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J Am Coll Cardiol, 2008; 51:865-884, doi:10.1016/j.jacc.2008.01.006
© 2008 by the American College of Cardiology Foundation
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FOCUS ISSUE: ATRIAL FIBRILLATION: ACC/AHA/PHYSICIAN CONSORTIUM PERFORMANCE MEASURE

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

N.A. Mark Estes, III, MD, FACC, FAHA, FHRS, Co-Chair, WRITING COMMITTEE MEMBER, Jonathan L. Halperin, MD, FACC, FAHA, Co-Chair, WRITING COMMITTEE MEMBER, Hugh Calkins, MD, FACC, FAHA, WRITING COMMITTEE MEMBER, Michael D. Ezekowitz, MB, ChB, DPhil, FACC, WRITING COMMITTEE MEMBER, Paul Gitman, MD, MACP, WRITING COMMITTEE MEMBER, Alan S. Go, MD, WRITING COMMITTEE MEMBER, Robert L. McNamara, MD, MHS, FACC, WRITING COMMITTEE MEMBER, Joseph V. Messer, MD, MACC, FAHA, WRITING COMMITTEE MEMBER, James L. Ritchie, MD, FACC, FAHA, WRITING COMMITTEE MEMBER, Sam J.W. Romeo, MD, MBA, WRITING COMMITTEE MEMBER, Albert L. Waldo, MD, FACC, FAHA, FHRS, WRITING COMMITTEE MEMBER and D. George Wyse, MD, PhD, FACC, FAHA, FHRS, WRITING COMMITTEE MEMBER

Key Words: ACC/AHA Performance Measures • nonvalvular atrial fibrillation • atrial flutter


   ACC/AHA Task Force on Performance Measures
Top
 ACC/AHA Task Force on...
Table of Contents
 Preamble
 I. Introduction
 II. Methodology
 III. Atrial Fibrillation and...
 IV. Discussion
 Staff
 Disclosures
 References
 
Robert O. Bonow, MD, FACC, FAHA, Chair; N.A. Mark Estes III, MD, FACC, FAHA, FHRS; Elizabeth DeLong, PhD; David C. Goff, Jr, MD, PhD, FAHA, FACP; Kathleen Grady, PhD, RN, FAHA, FAAN; Lee A. Green, MD, MPH; Ann Hiniker, RN, MS, CNS; Jane Ann Linderbaum, NP*; Frederick A. Masoudi, MD, MSPH, FACC; Ileana L. Piña, MD, FACC; Susan Pressler, DNS, RN, FAAN, FAHA*; Martha J. Radford, MD, FACC; John S. Rumsfeld, MD, PhD, FACC, FAHA


   Table of Contents
Top
 ACC/AHA Task Force on...
 Table of Contents
Preamble
 I. Introduction
 II. Methodology
 III. Atrial Fibrillation and...
 IV. Discussion
 Staff
 Disclosures
 References
 

Preamble......866
I Introduction......868
A Scope of the Problem......868
B Structure and Membership of the Writing Committee......868
C Disclosure of Relationships With Industry......868
D Review and Endorsement......868

II Methodology......868
A Definition of Atrial Fibrillation and Atrial Flutter......868
B Dimensions of Care......869
C Literature Review......869
D Definition and Selection of Measures......870

III Atrial Fibrillation and Atrial Flutter Performance Measures......870
A Patient Population and Care Period......870
B Brief Summary of the Measurement Set......870
C Data Collection......871

IV Discussion......871
A Risk Stratification......871
B Potential Measures Addressing Patients Undergoing Cardioversion......873
C Potential Measures Addressing the Quality of Anticoagulation Therapy......873

Appendix A: Relationships With Industry—Writing Committee......874
Appendix B. Relationships With Industry—Peer Reviewers......875
Appendix C: ACC/AHA/Physician Consortium AF Performance Measurement Set Specifications......876
Appendix D: Sample Performance Measure Survey Form and Exclusion Criteria Definitions......881
Appendix E: Sample Prospective Data Collection Flow Sheet......883
References......884


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  		Appendix A Relationships With Industry—Writing Committee for ACC/AHA/Physician Consortium 2008 Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter
 

