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• W2464486355 abstract "HomeCirculation: Cardiovascular Quality and OutcomesVol. 9, No. 42016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUB2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial FlutterA Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair Penelope Solis, JD N. A. Mark EstesIII, MD, FACC, FAHA Gregg C. Fonarow, MD, FACC, FAHA Corrine Y. Jurgens, PhD, RN, ANP, FAHA Joseph E. Marine, MD, FACC David D. McManus, and MD, MS, FACC, FAHA, FHRS Robert L. McNamaraMD, MHS, FACC Paul A. HeidenreichPaul A. Heidenreich Search for more papers by this author , Penelope SolisPenelope Solis Search for more papers by this author , N. A. Mark EstesIIIN. A. Mark EstesIII Search for more papers by this author , Gregg C. FonarowGregg C. Fonarow *ACC/AHA Task Force on Performance Measures Liaison. Search for more papers by this author , Corrine Y. JurgensCorrine Y. Jurgens Search for more papers by this author , Joseph E. MarineJoseph E. Marine †Heart Rhythm Society Representative. Search for more papers by this author , David D. McManusDavid D. McManus Search for more papers by this author , and Robert L. McNamaraRobert L. McNamara Search for more papers by this author Originally published27 Jun 2016https://doi.org/10.1161/HCQ.0000000000000018Circulation: Cardiovascular Quality and Outcomes. 2016;9:443–488is corrected byCorrection to: 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance MeasuresOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2016: Previous Version 1 Table of ContentsPreamble 4441. Introduction 4451.1. Scope of the Problem 4451.2. Disclosure of Relationships With Industry and Other Entities 4462. Methodology 4472.1. Literature Review 4472.2. Definition and Selection of Measures 4473. 2016 ACC/AHA Atrial Fibrillation/Atrial Flutter Clinical Performance and Quality Measures 4483.1. Discussion of 2016 Atrial Fibrillation/Atrial Flutter Clinical Performance and Quality Measures 4483.1.1. Retired Measures 4483.1.2. Revised Measures 4483.1.3. New Measures 4484. Areas for Further Research 449References 453Appendix A. 2016 ACC/AHA Atrial Fibrillation Clinical Performance and Quality Measures 457Performance Measures for Use in Patients With Inpatient and Outpatient Atrial Fibrillation or Atrial Flutter 457Inpatient Measures 457Short Title: PM-1: CHA2DS2-VASc Risk Score Documented Prior to Discharge457Short Title: PM-2: Anticoagulation Prescribed Prior to Discharge 459Short Title: PM-3: PT/International INR Planned Follow-Up Documented Prior to Discharge for Warfarin Treatment 461Outpatient Measures 462Short Title: PM-4: CHA2DS2-VASc Score Risk Score Documented 462Short Title: PM-5: Anticoagulation Prescribed 464Short Title: PM-6: Monthly INR for Warfarin Treatment 466Quality Improvement Measures for Inpatient or Outpatient Atrial Fibrillation or Atrial Flutter Patients 467Inpatient Measures 467Short Title: QM-1: Beta Blocker Prescribed Prior to Discharge (When LVEF ≤40) 467Short Title: QM-2: ACEI or ARB Prescribed Prior to Discharge (When LVEF ≤40) 468Short Title: QM-3: Inappropriate Prescription of Antiarrhythmic Drugs to Patients With Permanent Atrial Fibrillation 469Short Title: QM-4: Inappropriate Prescription of Dofetilide or Sotalol Prior to Discharge 470Short Title: QM-5: Inappropriate Prescription of a Direct Thrombin or Factor Xa Inhibitor Prior to Discharge 471Short Title: QM-6: Inappropriate Prescription of a Direct Thrombin or Factor Xa inhibitor (Rivaroxaban or Edoxaban) Prior to Discharge 472Short Title: QM-7: Inappropriate Prescription of Antiplatelet and Oral Anticoagulation Therapy Prior to Discharge 473Short Title: QM-8: Inappropriate Prescription of Nondihydropyridine Calcium Channel Antagonist Prior to Discharge 474Short Title: QM-9: Patients Who Underwent Atrial Fibrillation Catheter Ablation Who Were Not Treated With Anticoagulation Therapy Both During or After a Procedure 475Short Title: QM-10: Shared Decision Making Regarding Anticoagulation Prescription Prior to Discharge 476Outpatient Measures 478Short Title: QM-11: Beta Blocker Prescribed (When LVEF ≤40) 478Short Title: QM-12: Inappropriate Prescription of Antiarrhythmic Drugs to Patients With Permanent Atrial Fibrillation 479Short Title: QM-13: Inappropriate Prescription of Dofetilide or Sotalol 480Short Title: QM-14: Inappropriate Prescription of a Direct Thrombin or Factor Xa Inhibitor 481Short Title: QM-15: Inappropriate Prescription of a Direct Thrombin or Factor Xa Inhibitor (Rivaroxaban or Edoxaban) 482Short Title: QM-16: Inappropriate Prescription of Antiplatelet and Oral Anticoagulation Therapy 483Short Title: QM-17: Inappropriate Prescription of Nondihydropyridine Calcium Channel Antagonist 484Short Title: QM-18: Shared Decision Making in Anticoagulation Prescription 485Appendix B. Author Relationships