|SAMPLE SURVEY FORM|
|PERFORMANCE MEASURE SURVEY|
Please see the definition for each of the criteria below in the attached Performance Measure Survey Guide.
Indicate your selection by marking X in the appropriate field
|ACC/AHA PAD GUIDELINE RECOMMENDATIONS||A. Insufficient evidence||B. Uninterpretable||C. Not actionable||D. Unclear patient population||E. Not clinically meaningful||F. Uncertain reliability across settings||G. Uncertain feasibility due to data collection effort||H. Uncertain feasibility due to cost of data collection||I. Uncertain data collection period||Other, specify||Potential measure? Y/N/Other||Comment|
|Recommendation from guideline to be considered as potential measure⁎|
|Potential Challenge to Implementation||Considerations|
|Useful in Improving Patient Outcomes|
|1. Insufficient evidence: The scientific basis for the recommendation is not well established.||Considering level of evidence, mark this as a potential challenge to implementation if you believe it is inappropriate to consider as a potential performance measure.|
|2. Not interpretable: The results of the (potential) measure are not interpretable by practitioners||This is your assessment of the degree to which a provider can clearly understand what the results of a measure based on this recommendation mean and can take action if necessary.|
|3. Not actionable: The recommendation addresses an area that is not under the practitioner's control.||This is your assessment of the degree to which a provider is empowered and can influence the activities of the healthcare system toward improvement.|
|4. Unclear patient population||This is your assessment of whether the patient group to whom this recommendation applies (denominator) can be explicitly defined using criteria that are clinically meaningful.|
|5. Not clinically meaningful||The recommendation does not capture clinically meaningful aspects of care.|
|6. Uncertain reliability across settings||The recommendation is not likely to be applicable across organizations and delivery settings.|
|7. Uncertain feasibility due to data collection effort: The data required to measure successful implementation of recommendation cannot be obtained with reasonable effort.||From your perspective, the required data can be typically abstracted from patient charts or there are national registries or other databases readily available.|
|8. Uncertain feasibility due to cost of data collection: The data required to measure successful implementation of recommendation cannot be obtained at reasonable cost.|
|9. Uncertain data collection period: The data required to measure successful implementation of recommendation cannot be obtained within the period allowed for data collection.|
|10. Overall assessment: Considering your assessment of this recommendation on all dimensions above, rate this recommendation for inclusion in the ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS PAD Performance Measure set.|
ABI indicates ankle-brachial index; PAD, peripheral artery disease.
↵⁎ Example: The resting ABI should be used to establish the lower extremity PAD diagnosis in patients with suspected lower extremity PAD, defined as individuals with exertional leg symptoms, with nonhealing wounds, who are age ≥70 or who are age ≥50 y with a history of smoking or diabetes. (Level of Evidence: C).