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  		Appendix B Relationships With Industry—Peer Reviewers for ACC/AHA/Physician Consortium 2008 Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter
 

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  		Appendix C ACC/AHA/Physician Consortium AF Performance Measurement Set Specifications
 

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  		Appendix D Sample Performance Measure Survey Form and Exclusion Criteria Definitions
 

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  		Appendix E Sample Prospective Data Collection Flow Sheet
 

   Preamble
Top
 ACC/AHA Task Force on...
 Table of Contents
 Preamble
I. Introduction
 II. Methodology
 III. Atrial Fibrillation and...
 IV. Discussion
 Staff
 Disclosures
 References
 
Consistent with the national focus on healthcare quality, the American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multifaceted strategy to facilitate the process of improving clinical care. The first aspect of this effort is the creation of clinical practice guidelines that carefully synthesize available evidence to guide better patient care. Such guidelines are written to suggest diagnostic or therapeutic interventions that apply to patients in most circumstances, but clinical judgment is required to adapt these guidelines to the care of individual patients. The guidelines are based on available evidence, providing varying degrees of recommendation (Table 1). Occasionally, the evidence supporting a particular aspect or process of care is so strong that failure to perform such actions reduces the likelihood of optimum patient outcomes.


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  		Table 1 Applying classification of recommendations and level of evidence
 
Accordingly, the second aspect of the ACC/AHA effort to improve the quality of cardiovascular care is the development of performance measures. The ACC/AHA Task Force on Performance Measures was formed in February 2000, with 3 nominees from each organization charged with identifying the clinical topics for which performance measures are to be developed and then assembling teams of clinical and methodological experts for a given topic (eg, atrial fibrillation), both from within the sponsoring organizations and from other organizations dedicated to the care of the patients covered by the performance measurement set. The writing committee for each performance measure set is carefully guided with respect to the methodology of development of performance measures (1). Moreover, to avoid duplication of performance measure development efforts, writing committees are also instructed to evaluate existing nationally recognized performance measures using the attributes of good performance measures specified by the ACC/AHA. In addition, the measures are constructed to facilitate both retrospective and prospective data collection with explicit administrative and/or easily documented clinical criteria. Furthermore, the data elements required for the performance measures are linked to existing ACC/AHA clinical data standards to encourage uniform measurements of cardiovascular care.

Although the focus of the performance measures writing committees is on measures intended for quality improvement efforts, other organizations may use these measures for external review or public reporting of provider performance. Therefore, it is within the scope of the writing committee's task to comment, when appropriate, on the strengths and limitations of such external reporting for a particular cardiovascular disease state or patient population.

All the measures in this set have limitations and pose challenges to implementation that could result in unintended consequences when used for accountability. The implementation of these measures for purposes other than quality improvement requires field testing to address issues related but not limited to sample size, frequency of use of an intervention, comparability, and audit requirements. The way in which these issues are addressed is dependent on the type of accountability developed, including the method of data collection, assignment of patients to physicians for measurement purposes, establishment of baseline measures, incentives, and public reporting methods, among other things. The ACC/AHA encourages those interested in implementing these measures for purposes other than quality improvement to work with the ACC/AHA to understand these complex issues in pilot testing projects, to assess limitations and confounding factors, and to guide refinements of the measures to enhance their utility for these additional purposes.

By facilitating measurements of cardiovascular healthcare quality, ACC/AHA performance measurement sets may serve as vehicles to accelerate appropriate translation of scientific evidence into clinical practice. These documents are intended to provide practitioners with tools to measure the quality of care and identify opportunities for improvement. Because the target audience for these measures is the practitioner, they were constructed from the provider's perspective and not to characterize "good" or "bad" practice. Rather, it is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved.

