Table 1

Sample Data Collection Tools for the Cardiac Rehabilitaion/Secondary Prevention Performance Measurement Set B

American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Cardiology, and American Heart Association Cardiac Rehabilitation/Secondary Prevention Program Performance Measurement Set Data Collection Flow Sheet (ideally collected prospectively)
Patient Name or Code:Birth Date:
Gender: □M □FDate of event(s):
Diagnosis: □MI □CABG □Angina □Valve repair or replacement □PCI □Transplantation □CHF
Race/Ethnicity: □African American □Asian American □Native American □Non-White Hispanic □White □Other
Risk Category □Low □Moderate □High
Target GoalInitial AssessmentIntervention Plan and CommunicationReassessment Prior to Completion of ProgramChanges in Intervention Plan and Communication
Date
Tobacco UseComplete cessation of tobacco use
  • □ Never

  • □ Recent (quit less 6 months ago)

  • □ Current

  • Complete only if current or recent tobacco use

  • □ Individual education and counseling

  • or

  • □ Referral to a tobacco cessation program

  • and

  • □ Health care provider notified

  • □ Abstaining

  • □ Smoking

  • Complete only if still smoking

  • □ Individual education and counseling

  • or

  • □ Referral to a tobacco cessation program

  • and

  • □ Health care provider notified

Blood Pressure Control<140/90 mm Hg or <130/80 mm Hg if patient has diabetes or chronic kidney disease
  • □ Patient with diagnosis of treated or untreated hypertension

  • □ Not hypertensive

  • Complete only if patient has a diagnosis of hypertension:

  • Education completed:

  • □ Target BP goal

  • □ Medication compliance

  • □ Lifestyle modification

□ Intermittent monitoring of BP during CR□ Policy in place concerning communication with health care providers, including thresholds for communication
Lipid Control
  • For CVD and CVD equivalents:

  • LDL-C <100 mg/dL if triglycerides are >200 mg/dL, non–HDL-C should be <130 mg/dL

  • □ Optimal control

  • □ Suboptimal control

  • Applies to all patients with CVD:

  • Education completed:

  • □ Target lipid goals

  • □ Medication compliance

  • □ Lifestyle modification

  • Complete only if suboptimal control on initial assessment:

  • □ Patient encouraged to contact health care provider about reassessment of lipid control

□ Policy is in place to communicate with health care providers as needed
Physical Activity Habits30+ min, minimum 5 d per week
  • □ Optimal habits

  • □ Suboptimal habits

□ Education completed concerning optimal physical activity habits□ Optimal habitsComplete only if habits remain suboptimal
Complete only if habits are suboptimal□ Suboptimal habits□ An intervention plan is developed with the patient
□ Intervention plan developed with the patient□ Health care provider notified
Weight Management
  • Body mass index: 18.5 to 24.9 kg/m2

  • and

  • Waist circumference:

  • men <40 inches

  • women <35 inches

  • □ At target

  • □ Above target

  • Applies to all patients

  • □ Education completed concerning target goals, diet, behavior change, regular physical activity

  • or

  • □ Referral to a weight management program

  • and

  • □ Health care provider notified if above target

  • □ At target

  • □ Above target

  • Complete only if remains above target

  • □ Additional education completed for target goals, diet, behavior change, exercise

  • or

  • □ Referral to a weight management program

  • and

  • □ Health care provider notified

Presence or Absence of DM or IFG (fasting blood glucose 110–125 mg/dL)HbA1C <7%
  • □ Diagnosis of DM or IFG present

  • □ Diagnosis of DM or IFG absent

  • Complete only if diabetes mellitus is present:

  • □ Documentation that patient has attended skill training and medical nutrition therapy session

  • or

  • □ Referral to skill training and medical nutrition therapy session

  • or

  • □ Intervention plan recommended which includes: target goals for HbA1C, medical nutrition counseling, and skill training

  • Complete only if IFG is present:

  • □ Education is completed concerning the importance of weight management and physical activity

  • Complete only if diabetes mellitus or IFG is present:

  • □ Attendance at appropriate education or skill training session

□ A policy is in place concerning communication with appropriate health care professionals including thresholds for notification
Presence or Absence of DepressionAssessment of presence or absence of depression using a valid and reliable screening tool
  • □ Patient screened for depression

  • □ Patient not screened for depression

  • Complete only if screening tool indicates possible depression:

  • □ Results discussed with patient

  • and

  • □ Health care provider notified

  • □ Patient re-screened for depression

  • □ Patient not re-screened for depression

  • Complete only if screening tool indicates possible depression:

  • □ Results discussed with patient

  • and

  • □ Health care provider notified

Exercise CapacityAssessment of symptom-limited exercise tolerance and development of an individualized exercise prescription
  • □ Assessment and exercise prescription completed

  • □ Assessment and exercise prescription not completed

□ Exercise prescription communicated to the patient and health care provider
  • □ Re-assessment and exercise prescription completed

  • □ Re-assessment and exercise prescription not completed

□ Revised exercise prescription communicated to the patient and health care provider
Use of Preventive MedicationsAdherence to prescribed preventive medications□ Patient has been prescribed preventive medications by his/her health care provider(s)□ Individual education and counseling about the importance of adherence to appropriate preventive medications□ Individual or group education completed□ Patient is encouraged to discuss questions or concerns about prescribed preventive medications with his/her healthcare providers
or
□ Group education and counseling about the importance of adherence to appropriate preventive medications

Target goals are from the 2006 AHA/ACC Secondary Prevention Guidelines (39). Assessment terms and definitions are from the outcomes registry proposal. Reprinted, with permission, from Thomas et al. (15).

BP = blood pressure; CABG = coronary artery bypass grafting; CHF = congestive heart failure; CR = cardiac rehabilitation/secondary prevention; CVD = cardiovascular disease; DM = diabetes mellitus; HDL-C = high-density lipoprotein cholesterol; IFG = impaired fasting glucose; LDL-C = low-density lipoprotein cholesterol; MI = myocardial infarction; PCI = percutaneous coronary intervention.