Cardiovascular Project 2010-2013
1 - 30-Day All-Cause Risk Standardized Readmission Rate Following Heart Failure Hospitalization (risk adjusted)Organization: Centers for Medicare & Medicaid Services (CMS)
Description: The measure estimates a hospital-level risk-standardized readmission rate (RSRR), defined as a readmission for any cause within 30 days after discharge of the index admission date, for patients discharged from the hospital with a principal diagnosis of heart failure.
Type: Outcome
2 - ACE/ARB Therapy at Discharge for ICD Implant Patients with Heart Failure and LVSDOrganization: American College of Cardiology Foundation (ACCF)
Description: Proportion of ICD implant patients with a diagnosis of heart failure and left ventricular systolic dysfunction who were prescribed ACE-I or ARB therapy at discharge.
Type: Process
3 - Acute Myocardial Infarction 30-day MortalityOrganization: Centers for Medicare & Medicaid Services (CMS)
Description: The measure estimates a hospital-level risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date, for patients discharged from the hospital with a principal diagnosis of acute myocardial infarction.
Type: Outcome
4 - Aspirin at discharge for patients with PCIOrganization: American College of Cardiology Foundation (ACCF)/ Society for Cardiovascular Angiography and Interventions (SCAI)
Description: Proportion of PCI patients with aspirin prescribed at discharge.
Type: Process
5 - Assessment of Risk for Adverse Cardiovascular EventsOrganization: ACC/AHA Task Force on Performance Measures
Description: The cardiac rehabilitation/secondary prevention (CR) program has the following processes in place:
1. Documentation, at program entry, that each patient undergoes as assessment of clinical status (e.g., symptoms, medical history) in order to identify high-risk conditions for adverse cardiovascular events.
2. A policy to provide recurrent assessments for each patient during the time of participation in the CR program in order to identify any changes in clinical status that increase the patient's risk of adverse cardiovascular events. If such findings are noted, the CR staff contacts the program's physician director and/or the patient's primary health care provider according to thresholds for communication included in the policies developed for Performance Measure B-3 (Individualized Assessment and Evaluation of Modifiable Cardiovascular Risk Factors, Development of Individualized Interventions, and Communication With Other Health Care Providers).
Type: Process
6 - Assessment of Thromboembolic Risk FactorsOrganization: ACC/AHA Task Force on Performance Measures
Description: Patients with nonvalvular AF or atrial flutter in whom assessment of thromboembolic risk factors has been documented
Type: Process
7 - Beta Blocker at Discharge for ICD Implant Patients With a Previous MIOrganization: American College of Cardiology Foundation (ACCF)
Description: Proportion of ICD implant patients with a diagnosis of coronary artery disease and prior MI prescribed beta-blocker therapy on discharge.
Type: Process
8 - Beta Blocker at Discharge for ICD Implant Patients with Heart Failure and LVSDOrganization: American College of Cardiology Foundation (ACCF)
Description: Proportion of ICD implant patients with a diagnosis of heart failure and left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy on discharge.
Type: Process
9 - Beta Blocker at Discharge for ICD Implant Patients with Heart Failure and LVSDOrganization: American College of Cardiology Foundation (ACCF)
Description: Proportion of ICD implant patients with a diagnosis of heart failure and left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy on discharge.
Type: Process
10 - Cardiac Rehabilitation/Secondary Prevention (CR) Program Structure-Based Measurement SetOrganization: ACC/AHA Task Force on Performance Measures
Description: The cardiac rehabilitation/secondary prevention (CR) program has policies in place to demonstrate that:
1. A physician-director is responsible for the oversight of CR program policies and procedures and assures that policies and procedures are consistent with evidence-based guidelines, safety standards, and regulatory standards. This includes appropriate policies and procedures for the provision of alternative CR program services, such as home-based CR.
2. An emergency response team is immediately available to respond to medical emergencies.
A. In a hospital setting, physician supervision is presumed to be met when services are performed on hospital premises.
B. In the setting of a free-standing outpatient CR program (owned/operated by hospital, but not located on main campus), a physician-directed emergency response team must be present and immediately available to respond to emergencies.
C. In the setting of a physician-directed clinic or practice, a physician-directed emergency response team must be present and immediately available to respond to emergencies.
3. All professional staff have successfully completed the national Cognitive and Skills examination in accordance with the AHA curriculum for BLS with at least one staff member present who has completed the National Cognitive and Skills examination in accordance with the AHA curriculum for ACLS and has met state and hospital or facility medical-legal requirements for defibrillation and other related practices.
4. Functional emergency resuscitation equipment and supplies for handling cardiovascular emergencies are immediately available in the exercise area.
