New performance measures on performance measurement and reperfusion therapy

The ACC/AHA 2008 Task Force on Performance Measures' Statement on Performance Measurement and Reperfusion Therapy will webpost on Monday, November 10 at 2 pm ET. The statement clarifies key issues in the measurement of reperfusion therapy for patients with ST-segment elevation myocardial infarction.

The use of reperfusion therapy, drugs or procedures that restore blood flow to the heart during a heart attack, is one of the most powerful interventions available to improve a patient's likelihood of survival. While the appropriate and timely use of reperfusion therapy has improved substantially over the past decade, significant gaps in the quality of this important process of care persist. Proper measurement is critical to the assessment of hospital and health system performance and to identify targets for quality improvement.

This document provides a perspective on the evolution of the current measures, a justification for the approach and suggests additional measures needed to provide a more comprehensive assessment of care.

The document acknowledges the remaining controversy about the inclusion and exclusion criteria for these measures, and the determination of when measurement stops. Considerations in choosing how to construct the measure are discussed and specific recommendations are made to strengthen the current approach.

The major points addressed in this document include:

1. Acute reperfusion therapy—either with fibrinolytic therapy or percutaneous coronary intervention—is one of the most important treatments for patients with ST-segment elevation myocardial infarction (STEMI).

2. American College of Cardiology (ACC)/American Heart Association (AHA) guidelines recommend that fibrinolysis be provided within 30 minutes of first medical system contact and that primary percutaneous coronary intervention (PCI) be provided within 90 minutes of first medical system contact for patients presenting with STEMI.

3. The goals of the reperfusion performance measures are to provide a quantitative assessment of this important process of care; introduce accountability for performance in providing timely reperfusion; to improve the quality of care; and to reduce adverse outcomes of patients with STEMI.

4. The workgroup supports current efforts by CMS and The Joint Commission to simplify the current ECG interpretation data elements to the extent possible, acknowledging that it must provide adequate guidance to non-clinical abstractors in identifying possible candidates for acute reperfusion.

5. An additional measure that includes patients who are transferred from one hospital to another for the purpose of receiving reperfusion should be developed and implemented.

6. An exclusion that accounts for patient-centered reasons for delaying reperfusion therapy is clinically necessary.

7. Systems providing reperfusion therapy should synchronize all devices (e.g. ECG machines and electronic catheterization lab documentation systems) involved in establishing time landmarks in the reperfusion measures to a consistent external standard (e.g. satellite synchronization with atomic clocks).

8. After consideration of the relative benefits and limitations of the various approaches, the workgroup supports a measure that focuses upon the time of first device use rather than the time of restoration of flow or the time of other "upstream" events (e.g. time to first angiography).

9. The time to PCI for patients who are transferred for reperfusion should be reported separately from those who are not transferred.

10. In cases where a patient has a contraindication to reperfusion therapy, the clinician does not have the option of considering fibrinolysis rather than transfer, even if the transfer will be delayed. Thus, reporting of the time to PCI in patients who are transferred should be stratified by the presence or absence of contraindications to fibrinolytic therapy.