2020 Update to the 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

HomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 12020 Update to the 2016 ACC/AHA Clinical Performance Measures for Adults With Atrial Fibrillation or Flutter: A Report of American College Cardiology/American Heart Association Task Force on Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree ArticlePDF/EPUB2020 Writing Committee Members, Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair N. Mark Estes III, FAHA Gregg C. Fonarow, Corrine Y. Jurgens, PhD, RN, ANP, Michelle M. Kittleson, FACC Joseph E. Marine, MBA, FHRS David D. McManus, Robert L. McNamaraMD, MHS, Members Search more papers by this author , HeidenreichPaul Heidenreich IIIN. III FonarowGregg Fonarow JurgensCorrine Jurgens KittlesonMichelle Kittleson MarineJoseph Marine McManusDavid McManus McNamaraRobert McNamara Originally published7 Dec 2020https://doi.org/10.1161/HCQ.0000000000000100Circulation: Outcomes. 2021;14:e000100Table ContentsTop 5 Take-Home Messages 120Preamble 1201. Decision Measure Anticoagulation 1201.1. Background 1202. Updated 1212.1. Discussion Changes 121References 122Appendix 123Short Title: PM-1: CHA2DS2-VASc Risk Score Documented Prior Discharge PM-2: Prescribed 125Short PM-3: PT/INR Planned Follow-Up Warfarin Treatment 127Short PM-4: (Outpatient) 128Short PM-5: 130Appendix B. Author Relationships Industry Other Entities (Relevant) 131Appendix Reviewer (Comprehensive) 132Top FlutterThis document describes updates atrial fibrillation performance measures that are appropriate public reporting pay-for-performance programs.The taken from 2019 Association/Heart Rhythm Society guideline update selected strongest recommendations (Class 1 3).Quality provided not yet ready programs but might be useful clinicians healthcare organizations quality improvement.The recent change regarding definition valvular is now incorporated into measures. This includes patients with moderate severe mitral stenosis those a mechanical prosthetic heart valve.The changes different risk score treatment thresholds men (>1) women (>2) measures.PreambleThe Cardiology (ACC)/American (AHA) measurement sets serve as vehicles accelerate translation scientific evidence clinical practice. developed intended provide practitioners institutions deliver cardiovascular services tools measure care identify opportunities improvement.Writing committees instructed consider methodology development1,2 ensure aligned practice guidelines. The writing also charged constructing maximally capture important aspects quality, including timeliness, safety, effectiveness, efficiency, equity, patient-centeredness, while minimizing, when possible, burden imposed hospitals, practices, practitioners.Potential challenges implementation may lead unintended consequences. manner in which addressed dependent several factors, design, data collection method, attribution, baseline rates, methods, incentives linked these reports.The (Task Force) distinguishes metrics local improvement pay (uses measures). New initially evaluated potential inclusion In some cases, insufficiently supported other instances, guidelines support measure, committee feel it necessary have tested consequences implementation. then promoted status supporting becomes available.P. Michael Ho, FAHAChair, Measures1. Anticoagulation1.1. BackgroundIn 2020, convened begin process updating chronic anticoagulation therapy set.3 was task identifying any additional need accordance AHA/ACC/Heart (HRS) update.42. Measures2.1. AnticoagulationThere were 2 measures, both prompted AHA/ACC/HRS update.4 first, impacts all (see Appendix A, specifications), clarification either valve. second separation male female threshold score. only applies Fibrillation/Atrial Prescribed.ACC/AHA MeasuresP. Chair*; H. Vernon Anderson, FACC*; Ankeet S. Bhatt, MBA*; Biykem Bozkurt, FAHA†; Sandeep Das, MPH, FACC†; Joao F. Monteiro Ferreira, Ex Officio†; Stacy Garcia, RT(R), BSN, MBA-HCM*; Hall, Hani Jneid, Christopher Lee, Leo Lopez, FAHA*; Jeffrey W. Olin, DO, Manesh R. Patel, Faisal Rahman, BM BCh*; Katherine Salciccioli, MD†; Boback Ziaeian, FAHA*StaffAmerican CardiologyAthena Poppas, PresidentCathleen Gates, Interim Chief Executive OfficerJohn Rumsfeld, Science OfficerLara Slattery, Division Vice President, Registry AccreditationGrace Ronan, Team Lead, Policy PublicationTimothy Schutt, MA, AnalystAmerican AssociationAbdul Abdullah, Director, Guideline MethodologyRebecca Diekemper, Advisor, MeasuresAmerican AssociationMitchell S.V. Elkind, FAAN, PresidentNancy Brown, OfficerMariell Jessup, Medical OfficerRadhika Rajgopal Singh, Office Science, Medicine HealthJohanna Sharp, MSN, HealthMelanie Shahriary, Senior Manager, Metrics, Health ITJody Hundley, Production Operations Scientific Publications, OperationsFootnotesThe requests cited follows: PA, NAM 3rd, GC, CY, MM, JE, DD, RL. 2020 adults flutter: report Measures. Circ Cardiovasc Qual 2021;14:e000100. doi: 10.1161/HCQ.0000000000000100Developed Collaboration SocietyACC/AHA see page 122This Physician Measurement Set (PPMS) related specifications Consortium Improvement (the Consortium), (ACC), (AHA), (AMA), facilitate quality-improvement activities physicians. contained PPMS guidelines, do establish standard medical care, been applications. Although copyrighted, they can reproduced distributed, without modification, noncommercial purposes, example, use health providers connection their practices. Commercial defined sale, license, distribution commercial gain, incorporation product service sold, licensed, distributed gain. uses require license agreement between user AMA (on behalf Consortium) ACC AHA. Neither AMA, ACC, AHA, Consortium, nor