New PCI Performance Measure Guidelines Issued

December 19, 2013—The 2013 Performance Measures for Adults Undergoing Percutaneous Coronary Intervention (PCI) have been published online on the American College of Cardiology (ACC) website (www.cardiosource.org) and will be in future print issues of both the Journal of the American College of Cardiology and Circulation: Journal of the American Heart Association. The performance measures, which are intended to ensure high-quality clinical care, were released by the ACC and the American Heart Association, as well as the Society for Cardiovascular Angiography and Interventions, the American Medical Association-Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance. 

Carl Tommaso, MD, and Brahmajee Nallamothu, MD, are co-chairs of the writing committee for the performance measures document. Dr. Tommaso is an interventional cardiologist at NorthShore University Health-System in Evanston, Illinois. Dr. Nallamothu is Associate Professor of Cardiovascular Medicine with the Department of Internal Medicine at the University of Michigan in Ann Arbor, Michigan. 

According to an announcement from the ACC, the careful documentation of patient selection and procedure appropriateness is a critical—yet underutilized—step in ensuring high-quality care. The set of performance measures includes 11 measures that address both ambulatory and inpatient settings, with two measures that address documentation and appropriateness. The document focuses primarily on elective PCI. 

The ACC noted that the document breaks important ground for performance measurement examining care before, during, and after the procedure. It is the first set of cardiovascular performance measures to directly address procedure appropriateness. In addition, the measures incorporate other indicators of quality, such as procedural volume and whether the institution assesses benchmarks of care by participating in regional or national registries. 

As outlined by the ACC, the 11 measures are:  

1. Comprehensive documentation of the reasons for PCI 

2. An appropriate reason for elective PCI (benefits outweigh the risks) 

3. An evaluation of the individual's ability to receive dual-antiplatelet therapy (conducted before the procedure) 

4. The use of embolic protection devices in the treatment of saphenous vein bypass graft disease 

5. An assessment of renal function before the procedure (including glomerular filtration rate) and the documentation of contrast used during the procedure 

6. Documentation of the radiation dose used during the procedure 

7. The prescription of optimal medical therapy at discharge (aspirin, P2Y₁₂ inhibitors, and statins)  

8. A referral to an outpatient cardiac rehabilitation program (to reduce the risk of recurrent events)  

9. Participation in a regional or national PCI registry 

10. The average annual volume of PCIs performed by the physician over the last 2 calendars years 

11. The average annual volume of PCIs performed by the hospital over the last calendar year 

The ACC noted that items 1, 3, 5, 7, 8, 9, and 11 are performance measures, and 2, 4, 6, and 10 are quality metrics. Quality metrics may not meet all specifications of formal performance measures or may be associated with unintended consequences of public reporting. The writing committee stated that the measures may “serve as vehicles to accelerate appropriate translation of scientific evidence into clinical practice.” The committee goal was to create measures that capture many important aspects of quality while minimizing the reporting burden.  

In the ACC press release, Dr. Tommaso commented, “Hospitals and health systems are increasingly facing a burden with measurement across multiple conditions and services. We wanted to focus on those aspects of PCI care that we thought would give us the greatest yield in terms of improving patient care.”  

Dr. Nallamothu stated that this document is the first step in the evolving process of performance measurement and added, “Through these measures, we have moved beyond simple measurement of a few treatments to incorporating key concepts like appropriateness. There is still much more work to be done, however, and an important part of this process was to identify important areas for future investigation.”  

The committee identified four areas of research that will generate better performance measures in the future: (1) measuring the filling of prescriptions (not just the prescription of drugs) and optimal dosing, (2) better utilizing current data systems to track PCI quality, (3) building accountability by all practitioners involved into quality metrics, and (4) utilizing patient surveys to track performance.