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ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction
Test Measure T-2. Excessive Initial Unfractionated Heparin (UFH) Dose
Test measure T-2 (Excessive Initial Unfractionated Heparin [UFH] Dose), which appeared on page 2088 of the ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction (J Am Coll Cardiol 2008;52:2046–99), published in the December 9, 2008, issue of the Journal, should be replaced by the corrected measure specifications included herein.
Test measure T-2 has been in use in ACTION Registry-GWTG since shortly after the 2008 ACC/AHA Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction was published. Over the course of time, it became apparent that the upper limit for dosing was, in some cases, capturing patients who go for planned primary PCI who may have appropriately received higher doses of UFH. The intention in the 2008 paper was to exempt this group from the measure by excluding patients who receive their initial dose of UFH in the cardiac catheterization laboratory. Experience in ACTION Registry-GWTG, however, has shown that not all patients who are going for planned primary PCI receive their initial dose in the catheterization laboratory. Some patients, for example, receive the initial dose in the emergency department prior to transfer to the catheterization laboratory. These patients are then inappropriately identified as having received an excessive dose. This measure is therefore being corrected to ensure that it more accurately captures excessive dosing of UFH as intended.
Section 4.3.2. Initial Parenteral Anticoagulant and Antiplatelet Dosing
Section 4.3.2, Initial Parenteral Anticoagulant and Antiplatelet Dosing, should be amended to reflect the corrections to Test Measure T-2. In the third paragraph of the section (p. 2060), after the sentence beginning “We excluded patients who received treatment initially in...,” the following sentence should be inserted:
For a similar reason, the performance measure for unfractionated heparin also excluded patients with STEMI who underwent primary PCI because higher doses of unfractionated heparin may be used in anticipation of the procedure.
In the first paragraph of Section 4.3.2, in the second sentence, which begins “However, excess dosing in patients with UA/NSTEMI is a common occurrence...,” the correct references to be cited are 48 and 49.
Section 4.3.1. Clopidogrel at Discharge
In the fourth paragraph of Section 4.3.1, in the first sentence, which begins “In contrast, there is evidence of substantially greater variability...,” the correct reference to be cited is 47.
Performance Measure 13: Cardiac Rehabilitation Patient Referral From the Inpatient Setting
Performance Measure 13 (Cardiac Rehabilitation Patient Referral From the Inpatient Setting) was adapted from a measure included in Thomas RJ, King M, Lui K, et al. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services (J Am Coll Cardiol 2007;50:1400–33), which was updated in Thomas RJ, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services (J Am Coll Cardiol 2010;56:1159–67). Measure 13 should therefore be updated to reflect the changes in the 2010 update of the cardiac rehabilitation measures from which it was adapted. Revised Measure 13 is included herein and includes the following new references:
68. King SB III, Smith SC Jr., Hirshfeld JW Jr., et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:172–209.
69. Thomas RJ, King M, Lui K, et al. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol. 2007;50:1400–33.
70. Thomas RJ, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol. 2010;56:1159–67.
Corrected Test Measure T-2
|T-2. Excessive Initial Unfractionated Heparin (UFH) Dose⁎|
|Acute myocardial infarction (AMI) patients who received excess dosing of unfractionated heparin (UFH) initially|
|Numerator||AMI patients who received:|
|Denominator||AMI patients who received intravenous UFH.|
|Period of Assessment||Reporting year|
|Sources of Data||Prospective flowsheet, retrospective medical record review, electronic medical record, inpatient pharmacy records|
|Recommended doses for anticoagulant therapy (and intravenous glycoprotein IIb/IIIa inhibitors) are well-established. However, recent national registry data suggest that excess dosing in patients with acute coronary syndromes is common.|
|Method of Reporting|
|Aggregate rate (standard error) generated from count data reported as a proportion.|
|Challenges to Implementation|
|The performance measure will require accurate assessments of patient weight (in kilograms) and timing and dose of initial therapy including bolus and infusion rate.|
↵⁎ This measure has been designated for use in internal quality improvement programs only. It is not appropriate for any other use, e.g., pay for performance, physician ranking or public reporting programs.
Updated Performance Measure 13
|13. Cardiac Rehabilitation Patient Referral From an Inpatient Setting⁎|
|All patients hospitalized with a primary diagnosis of acute myocardial infarction (AMI) referred to an early outpatient cardiac rehabilitation/secondary prevention (CR) program.|
|Period of Assessment||Inpatient hospitalization|
|Sources of Data||Administrative data and/or medical records.|
|Corresponding Guidelines and Clinical Recommendations|
|Method of Reporting|
|Proportion of health care system's patients with a qualifying event/diagnosis who had documentation of their referral to an outpatient CR program|
|Challenges to Implementation|
|Identification of all eligible patients in an inpatient setting will require that a timely, accurate, and effective system be in place. Communication of referral information by the inpatient hospital service team to the outpatient CR program represents a potential challenge to the implementation of this performance measure. However, this task is generally performed by an inpatient cardiovascular care team member or a hospital discharge planning team member.|
↵⁎ The format of this measure differs somewhat from others in this set since it was taken almost verbatim from the previously published AACVPR/ACC/AHA Cardiac Rehabilitation/Secondary Prevention Performance Measure Set documents (69,70).
↵† The definition used by the U.S. Public Health Service and by the AACVPR/ACC/AHA Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee is as follows: “Cardiac rehabilitation services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or re-infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients” (67).
- American College of Cardiology Foundation