Eric D. Peterson, MD, MPH, FACC, FAHA; Frederick A. Masoudi, MD, MSPH, FACC∥∥; Elizabeth DeLong, PhD; John P. Erwin III, MD, FACC; Gregg C. Fonarow, MD, FACC, FAHA; David C. Goff, Jr, MD, PhD, FAHA, FACP; Kathleen L. Grady, PhD, APN, FAHA, FAAN; Lee A. Green, MD, MPH; Paul A. Heidenreich, MD, MS, FACC, FAHA; Kathy J. Jenkins, MD, MPH, FACC; Ann Loth, RN, MS, CNS; David M. Shahian, MD, FACC

Over the last decade, there has been an increasing awareness that the quality of medical care in the United States, which should be effective, timely, safe, equitable, efficient, and patient-centered medical care, has the potential for improvement (1).

Consistent with this focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) work together as a leading force to define “what works in medicine,” by developing ACCF/AHA practice guidelines statements and creating performance measures in order to define what should (or should not be done) to ensure that patients with cardiovascular disease receive optimal care (Table 1).

The ACCF/AHA Task Force on Performance Measures is charged with identifying the clinical topics appropriate for the development of performance measures and with assembling writing committees composed of clinical and methodological experts. When appropriate, these committees have included representation from other organizations involved in the care of patients with the condition of focus. Committee members are informed about the methodology of performance measure development (2) and are instructed to construct measures for broad use that meet these criteria. Writing committees are also instructed to strive to create measures that minimize the reporting burden for participants and measures that are aligned with national standards so as to promote harmony among measures.

All selected measures pose potential challenges to implementation that could result in unintended consequences. The manner in which these issues are addressed is dependent on several factors, including the measure design, method of data collection, performance attribution, baseline performance rates, reporting methods used, and incentives linked to these reports. The ACCF/AHA encourages those interested in implementing these measures for purposes beyond quality improvement to work with the ACCF/AHA to consider these complex issues in pilot testing projects, assess limitations and confounding factors, and guide refinements of the measures to enhance their utility for these additional purposes.

The current heart failure (HF) performance measure set is notable for several reasons. First, an earlier group of performance measures was retired when the measures were not found to reflect quality of care delivered when implemented in the community setting, given that there was limited opportunity for further improvement, and/or they were already captured by other performance measure sets. Retirement of measures that no longer serve their intended purpose is an important part of the performance measure life cycle. As a result of its activities, the committee has reduced the documentation burden on clinicians and hospitals in the hope that this will thereby allow them to focus on more critical areas of quality measurement and improvement. The committee has also extended some inpatient measures to the outpatient setting to emphasize the need to measure the quality of care over time, often across providers who care for patients with HF. Finally, the performance measures were extended to assess functional outcomes. This new and modified HF measure set thus spans the spectrum of quality of care and, once implemented, should lead to improved outcomes in patients with HF.

Eric D. Peterson, MD, MPH, FACC, FAHA, Chair, ACCF/AHA Task Force on Performance Measures

The ACCF/AHA/American Medical Association–Physician Consortium for Performance Improvement (AMA-PCPI) 2011 Performance Measures for Adults With Heart Failure Writing Committee (the writing committee) was charged with the development of performance measures concerning the diagnosis, treatment, and outcomes of patients with HF. The purpose of this effort is to provide measures that can be used to improve care for patients with HF. This updated performance measure document set addresses both in-hospital care and continuing care in the outpatient setting. Many guideline-recommended processes were considered but ultimately not translated into performance measures. Decisions about which measures to include were based on many factors. Common considerations included the complexity of the guideline recommendations (making translation difficult), ability to define patients to be included in the denominator without a large number of exclusions, and feasibility of collecting the required data. This document is intended to supersede the prior publication of HF performance measures (3).

This updated performance measure set presents 9 measures, including 3 new measures and 6 revised measures, of which 3 measures are designated as quality metrics (appropriate for internal quality improvement only). Two measures apply to care in both the inpatient and outpatient setting, 5 measures address care in the outpatient setting only, and 2 measures address care in the inpatient setting only. In addition, 8 earlier measures have been retired. The 3 quality metrics represent test measures that address areas worthy of measurement, but for considerations such as strength of evidence and uncertainty regarding feasibility, these are not considered appropriate for use for public accountability at this time. A summary of the new measure set is presented in (Table 2).

