Performance, Quality Measures Updated for Atrial Fibrillation/Flutter

Pam Harrison

July 06, 2016

PALO ALTO, CA ― The American College of Cardiology and American Heart Association (AHA) have jointly issued new clinical performance and quality measures for adults with atrial fibrillation or atrial flutter (together AF).

The document, published online in the Journal of the American College of Cardiology[1] and Circulation Cardiovascular Quality Outcomes[2], updates the last version released in February 2008 and related implementation notes issued in 2011.

"Compared with 2008, the new document has expanded performance measures to the inpatient setting, while quality measures are to be used by physician groups, hospitals, or other organizations to look for potential quality issues," Dr Paul Heidenreich (Stanford Health Policy, Palo Alto, California), chair of the writing committee and the ACC/AHA task force on performance measures, told heartwire from Medscape in an email.

"And eventually, we hope that some of the quality measures can be promoted to performance measures," he added.

The three main outpatient performance measures for practitioners include:

  • Documenting the CHA2DS2-VASc risk score to establish patients' risk of stroke and eligibility for anticoagulation therapy.

  • Prescribing an anticoagulant for appropriate patients.

  • Monitoring the international normalized ratio for warfarin monthly.

"Performance measures should be given more importance than the quality measures," Heidenreich noted.

"If quality improvement efforts are limited, then practitioners should first focus on maximizing the three performance measures."

Heidenreich also pointed out that a large number of quality measures have been identified in the updated document as well. These measures are to be used to improve quality of care locally but are not intended for public reporting or pay for performance.

Six of the quality measures for the outpatient setting involve inappropriate prescription of various medications that are ineffective or associated with serious safety concerns.

Specifically, the task force warned against inappropriate prescription of:

  • Antiarrhythmic drugs to patients with permanent AF for rhythm control.

  • Dofetilide or sotalol in patients with AF and end-stage renal disease (ESRD) or on dialysis.

  • A direct thrombin or factor Xa inhibitor in patients with AF and a mechanical heart valve. The same caution applies to patients with AF and ESRD or on dialysis who similarly should not receive a direct thrombin or factor Xa inhibitor, including rivaroxaban (Xarelto, Bayer/Janssen Pharmaceuticals) or edoxaban (Savaysa, Daiichi-Sankyo).

  • An antiplatelet agent or oral anticoagulation therapy for patients who do not have CAD or vascular disease.

  • A nondihydropyridine calcium-channel antagonist in patients with reduced-ejection-fraction heart failure.

Also, the more than six million Americans living with AF may notice a change in their care with the addition of shared decision-making as a quality measure.

"A shared decision-making measure could mean physicians will take more time to explain anticoagulant therapy options and consider a patient's personal goals and values," task force member Dr Gregg Fonarow (David Geffen School of Medicine, Los Angeles, California) said in a statement.

Task-force members acknowledge that it may be difficult for some health systems to implement all 13 inpatient or 11 outpatient measures.

However, the use of the AF performance and quality measures "will improve patient care and substantially lower the risk of death or a permanently disabling stroke," Fonarow suggests.

AF is costly from both a medical and social viewpoint, at an estimated $6 billion a year for direct care of AF alone.

"On the basis of this . . . identifying performance and quality measures that can be implemented by providers or healthcare systems may aid not only in improving patient care, but also in reducing costs by reducing adverse outcomes of AF (eg, fewer strokes)," task force members write.

Heidenreich reported no relevant financial relationships. Fonarow reported consulting for Amgen, Janssen, Bayer, Boston Scientific, Johnson & Johnson, the Medicines Company, Medtronic, Novartis, and Takeda and research funding from Gambro, Medtronic, the National Heart, Lung, and Blood Institute, the National Institutes of Health/National Institute of Allergy and Infectious Diseases, and Novartis. Disclosures for the coauthors are listed in the paper.

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