New A-fib Performance and Quality Measures Emphasize Shared Decision-Making, Inpatient and Outpatient Care

The American College of Cardiology (ACC) and American Heart Association (AHA) have released new clinical performance and quality measures for treating patients with atrial fibrillation and atrial flutter. The new report expands on the scope of the previously set measures by broadening the focus to include the inpatient setting and providing new metrics to address patient safety, effective clinical care, and patient-physician communication.

Speaking with TCTMD, Paul Heidenreich, MD (Stanford University, Stanford, CA), chair of the ACC/AHA Task Force on Performance Measures, said the updated measures are designed to help translate scientific evidence into clinical practice. “We wanted to try to expand and cover as much of atrial fibrillation care as we thought the evidence supported,” he said.

In 2008, the ACC/AHA consortium established just three performance measures for atrial fibrillation: the assessment of thromboembolic risk factors, the use of chronic anticoagulation therapy, and the monthly measurement of the international normalized ratio (INR). In contrast, the 2016 report includes six performance and 18 quality measures for the management of patients with atrial fibrillation and atrial flutter. The new document does not discard the older performance measures but rather expands upon them, according to the ACC/AHA task force.

The six performance measures include:

• CHA₂DS₂-VASc risk score documented prior to discharge (inpatient)
• Anticoagulation prescribed to discharge (inpatient)
• Prothrombin/INR planned follow-up documented prior to discharge for warfarin (inpatient)
• CHA₂DS₂-VASc risk score documented (outpatient)
• Anticoagulation prescribed (outpatient)
• Monthly INR for warfarin treatment (outpatient)

To TCTMD, Heidenreich said the performance measures are designed to capture “good, quality care in line with the clinical guidelines.” They are intended not only for quality improvement but also can be considered for purposes of public reporting, pay-for-performance, or other forms of accountability. Quality measures, on the other hand, do not have the same level of evidence and have not been formally developed using the ACC/AHA performance-measure methodology. They are intended for quality improvement at the provider, hospital, or healthcare system level and, according to the ACC/AHA, might be considered as preliminary or evolving. They are not designed for accountability purposes. 

The 18 quality measures include 10 metrics for inpatient care and eight for the outpatient setting. The quality measures also include a number of “don’ts,” said Heidenreich. For example, two warn against inappropriate prescription of a direct thrombin or factor Xa inhibitor in atrial fibrillation patients with a mechanical heart valve or those with end-stage kidney disease or on dialysis. For patients with left-ventricular ejection fraction ≤ 40%, use of beta blockers and ACE inhibitor/angiotensin receptor blockers are included as a measure of quality care.  

“I think it formalizes things,” said Heidenreich. “If you ask physicians who deal with atrial fibrillation, are these things good to do? I don’t think anything would be controversial.”

The ACC/AHA task force also added an inpatient and outpatient quality measure emphasizing shared decision-making between physicians and patients regarding the use of anticoagulants. For clinicians looking to “improve the physician-patient interaction in some way, this gives them a measure to use,” said Heidenreich.

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