HF is a major and growing public health problem in the United States. For a detailed discussion of the scope of the problem and opportunities to improve the quality of care provided to patients with this condition, see the ACCF/AHA/AMA-PCPI 2011 HF performance measurement set (4).

The members of the ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Heart Failure Writing Committee included clinicians specializing in cardiology, internal medicine, family medicine, preventive medicine, hospital medicine, cardiac electrophysiology, and cardiovascular nursing, as well as people with expertise in performance measure development, implementation, and testing. The writing committee also included patient/consumer representatives, a payer representative, representatives from the ACCF/AHA Heart Failure Guideline Writing Committee, and the ACCF/AHA/AMA-PCPI Coronary Artery Disease/Hypertension Performance Measures Writing Committee to ensure consistency across these clinical documents. The writing committee also included representatives of the American Academy of Family Physicians, the American Academy of Hospice and Palliative Medicine, the American Nurses Association, the American Society of Health-System Pharmacists, the Heart Rhythm Society, and the Society of Hospital Medicine.

The work of the writing committee was supported exclusively by the ACCF, AHA, and AMA-PCPI without commercial support. Writing committee members volunteered their time to this effort. Meetings of the writing committee were confidential and attended only by committee members and staff from the ACCF, AHA, AMA-PCPI, The Joint Commission, and the National Committee for Quality Assurance to promote harmonization across similar measure sets as described further below. Writing committee members were required to declare in writing all relationships with industry and other entities relevant to this topic. Less than 50% of the writing committee members have relationships with industry and other entities relevant to this topic, in accordance with standard requirements of the ACCF and AHA. Please see Appendix A for relevant relationships of the writing committee and Appendix B for relevant peer reviewer relationships of the peer reviewers.

Between August 18, 2009, and September 20, 2009, the “ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Heart Failure” underwent a 30-day public comment period during which time ACCF, AHA, and AMA-PCPI members, as well as other healthcare professionals and members of the general public, had an opportunity to review and comment on the draft document before its final approval and publication. An official peer and content review of the full document was also conducted with 2 peer reviewers nominated by the ACCF and 2 reviewers nominated by the AHA. Additional comments were sought from clinical content experts and performance measurement experts.

The “ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Heart Failure” was adopted by the ACCF Board of Trustees and AHA Science Advisory and Coordinating Committee in December 2011 and approved by the AMA-PCPI in December 2011. These measures will be reviewed for currency once annually and updated as needed. They should be considered valid until either updated or rescinded by the ACCF/AHA Task Force on Performance Measures and the AMA-PCPI.

The development of performance measures involves identification of a set of measures targeted to a particular patient population, observed over a particular time period. To achieve this goal, the ACCF/AHA Task Force on Performance Measures has outlined and published the methodology of sequential tasks required for the development of process-of-care measures, as well as for outcomes measures suitable for public reporting (2,15- 16). In addition, the AMA-PCPI has developed a work group charge that outlines the process steps that should be followed by writing committees that develop performance measures (17). The following sections outline how the writing committee applied these methodologies.

The “ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult” (18) classified HF into 4 stages (Table 3). For purposes of this document, only the latter 2 stages, which qualify for the traditional diagnosis of HF (stages C and D), were considered for inclusion in the measure population. Thus, the inpatient and outpatient performance measures do not apply to patients for whom established risk factors and structural disorders occur without left ventricular systolic dysfunction or symptoms associated with HF (stages A and B). In addition, specific diagnosis codes, based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), which are available on the AMA-PCPI Web site at http://www.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI, should be used to screen and select the target patient population. The inpatient measures are constructed to include only those patients with a principal discharge diagnosis of HF, which identifies the condition for which, in retrospect, the patient was admitted to the hospital. The writing committee also recognizes that in some cases the principal discharge diagnosis code may identify patients for whom these measures may not be appropriate. In part because of this, all measures are written with exclusions that permit clinicians to document the reasons for not applying particular measures to individual patients. Additional codes have been added to the ICD-9-CM codes previously defined by The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) to screen and select cohorts for HF performance measures based on experience gained during testing/implementation of the 2005 measures.

