Providing Quality Healthcare: The Role of Performance Measures for Allied Health Professionals

What are clinical performance measures?

Clinical performance measures arose from the concept of quality in healthcare, a topic that has become increasingly important in the current era of healthcare reform. The Institute of Medicine defines quality in healthcare as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”¹

Quality measures have been developed in order to quantify quality of care. Good quality measures are evidence-based, relevant to clinical practice, offer the potential for quality improvement, and must be feasible to implement. Clinical performance measures are quality measures that are standardized for application to a healthcare system and increasingly reported publicly. 

Are performance measures just rigid, bureaucratic nonsense?

In the midst of healthcare reform in the United States, performance measures and pay-for-performance programs can seem like administrative ploys to make clinicians’ lives miserable. However, performance measures derive from a real motivation to improve quality of patient care. Errors in clinical medicine can have devastating consequences, and one goal of performance measures is to systematically reduce such errors. For example, widespread implementation of performance measures nationwide has targeted wrong-site surgery through surgical site marking and “timeout” protocols.  

How do performance measures improve the quality of healthcare?

When integrated with clinical guidelines and outcomes research, measuring performance becomes a key step in providing continuous quality improvement.^3,4 Evidence-based practice guidelines are used to develop quality indicators, often derived from class I or class III recommendations (see examples below). Performance measures are then established to quantify whether the quality indicators are met. With a concrete way to measure performance, clinical outcomes can then be assessed and behaviors can be altered in order to improve those outcomes. 

How are performance measures developed?

The American College of Cardiology (ACC) and the American Heart Association (AHA) described the approach in creating performance measures to help quantify healthcare quality.⁵ To summarize, there are three phases in the development of performance measures: constructing a measurement set, determining the feasibility and reliability of data collection, and measuring performance. Examples using nonvalvular atrial fibrillation (AF)/atrial flutter (Afl) performance measures will be provided below (in italics).⁶ 

In constructing the set of measures, five tasks must be achieved:

• Define the target population and observational period: Adults with non-valvular AF/Afl lasting >30 seconds in the outpatient setting.
• Identify the dimension of care that is measured: Assessment of thromboembolic risk in this patient population.
• Review the literature for guidelines and existing performance measures, focusing on strength of evidence and clinical relevance: ACC/AHA guidelines specify a Class IA recommendation for warfarin therapy in a patient with any high-risk factor or more than one moderate risk factor.
• Define potential measures including the period of care, the target population, and specify when performance measures are met. Period of care: reporting year; target population: all patients except pregnant patients, those with warfarin allergy, or those with contraindications for anticoagulation; performance measure is met when patients with documented thromboembolic risk as assessed by CHADS₂ score are prescribed oral anticoagulation (unless documented refusal by patient).
• After completion of the above tasks, measures can then be selected for inclusion in the performance measurement set.

To determine the feasibility of data collection, one must assess ease of sample identification and data measurement. This can be assessed by distributing surveys or rating forms to potential reporting units. The data can be prospective, retrospective, inpatient, outpatient, or registry-based. 

Measurement of performance is done at the patient level; however, the reporting unit must be identified — either at individual clinician level, group level, or health plan level. 

What are some examples of performance measures already in use today?

The National Quality Forum is a non-profit, non-partisan organization in the United States that endorses performance measures at a national level. Overall there are more than 500 performance measures endorsed, and over 80 in cardiovascular (CV) medicine. However, there are only five pertaining to the field of clinical cardiac electrophysiology (EP). These include: 1) ICD infection rates; 2) deactivation of implantable cardioverter defibrillators (ICD) in expected deaths, such as hospice patients; 3) the rate of device complications reported to the NCDR-ICD Registry; 4) proper anticoagulation of AF patients if no contraindications exist; and 5) checking thyroid-stimulating hormone levels in patients with newly diagnosed AF and those taking amiodarone.⁶

There seems to be a lack of performance measures in cardiac EP; what more can be done?

As stated above, performance measures are a tool used to improve quality and reinforce accountability. Soon this process will be used and mandated in pay-for-performance programs and for increased transparency in healthcare delivery. Lack of performance measures will likely affect the field of EP as a whole, because it will be difficult to track improvements in outcomes for the care that is provided. 

