35%, left bundle branch block (LBBB), QRS duration of 150 ms or greater, NYHA class II, III, and IV, despite ACE inhibitor, ARB, or ARNI and beta-blocker therapy for at least 3 months who have undergone CRT implantation.
  • QM-2: Measurement of Patient-Reported Outcome-Health Status (Outpatient Setting). Measure Description: Percentage of outpatients aged 18 years or older with a diagnosis of heart failure who have a disease-specific patient-reported health status measurement recorded within each 6-month period.
  • QM-3: Sustained or Improved Health Status (Patient-Reported Symptoms, Function, and Quality of Life) During the Reporting Period for All Patients With Heart Failure. Measure Description: Percentage of patients aged 18 years or older with heart failure whose patient-reported outcome score does not decline significantly (a decrease in scores of 5 points or more for the Kansas City Cardiomyopathy Questionnaire or an increase of 7 points or more for the Minnesota Living with Heart Failure Questionnaire) during a 12-month period.
  • SM-1: Participation in 1 or More Regional or National Registries That Include Patients With Heart Failure. Measure Description: Participation in a national or regional heart failure registry that provides regular performance reports based on benchmarked data.

The ACC/AHA update is endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Society of Health-System Pharmacists, Heart Rhythm Society, and the International Society for Heart and Lung Transplantation.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

References

  1. Writing Committee Members; Heidenreich PA, Fonarow GC, Breathett K, et al. 2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes. 2020;13(11):e000099. doi: 10.1161/HCQ.0000000000000099

2. Heidenreich PA, Fonarow GC, Breathett K, et al. 2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2020;76(21):2527-2564. doi: 10.1016/j.jacc.2020.07.023

3. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136(6):e137-e161. doi: 10.1161/CIR.0000000000000509