With Industry and Other Entities (Relevant)—2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter 487Appendix C. Peer Reviewer Relationships With Industry and Other Entities—2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter 488PreambleThe American College of Cardiology (ACC)/American Heart Association (AHA) clinical performance and quality measure sets serve as vehicles to accelerate translation of scientific evidence into clinical practice. Measure sets developed by the ACC/AHA are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement.Writing committees are instructed to consider the methodology of clinical performance measure development1 and to ensure that the measures developed are aligned with ACC/AHA clinical guidelines. The writing committees also are charged with constructing measures that maximally capture important aspects of care quality, including timeliness, safety, effectiveness, efficiency, equity, and patient-centeredness, while minimizing, when possible, the reporting burden imposed on hospitals, practices, and practitioners.Potential challenges from measure implementation may lead to unintended consequences. The manner in which challenges are addressed is dependent on several factors, including the measure design, data collection method, performance attribution, baseline performance rates, reporting methods, and incentives linked to these reports.The ACC/AHA Task Force on Performance Measures distinguishes quality measures from performance measures. Quality measures are metrics that may be useful for local quality improvement but are not yet appropriate for public reporting or pay-for-performance programs (ie, contexts in which performance measures are used). New measures are initially evaluated for potential inclusion as performance measures. In some cases, a measure is insufficiently supported by the guidelines. In other instances, when the guidelines support a measure, the writing committee may decide it is necessary to have the measure tested to identify the consequences of measure implementation. Quality measures may then be promoted to the status of performance measures as supporting evidence becomes available.Paul A. Heidenreich, MD, MS, FACC, FAHAChair, ACC/AHA Task Force on Performance Measures1. IntroductionIn the summer of 2015, the ACC/AHA convened the writing committee to begin the process of revising the existing atrial fibrillation (AF) and atrial flutter measure set that was released in 20082 and for which implementation notes had been issued in 2011.3 The writing committee also was charged with the task of developing new measures to benchmark and improve the quality of care for patients with AF or atrial flutter. Throughout the report, the term AF will include atrial flutter, unless specifically stated.All the measures included in the clinical performance and quality measure set are briefly summarized in Table 1, which provides information on the measure number, measure title, and care setting. The detailed measure specifications (available in Appendix A) provide not only the information included in Table 1 but also more detailed information, including the measure description, numerator, denominator (including denominator exclusions and exceptions), rationale for the measure, guidelines that support the measure, measurement period, source of data, and attribution.Table 1. 2016 ACC/AHA Atrial Fibrillation Clinical Performance and Quality MeasuresNo.Measure TitleCare SettingMeasure DomainPerformance MeasuresPM-1CHA2DS2-VASc Risk Score Documented Prior to DischargeInpatientEffective Clinical CarePM-2Anticoagulation Prescribed Prior to DischargeInpatientEffective Clinical CarePM-3PT/INR Planned Follow-Up Documented Prior to Discharge for Warfarin TreatmentInpatientEffective Clinical CarePM-4CHA2DS2-VASc Risk Score DocumentedOutpatientEffective Clinical CarePM-5Anticoagulation PrescribedOutpatientEffective Clinical CarePM-6Monthly INR for Warfarin TreatmentOutpatientEffective Clinical CareQuality MeasuresQM-1Beta Blocker Prescribed Prior to Discharge (When LVEF ≤40)InpatientEffective Clinical CareQM-2ACEI or Angiotensin-Receptor Blocker Prescribed Prior to Discharge (When LVEF ≤40)InpatientEffective Clinical CareQM-3Inappropriate Prescription of Antiarrhythmic Drugs Prior to Discharge to Patients With Permanent Atrial Fibrillation for Rhythm ControlInpatientPatient SafetyQM-4Inappropriate Prescription of Dofetilide or Sotalol Prior to Discharge in Patients With Atrial Fibrillation and End-Stage Kidney Disease or on Dialysis Prior to DischargeInpatientPatient SafetyQM-5Inappropriate Prescription of a Direct Thrombin or Factor Xa Inhibitor Prior to Discharge in Patients With Atrial Fibrillation With a Mechanical Heart ValveInpatientPatient SafetyQM-6Inappropriate Prescription of a Direct Thrombin or Factor Xa Inhibitor (Rivaroxaban