Type: Structure
11 - Chronic Anticoagulation TherapyOrganization: ACC/AHA Task Force on Performance Measures
Description: Prescription of warfarin for all patients with nonvalvular AF or atrial flutter at high risk for thromboembolism, according to risk stratification and 2006 guideline recommendations
Type: Process
12 - Chronic Stable Coronary Artery Disease: Blood Pressure ControlOrganization: American Medical Association-Physician Consortium for Performance Improvement
Description: Percentage of patients aged 18 years and older with a diagnosis of CAD with a blood pressure <140/90 mm Hg OR patients with a blood pressure =140/90 mm Hg and prescribed 2 or more anti-hypertensive medications during the most recent visit during the measurement period
Type: Process
13 - Chronic Stable Coronary Artery Disease: Symptom ManagementOrganization: American Medical Association-Physician Consortium for Performance Improvement
Description: Percentage patients aged 18 years and older with a diagnosis of CAD and with results of an evaluation of level of activity AND an evaluation of presence or absence of anginal symptoms, with appropriate management of anginal symptoms (evaluation of level of activity and symptoms includes no report of anginal symptoms OR evaluation of level of activity and symptoms includes report of anginal symptoms and a plan of care is documented to achieve control of anginal symptoms)
Type: Process
14 - Heart Failure 30-day MortalityOrganization: Centers for Medicare & Medicaid Services (CMS)
Description: The measure estimates a hospital-level risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date, for patients discharged from the hospital with a principal diagnosis of heart failure.
Type: Outcome
15 - Heart Failure: Post-Discharge Appointment for Heart Failure PatientsOrganization: American Medical Association-Physician Consortium for Performance Improvement
Description: Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of heart failure for whom a follow up appointment was scheduled and documented including location, date and time for a follow-up office visit, or home health visit (as specified)
Type: Process
16 - Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following an ischemic stroke hospitalizationOrganization: Centers for Medicare & Medicaid Services (CMS)
Description: The measure estimates a hospital-level risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date, for patients discharged from the hospital with a principal diagnosis of acute ischemic stroke.
Type: Outcome
17 - Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following an ischemic stroke hospitalizationOrganization: Centers for Medicare & Medicaid Services (CMS)
Description: The measure estimates a hospital 30-day, risk-standardized readmission rate (RSRR), defined as readmission for any cause within 30 days after the date of discharge of the index admission for patients discharged from the hospital with a principal diagnosis of acute ischemic stroke.
Type: Outcome
18 - Hypertension: Blood Pressure ControlOrganization: American Medical Association-Physician Consortium for Performance Improvement
Description: Percentage of patients aged 18 years and older with a diagnosis of hypertension with a blood pressure <140/90 mm Hg OR patients with a blood pressure =140/90 mm Hg and prescribed 2 or more anti-hypertensive medications during the most recent office visit during the measurement period
Type: Process
19 - Individualized Assessment and Evaluation of Modifiable Cardiovascular Risk Factors, Development of Individualized Interventions, and Communication With Other Health Care ProvidersOrganization: ACC/AHA Task Force on Performance Measures
Description: This performance measure includes 10 individual sub-measures for the evaluation of modifiable cardiovascular risk factors, development of individualized interventions, and communication with other health care providers concerning these risk factors and interventions.
The rationale for including both recognition and intervention for satisfactory fulfillment of these measures is predicated upon the belief that high-quality cardiovascular care requires both the identification and treatment of known cardiovascular risk factors.
An important component of this performance measure is the expectation that the cardiac rehabilitation/secondary prevention (CR) staff communicates with appropriate primary care providers and treating physicians in order to help coordinate risk factor management and to promote life-long adherence to lifestyle and pharmacological therapies. Individual sub-measures address: A. Tobacco use
B. Blood pressure control
C. Optimal lipid control
D. Physical activity habits
E. Weight management
F. Diagnosis of diabetes mellitus or impaired fasting glucose
G. Presence or absence of depression
H. Exercise capacity
I. Adherence to preventive medications
J. Communication with Health Care Providers
Type: Process
20 - Monitor Response to Therapy and Document Program EffectivenessOrganization: ACC/AHA Task Force on Performance Measures
Description: For each cardiac rehabilitation/secondary prevention (CR) program in a health care system, a written policy is in place to:
1. Document the percentage of patients for whom the CR program has received a formal referral request who actually enroll in the program.
2. Document for each patient a standardized plan to assess completion of the prescribed course of CR as defined on entrance to the program.
3. Document for each patient a standardized plan to assess outcome measurements at the initiation and again at the completion of CR, including at least 1 outcome measure for the core program components as outlined in the Cardiac Rehabilitation/Secondary Prevention Performance Measure Set B, Performance Measure 3.
4. Describe the program’s methodology to document program effectiveness and initiate quality improvement strategies.
Type: Structure