Robert O. Bonow, MD, FACC, FAHA

Chair, ACC/AHA Task Force on Performance Measures


   I. Introduction
Top
 ACC/AHA Task Force on...
 Table of Contents
 Preamble
 I. Introduction
II. Methodology
 III. Atrial Fibrillation and...
 IV. Discussion
 Staff
 Disclosures
 References
 
The ACC/AHA/Physician Consortium Atrial Fibrillation or Atrial Flutter Performance Measures Writing Committee (the Writing Committee) was charged to develop performance measures concerning the diagnosis and treatment of atrial fibrillation (AF) and atrial flutter. These performance measures refer to adults (18 years of age or older) with nonvalvular AF evaluated in the outpatient setting. They do not apply to patients with acute, reversible causes of AF or flutter, such as postoperative patients, patients with transient or reversible causes of AF (eg, pneumonia or hyperthyroidism), patients with mitral stenosis or prosthetic heart valves, or patients who are pregnant.

A. Scope of the Problem.   Atrial fibrillation is the most common arrhythmia encountered in clinical practice, accounting for approximately one third of all hospitalizations for cardiac rhythm disturbances. It has been estimated that 2.2 million Americans have paroxysmal or persistent AF, but the actual number may be higher (2). The prevalence of AF increases with age, reaching as high as 9% in octogenarians (3,4). During the past 20 years, there has been a 66% increase in hospital admissions for AF due to a combination of factors, including the aging of the population, a rising prevalence of chronic heart disease, and more frequent diagnosis through use of ambulatory monitoring devices (3,4). Atrial fibrillation is associated with an increased risk of stroke, heart failure, and all-cause mortality, especially in women. The mortality rate of patients with AF is higher than that of patients in normal sinus rhythm and is linked to severity of underlying heart disease (3,4). The guidelines for management of patients with AF recommend as a Class I indication that antithrombotic therapy for patients with atrial flutter follow the same approach as for patients with AF, given the evidence of their comparable risk of thromboembolism (4). Accordingly, these performance measures also apply to patients with atrial flutter who do not have valvular heart disease.

Given the morbidity, mortality, and costs associated with AF and atrial flutter, the ACC, AHA, and Physician Consortium chose this topic for performance measures both to raise the level of awareness of current guidelines and to provide tools physicians can use in practice to improve the quality of care provided to patients with nonvalvular AF and atrial flutter.

B. Structure and Membership of the Writing Committee.   The members of the Writing Committee included senior clinicians, specialists in cardiac arrhythmias and electrophysiology, and a representative from the ACC/AHA/European Society of Cardiology (ESC) Atrial Fibrillation Guideline Revision Writing Committee. The Writing Committee also included members of the American Medical Association, the American College of Physicians, and the Heart Rhythm Society.

C. Disclosure of Relationships With Industry.   The work of the Writing Committee was supported exclusively by the ACC, AHA, and Physician Consortium for Performance Improvement. Committee members volunteered their time, and there was no direct commercial support for the development of these performance measures. Meetings of the Writing Committee were confidential and attended only by committee members and staff. Writing Committee members were required to disclose in writing all financial relationships with industry relevant to this topic according to standard ACC and AHA reporting policies, and they verbally acknowledged these relationships to the other members (Appendix A).

D. Review and Endorsement.   Between January 15 and February 15, 2007, the performance measures document underwent a 30-day public comment period, during which ACC and AHA members and other healthcare professionals had an opportunity to review and comment on the text in advance of its final approval and publication. More than 15 responses were received.

The official peer review/content review of the document was conducted simultaneous with the 30-day public comment period, with 6 peer reviewers nominated by the ACC and 3 by the AHA (Appendix B). Additional comments were sought from clinical content experts and performance measurement experts.

The ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Atrial Fibrillation or Atrial Flutter were adopted by the respective governing bodies of the ACC and the AHA in September 2007 and approved by the American Medical Association–Physician Consortium for Performance Improvement in December 2007. These measures will be reviewed for currency once every year and updated as needed. They should be considered valid until either updated or rescinded by the ACC/AHA Task Force on Performance Measures.


   II. Methodology
Top
 ACC/AHA Task Force on...
 Table of Contents
 Preamble
 I. Introduction
 II. Methodology
III. Atrial Fibrillation and...
 IV. Discussion
 Staff
 Disclosures
 References
 
The development of performance measures involves identification of measures that target a specific patient population observed over a particular time period. To achieve this goal, the ACC/AHA Task Force on Performance Measures delineated 5 mandatory sequential steps. The following sections outline how the Writing Committee addressed these elements.