To guide the selection of measures to include in the measure set, the writing committee sought to identify outcomes that are meaningful to patients with HF and the structures or processes linked with those outcomes. These outcomes include improving survival rates, decreasing symptoms of HF, and reducing hospitalizations. A complete list of the desirable outcomes identified by the writing committee and how they relate to the proposed process measures is included in the measure specifications (4).

These measures are intended for use by physicians, other eligible healthcare professionals, and healthcare systems to manage the care of patients aged ≥18 years with HF. They may be used to assess performance at the practitioner or system level as specified by each measure. The level of aggregation (clinician versus system) will also depend on the availability of adequate sample sizes to provide stable estimates of performance.

Given the multiple domains of providing care that can be measured, the writing committee identified and explicitly articulated the relevant dimensions of care that should be evaluated. As part of the methodology, each potential performance measure was categorized into its relevant dimension of care (Tables 4, 5). Classification into dimensions of care facilitated identification of areas where evidence was lacking and prevented duplication of measures within the set. Diagnostics, patient education (including prognosis and etiology), treatment, self-management, and monitoring of disease status were selected as the relevant dimensions of care for HF performance measures.

In addition, to ensure that the measure set is as comprehensive as possible, the writing committee also compared the potential measures against the Institute of Medicine domains of healthcare quality (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity) (1). Although focusing primarily on processes of care, the writing committee also considered measures of structures of care and outcomes (e.g., symptom management). The measures proposed in this set are intended to complement existing National Quality Forum–endorsed HF outcome measures, such as the CMS 30-day mortality and readmission measures.

As the primary sources for updating the 2005 ACC/AHA HF performance measures (3) and deriving new measures as specified in the ACC/AHA methodology for developing process measures (2,16) and the AMA “Physician Consortium for Performance Improvement (PCPI) Position Statement: The Evidence Base Required for Measures Development” (20), the writing committee reviewed the “2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults” (19) and the “ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult” (18). One co-chair of this writing committee also participated on the writing committees of both the 2009 HF focused update and the 2005 HF guideline. In addition, the chair of the 2009 HF focused update writing committee was a member of this writing committee. As participants on the guideline writing committees, these individuals were able to offer insights into measurement issues and provide suggestions for clarity and specificity consistent with guideline recommendations. Other sources reviewed included the “ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities” (21), the “HFSA 2006 Comprehensive Heart Failure Practice Guideline” (22), the “HFSA 2010 Comprehensive Heart Failure Practice Guideline” (23), the American College of Physicians clinical practice guideline “Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life” (24), and the “ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and Transesophageal Echocardiography” (25).

To avoid duplication of efforts and to harmonize with other national measures to the degree possible, the writing committee also reviewed existing HF measures, including outcome measures developed by The Joint Commission and CMS, the Agency for Healthcare Research and Quality, the Institute for Clinical Systems Improvement, CareScience, and PacifiCare and process measures developed by The Joint Commission, CMS, the IMPROVE HF Registry (26), and the RAND Corporation (27). A comparison of the 2005 and 2011 measure sets is provided in (Table 6).

Explicit criteria exist for the development of process performance measures so that they accurately reflect the quality of care. These include evidence of strong scientific validity, specification of numerators and denominators, and certainty that a potential measure is interpretable, applicable, and feasible (2,16). The writing committee sought to identify measures for which there is strong evidence and clear consensus about their importance in the care of HF patients that are linked to improved outcomes. To determine the processes of care with adequate evidence support to be considered for inclusion in the performance measurement set, the writing committee reviewed and prioritized the Class I and Class III recommendations from the 2005 HF guideline (18) and the 2009 HF focused update (19), with particular attention to changes in any guideline recommendations on which the 2005 HF performance measures (3) were based.

In addition to analyzing the updated guideline recommendations, the writing committee reviewed other clinical guidance documents, as detailed below, as well as available information on gaps in care and unexplained variations in care for HF patients. The writing committee also reviewed data on feasibility, reliability, and exception reporting available from implementation of a subset of the 2005 measures (28- 30). The writing committee applied a patient-centric approach to identify areas in which new measures or revisions to the 2005 measures might be needed. As part of this process, the writing committee also considered whether any of the 2005 measures should be retired. After extensive discussion and additional review of the literature, consensus was reached on revisions to be made to the measures included in the 2005 inpatient and outpatient measure sets. All measures were designed to assess high-quality care in appropriate patients across a variety of care settings and care teams and to support achievement of the identified desirable outcomes. The measures were also designed to allow for the exclusion of patients with contraindications to the process of care or other valid reasons for not being included in the measure. In defining the measure exclusions, the writing committee was guided by the AMA-PCPI “Specification and Categorization of Measure Exclusions” (31).

