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Back To Vidyya Heart Failure Provider Performance Quality Indicators


Heart Failure Quality Improvement

In January, 1999, HCFA launched the Heart Failure National Project, a major effort to improve the care provided to Medicare patients with heart failure. Peer Review Organizations in all states and territories will work with hospitals over three years to improve left ventricular function evaluation and appropriate use of ACEI in patients hospitalized with heart failure.

PROVIDER PERFORMANCE QUALITY INDICATORS

Provider Performance Indicator 1: Proportion of eligible discharges not admitted on angiotensin-converting enzyme inhibitor ( ACEI)3 or angiotensin-receptor-blocker (ARB)4 with ejection fraction (EF) evaluated before or during admission.

inclusion criteria:
Alive at discharge

exclusion criteria:
Admitted on ACEI or ARB
Discharge plan for LVF evaluation after discharge

denominator: Number in sample after exclusion and inclusion criteria applied
numerator: Those in denominator with EF evaluation documented in medical record

Documentation of EF = Quantitative or qualitative inpatient or pre-admission lab or physician report of ejection fraction OR chart evidence that EF evaluation performed during hospitalization but results not available at time of discharge.

Provider Performance Indicator 2: Proportion of discharges not admitted on ACEI or ARB with documented left ventricular systolic dysfunction (LVSD) who:
1. are discharged on ACEI; OR
2. have documented reason for not being on ACEI

inclusion criteria:
In numerator of PPI-1
Documented LVSD: EF <40%
if no quantitative report of EF, narrative report of reduced EF

exclusion criteria:
On ARB but not ACEI at discharge5
Chart evidence that EF evaluation performed during hospitalization but results not available at time of discharge
Chart documentation of participation in a clinical trial testing alternatives to ACEI as first-line heart failure therapy

denominator: Number in this sample after exclusion and inclusion criteria applied
numerator: Those in denominator who meet at least one of the following conditions:
(1) On ACEI at discharge; OR
(2) Chart documentation of one or more of the following absolute contraindications to ACEI use:
(a) moderate or severe aortic stenosis;
(b) bilateral renal artery stenosis;
(c) history of angioedema, hives, or severe rash with ACEI use; OR
(3) Physician documentation of any specific reason why ACEI is not used.

PRO EVALUATION QUALITY INDICATOR

This is the single quality indicator which will be used to evaluate Peer Review Organization (PRO) performance. The quality indicator is designed to be statistically robust, based on process of care elements derived from published treatment guidelines, capable of being reliably measured, and amenable to improvement.

PRO Evaluation Indicator: Proportion of heart failure discharges with appropriate use/non-use of ACEI at discharge

inclusion criteria:
Alive at discharge

exclusion criteria:
On ARB but not ACEI at discharge6

denominator: Number in sample after exclusion and inclusion criteria applied
numerator: Those in denominator who meet at least one of the following conditions:
a) Documented left ventricular function (LVF) evaluation not consistent with left ventricular systolic dysfunction (ejection fraction (EF) equal or greater to 40% or equivalent narrative description); OR
b) On ACEI at discharge; OR
c) Chart documentation of one or more of the following absolute contraindications to ACEI use:
1) moderate or severe aortic stenosis; OR
2) bilateral renal artery stenosis; OR
3) history of angioedema, hives, or severe rash with ACEI use; OR
d) Physician documentation of any specific reason why ACEI is not used; OR
e) Chart documentation of participation in a clinical trial testing alternatives to ACEIs as first-line heart failure therapy; OR
f) Documented plan for LVF evaluation after discharge7; OR
g) LVF evaluation performed during hospitalization but results not in chart.

TEST PERFORMANCE QUALITY INDICATORS

These are quality indicators which have not yet been incorporated into published guidelines, or for which it is uncertain whether the process of care can be feasibly and reliably assessed or is amenable to quality improvement efforts. These quality indicators may prove useful in local improvement projects and might be eligible for inclusion as performance quality indicators in the next PRO contract cycle.

TPI-1: Proportion of eligible discharges to home with appropriate discharge instructions documented in the medical record.

inclusion criterion:
Discharge destination is home

TPI-1a:Proportion of eligible discharges with documentation of smoking status

denominator: Number in sample after inclusion criterion applied
numerator: Those in denominator with smoking status documented

TPI-1b:Proportion of smokers with documentation of instructions regarding smoking cessation

denominator: Number from numerator of TPI-1a who are smokers
numerator: Those in denominator with documentation of instructions regarding smoking cessation

TPI-1c8: Proportion of eligible discharges with copies of written discharge instructions for patient or surrogate in the medical record addressing all of the following:
--all discharge medications
--weight monitoring
--diet
--activity level
--follow-up appointment
--what to do if symptoms worsen

denominator: Number in sample after inclusion criterion applied with copy of written discharge instructions in medical record
numerator: Those in denominator with all six discharge instruction elements
N.B.: Analyses of each individual discharge instruction element will also be performed.