A. Definition of AF and Atrial Flutter.   The Writing Committee used the "ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation" and the "ACC/AHA Key Data Elements and Definitions for Measuring the Clinical Management and Outcomes of Patients With Atrial Fibrillation" for definitions of AF and atrial flutter (4,5). These guidelines define AF as a supraventricular tachyarrhythmia characterized by uncoordinated atrial activity with consequent deterioration of atrial mechanical function (4,5). On the electrocardiogram (ECG), AF is characterized by the replacement of consistent P waves with rapid oscillations or fibrillatory waves that vary in amplitude, shape, and timing, associated with an irregular, frequently rapid ventricular response when atrioventricular conduction is intact (4,5).

Multiple classification schemes for AF have been proposed with a consensus driven by the desire for simplicity and clinical relevance (4,5). The clinician should distinguish a first-detected episode of AF, whether or not it is symptomatic or self-limited, recognizing that there may be uncertainty about the duration of the episode and about previous undetected episodes. With 2 or more episodes, AF is considered recurrent. If AF terminates spontaneously, recurrent AF is designated as paroxysmal; when sustained, AF is designated as persistent. When persistent, AF that terminates with pharmacological therapy or electrical cardioversion does not change the designation. Persistent AF may be either the initial presentation of the arrhythmia or the culmination of recurrent episodes of paroxysmal AF. The category of persistent AF also includes cases of longstanding AF (ie, more than 1 year) when cardioversion is not indicated, not attempted, or unsuccessful. This usually leads to permanent AF. This terminology applies to episodes of AF that last more than 30 seconds and that are unrelated to a reversible cause (4,5). These performance measures were developed to apply to all classifications of AF lasting longer than 30 seconds, with the exclusion of secondary AF due to acute reversible causes (4).

Reversible or secondary AF can occur in the setting of acute myocardial infarction, cardiac surgery, pericarditis, myocarditis, hyperthyroidism, pulmonary embolism, pneumonia, acute pulmonary disease, or other acute illness. This form of reversible AF is considered separately because AF is less likely to recur once the precipitating condition has resolved. In these settings, AF is not the primary problem, and treatment of the underlying disorder concurrently with management of the episode of AF usually results in termination of the arrhythmia without recurrence (4). These performance measures do not apply to such forms of secondary AF that are due to acute reversible causes.

Atrial fibrillation may occur in association with atrial flutter or atrial tachycardia (4). The typical form of atrial flutter is characterized by a sawtooth pattern of regular atrial activation called flutter (f) waves on the ECG, particularly visible in leads II, III, aVF, and V1. If untreated, the atrial rate typically ranges from 240 to 320 beats per minute, with f waves inverted in leads II, III, and aVF and upright in lead V1 (4,5). The direction of activation in the right atrium may be reversed, resulting in upright f waves in leads II, III, and aVF and inversion in lead V1. Atrial flutter may degenerate into AF, and AF may convert to atrial flutter. Atrial flutter is usually readily distinguished from AF, but misdiagnosis may occur when coarse fibrillatory atrial activity is prominent in more than 1 ECG lead (4,5).

The guidelines indicate that it is prudent to estimate thromboembolic risk for patients with atrial flutter using the same criteria as for AF (4). Although there are fewer data regarding risk stratification and anticoagulation for atrial flutter, and treatment strategies for atrial flutter differ from those for AF, the Writing Committee included atrial flutter as an arrhythmia appropriate for these performance measures on the basis of several considerations. Atrial flutter commonly occurs in patients with AF at risk for thromboembolism. The current guidelines indicate as a Class I recommendation that it is prudent to stratify patients on the basis of thromboembolic risk and to consider anticoagulation for atrial flutter in a fashion similar to that for patients with AF. To align these performance measures with the practice guidelines, the Writing Committee developed the performance measures to apply both to patients with AF and to those with atrial flutter (4).

Table 2 lists the relevant International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes for these measures. The specific period of interest for each measure is further defined in the full specifications in Appendix C.


