First-Ever Performance, Quality Metrics Created for Valvular and Structural Disease

The American College of Cardiology and American Heart Association (ACC/AHA) have issued the first-ever performance and quality metrics for the treatment of patients with valvular and structural heart disease, focusing on evidence-based and actionable aspects of care to ensure the best possible outcomes.

The five performance measures, four of which are related to proven therapies, are considered sound enough for public reporting or pay-for-performance programs, while the six quality metrics might be useful for internal reviews or quality-improvement initiatives, according to the ACC/AHA writing committee.

“The reason we have these metrics is to measure care, track care, and, importantly, compare care across institutions,” Hani Jneid, MD (University of Texas Medical Branch, Galveston), chair of the writing committee, told TCTMD.  

The performance and quality metrics, developed in collaboration with the Society for Cardiovascular Angiography and Interventions and the American Association for Thoracic Surgery, are the first of their kind for valvular and structural heart disease, so the ACC and AHA will be keeping close tabs on whether the metrics are “topped out or if there’s room for improvement,” said Jneid. “This is a dynamic process and we’re going to observe how these metrics behave in the real world, whether they’re measurable without burdening physicians, and whether there are any unintended consequences.”

The new document was published online in the Journal of the American College of Cardiology and Circulation: Cardiovascular Quality and Outcomes.   

To TCTMD, Jneid explained that the performance metrics are derived from the 2020 ACC/AHA valvular heart disease guidelines and all measures are supported by class 1 recommendations. “[Performance measures] should have a very high impact and the magnitude of benefit should far outweigh the risk,” he said, adding that they should be easy to measure. “To be a performance measure, they also need to be actionable and have good face validity.”

The performance measures include the following:

• Use of a vitamin K antagonist for patients who receive a mechanical heart valve
• Aortic valve intervention for patients with severe symptomatic aortic stenosis
• Aortic valve surgery for patients with chronic severe aortic regurgitation
• Use of transthoracic echocardiography for asymptomatic chronic severe primary mitral regurgitation (MR)
• Mitral valve intervention for chronic severe primary MR

Quality metrics, said Jneid, are a “little bit looser” in that they are not usually as high impact or readily measurable, but physicians and institutions are advised to use them for internal reviews.

In terms of quality metrics, the first is the documentation of risk and a discussion among the heart team before a patient undergoes surgical aortic valve replacement or TAVI. The remaining quality measures include aortic valve replacement for patients with asymptomatic aortic stenosis with LV systolic dysfunction; TAVI for older patients (> 80 years) with severe symptomatic aortic stenosis; use of echocardiography after aortic valve replacement to serve as a baseline for future measurements; adequate blood pressure control in patients with aortic regurgitation; and treatment of symptomatic severe rheumatic mitral stenosis.

We’re going to observe how these metrics behave in the real world, whether they’re measurable without burdening physicians, and whether there are any unintended consequences. Hani Jneid

The ACC/AHA performance and quality metrics focus primarily on the management and treatment of aortic and mitral valve disease, with no measures for the treatment of tricuspid or pulmonary valve disease. 

“Most of the class 1 recommendations in the guidelines are really pertinent to the aortic and mitral valve,” said Jneid. “These left-sided valves are where most of the evidence is derived from, and this is where the prevalence of valvular disease is the highest currently.” However, the document will be updated as new data becomes available. “This is a rapidly evolving field and tricuspid valve disease and tricuspid valve intervention is a very hot topic [with] much needed technology and innovation coming into this space.”

Additionally, there are no performance or quality metrics for dealing with patients with secondary MR, despite evidence from the COAPT trial showing the benefits of transcatheter-edge-to-edge repair (TEER) in this setting. Jneid explained that TEER has a class 2a recommendation in the guidelines for patients with chronic severe secondary MR related to LV systolic dysfunction. In fact, none of the recommendations for intervening in secondary MR carry a class 1 recommendation, so the ACC/AHA writing committee did not include treatments as part of the performance/quality metrics.

“Now, this is undoubtedly going to evolve with the evolution of the guidelines that will parallel the accumulation of evidence,” said Jneid. “We may see these metrics being updated [in the future].”