TPI-2: Proportion of discharges with admission diagnosis9 of heart failure with weights measured on at least 50% of hospital days.

inclusion criterion:
Admission diagnosis of heart failure

denominator: Number in sample after inclusion criterion applied
numerator: Those in denominator with weights measured on at least 50% of hospital days

TPI-3: Proportion of those with documented LVSD and a history of heart failure admitted on beta blocker.10

inclusion criteria:
History of heart failure documented in hospital record
Documented LVSD: EF < 40%
if no quantitative report of EF, narrative report of reduced EF

denominator: Number in sample after inclusion criteria applied
numerator: Those in denominator admitted on beta blocker

TPI-4: Proportion of discharges with follow-up provider visit within four weeks of discharge.11

inclusion criteria: Alive four weeks after discharge Part B coverage during four weeks after discharge Part A fee-for-service coverage during four weeks after discharge Discharged home

exclusion criteria:
Hospital admission within four weeks after discharge

denominator: Number in sample after inclusion and exclusion criteria applied
numerator: Those in denominator with billing data documenting physician visit within four weeks of discharge.

TPI-5: Proportion of patients with coronary artery disease discharged on aspirin, another antiplatelet agent, or warfarin.

inclusion criteria: Alive at discharge
History of/current coronary artery disease, as evidenced by:
(1) History of/current angina OR
(2) History of myocardial infarction, or coronary artery disease; OR
(3) History of PTCA or CABG; OR
(4) Myocardial infarction, PTCA or CABG during hospitalization; OR
(5) Cardiac catheterization during hospitalization consistent with coronary artery disease; OR
(6) Stress test during hospitalization consistent with coronary artery disease

denominator: Number in sample after inclusion criteria applied
numerator: Those in denominator discharged on aspirin, another antiplatelet agent, or warfarin.

TPI-6: Proportion of those with documented LVSD and a history of heart failure admitted on ACEI12 with dose at least 50% of that shown to be effective in clinical trials.

inclusion criteria:
Admitted on Captopril, Enalapril, Lisinopril, Benazepril, Fosinopril, Quinapril, Ramipril
History of heart failure documented in the hospital record
Documented LVSD: EF <40%
if no quantitative report of EF, narrative report of reduced EF

exclusion criteria:
Inability to determine ACEI dose or frequency OR
Moderate or severe aortic stenosis OR
Bilateral renal artery stenosis OR
History of angioedema, hives, or severe rash with ACEI use;

denominator: Number in sample after inclusion and exclusion criteria applied
numerator: Those in denominator whose admission dose of ACEI is at least 50% of the following ACEI doses demonstrated effective in clinical trials13:

        Captopril 150 mg/day
        Enalapril 20-40 mg/day
        Lisinopril 20-40 mg/day
        Benazepril 20-40 mg/day
        Fosinopril 20-40 mg/day
        Quinapril 20-40 mg/day
        Ramipril 10 mg/day

ADDITIONAL PERFORMANCE-RELATED ANALYSES

Admission and discharge medication data will be available to calculate utilization of ARBs, digoxin, nitrates/hydralazine, calcium channel blockers, beta blockers, NSAIDs, and diuretics.


3 Several members of the technical panel argued that, in the inpatient setting, LVF evaluation may not be necessary for someone already on ACEI; thus this measure excludes those admitted on ACEIs. We recognize the importance of ascertaining the LVEF to determine initial eligibility not only for ACEIs, but also for medications such as beta blockers and digoxin most often initiated in the outpatient setting.

4 Patients admitted on ARBs were excluded to avoid distracting providers' quality improvement focus by provoking debate over the equivalence/non-equivalence of ACEIs and ARBs. Guidelines available subsequent to development of these measures, based on recently-published study results, recommend use of ARBs only if ACEI is contraindicated (Heart Failure Society of America Guidelines for Management of Patients with Heart Failure Caused by Left Ventricular Systolic Dysfunction-Pharmacological Approaches, J Cardiac Failure 1999;5:357-82).

5 See previous footnote.

6 See previous footnote.

7 This provision is designed to account for those States/Territories with several providers lacking onsite EF assessment capability.

8 TPI-1c focuses on the quality of discharge instructions. Because assessment of discharge instruction quality using chart notes is of questionable validity, these Quality Indicators will assess only the quality of written discharge instructions provided to the patient/care giver with copies included in the chart. We realize that written instructions may be given to patients/care givers without inclusion of copies in the chart, in which case the quality cannot be assessed. PROs who are interested in calculating the proportion of discharges with chart documentation of provision of any discharge instructions will have access to the abstraction data needed to perform this analysis.

9 This test Quality Indicator uses admission diagnosis, since patients admitted with other diagnoses might not be expected to have intensive weight monitoring from the first day of hospitalization.

10 This test quality indicator is designed to assess outpatient care (since beta blockers are usually initiated on an outpatient basis), and thus includes only those with a history of heart failure who are on beta blockers at admission.

11 Because of delays in submission of Part B bills, calculation of this test quality indicator may be delayed.

12 This test quality indicator is designed to assess outpatient care, and thus includes only those with a history of heart failure admitted on ACEI.

13 The quality indicator includes only those ACEIs which have been demonstrated to be effective treatment for heart failure in published clinical trials. Since these trials suggest several "effective" doses for Enalapril, Benazepril, Fosinopril, and Quinapril, this quality indicator will be calculated separately for the lower and upper limits of the effective dose range. Because standard doses have not been established for Moexipril and Trandolapril, they are not included in this quality indicator.


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Editor: Susan K. Boyer, RN
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