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  		Table 2 Relevant ICD-9-CM Diagnosis Code
 
B. Dimensions of Care.   Given the multiple aspects of treatment that can be measured, the Writing Committee identified the dimensions of care that should be evaluated and categorized each potential performance measure into the relevant dimension of care. The dimensions of care selected as performance measures for AF include evaluation and management. Classification into dimensions of care facilitated the identification of areas in which evidence was lacking and prevented duplication of measures.

The focus of this initial set of performance measures is prevention of thromboembolism. Although the Writing Committee considered a number of additional potential measures that focus on equally important aspects of care, either the evidence base or other challenges to measurement of these components of care across all patients undermined their benefits.

Although the Writing Committee considered outcomes as potential performance measures, none were included at this time. These performance measures focus only on processes, because their specific purpose is to assist physicians in improving clinical care. The dimensions of care measurement matrix relevant to the performance measures for AF is presented in Table 3.


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  		Table 3 ACC/AHA/Physician Consortium AF and Atrial Flutter Performance Measurement Set: Dimension of Care Measures Matrix
 
C. Literature Review.   The Writing Committee reviewed the 2001 "ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation," the 2003 "Management of Newly Detected Atrial Fibrillation: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians," the 2004 "Key Data Elements and Definitions for Measuring the Clinical Management and Outcomes of Patients With Atrial Fibrillation," and the "ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation" as the primary sources for deriving these measures (3–6). One of the co-chairs of the Writing Committee also participated on the writing committee to develop the "ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation" (4), and 4 members participated in the development of the "ACC/AHA Key Data Elements and Definitions for Measuring the Clinical Management and Outcomes of Patients With Atrial Fibrillation" (5). As a participant in the guideline writing committee, the co-chair was able to offer insights into measurement issues and provide suggestions for clarity and specificity of guideline recommendations.

D. Definition and Selection of Measures.   Explicit criteria exist for the development of performance measures that accurately reflect quality of care; these include definition of the numerators and denominators of potential measures and evaluation of their applicability, interpretability, and feasibility. To select measures for inclusion in the performance measurement set, the Writing Committee prioritized the Class I and Class III recommendations from the 2001 ACC/AHA/ESC AF guideline and the grade 1 recommendations from the 2003 American College of Physicians/American Academy of Family Physicians guidelines for the management of newly detected AF (3,6). After publication of the "ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation" (4), the Writing Committee re-evaluated the performance measures to ensure consistency with the 2006 recommendations for risk stratification and anticoagulation (4).

From analysis of these recommendations, the Writing Committee identified potential measures relevant to the management of patients with AF and then independently evaluated their potential for use as performance measures using exclusion criteria adapted from the ACC/AHA "Attributes of Good Performance Measures" (Table 4) and the quality indicator survey form and definitions (Appendix D). Member ratings of all the potential measures were collated and discussed by the full committee to reach a consensus on which measures should advance for inclusion in the final measure set. Eight potential measures then advanced for full specification to assess their suitability as performance measures. The Writing Committee met again to review and clarify these specifications and to select measures for inclusion in the final set. At this stage, the Writing Committee also decided to include as an additional measure the assessment of thromboembolic risk factors.


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  		Table 4 Summary of ACC/AHA Attributes of Good Performance Measures
 

   III. Atrial Fibrillation and Atrial Flutter Performance Measures
Top
 ACC/AHA Task Force on...
 Table of Contents
 Preamble
 I. Introduction
 II. Methodology
 III. Atrial Fibrillation and...
IV. Discussion
 Staff
 Disclosures
 References
 
A. Patient Population and Care Period.   The target population consists of patients aged 18 years or older with a diagnosis of nonvalvular AF or atrial flutter. Exclusion criteria specific to each measure were developed to further specify the target population (see Appendix D for an outline of the process employed). For the present document, the outpatient care period is defined as the time under evaluation for care provided in an outpatient setting (1 reporting year).

B. Brief Summary of the Measurement Set.   Table 5 shows the ACC/AHA/Physician Consortium AF and Atrial Flutter Performance Measurement Set, which consists of those measures with the highest level of evidence and the greatest support among the committee members. The measures include the following: 1) assessment of thromboembolic risk factors, 2) chronic anticoagulation therapy, and 3) monthly international normalized ratio (INR) measurement. These performance measures are intended for patients with nonvalvular AF or atrial flutter that is not due to acute reversible causes. Appendix C provides the detailed specifications for each performance measure, including the numerator, denominator, period of assessment, method of reporting, sources of data, rationale, clinical recommendations, and challenges to implementation.