its members shall responsible PPMS.The “as is” warranty kind.Limited proprietary coding convenience. Users code should obtain licenses owners sets. National Assurance (NCQA), (PCPI) disclaim liability accuracy Current Procedural Terminology (CPT) specifications.CPT copyright 2004–2012 Association. LOINC Regenstrief Institute, Inc. material contains SNOMED CLINICAL TERMS (SNOMED CT) International Standards Development Organization. All rights reserved.This underwent 14-day peer review April 16, May 1, 2020.This approved Approval June 29, 2020; Advisory Coordinating July August 10, 6, 2020.Supplemental available article at https://www.ahajournals.org/doi/suppl/10.1161/HCQ.0000000000000100This has copublished Journal Cardiology.Copies: websites (www.acc.org) (https://professional.heart.org). copy https://professional.heart.org/statements selecting “Guidelines & Statements” button. To purchase reprints, call 215-356-2721 email Meredith.[email protected]com.The expert AHA-commissioned documents (eg, statements, systematic reviews) conducted AHA Operations. For statements development, visit https://professional.heart.org/statements. Select drop-down menu near top webpage, click “Publication Development.”Permissions: Multiple copies, alteration, enhancement, and/or permitted express permission Instructions obtaining located https://www.heart.org/permissions. link “Copyright Permissions Request Form” appears paragraph (https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form).References1. Spertus JA, Bonow RO, Chan P, et al.. ACCF/AHA new insights measurement: Foundation/American Measures.Circulation. 2010; 122:2091–106LinkGoogle Scholar2. Eagle KA, Krumholz HM, selection creation quantifying care.Circulation. 2005; 111:1703–12.LinkGoogle Scholar3. Solis NAM, Measures.Circ 2016; 9:443–88.LinkGoogle Scholar4. January CT, Wann LS, Calkins H, focused 2014 management fibrillation: Practice Guidelines Developed collaboration Thoracic Surgeons.Circulation. 2019; 140:e125–51LinkGoogle Scholar5. Lin HJ, Wolf Kelly-Hayes M, Stroke severity Framingham Study.Stroke. 1996; 27:1760–4LinkGoogle Scholar6. 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Hohnloser SH, Duray GZ, Baber U, Prevention current strategies future directions.Eur Suppl. 2008; 10:H4–10CrossrefGoogle ScholarAppendix A.Updated MeasuresShort DischargePM-1: DischargeMeasure Description: Percentage patients, age ≥18 y, AF flutter whom documented record.NumeratorPatients prior dischargeFor flutter, assessment include:CHA2DS2-VAScScoreCongestive HF1Hypertension1Age 65-74 y1Age ≥75 y2Diabetes mellitus1Stroke, TIA, thromboembolism2Vascular disease (prior myocardial infarction, peripheral artery disease, aortic plaque)1Sex category (ie, female)1DenominatorAll flutterDenominator ExclusionsPatients <18 yPatients stenosisPatients valvePatients transient reversible causes pneumonia, hyperthyroidism, pregnancy, cardiac surgery)Patients who leave against advicePatients die during hospitalizationPatients comfort onlyPatients transferred another acute hospitalPatients indication anticoagulationDenominator ExceptionsDocumentation reason assessing documenting score, present planned left appendage occlusion ligation, hypertrophic cardiomyopathy, reasonsDocumentation patient preference receiving anticoagulationMeasurement PeriodEncounterSources DataMedical record database administrative, clinical, registry)AttributionMeasure reportable facility physician levelCare SettingInpatientRationale AF, whether permanent, symptomatic silent, significantly increases ischemic stroke. 5-fold, setting 20-fold over sinus rhythm. stroke, certain factors. Thromboembolism occurring associated greater recurrent disability, mortality.5 Silent stroke.6–9 control hypertension hypercholesterolemia, substantially reduce risk. One meta-analysis stratified among point scoring system:10 Investigators; CHA2DS2 (congestive hypertension, mellitus, attack [doubled]), y [doubled],11 TIA [doubled], vascular 65–74 sex category). Compared score,12 broader range (0 9) larger number (female sex, age, disease).13,14 agent based shared decision-making takes account cost, tolerability, preference, drug interactions, characteristics, time INR therapeutic if warfarin, irrespective pattern permanent.Clinical Recommendation(s) Management Patients Fibrillation4 1. elevated 3 women, recommended. Options include: Level Evidence: A)15–17 B)18 B)19 B),20 B-R)21 MODIFIED: recommendation updated response approval edoxaban, factor Xa inhibitor. More precision specified subsequent recommendations. LOEs dabigatran, rivaroxaban, apixaban granularity per LOE system (Section 4.1. Guideline.4) original text found Section 4.1 guideline.22 Additional information about comparative effectiveness DOACs 4.2.2.2. 2. (dabigatran, apixaban, edoxaban) recommended DOAC-eligible (except valve).18–21 A) NEW: Exclusion criteria When DOAC trials considered group, direct thrombin inhibitor inhibitors least noninferior and, trials, superior preventing systemic embolism lower risks serious bleeding. 3. Among treated determined weekly initiation monthly (INR range) stable.23–25 “Antithrombotic” changed “anticoagulant.” 4. valve), risk.15–17 B) 5. valves, recommended.26–30 6. thromboembolism, permanent.31–34 7. individualized basis after discussion absolute relative bleeding, well patient’s values preferences. C) 8. according same used AF. 9. Reevaluation choice periodic intervals reassess risks. “anticoagulant.”All exclusions removed denominator. exceptions denominator numerator met.ACC indicates Cardiology; fibrillation; Association; DOAC, direct-acting anticoagulant; failure; HRS, Society; INR, ratio; LOE, level evidence; PM, measure; attack.Short DischargePM-2: