But Ileana Piña said it doesnt make sense to use short-term outcomes to assess performance measuressuch as smoking-cessation counselingdesigned with long-term benefits in mind.
Piña directs Case Western Reserve Universitys heart failure and cardiac transplant program and serves on the American College of Cardiology/American Heart Association Writing Committee to Develop Heart Failure Clinical Performance Measures.
It does a disservice to say the performance measures dont work, Piña said. A 60- to 90-day mortality/readmission rate is not going to give you a true picture.
Fonarow, however, said it all comes down to the argument of process measures vs. outcome measures. He insisted that focusing on the latter breaks down medical-department silos, while an emphasis on the former pigeonholes patients into different disease-state categories even though its highly likely that what is required for them is the simultaneous management of several co-morbidities.
Outcome measures create an incentive to invest in the development of high quality of care across all components of careand not just where the performance measures apply, Fonarow said. Also, there is a potential for harm because you do have some hospitals and physicians who are focusing on performance measures to the exclusion of the
Whats more, according to the reports findings, none of the actions mandated under the five American College of Cardiology/American Heart Association heart-failure performance measures was a significant independent predictor of death in the first 60 to 90 days after hospital discharge. Those actions were: providing discharge instructions, evaluating left ventricular systolic function, prescribing an angiotensin-converting enzyme, or ACE, inhibitor or angiotensin receptor blocker for left ventricular systolic dysfunction, offering adult smoking cessation advice/counseling, and giving an anti-coagulant at discharge for patients with atrial fibrillation.
On top of that, only one of the five measures was associated with lowering the 60- to 90-day mortality/readmission rate and one common and measurably significant treatmentthe use of beta blockersis not included in the set of performance measures.
Fonarow and colleagues analyzed data from 5,791 heart-failure patients at 91 hospitals from March 2003 to December 2004 to determine the relationship between five recognized practice guidelines and readmissions and death after discharge.
According to the study, only the use of an ACE inhibitor or an angiotensin-receptor blocker had a significant impact, and this measure was associated with a 49% lower risk for 60- to 90-day mortality and readmissions. Additionally, even though its use isnt included in the performance measures, the prescription of a beta blocker at discharge was associated with a 52% reduced risk of death and a combined 27% lower risk of death and readmission, the report said.
The importance of measuring and trying to improve quality of care is unchangedits critically important with the huge variation in care that exists, Fonarow said. This article highlights how more needs to be done. The additional step of testing the performance of performance measures has not really been done. This study illustrates that this is an important step.
Piña said the American College of Cardiology and the American Heart Association already have a process in place to review and revise, if necessary, the heart-failure guidelines.
When we launched these, we said at some point well look at how performance measures affect care, she said.
Regarding the lack of a beta blocker measure, Piña said that the performance measures were developed through a very organized and rigorous process that calls for measures to be backed with evidence derived from randomized, controlled studies.
The only randomized controlled heart-failure studies done on beta blockers, she said, were done on an outpatient basis, sountil more inpatient research is donethere cant be hospital-performance measures mandating their use.
Fonarow also criticized the guidelines for providing discharge instructions and smoking-cessation counseling as not going far enough. If the doctor walks into the room and says Quit smoking, that fulfills that measure, he said. Also, counseling smokers is not the equivalent of patients quitting.
Piña noted that, in particular, documentation requirements for discharge instruction have gotten stricter.
In a medical record, just to say discharge instruction given, thats not sufficient anymore, she said, explaining that physicians must specify in detail what instructions have been given.