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  		Table 5 ACC/AHA/Physician Consortium AF and Atrial Flutter Performance Measurement Set
 
C. Data Collection.   These performance measures for AF and atrial flutter are intended for prospective use to enhance the quality improvement process but may also be applied retrospectively if prospective data collection is not possible. Use of a data collection instrument is recommended to aid compilation, and a sample instrument is provided in Appendix E. Individual institutions may modify the instrument or develop a different tool based on local practice and standards.


   IV. Discussion
Top
 ACC/AHA Task Force on...
 Table of Contents
 Preamble
 I. Introduction
 II. Methodology
 III. Atrial Fibrillation and...
 IV. Discussion
Staff
 Disclosures
 References
 
The Writing Committee added exclusion criteria, recognizing that there are justifiable reasons for not meeting the performance measures. These reasons should be recorded on the data collection form. Documentation of such factors should be encouraged to provide data for future research and facilitate in-depth quality improvement in situations in which there are apparent outliers with respect to the number of patients with medical or patient-centered reasons for exclusion.

Challenges to implementation of the measures are discussed where applicable. In general, the initial challenge facing any measurement effort is inadequate documentation. Discussion of these challenges is not an argument against any individual measure. Rather, such discussion should be considered a cautionary note that draws attention to areas in which additional research should be considered to enhance the value of the measures.

A. Risk Stratification.   The Writing Committee recognizes that controversy exists regarding the threshold for use of chronic anticoagulation, especially for patients at intermediate risk of thromboembolism (4,7). In addition to prior stroke or transient ischemic attack (TIA), heart failure or impaired left ventricular systolic function, hypertension, advanced age, and diabetes mellitus have consistently emerged as independent risk factors for ischemic stroke associated with nonvalvular AF (3–6,8). The relative risk of ischemic stroke associated with specific clinical features, derived from a collaborative analysis of participants given no antithrombotic therapy in the control groups of 5 randomized trials, is displayed in Table 6 (9).


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  		Table 6 Risk Factors for Ischemic Stroke or Systemic Embolism in Patients With Nonvalvular AF*
 
In patients with nonvalvular AF, prior stroke or TIA is the most powerful independent predictor of stroke, being significantly associated with stroke in all 6 studies in which it was evaluated, with incremental relative risk between 1.9 and 3.7 (averaging approximately 3.0) (4). All patients with prior stroke or TIA require anticoagulation unless contraindications exist in a given patient (3–6,8–11). Risk stratification based on other clinical features should be based on their independent predictive value and the absolute stroke rates with which they are associated for primary prevention. Patient age is a consistent independent predictor of stroke, but older people are also at increased risk for anticoagulant-related bleeding (3–6,8–11). Similarly, hypertension is a consistent, powerful predictor of stroke, with a history of hypertension being independently predictive in 5 studies (median relative risk approximately 2.0) and with systolic blood pressure higher than 160 mm Hg being significant in 2 others (mean relative risk approximately 2.0). The effect of blood pressure control on the risk of thromboembolism has not been investigated. Diabetes mellitus was a significant independent predictor in 4 studies, being associated with an average relative risk of 1.8, but was not a significant predictor in 2 others, and this condition is a less powerful independent predictor than prior stroke/TIA, hypertension, or age; however, the type, duration, and control of diabetes mellitus have not been evaluated to refine its predictive value for thromboembolism in patients with AF. Clinical heart failure has not been shown conclusively to have independent predictive value for stroke in studies of AF patients, but when the definition of the risk factor was expanded to include left ventricular systolic dysfunction (defined as echocardiographic fractional shortening less than 25%) with or without clinical heart failure within 3 months, it became a significant independent predictor (3–6,8–11) . Although coronary artery disease, variously defined, was a relatively weak but statistically significant predictor of stroke in 1 large study, it was not independently predictive of stroke in 3 other patient cohorts.