or Edoxaban) Prior to Discharge in Patients With Atrial Fibrillation and End-Stage Kidney Disease or on DialysisInpatientPatient SafetyQM-7Inappropriate Prescription of Antiplatelet and Oral Anticoagulation Therapy Prior to Discharge for Patients Who Do Not Have Coronary Artery Disease and/or Vascular DiseaseInpatientPatient SafetyQM-8Inappropriate Prescription of Nondihydropyridine Calcium Channel Antagonist Prior to Discharge in Patients With Reduced Ejection Fraction Heart FailureInpatientPatient SafetyQM-9Patients Who Underwent Atrial Fibrillation Catheter Ablation Who Were Not Treated With Anticoagulation Therapy During or After a ProcedureInpatientPatient SafetyQM-10Shared Decision Making Between Physician and Patient in Anticoagulation Prescription Prior to DischargeInpatientCommunication and Care CoordinationQM-11Beta Blocker Prescribed (When LVEF ≤40)OutpatientEffective Clinical CareQM-12Inappropriate Prescription of Antiarrhythmic Drugs to Patients With Permanent Atrial Fibrillation for Rhythm ControlOutpatientPatient SafetyQM-13Inappropriate Prescription of Dofetilide or Sotalol in Patients With Atrial Fibrillation and End-Stage Kidney Disease or on DialysisOutpatientPatient SafetyQM-14Inappropriate Prescription of a Direct Thrombin or Factor Xa Inhibitor in Patients With Atrial Fibrillation With Mechanical Heart ValveOutpatientPatient SafetyQM-15Inappropriate Prescription of a Direct Thrombin or Factor Xa Inhibitor (Rivaroxaban or Edoxaban) in Patients With Atrial Fibrillation and End-Stage Kidney Disease or on DialysisOutpatientPatient SafetyQM-16Inappropriate Prescription of Antiplatelet and Oral Anticoagulation Therapy for Patients Who Do Not Have Coronary Artery Disease and/or Vascular DiseaseOutpatientPatient SafetyQM-17Inappropriate Prescription of Nondihydropyridine Calcium Channel Antagonist in Patients With Reduced Ejection Fraction Heart FailureOutpatientPatient SafetyQM-18Shared Decision Making Between Physician and Patient in Anticoagulation PrescriptionOutpatientCommunication and Care CoordinationACC indicates American College of Cardiology; ACE, angiotensin-converting enzyme; ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; INR, International Normalized Ratio; LVEF, left ventricular ejection fraction; PM, performance measure; PT, prothrombin time; and QM, quality measure.This AF clinical performance and quality measure set is notable for several reasons. First, the writing committee considered whether measures should be developed for the inpatient setting, expanding the scope of the original measure set. Specifically, the writing committee decided to broaden the care setting, from a solely outpatient context to the inpatient setting, to further improve the continuity of care for these patients by addressing the multiple settings in which they receive care.Second, new measures were developed for care domains that were not previously addressed, including patient safety, effective clinical care, communication, and care coordination. Many measure concepts were considered but were ultimately not included in this set after committee discussion. It is the hope of this writing committee that this clinical performance and quality measure set will be reassessed as new science is developed and as electronic health record data standards are more broadly implemented across settings.The writing committee has developed a comprehensive AF measure that includes 24 total measures, including 6 performance measures (3 inpatient measures and 3 outpatient measures) and 18 quality measures (10 inpatient measures and 8 outpatient measures), as reflected in Table 1 and the full measure specifications in Appendix A. The writing committee believes that implementation of this clinical performance and quality measure set by providers, physician practices, and hospital systems will help to enhance the quality of care provided to patients with AF in both the inpatient and outpatient settings.The clinical performance and quality measure set that is represented in this report is intended to serve as an ACC/AHA AF measures library. The writing committee acknowledges that a site may not adopt all of the quality measures, but the writing committee wanted to ensure that the quality measures were developed on the basis of guideline recommendations and were made available to sites that may choose to implement them to look at the quality of care rendered to patients with AF.1.1. Scope of the ProblemAF is recognized as the most common cardiac arrhythmia in the United States and is associated with increased mortality rate for individuals who have other cardiovascular conditions and procedures, such as heart failure,4–6 myocardial infarction,7,8 coronary artery bypass graft,9,10 stroke11 and hypertension.12–15 Furthermore, AF is associated with a 4- to 5-fold increased risk for