ACC, AHA release updated performance, quality measures for afib

The American College of Cardiology (ACC) and the American Heart Association (AHA) released updated clinical performance and quality measures this week for treatment of atrial fibrillation or atrial flutter in adults in both outpatient and inpatient settings.

The AHA/ACC writing committee reviewed evidence-based guidelines and clinical guidance documents to develop 24 total measures, including 6 performance measures (3 inpatient and 3 outpatient) and 18 quality measures (10 inpatient and 8 outpatient). All of the measures were designed to assess care quality for inpatients and outpatients with atrial fibrillation or atrial flutter, excluding patients younger than age 18 and those receiving comfort care only.

The performance measures, classified under the domain of effective clinical care, were as follows:

• CHA₂DS₂-VASc risk score documented before discharge (inpatient)
• Anticoagulation prescribed before discharge (inpatient)
• Planned follow-up documented before discharge for warfarin treatment (inpatient)
• CHA₂DS₂-VASc risk score documented (outpatient)
• Anticoagulation prescribed (outpatient)
• Monthly international normalized ratio for warfarin treatment (outpatient)

The quality measures were classified under the domains of effective clinical care, patient safety, or communication and care coordination. Measures that addressed both inpatient and outpatient care were as follows, with inpatient measures applying prior to discharge:

• Beta-blocker prescription when the left ventricular ejection fraction is less than or equal to 40%
• Inappropriate prescription of antiarrhythmic drugs for rhythm control in patients with permanent atrial fibrillation
• Inappropriate prescription of dofetilide or sotalol in patients with atrial fibrillation and end-stage kidney disease or on dialysis
• Inappropriate prescription of a direct thrombin or factor Xa inhibitor in patients with atrial fibrillation with a mechanical heart valve
• Inappropriate prescription of a direct thrombin or factor Xa inhibitor in patients with atrial fibrillation and end-stage kidney disease or on dialysis
• Inappropriate prescription of antiplatelet or oral anticoagulation therapy for patients who do not have coronary artery disease and/or vascular disease
• Inappropriate prescription of nondihydropyridine calcium-channel antagonist in patients with reduced ejection fraction heart failure
• Shared decision making between physicians and patients regarding anticoagulation prescription

Inpatient-only quality measures included prescription of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker when left ventricular ejection fraction is less than or equal to 40% and lack of anticoagulant treatment during or after a procedure in patients who had atrial catheter ablation.

The writing committee did not recommend documentation of a bleeding score or bleeding risk assessment because not enough data were available. “Future research is needed to determine whether bleeding scores can lead to actionable risk stratification of patients,” the committee wrote.

The committee also called for more research on use of an outcome such as stroke rate per capita as a measure of care quality in atrial fibrillation and on anticoagulation in at-risk adults with congenital heart disease. Other areas highlighted for future study included shared decision making about rhythm or rate control strategies, inappropriate use of anticoagulation in very low-risk patients, and pharmacokinetic guides for dose adjustment of new oral anticoagulants.

The performance and quality measures were published jointly online June 27 by the Journal of the American College of Cardiology and Circulation: Cardiovascular Quality and Outcomes.