The writing committee evaluated the potential new and revised measures against the ACCF/AHA attributes of performance measures (Table 7) to reach consensus on which measures should advance for inclusion in the final measure set and whether to designate any of the measures as test measures (appropriate for internal quality improvement only) in the final set. After the peer review and public comment period, the writing committee reviewed and discussed the comments received and further refinements were made to the measure set.

The target population for the inpatient measures consists of hospitalized patients aged ≥18 years with a principal discharge diagnosis of HF. The principal diagnosis is the condition established after study to be chiefly responsible for the hospitalization. Detailed specifications, including exception criteria, methods of reporting, and additional background, are available on the AMA-PCPI Web site at http://www.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI. For all inpatient measures, patients who were transferred to another acute care facility, left against medical advice, were discharged to hospice, or died during the index admission are excluded.

The target population for the outpatient measures consists of patients aged ≥18 years with a diagnosis of HF. Detailed specifications, including exception criteria, methods of reporting, and additional background, are available on the AMA-PCPI Web site at http://www.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI. For purposes of this document, the outpatient care period is defined as the care provided in an outpatient setting within the time period under evaluation (12-month reporting period).

These performance measures are ideally intended for prospective use to enhance the quality improvement process but may also be applied retrospectively. The technical specifications for multiple data sources, including electronic health record data, electronic administrative data (claims), expanded (multiple-source) administrative data, and paper medical record/retrospective data collection flow sheet can be found in Appendix C.

The writing committee added exclusion criteria, recognizing that there are justifiable reasons for not meeting the performance measures. Specific documentation of these measure exceptions, which may be due to patient, medical, or system reasons, should be captured to provide data for future research and facilitate in-depth quality improvement in situations where there are apparent outliers with respect to the number of patients with exceptions.

The “ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Heart Failure” addresses many of the same processes of care as earlier measurement sets published by the ACCF/AHA, the AMA-PCPI, and other organizations. The writing committee has been cognizant of the previous efforts of other groups and sought to enhance and clarify measures in ways that reflect the advancement of the underlying science, the complexity of care, and the challenges of accurate and complete data collection. In particular, the present document incorporates the performance measures developed jointly by CMS and The Joint Commission for management of patients with HF (33).

The writing committee recognizes that not all Class I guideline recommendations lend themselves to the development of excellent performance measures, because many do not easily fit the attributes of performance measures in terms of usefulness, accuracy, feasibility, and measurability. Thus, the writing committee selected only those Class I recommendations that were considered to perform well as performance measures in the inpatient or outpatient setting. In addition, in the case of the angiotensin-converting enzyme (ACE) inhibitor/angiotensin II receptor blocker (ARB) therapy measure, a Class IIa guideline recommendation for the use of ARBs as first-line therapy was accepted by the committee, and the use of ARB therapy was considered equivalent to ACE inhibitor therapy for this measure, which was also the case in the 2005 HF performance measures (3). Although Class IIa recommendations are not considered for stand-alone measures, in some cases, such as this one, they provide additional information about valid alternative therapies that are considered by the committee for inclusion in a measure set. This exception is made so that physicians receive credit for prescribing or continuing ARB therapy in HF patients who have left ventricular systolic dysfunction.

The support for use of ARBs in patients with HF and reduced left ventricular ejection fraction has evolved significantly in response to published clinical trials that showed ARBs to be an effective alternative therapy (34), and such use is recommended in the 2009 HF focused update (19) as a reasonable alternative therapy. Thus, the writing committee decided to continue the inclusion of ARB therapy in the ACE inhibitor measure for use in both the inpatient and outpatient setting.

