New ACC/AHA Performance, Quality Measures for Cardiac Rehab

Megan Brooks

April 05, 2018

The American College of Cardiology (ACC) and American Heart Association (AHA) have released a new set of performance and quality measures for cardiac rehabilitation (CR).

The ACC/AHA Task Force on Performance Measures believes that implementation of this measure set by healthcare systems, healthcare providers, health insurance carriers, chronic disease management organizations, CR programs, and other groups who have responsibility for the delivery of care to persons with cardiovascular disease will "enhance the structure, process, and outcomes of care provided to patients who are eligible for CR services," they write.

The 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation were published online March 29 in the Journal of the American College of Cardiology

The task force first issued CR performance measures (PMs) in 2007  and published a focused update in 2010.  The latest version includes six PMs (two revised, four new) and adds three quality measures (QMs).

The revised CR PMs address referral from the inpatient (PM-1) and outpatient (PM-3) settings. 

PM-1 on CR referral from an inpatient setting states that all patients hospitalized with a CR-eligible diagnosis or procedure should be referred to an outpatient CR program prior to discharge.

PM-3 on CR referral from an outpatient setting states that all outpatients who are eligible for CR and have not yet participated in CR should be referred to an outpatient CR program.

For both, the task force notes that if the patient declines CR referral, referral order and patient materials should not be sent to the receiving CR program against the patient's wishes. CR referral would still be met as long as other aspects of CR referral have been met (CR referral recommended and documented).

Noteworthy new PMs advise that patients with heart failure with reduced ejection fraction (HFrEF) be referred for CR and include measures to assess enrollment in CR, Randal J Thomas, MD, Mayo Clinic, Rochester, Minnesota, and chair of the ACC/AHA Task Force on Performance Measures, noted in an interview with theheart.org | Medscape Cardiology.

I think there are still some physicians who don't know that cardiac rehabilitation is not only a strong recommendation for patients with heart failure with reduced ejection fraction but also that it's covered by insurance. Randal J Thomas

"I think there are still some physicians who don't know that cardiac rehabilitation is not only a strong recommendation for patients with heart failure with reduced ejection fraction but also that it's covered by insurance. The addition of enrollment measures helps make sure we are catching that part as well," Thomas said.

Referral to exercise training is advised for patients with HF from the inpatient setting (PM-2) and the outpatient setting (PM-4).

Exercise training is a Class 1 recommendation for patients with HFrEF and is typically provided through an outpatient CR program, the task force says. Exercise training has been shown to help improve functional capacity for patients with HFrEF. In addition, CR improves functional capacity, exercise duration, health-related quality of life, and mortality (Class IIa, Level of Evidence B), they note.

CR enrollment PMs address claims-based enrollment (PM-5a) and registry/electronic health record (EHR)–based enrollment (PM-5b). Although CR referral is a "critically important" first step in CR participation, CR enrollment is the goal of CR referral and is essential for patients to derive the benefits associated with CR participation, the task force notes.

They say the option, to use claims-based data, is included to allow flexibility in the measure assessment for healthcare organizations that may wish to use claims-based data, with or without the use of registry/electronic health record data. The same goes for organizations that may wish to use registry/EHR data as opposed to claims-based data.

The three CR QMs deal with enrollment, adherence and communication:

  • QM-1: CR Time to Enrollment. "We have good evidence to show that the sooner people enroll in cardiac rehab, the better their outcomes and adherence," Thomas said.

  • QM-2: CR Adherence. Research demonstrates a graded dose response in which attending 36 or more CR sessions is associated with lower risks for death and myocardial infarction at 4 years compared with attending fewer sessions. "The more sessions patients attend has also been shown to correlate with better outcomes," Thomas said.

  • QM-3: CR Communication. "Communication between the CR program and the healthcare providers is important to make sure there is good coordination of care," Thomas said.

"Quality measures are important," he added, "but don't meet the same strict criteria that performance measures do. But the quality measures may, in the future, become performance measures as more evidence becomes available on them."

The 2017 AHA Heart Disease and Stroke Statistics report  highlights the large number of patients who require CR each year, including 625,000 patients discharged from US hospitals after acute coronary syndrome, 954,000 patients who underwent percutaneous coronary interventions, 500,000 patients discharged with a new diagnosis of heart failure, and 397,000 who underwent coronary artery bypass graft surgery.

Yet, despite strong evidence demonstrating the benefits of CR, it remains "underutilized," Thomas told theheart.org | Medscape Cardiology. "The referral side is improving," he said, "at least in those hospitals focused on quality, but it's still not perfect. Unfortunately, we don't have a lot of good data as far as CR participation rates and completion rates."

The 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation document was developed in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation and has been endorsed by the American College of Sports Medicine, the American Physical Therapy Association, the Canadian Association of Cardiovascular Prevention and Rehabilitation, the Clinical Exercise Physiology Association, the Heart Failure Society of America, the InterAmerican Heart Foundation, the International Council of Cardiovascular Prevention and Rehabilitation, the National Association of Clinical Nurse Specialists, and the Preventive Cardiovascular Nurses Association.

Thomas has no relevant disclosures. Disclosures for all task force members are listed with the original article.

J Am Coll Cardiol. Published online March 29, 2018. Abstract

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