stroke.16It is estimated that AF impacts between 2.7 million and 6.1 million American adults, and this number is expected to double by 2050.17,18 Among Medicare patients who are ≥65 years of age who were diagnosed from 1993 to 2007, the prevalence of AF increased 5% per year, from approximately 41.1 per 1000 beneficiaries to 85.5 per 1000 beneficiaries.19Hospitalizations with AF listed as the primary diagnosis increased by 34% from 1996 to 2001.20 Just over half of patients admitted for AF were men (50.8%).21 The costs of care for patients with AF are substantial, with estimates ranging from $6 billion to $26 billion a year, of which $6 billion was attributed directly to AF, $9.9 billion to other cardiovascular expenses, and $10.1 billion to noncardiovascular expenses.22 On the basis of this information, identifying performance and quality measures that can be implemented by providers or healthcare systems may aid not only in improving patient care, but also in reducing costs by reducing adverse outcomes of AF (eg, fewer strokes).Accordingly, updating the existing AF performance measure set was a priority for the ACC and AHA. Particular attention was given to assessments, therapies, and interventions that could improve the quality of life for patients with AF. Effective clinical care, patient safety, and care coordination measures were developed. The writing committee believes that these measures have the potential to improve the patient care and thereby improve the quality of life. This document serves to reflect those measures that were developed by the writing committee after comprehensive internal discussion, peer review, and public comment.1.2. Disclosure of Relationships With Industry and Other EntitiesThe ACC/AHA Task Force on Performance Measures makes every effort to avoid actual, potential, or perceived conflicts of interest that could arise as a result of relationships with industry or other entities (RWI). Detailed information on the ACC/AHA policy on RWI can be found online. All members of the writing committee, as well as those selected to serve as peer reviewers of this document, were required to disclose all current relationships and those existing within the 12 months before the initiation of this writing effort. ACC/AHA policy also requires that the writing committee co-chairs and at least 50% of the writing committee have no relevant RWI.Any writing committee member who develops new RWI during his or her tenure on the writing committee is required to notify staff in writing. These statements are reviewed periodically by the Task Force and by members of the writing committee. Author and peer reviewer RWI that are relevant to the document are included in the appendixes: Please see Appendix B for relevant writing committee RWI and Appendix C for relevant peer reviewer RWI. Additionally, to ensure complete transparency, the writing committee members’ comprehensive disclosure information, including RWI not relevant to the present document, is available online. Disclosure information for the Task Force is also available online.The work of the writing committee was supported exclusively by the ACC and the AHA without commercial support. Members of the writing committee volunteered their time for this effort. Meetings of the writing committee were confidential and attended only by writing committee members and staff from the ACC and AHA, as well as from the Heart Rhythm Society (HRS), which served as a collaborator on this project.2. Methodology2.1. Literature ReviewIn developing the updated AF clinical performance and quality measure set, the writing committee reviewed evidence-based guidelines and statements that would potentially impact the construct of the measures. The practice guidelines and statements that most directly contributed to the development of these measures can be seen in Table 2.Table 2. Associated Guidelines and Other Clinical Guidance DocumentsGuidelines2014 AHA/ACC/HRS Guidelines for the Management of Patients With Atrial Fibrillation232013 ACCF/AHA Guideline for Management of Heart Failure24Statements2013 Treatment of Atrial Fibrillation25,262012 AHA/ASA Oral Antithrombotic Agents for the Prevention of Stroke in Nonvalvular Atrial Fibrillation: A Science Advisory for Healthcare Professionals272012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation Recommended for Patient Selection, Procedural Techniques, Patient Management and Follow-Up, Definitions, Endpoints, and Research Trial Design28ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; ASA, American Stroke Association; ECAS, the European Cardiac Arrhythmia Society; EHRA, European Heart Rhythm Association; and HRS, Heart Rhythm Society.2.2. Definition and Selection of MeasuresThe writing committee reviewed both recent guidelines and other clinical guidance documents referenced