Measuring quality of outpatient cardiovascular care.

Accurately measuring the quality of cardiovascular care and attempting to determine the sources of quality deficits are difficult challenges, particularly in the outpatient setting. Clinical trials have documented the benefits of warfarin in atrial fibrillation, angiotensin-converting enzyme (ACE) inhibitors in systolic heart failure, and aspirin and betaadrenergic blocking agents in myocardial infarction, and these treatments have been adopted into clinical guidelines (1–4). Despite the strong clinical evidence supporting the uses of these treatments, numerous reports have shown that their use is lower than ideal, although increasing with time (5–12). Prior studies have suggested that utilization of these drugs remains particularly low among patients cared for by noncardiovascular specialists (13–17). These potential gaps in quality have caused the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) to include these clinical conditions in the group of conditions targeted for quality improvement. Additionally, some third-party payers (i.e., Blue Cross Blue Shield) have selected these clinical practice domains to measure performance in an effort to provide incentive to optimize care. However, in the absence of prospective case review, determining the ideal rate of use of these medications in the outpatient clinical setting can be hampered by incomplete access to clinical information needed to determine if particular patients are truly candidates for the therapy.