The inpatient and outpatient measures are designed to be implemented in either a retrospective chart abstraction process or they can be used as part of a prospective quality improvement process. The data collection tool suggested for use with the inpatient measures (Appendix C) permits prospective data capture as well and promotes the prospective identification of HF patients. For example, documentation of patient education is often difficult to obtain in retrospective chart review but can be easily implemented using a prospective patient management tool. These inpatient and outpatient measures will require additional testing in practice to determine reliability and validity and may require modification in the future.

The writing committee also deemed it important to add exclusion criteria to the measures to recognize that there are justifiable medical and patient reasons for not meeting the performance measures. In the inpatient set, these reasons should be included in the “reasons documented by physician, nurse practitioner, or other healthcare provider for not ….” In the outpatient set, medical and patient reasons for not meeting the measure are listed separately. Documentation of such factors should be encouraged and will provide valuable data for future research and conducting in-depth quality improvement for situations where there seem to be outliers with respect to the number of patients with medical or patient-centered exclusions for the performance measures.

Challenges to implementation of measures are discussed where applicable. In general, inadequate documentation is the initial challenge of any measurement effort. The fact that these challenges are discussed is not intended as an argument against measurement. Rather, they should be considered as cautionary notes that draw attention to areas where additional focus on research and improvement of the measures should be considered.

The 2011 HF performance measures address processes of care. The writing committee did not develop measures of patient outcome in terms of mortality or repeat hospitalization because these outcome measures are already in place and publicly reported by CMS. The new measure of symptom management does address one component of outcome and calls for a plan of action if patient status has not improved or has deteriorated.

Eight measures in the 2005 HF performance measures (3) were retired in the present measure set (Table 6). The measure on anticoagulation therapy for patients with HF and atrial fibrillation was retired from the inpatient and outpatient measures because a similar measure has been developed for the broader population of patients with atrial fibrillation (12) and is recommended for adoption in place of the previous narrower version of this measure. The measure on discharge instructions addressed an important component of care for the hospitalized patient, but its implementation in practice seems to have resulted in improved compliance without regard to the quality of discharge instructions provided. Another measure that addresses the important transition from inpatient to outpatient care has been included as part of the present measure set (9. Postdischarge appointment for HF patients) and was developed with the intent of having a greater impact on morbidity and readmission. The measure on smoking cessation advice/counseling was retired, because a similar measure has been developed for a much broader patient population. The measure “Tobacco Use: Screening and Cessation Intervention” can be accessed under the Preventive Care & Screening project on the AMA-PCPI Web site at http://www.ama-assn.org/ama1/pub/upload/mm/370/pcs_final08.pdf and is recommended for adoption in place of the previous narrower measure. The outpatient measures on initial laboratory testing, weight measurement, and blood pressure measurement were retired because they represent standards of care, performance is believed to be high, and the measures are not likely to have a significant impact on care or improvement in outcomes. Finally, the measure on assessment of signs of volume overload was retired because the supporting evidence is not strong and does not meet the rigorous standard now required for performance measurement.

Beta-blocker therapy for patients with HF and left ventricular systolic dysfunction was an outpatient measure in the 2005 HF performance measures (3). Although a measure for inpatient treatment with beta blockers was considered at that time, no inpatient measure was developed because there was no specific guideline recommendation for the use of beta blockers in the inpatient setting in 2005. In response to the new Class I recommendation for beta-blocker therapy at discharge in the 2009 HF focused update (19), the beta-blocker measure has been expanded in the current performance measures to include both outpatient and inpatient settings. In addition, clinical trial data indicate that the benefit of beta-blocker therapy does not appear to represent a class effect, and the 2009 HF focused update recommends that specific beta blockers be prescribed (19). Thus, the revised measure specifies 1 of 3 evidence-based beta blockers (bisoprolol, carvedilol, or sustained-release metoprolol succinate) in the numerator.

It should be emphasized that in-hospital initiation of beta blockers is recommended only in stable patients before hospital discharge (19). Regardless of the severity of symptoms, patients should not be hospitalized in an intensive care unit, should have no or minimal evidence of fluid overload or volume depletion, and should not have required recent treatment with an intravenous positive inotropic agent.

Symptom assessment remains an important component of every encounter with a patient with HF. However, symptom assessment alone is insufficient in patients whose symptoms are progressive or poorly controlled. Hence, the writing committee developed a new measure on symptom management that can be paired with the measure on symptom assessment. The symptom management measure includes documentation of a care plan to attempt to alleviate ongoing symptoms by changing medication doses, adding new medications, considering device therapy, or referring patients to specialty HF teams for advanced care.

