ACC/AHA announce revisions to 2011 Heart Failure Measure set
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The American College of Cardiology and the American Heart Association, in collaboration with the Heart Failure Society of America, released retired, revised and new measures for the 2011 Heart Failure Measure set.
“HF remains one of the leading causes of impaired health status, hospitalizations, mortality and health care expenditures among adult men and women in the U.S.,” Gregg C. Fonarow, MD, director of the Ahmanson-UCLA Cardiomyopathy Center, co-director of the UCLA Preventive Cardiology Program, co-chief of the division of cardiology at UCLA and Eliot Corday Chair in Cardiovascular Medicine and Science, told Healio. “Since 2011, there have been a number of important therapeutic advances in medications and devices to improve patient-centered outcomes in patients with HF. However, study after study have demonstrated in most clinical settings there are significant gaps, variations and inequities in how therapies are utilized and dosed.
“If these ACC/AHA HF performance measures were applied in all settings in which patients with HF in the U.S. are being cared for and optimal and equitable conformity with each of these measures were achieved, over 100,000 lives [per] year of patients with HF could be saved,” Fonarow said in an interview. “There is an urgent need to measure and improve heart failure care quality.”
Retired measure
Because inpatient documentation of left ventricular ejection fraction is greater than 97%, the writing committee decided to retire the measure from the 2011 Heart Failure Measure set. LVEF assessment in the outpatient setting was retained.
“The LVEF assessment performance measure for hospitalized patients with heart failure had reached a level of 98% to 99% conformity, so this measure has largely topped out and, thus, less useful to discriminate differences in care quality,” Fonarow said in an interview. “Further, there were concerns that this measure was being misinterpreted that the EF should be re-measured each time the patient was being hospitalized. It is important to recognize that the LVEF assessment in patients with HF in the outpatient setting remains a performance measure.”
Revised measures
The committee also revised three of the other HF measures from the 2011 set, including points on patient self-care education; ACE inhibitor or angiotensin receptor blocker therapy for LV systolic dysfunction; and postdischarge appointments.
Patient self-care education was moved from performance measure to a quality measure. This was due to concern for the accuracy of self-care education documentation and limited evidence of improved outcomes even with better documentation.
The committee decided to add angiotensin receptor-neprilysin inhibitors as a treatment option for LV systolic dysfunction, citing how the 2017 ACC/AHA/HFSA HF guideline update made this a recommendation.
In addition, the committee made the decision to move the postdischarge appointment from a performance measure to a quality measure and included a time limit of 7 days. This decision was made due to the 2013 ACCF/AHA HF clinical practice guideline that lists postdischarge appointment from 7 to 14 days as a class 2a recommendation.
New measures
The writing committee added seven new measures to the 2011 Heart Failure Measure set.
“There are new measures for use of the angiotensin receptor-neprilysin inhibitor, sacubitril/valsartan, which is class I recommended in the heart failure guidelines and has been demonstrated to improve health status and reduced CV death and HF hospitalization superiorly to that of ACE inhibitors in patients with HFrEF,” Fonarow told Healio. “For the first time, the HF performance measure sets also focus on not just use of guideline-recommended medication at any dose, but on utilizing the doses that are evidence-based and guideline recommended, so long as well tolerated. The measure set now includes assessment of patients being treated with doses of medications at 50% or greater of target dose, in the absence of contraindications or documented intolerance.
“There are new measures regarding the safe and effective use of mineralocorticoid receptor antagonists in patients with HF, including the monitoring of serum potassium after initiation,” Fonarow said in an interview. “There is a new measure regarding use of cardiac resynchronization therapy in eligible patients. This therapy can significantly improve functional capacity and outcomes in appropriately selected patients.”
The following are the new additions:
- angiotensin receptor-neprilysin inhibitor therapy for outpatients and inpatients with HFrEF;
- dose of beta-blocker therapy for outpatients with HFrEF;
- dose of ACE inhibitor, angiotensin receptor blocker or angiotensin receptor-neprilysin therapy for outpatients with HFrEF;
- mineralocorticoid receptor antagonist for outpatients and inpatients with HFrEF;
- laboratory monitoring in outpatients and inpatients undergoing new mineralocorticoid receptor antagonist therapy;
- hydralazine/isosorbide dinitrate therapy for outpatients and inpatients with HFrEF who self-identified as Black;
- cardiac resynchronization device implantation for outpatients with HFrEF on guideline-directed medical therapy;
- a new quality measure for outpatient-reported, outcome-health status;
- a new quality measure for sustained or improved health status in outpatients with HF; and
- outpatient and inpatient participation in the Heart Failure registry.
Further research still needed
“There have been recent clinical trials that have shown SGLT2 inhibitors reduce CV death and HF hospitalizations, including in HF patients without diabetes. Since the ACC/AHA heart failure guidelines had not yet been updated to recommend these therapies and, thus, they could not be included in this performance measure set,” Fonarow told Healio. “There is also an urgent need for discovery science to uncover therapies that are safe and effective for heart failure with preserved ejection fraction.”
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