The CHADS2 (Cardiac failure, Hypertension, Age, Diabetes, Stroke [Doubled]) index integrates elements from several schemes (12) and is based on a point system in which 2 points are assigned for a history of stroke or TIA and 1 point each is assigned for age over 75 years and a history of hypertension, diabetes mellitus, or recent heart failure, as shown in Table 7. The predictive value of this scoring system was evaluated in 1733 Medicare beneficiaries with nonvalvular AF between the ages of 65 and 95 years who were not given warfarin at hospital discharge (Table 8) (12–15). Although high scores were associated with an increased stroke rate in this elderly cohort, few patients had a score of 5 or more or a score of zero. Relatively few patients (8% of the CHADS2 derivation cohort) had a history of stroke or TIA in the absence of other independent predictors. Hence, the index may underestimate the incremental risk contributed by prior thromboembolism, and anticoagulation is indicated for secondary prevention regardless of the CHADS2 score.


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  		Table 7 CHADS2 Stroke Risk Stratification Scheme
 

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  		Table 8 Stroke Risk in Patients With Nonvalvular AF Not Treated With Anticoagulation According to the CHADS2 Stroke Risk Stratification Scheme Applied to Several Patient Cohorts*
 
Although schemes for stratification of stroke risk identify patients who benefit most and least from anticoagulation, the threshold for use of anticoagulation remains controversial. Opinion is particularly divided about anticoagulation for those at intermediate risk (stroke rate 3% to 5% per year). Some advocate the routine use of anticoagulation for patients with stroke rates in this range, whereas others favor selective anticoagulation for patients at intermediate risk, with consideration given to individual bleeding risks, availability of organized anticoagulation management programs, and patient preferences (4,8,10). The threshold of benefit at which AF patients decide with their physicians to initiate anticoagulation varies; some at intermediate risk elect to undergo anticoagulation, whereas others do not (4,7). Table 9 summarizes the recommendations for antithrombotic therapy in patients with AF and atrial flutter given in the 2006 ACC/AHA/ESC AF guidelines. Table 10 shows risk factors for AF and atrial flutter.


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  		Table 9 Antithrombotic Therapy for Patients With Nonvalvular AF*
 

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  		Table 10 Risk Factors for Stroke in Patients With AF
 
B. Potential Measures Addressing Patients Undergoing Cardioversion.   A key goal of this initial phase of AF performance measure development is to increase awareness of the AF guidelines and the evidence in support of these guidelines among all practitioners. The Writing Committee therefore designed this set of performance measures to apply to the widest possible patient and physician populations. Because cardioversion is performed only by specialists and for only a selected subset of patients, measures related to this procedure were not included. It is anticipated that measures related to cardioversion of AF or atrial flutter will be considered for addition to an expanded set of AF performance measures in the future.

C. Potential Measures Addressing the Quality of Anticoagulation Therapy.   Although clearly an essential part of the care of patients receiving chronic anticoagulation therapy, assessment of the consistency of anticoagulation (eg, the proportion of the treatment period during which the INR is maintained in the target therapeutic range) does not lend itself easily to the development of performance measures. The data collection effort required for measurement of performance would be substantial, because it depends on determining both when the patient was taking warfarin and the dates of all INR measurements. In addition, numerous clinical trials have shown that even in controlled environments, the maintenance of INR within a narrow target range for patients prescribed warfarin for stroke prevention is challenging. The goal for this measure would therefore be less than 100 percent, which would make it necessary to define an acceptable level of performance. For these reasons, the Writing Committee deferred the inclusion of a performance measure related to achievement of target INR intensity for future consideration (14,15).