Patient education about lifestyle, physical activity, diet, and medications is an important component of providing quality care for patients with HF. However, whether documentation of patient education in the medical record improves outcomes is uncertain. Compliance with a measure of patient education is relatively easy to achieve without regard to the quality of actual education provided. For this reason, the patient education measure was changed from a performance measure recommended for public reporting to a quality metric for internal quality improvement.

The writing committee considered a measure for implantation of an implantable cardioverter-defibrillator for the reduction of occurrence of sudden death in patients with severe left ventricular systolic dysfunction. Such a measure was not developed because of concerns related to the large number of exceptions due to patient factors (age, comorbidities, patient preference) and physician factors. Rather, the writing committee developed a measure to address counseling about the potential benefits of implantable cardioverter-defibrillators in appropriately selected patients instead of the actual implantation itself.

The writing committee considered including a composite measure of the prescription of both ACE inhibitor and beta-blocker therapy. The complexities of developing and implementing such an “all or none” optimal medical therapy measure (35) became clear during the public comment and peer review processes and led the writing committee to develop separate ACE inhibitor and beta-blocker measures that could be used as paired measures instead of a single composite measure.

Two other measures were developed by the writing committee but ultimately removed from the HF performance measure set after the peer review and public comment periods. These were the “Overuse of Echocardiography” measure from the outpatient set and “End-of-Life Care Plan” measure from the inpatient set. These measures, although potentially of value for improving patterns of care, were not felt to have been tested in clinical situations to ensure their reliability and validity. The writing committee notes 2 broader measures that address the provision of palliative care and end-of-life care and are intended for use in eligible patients with HF. One measure jointly developed by the AMA-PCPI and the National Committee for Quality Assurance, “Advance Care Planning,” can be accessed under the Palliative Care project on the AMA-PCPI Web site at http://www.ama-assn.org/ama1/pub/upload/mm/pcpi/palliative-care.pdf. The other measure developed by the AMA-PCPI, American Geriatrics Society, and National Committee for Quality Assurance that has been targeted to a broader patient population, “Advance Care Plan,” can be accessed under the Geriatrics project on the AMA-PCPI Web site at http://www.ama-assn.org/ama1/pub/upload/mm/pcpi/geriatrics-ws.pdf.

The writing committee considered a number of additional potential measures that focus on equally important aspects of care, but after extensive discussion, the committee declined to develop these measures either because of an anticipated large number of exclusions in the denominator or because of challenges in implementation. Such is the case for cardiac resynchronization therapy, in which methods to predict which patients will derive improved outcomes remain imperfect and the identification of all patients with prolonged QRS complexes, who would constitute the denominator, would be a feasibility challenge. Another measure related to treatment with aldosterone receptor antagonists was considered but not developed because of the large number of patients excluded from the denominator because of renal insufficiency or hyperkalemia before or during treatment with these agents. In addition, the development of serious renal failure or hyperkalemia in large numbers of patients might be an unintended consequence of the broad implementation of such a measure. Finally, treatment with combined hydralazine and nitrate therapy for black patients with HF was also considered but not developed. Although this therapy has been shown to be efficacious in blacks, defining the denominator would be difficult or impossible for most practices. If future methods to collect information on race/ethnicity are determined to be reliable, this barrier to measurement may be overcome.

The “2005 ACC/AHA Heart Failure Performance Measures” (3) were well aligned with the HF measures of the CMS and The Joint Commission. The ACCF, AHA, and AMA-PCPI will continue to work with the CMS, The Joint Commission, and the National Quality Forum to harmonize measures for care of patients with HF.

To be successful as quality improvement tools, these 9 measures in the current HF performance measure set need to be adopted, implemented, and integrated as routine components of patient care across various care settings. These measurement sets should contribute to the evolution of reporting systems that allow physicians and other healthcare providers to improve care for a critical patient population. Quality improvement is a continuous process, and this document reflects the lessons the practicing community has learned to date in using existing measures and knowledge gained about how these measures might be improved. The clinical care team should collect data and review adherence to these measures on a routine basis, look for changes, and adjust practice patterns as needed to improve performance.