in Table 2. The writing committee also examined available information on gaps in care to address which new measures might be appropriate as performance measures or quality measures for this measure set update.All measures were designed to assess quality of care experienced by individuals who have AF or atrial flutter in the inpatient and outpatient setting. The measures also were designed to limit clinical performance and quality measurement to patients without a valid reason for exclusion from the measure. Measure exclusions are those reasons that automatically remove a patient from the denominator. For example, all measures excluded patients who were <18 years of age or on comfort care. In contrast to exclusions, denominator exceptions are conditions that remove a patient from the denominator only if the numerator criteria are not met.29 Denominator exceptions are used in select cases to allow for a fairer measurement of quality for providers who serve higher-risk populations. Exceptions are also used to defer to the clinical judgment of the provider. Several of the measures include exceptions. For example, in the case of the inpatient and outpatient anticoagulation measure, a physician may write a script for anticoagulation therapy even if the patient says that he/she will not take the medication for a number of reasons (eg, religion). In this case, the physician would receive credit for the measure. If the patient has told the physician that he/she does not wish to have the medication prescribed, the physician can choose not to write the script and to document in the medical record that the patient refused the medication. In this scenario, the provider will not be penalized for not writing a prescription if the patient’s reason is documented. The writing committee closely examined which exceptions should be included for each measure and in some cases determined to not include any exceptions, as in the case of the patient safety measures.During the course of developing the clinical performance and quality measure set, the writing committee evaluated the potential measures against the ACC/AHA attributes of clinical performance and quality measures which were derived on work of experts30 (Table 3) to reach consensus on which measures should be advanced for inclusion in the final clinical performance and quality measure set. After the peer review and public comment period, the writing committee reviewed and discussed the comments received and further refined the measure set. The writing committee acknowledges that the new measures created in this set will need to be tested and validated over time. By publishing this clinical performance and quality measure set, the writing committee encourages adoption of these performance and quality measures, which will help to facilitate the collection and analysis of data needed to assess the validity of these measures. In the future, the writing committee anticipates having data that will allow them to reassess whether any of the measures included in this set should be modified or potentially promoted from a quality measure to a performance measure.Table 3. ACC/AHA Task Force on Performance Measures: Attributes for Clinical Performance and Quality Measures301. Evidence basedHigh-impact area that is useful in improving patient outcomesa) For structural measures, the structure should be closely linked to a meaningful process of care that in turn is linked to a meaningful patient outcome.b) For process measures, the scientific basis for the measure should be well established, and the process should be closely linked to a meaningful patient outcome.c) For outcome measures, the outcome should be clinically meaningful. If appropriate, performance measures based on outcomes should adjust for relevant clinical characteristics through the use of appropriate methodology and high-quality data sources.2. Measure selectionMeasure definitiona) The patient group to whom the measure applies (denominator) and the patient group for whom conformance is achieved (numerator) are clearly defined and clinically meaningful.Measure exceptions and exclusionsb) Exceptions and exclusions are supported by evidence.Reliabilityc) The measure is reproducible across organizations and delivery settings.Face validityd) The measure appears to assess what it is intended to.Content validitye) The measure captures most meaningful aspects of care.Construct validityf) The measure correlates well with other measures of the same aspect of care.3. Measure feasibilityReasonable effort and cosa) The data required for the measure can be obtained with reasonable effort and cost.Reasonable time periodb) The data required for the measure can be obtained within the period allowed for data collection.4. AccountabilityActionablea) Those held accountable can affect the care process or outcome.Unintended consequences avoidedb) The likelihood of negative unintended consequences with the measure is low.ACC indicates American College of Cardiology; AHA, American Heart Association.3. 