   Staff
Top
 ACC/AHA Task Force on...
 Table of Contents
 Preamble
 I. Introduction
 II. Methodology
 III. Atrial Fibrillation and...
 IV. Discussion
 Staff
Disclosures
 References
 
American College of Cardiology

John C. Lewin, MD, Chief Executive Officer

Charlene May, Director, Clinical Policy and Documents

Tilithia McBride, Associate Director, Performance Measurement Policy

Melanie Shahriary, RN, BSN, Clinical Performance Measurement

Erin A. Barrett, Senior Specialist, Clinical Policy and Documents

American Heart Association

M. Cass Wheeler, Chief Executive Officer

Gayle R. Whitman, RN, PhD, FAAN, FAHA, Vice President, Office of Science Operations

Kathryn A. Taubert, PhD, FAHA, Senior Science Advisor


   Disclosures
Top
 ACC/AHA Task Force on...
 Table of Contents
 Preamble
 I. Introduction
 II. Methodology
 III. Atrial Fibrillation and...
 IV. Discussion
 Staff
 Disclosures
References
 


   Footnotes
 
This document was approved by the American College of Cardiology Board of Trustees in September 2007, by the American Heart Association Science Advisory and Coordinating Committee in September 2007, and by the Physician Consortium for Performance Improvement in December 2007.

The ACC and AHA request that this document be cited as follows: Estes NAM III, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS, McNamara RL, Messer JV, Ritchie JL, Romeo SJW, Waldo AL, Wyse DG. 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 Performance Measures for Atrial Fibrillation). J Am Coll Cardiol 2008;51:865–84.

This article has been copublished in Circulation.

Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and the American Heart Association (my.americanheart.org). For copies of this document, please contact Elsevier Inc. reprint department, fax (212) 633-3820, e-mail reprints{at}elsevier.com.

This Physician Performance Measurement Set (PPMS) and related data specifications were developed by the Physician Consortium for Performance Improvement (the Consortium) including the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Medical Association (AMA) to facilitate quality improvement activities by physicians. The performance measures contained in this PPMS are not clinical guidelines and do not establish a standard of medical care, and they have not been tested for all potential applications. This PPMS is intended to assist physicians to enhance quality of care and is not intended for comparing individual physicians to each other or for individual physician accountability by comparing physician performance against the measure or guideline.

This PPMS is subject to review and may be revised or rescinded at any time by the Consortium. The PPMS may not be altered without the prior written approval of the Consortium. A PPMS developed by the Consortium, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the performance measures for commercial gain, or incorporation of the performance measures into a product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the performance measures require a license agreement between the user and the AMA (on behalf of the Consortium) or the ACC or the AHA. Neither the Consortium nor its members shall be responsible for any use of this PPMS.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the ACC, the AHA, the Consortium and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT) or other coding contained in the specifications.

CPT contained in the measures specifications is copyright 2005 American Medical Association. LOINC copyright 2004 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT) copyright 2004 College of American Pathologists (CAP). All Rights Reserved. Use of SNOMED CT is only authorized within the United States.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation or the American Heart Association. Please contact Elsevier’s permission department at healthpermissions{at}elsevier.com.

* Former Task Force member during this writing effort. Back


   References
Top
 ACC/AHA Task Force on...
 Table of Contents
 Preamble
 I. Introduction
 II. Methodology
 III. Atrial Fibrillation and...
 IV. Discussion
 Staff
 Disclosures
 References
 

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  2. Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence[published correction appears in Circulation. 2006;114:e498] Circulation 2006;114:119-125.[Abstract/Free Full Text]
  3. Fuster V, Rydén LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) J Am Coll Cardiol 2001;38:1231-1266.[Free Full Text]
  4. Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation)[published correction appears in J Am Coll Cardiol. 2007;50:562] J Am Coll Cardiol 2006;48:854-906.[Free Full Text]
  5. McNamara RL, Brass LM, Drozda Jr JP, et al. ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Data Standards on Atrial Fibrillation) Circulation 2004;109:3223-3243.[Free Full Text]
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  12. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation JAMA 2001;285:2864-2870.[Abstract/Free Full Text]
  13. Van Walraven C, Hart RG, Wells GA, et al. A clinical prediction rule to identify patients with atrial fibrillation and a low risk for stroke while taking aspirin Arch Intern Med 2003;163:936-943.[Abstract/Free Full Text]
  14. Go AS, Hylek EM, Chang Y, et al. Anticoagulation therapy for stroke prevention in atrial fibrillation: how well do randomized trials translate into clinical practice? JAMA 2003;290:2685-2692.[Abstract/Free Full Text]
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