ACC/AHA Classification of Care Metrics Clinical performance measures: Those measures specifically suitable for public reporting, external comparisons, and possibly pay-for-performance programs. Performance measurements are developed using evidence based guidelines for life-extending or life-hancing therapies Quality metrics: Those measures that have been developed to support self assessment and quality improvement at the provider, hospital, and/or health care system level. These metrics represent valuable tools to aid clinicians and hospitals in improving quality of care and enhancing patient outcomes but may not have the rigor to be considered as clinical performance measures Bonow R J Am Coll Cardiol (Published online 10 November 2008)

Key Publications (2) Bonow RO et al. JACC 2005;46:1144-78 (3) AMA Physician Consortium AMA-assn.org (4) AHA Physician Consortium AMA-ass.org (5) Krumholtz HM et al JACC 2006; 47:236-65 (6) Thomas RJ et al JACC 2007; 50: 1400-33 (7) Estes NA et al JACC 2008; 51:865-84

ACC/AHA 2008 Care Metrics for AMI J Am Coll Cardiol, doi:10.1016/j.jacc.2008.10.012 (Published online 10 November 2008) Krumholz HM et al J Am Coll Cardiol (Published online 14 November 2008)

Caveats: Does not include UA Includes only patients admitted with the diagnosis of AMI not those who develop AMI while in-hospital Retrospective identification of cases for review General alignment with CMS/TJC measures Documentation by nursing or medical students not sufficient

Omitted Performance Measure: Early B Blocker therapy Early B Blocker therapy has been shown to reduce recurrent angina and MI but not mortality. The COMMIT study showed that B blocker therapy reduced arrhythmic death and reMI but significantly increased the incidence of cardiogenic shock, particularly with CHF and hemodynamic instability Krumholz HM J Am Coll Cardiol (Published online 14 November 2008)

ACC/AHA 2008 Specific Changes Revised Performance Measure: Statins at Discharge HMG Co-A reductase inhibitors reduce the risk of death/reMI to the same magnitude of ACE inhibitors and BB, irrespective of the baseline LDL concentration. Patients with a known LDL cholesterol < 100 mg/dL are not included LDL cholesterol measurement moved to Test Measure New Performance Measure: Evaluation of LV systolic function Patients with reduced LVEF may be candidates for additional therapies, including ACEI or ARBs or invasive therapy. May also document intention to measure LVEF as outpatient Measurements more concordant with the CMS-TJC Krumholz HM J Am Coll Cardiol (Published online 14 November 2008)

* New Performance Measures Krumholz HM J Am Coll Cardiol (Published online 14 November 2008)

ACC/AHA 2008 Specific Changes New Performance Measurement: Timely Reperfusion For Primary PCI, measurement stops with use of 1st device, including thrombectomy devices, balloon, and stent Performance metric now includes transfer times and door in-door out at referring hospital  total door-to-balloon time. Although a benchmark value has not been set, incentives now present to short this time (v. fibrinolytic therapy) New integrated measurements will facilitate communications between transferring and receiving hospitals Quality assurance analysis of “false alarms” encouraged Masoudi FA et al. ACC/AHA 2008 Statement on Performance Measurement and Reperfusion Therapy JACC on line Nov 10, 2008 Krumholz HM J Am Coll Cardiol (Published online 14 November 2008)

New test measures rather than performance measures Krumholz HM J Am Coll Cardiol (Published online 14 November 2008)

ACC/AHA 2008 Specific Changes Initial Parenteral Anticoagulation and Antiplatelet Dosing Concern over over-dosing of anticoagulation therapy, particularly with the use of GPI and in the eldery Collection of GFR using Cockroft-Gault or MDRD formula As a test measure, these indices are useful for internal QA activities and not as a performance measure New Test Measure: Clopidogrel at Discharge Dual anti-platelet therapy received in high percentage of patients who receive PCI and stents with hospitalization. This measure focuses on those patients treated with medical therapy alone (PCI and CABG patients excluded) Requires careful documentation of reasons why DAP not given in this heterogeneous patient population Krumholz HM J Am Coll Cardiol (Published online 14 November 2008)

Take Home Messages ACC/AHA Care Metrics including both Quality Performance Measures and Care Metrics for AMI (STEMI and NSTEMI) Updated ACC/AHA statement moves these criteria more in line with CMS and TLC Core Measures for AMI Key points in review: - Early B blocker therapy removed as Performance Measure - Statin therapy initiated on all patients with AMI - Addition of additional markers for reperfusion times that account for interhospital transfer delays - Cardiac rehabilitation referrals as part of Performance Measures Addition of a series of Quality Metrics focused on appropriate dosing of anticoagulation and avoidance of bleeding complications, particular in patients with renal insufficiency and in the elderly