2016 ACC/AHA Atrial Fibrillation/Atrial Flutter Clinical Performance and Quality Measures3.1. Discussion of 2016 Atrial Fibrillation/Atrial Flutter Clinical Performance and Quality MeasuresAfter reviewing the existing guidelines, the 2008 measure set,2 and the 2011 implementation notes,3 the writing committee discussed which measures needed to be revised to reflect the updated science and worked to identify which guideline recommendations could serve as the basis for new performance or quality measures. The writing committee also reviewed existing measure sets that were publicly available.The following subsections serve as a synopsis of the revisions that were made to previous measures and a description of why the new measures were created for both the inpatient and outpatient settings.3.1.1. Retired MeasuresThe writing committee decided not to retire the 3 measures that were previously included in the 2008 measure set. Although the writing committee did note that the data needed for the monthly International Normalized Ratio Warfarin Treatment measure have proved difficult to collect for some institutions, it was noted that some healthcare systems, such as the US Department of Veterans Affairs, may be able to collect this information. The writing committee hopes that by maintaining this as a performance measure, health systems will encourage sites to improve data collection. The writing committee also anticipates that increased interoperability of healthcare data in general, and across inpatient and outpatient records in particular, will facilitate reporting of this measure.3.1.2. Revised MeasuresThe writing committee did make a number of changes to the 3 measures, which are summarized in Table 4. The majority of the changes were made to reflect the updated guideline recommendations, whereas other changes were made to strengthen the measure construct. Table 4 provides the measure care setting, title, and a brief rationale for the revisions made to the measure.Table 4. Revised Atrial Fibrillation MeasuresNo.Care SettingMeasure TitleRationale for RevisionsPM-4OutpatientCHA2DS2-VASc Risk Score DocumentedThis measure was revised to reflect the update in the “2014 AHA/ACC/HRS Guideline for Management of Patients With Atrial Fibrillation”23 that recommends the use of the CHA2DS2-VASc score instead of the CHA2DS2. Additionally, this measure was revised to allow for a patient reason exception that reflects instances in which a patient chooses to have an atrial appendage device placed or to clearly account for medical instances in which a patient already has such a device in place.PM-5OutpatientAnticoagulation PrescribedThis measure had the same changes made as noted in the CHA2DS2-VASc Risk Score Documented “Rationale for Revisions.” This measure was also revised to require that the healthcare provider document if the patient has a CHA2DS2-VASc Risk Score of ≥2 as a reason for why anticoagulation was prescribed. This was accomplished by modifying the denominator to include in this measure all patients with nonvalvular atrial fibrillation or atrial flutter who do not have a score of 0 or 1 documented in the medical record.PM-6OutpatientMonthly INR for Warfarin TreatmentThis measure was maintained as previously specified in the 2008 measure set. However, the attribution was changed to facility or provider level instead of being limited to physician level. The writing committee acknowledged that this measure has been difficult to implement in registries; however, the sentiment was that this measure does lead to improved patient care and can be implemented in certain instances, such as in the Department of Veterans Affairs or integrated healthcare systems. It is the hope of the writing committee that with increased interoperability and common data standards, this measure may be more readily adopted by more systems in the future.ACC indicates American College of Cardiology; AHA, American Heart Association; HRS, Heart Rhythm Society; INR, International Normalized Ratio; and PM, performance measure.3.1.3. New MeasuresThe writing committee has worked to create a comprehensive list of measures that can be used for patients with AF. This set includes 21 new measures, of which 3 are inpatient performance measures and 18 are quality measures (10 inpatient, 8 outpatient). Table 5 includes a list of the measures with information on the care setting and a brief rationale.Table 5. New Atrial" @default.
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• W2464486355 title "2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter" @default.
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