New AHA/ACC Performance and Quality Metrics for Coronary Revascularization

The American Heart Association and American College of Cardiology (AHA/ACC) have introduced a comprehensive list of clinical performance measures intended to target meaningful gaps in care, and that can be used to aid public reporting and pay-for-performance programs.

In addition to the 15 performance measures, which are based on the 2021 guidelines for coronary artery revascularization, the ACC/AHA issued five new quality metrics that may form future quality-improvement initiatives, but don’t quite have strong enough evidence to be used for public reporting. Two new structural measures also were introduced—one that recommends preprocedural assessment by the heart team, the other advising surgery and PCI programs to participate in state, regional, or national registries—to help assess hospital infrastructure, systems, and processes of care.

The performance and quality measures, which were published July 27, 2003, in the Journal of the American College of Cardiology, were developed in collaboration with the American Association for Thoracic Surgery (AATS) and the Society for Cardiovascular Angiography and Interventions (SCAI). The Society of Thoracic Surgeons was asked to participate in drafting the document but declined.

“This is the first performance measure document that specifically deals with coronary artery revascularization,” Gregory J. Dehmer, MD (Carilion Clinic, Roanoke, VA), chair of the ACC/AHA writing committee, told TCTMD. “It doesn’t replace any other document. There are some measures that we identified from previous documents in different places, that we adopted and put into this document, but this is really the first that has specifically looked at performance measures for coronary revascularization.”

The performance metrics are “based on the highest level of evidence that is available,” said Dehmer, noting that these are high-impact measures that are useful for improving patient outcomes. These are typically based on class 1 recommendations from the clinical practice guidelines, although there is a lone measure based on a class 3 recommendation that advises against routine PCI of a non-infarct-related artery in patients with STEMI complicated by cardiogenic shock.

The performance measures include directives to use coronary physiology to guide revascularization rather than rely on a visual assessment of lesions of intermediate severity as well as directions on the use of dual antiplatelet therapy during PCI or the index hospitalization and on the use antiplatelet and anticoagulation therapy after PCI in patients with atrial fibrillation (AF). The other performance measures include:

• P2Y12 inhibitor therapy in patients undergoing PCI after fibrinolytic therapy
• Aspirin use after CABG surgery
• Use of high-intensity statin therapy after revascularization
• Glycemic control during and after CABG to prevent perioperative complications
• Use of the internal mammary artery for bypassing the LAD artery during CABG surgery
• Radial access during PCI
• CABG surgery for patients with diabetes and multivessel disease
• Revascularization on non-infarct-related artery in stable patients after STEMI
• Revascularization for the management of ventricular arrhythmias
• Referrals to cardiac rehabilitation from the inpatient and outpatient settings

With respect to quality metrics, these are directives that aren’t “quite ready for prime time” based on the available evidence, said Dehmer. These can used to improve care at hospitals but shouldn’t be used for public reporting and pay-for-performance programs. The five quality measures for coronary revascularization emphasize shared decision-making and informed consent, use of periprocedural hydration in cardiovascular angiography, smoking cessation after revascularization, risk assessment in patients considered for surgery, and use of beta-blockers after CABG to prevent AF.

While the guidelines are an exhaustive review of the current evidence, Dehmer said performance metrics translate the information “into a way that you can actually measure this, with both a numerator and denominator, so that hospitals can evaluate how they’re doing.” The performance measures tend to be picked up by insurance providers and the Centers for Medicare & Medicaid Services (CMS) as a way to evaluate patient care.

Avoiding Controversy

When the 2021 ACC/AHA/SCAI guidelines for coronary revascularization were released, they were somewhat controversial given that neither the AATS nor STS endorsed the recommendations. The surgical groups had issues with some of the recommendations, particularly that surgery was downgraded from a class 1 recommendation in patients with three-vessel disease and normal left ventricular function, as well as in those with mild-to-moderate left ventricular dysfunction. They also believed that the long-term superiority of CABG compared with PCI wasn’t fully appreciated and disagreed with awarding a class 1 recommendation to using radial artery grafts in bypass surgery.   

To TCTMD, Dehmer said they were aware of the guideline disagreements but noted that three cardiac surgeons, including Jennifer Lawton, MD (Johns Hopkins Medicine, Baltimore, MD), who chaired the guideline writing committee, helped draft the clinical performance and quality measures

“We did have some robust discussions about what to include and not to include,” said Dehmer. “In general, we sought to avoid those areas where there seemed to be some controversy. Getting back to the root of the performance measures, these are measures that are so widely accepted and so agreed upon that surgeons, interventional cardiologists, general cardiologists, prevention experts, and I could go on, all agree that these things have a strong preponderance of evidence. They’re not really controversial. They belong in the performance measure category.”

Dehmer added that the writing committee was duty bound to rely solely on recommendations from the 2021 revascularization guidelines. “If it wasn’t listed in the guidelines, we couldn’t make it a performance measure,” he said. “We had to pick and choose from [recommendations] already in the guidelines.”

The performance and quality measures are endorsed by the Heart Failure Society of America, Heart Rhythm Society, and International Society for Heart and Lung Transplantation, among several other groups. TCTMD reached out to STS to ask about their reasons for not participating in drafting the performance/quality metrics but did not hear back from the group at the time of publication.