New performance measures released for in- and outpatient heart failure care

Updated heart failure performance measures, released last week by three major medical groups, include expanded use for beta-blockers in the inpatient setting. The new measures, which appear online at Circulation, include changes to inpatient and outpatient care.

Changes to inpatient measures include the following:

Left ventricular systolic function. The new measures added a qualitative description of left ventricular ejection fraction (LVEF) to allow easier implementation of treatment-based measures.

Beta-blocker therapy for left ventricular systolic dysfunction (LVSD). The new measures added this to the inpatient setting and specified bisoprolol, carvedilol and sustained-release metoprolol succinate to harmonize treatment across settings. Starting these therapies is recommended in stable patients before hospital discharge.

Angiotensin-converting enzyme inhibitors (ACEs) or angiotensin receptor blockers (ARBs) for LVSD. The measure set combines inpatient and outpatient measures, defines what is prescribed, and simplifies exclusions. This harmonizes treatment across settings, clarifies which drugs should be used, and allows for patient preferences and clinical judgment.

Postdischarge appointment for heart failure patients. This is a new measure.

The report retired the measures on use of anticoagulants at discharge, discharge instructions and smoking cessation counseling because they have become a standard of care for broader populations.

Changes to outpatient measures include:

LVEF assessment. The description was modified because evaluation of LVEF in heart failure patients provides important information to direct appropriate treatment.

Symptom and activity assessment. Assessment of activity levels and assessment of clinical symptoms of volume overload were combined to provide a more comprehensive overview of patient status.

Symptom management. This new measure is intended as a quality metric.

Patient self-care education. This measure changed to a quality metric.

ACEs or ARBs for LVSD. Use of these classes of drugs remains suboptimal, especially in the outpatient setting.

Counseling about implantable cardioverter defibrillators (ICDs). This quality metric changed to a measure because ICDs have proved to be highly effective for preventing sudden death, but half of eligible patients don't undergo implantation.

Initial lab tests and weight measurement were retired because they have become a standard of care. Blood pressure measurement and assessment of volume overload were retired as measures because of poor evidence support. Warfarin for patients with atrial fibrillation was retired because it became part of a larger measure set for a broader population of patients.

The measures were released by the American College of Cardiology Foundation, the American Heart Association and the American Medical Association-Physician Consortium for Performance Improvement.