Ambulatory care CAD guidelines push targets

A group of professional societies has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote them, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care.

“It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved,” wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee led by the American College of Cardiology Foundation, the American Medical Association, and the American Heart Association.

The last such measures were issued in 2005. Seven performance measures were carried over but were updated.

For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control.

Similarly, for lipids, the guideline has evolved from measuring and providing medications to also reporting on control. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners now are asked to assess them simultaneously.

For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on evaluation of the presence or absence of angina symptoms with appropriate management of those symptoms.

A second measure calls on physicians to refer all patients who’ve had an acute MI, coronary artery bypass graft surgery percutaneous coronary intervention, cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered “difficult to implement,” according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that, “although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control.” If such a measure existed, physicians might avoid caring for patients who were nonadherent.