For example, several studies have shown an underutilization of primary prevention ICDs in patients with heart failure and left ventricular dysfunction, despite unequivocal evidence that ICDs save lives. Currently no performance measure exists to encourage implantation of ICDs in these patients, unlike the use of beta-blocker therapy. Development of a measurement set would help address this evidence-based practice, and reduce the presence of gaps and disparities in the management of sudden cardiac arrest.²

The Heart Rhythm Society (HRS) proposed and submitted six candidate performance measures to the Centers for Medicare and Medicaid Services (CMS), in response to their call for measures: 

• Rates of procedural complications following catheter ablation treatment for paroxysmal AF
• Achieving adequate heart rate control for patients with AF by looking at proportion of adult patients with AF with a resting heart rate of >110 beats per minute at three successive encounters over a month
• Patient-specific risk-standardized rates for procedural complications following the implantation of ICDs
• Proportion of adult patients with a new implantable device with an in-person evaluation within 2-12 weeks following implantation
• Infection rates following device implantation, replacement, or revision (three-year rolling average)
• Rate of cardiac tamponade following AF ablation (three-year rolling average)

HRS also sent surveys to its members regarding specific measures. Additionally, it expanded the number of talks on performance measures at its annual scientific sessions.

What are some limitations in implementing performance measures?

Similar to other clinical/outcomes research, the accuracy of data collection is essential. For example, if data is extracted from medical records, the frequency of missing patient records should be documented. If data comes from a registry, the reliability of data input and abstraction should be assessed. Finally, if patient survey data are used, the nonresponse rate and issues such as recall bias and selection bias should be taken into consideration. 

Other potential limitations besides inadequate data quality include lack of generalizability, potential for gaming the system and unintended consequences, and the inability to risk-adjust and to account for individual patients/sound clinical judgment.²

Are device vendors or EP labs tracking certain quality measures?

Due to the number of device and lead recalls, major vendors now have teams dedicated to tracking and analyses of their products. Some have software built into the device programmers, while others rely on representatives, clinical field engineers, and device clinic staff to report potential issues. Individual companies have databases and research divisions to track the long-term outcomes of their products. However, this is on a voluntary basis and is not yet a standard across the industry.

Besides participation in the NCDR-ICD registries, many EP labs are tracking radiation exposure and fluoroscopy time, as radiation safety has become an increasingly important topic due to long ablation cases. With the advent of electronic medical records, several measures can now be identified and followed more easily.

How does one bring performance measures from his/her own clinic or hospital to the national level?

Widely enforced performance measures must go through the development process detailed above. Participation in professional societies is the most immediate way to develop local performance initiatives for implementation at a national level. 

How can allied professionals apply potential measures and affect care?

Allied professionals often have the most patient encounters, such as through device clinics. When there is a device or a lead problem, being diligent about reporting the problem is important. Adequate and consistent reporting is crucial, as it captures multiple data points and avoids selection bias.

Many hospitals have lab staff or nursing staff input data for the national registries. Being accurate with data extraction and input would eliminate one of the most significant limitations in performance measures, namely inadequate data quality.

Finally, one can propose quality measure targets on a local level or create potential registries as an initial step for the development of performance measures.

Disclosure: The author has no conflicts of interest to report relative to the content of this article.

References

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.
2. Al-Khatib SM, Fonarow GC, Hayes DL, et al. Performance measures to promote quality improvement in sudden cardiac arrest prevention and treatment. Am Heart J. 2013;165(6):862-868.
3. Estes NA, 3rd, Homoud M, Weinstock J, et al. Interdisciplinary strategies for arrhythmia program development: measuring quality, performance, and outcomes. J Interv Card Electrophysiol. 2011;31(1):91-99.
4. Califf RM, Peterson ED, Gibbons RJ, et al. Integrating quality into the cycle of therapeutic development. J Am Coll Cardiol. 2002;40(11):1895-1901.
5. Spertus JA, Eagle KA, Krumholz HM, Mitchell KR, Normand SL. American College of Cardiology and American Heart Association methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. J Am Coll Cardiol. 2005;45(7):1147-1156.
6. Estes NA, 3rd, Halperin JL, Calkins H, et al. ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults with Nonvalvular Atrial Fibrillation or Atrial Flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation) Developed in Collaboration with the Heart Rhythm Society. J Am Coll Cardiol. 2008;51(8):865-884.

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