Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative.

BACKGROUND: Despite cardiac rehabilitation (CR) being shown to improve health outcomes among patients with heart disease, its use has been suboptimal. In response, the Million Hearts Cardiac Rehabilitation Collaborative developed a road map to improve CR use, including increasing participation rates to ≥70% by 2022. This observational study provides current estimates to measure progress and identifies the populations and regions most at risk for CR service underutilization. METHODS AND RESULTS: We identified Medicare fee-for-service beneficiaries who were CR eligible in 2016, and assessed CR participation (≥1 CR session attended), timely initiation (participation within 21 days of event), and completion (≥36 sessions attended) through 2017. Measures were assessed overall, by beneficiary characteristics and geography, and by primary CR-qualifying event type (acute myocardial infarction hospitalization; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant). Among 366 103 CR-eligible beneficiaries, 89 327 (24.4%) participated in CR, of whom 24.3% initiated within 21 days and 26.9% completed CR. Eligibility was highest in the East South Central Census Division (14.8 per 1000). Participation decreased with increasing age, was lower among women (18.9%) compared with men (28.6%; adjusted prevalence ratio: 0.91 [95% CI, 0.90-0.93]) was lower among Hispanics (13.2%) and non-Hispanic blacks (13.6%) compared with non-Hispanic whites (25.8%; adjusted prevalence ratio: 0.63 [0.61-0.66] and 0.70 [0.67-0.72], respectively), and varied by hospital referral region and Census Division (range: 18.6% [East South Central] to 39.1% [West North Central]) and by qualifying event type (range: 7.1% [acute myocardial infarction without procedure] to 55.3% [coronary artery bypass surgery only]). Timely initiation varied by geography and qualifying event type; completion varied by geography. CONCLUSIONS: Only 1 in 4 CR-eligible Medicare beneficiaries participated in CR and marked disparities were observed. Reinforcement of current effective strategies and development of new strategies will be critical to address the noted disparities and achieve the 70% participation goal.

Vital Signs: State-Level Variation in Nonfatal and Fatal Cardiovascular Events Targeted for Prevention by Million Hearts 2022.

INTRODUCTION: Despite its preventability, cardiovascular disease remains a leading cause of morbidity, mortality, and health care costs in the United States. This study describes the burden, in 2016, of nonfatal and fatal cardiovascular events targeted for prevention by Million Hearts 2022, a national initiative working to prevent one million cardiovascular events during 2017-2021. METHODS: Emergency department (ED) visits and hospitalizations were identified using Healthcare Cost and Utilization Project databases, and deaths were identified using National Vital Statistics System data. Age-standardized Million Hearts-preventable event rates and hospitalization costs among adults aged ≥18 years in 2016 are described nationally and across states, as data permit. Expected 2017-2021 event totals and hospitalization costs were estimated assuming 2016 values remain unchanged. RESULTS: Nationally, in 2016, 2.2 million hospitalizations (850.9 per 100,000 population) resulting in $32.7 billion in costs, and 415,480 deaths (157.4 per 100,000) occurred. Hospitalization and mortality rates were highest among men (989.6 and 172.3 per 100,000, respectively) and non-Hispanic blacks (211.6 per 100,000, mortality only) and increased with age. However, 805,000 hospitalizations and 75,245 deaths occurred among adults aged 18-64 years. State-level variation occurred in rates of ED visits (from 56.4 [Connecticut] to 274.8 per 100,000 [Kentucky]), hospitalizations (484.0 [Wyoming] to 1670.3 per 100,000 [DC]), and mortality (111.2 [Vermont] to 267.3 per 100,000 [Mississippi]). Approximately 16.3 million events and $173.7 billion in hospitalization costs could occur during 2017-2021 without preventive intervention. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Million Hearts-preventable events place a considerable health and economic burden on the United States. With coordinated efforts, many of these events could be prevented in every state to achieve the initiative's goal.

Electronic clinical quality measure reporting challenges: findings from the Medicare EHR Incentive Program's Controlling High Blood Pressure Measure.

Objective: To identify physician and practice characteristics associated with high clinical and technical performance on the electronic clinical quality measure (eCQM) that calculates the proportion of patients with hypertension who have controlled blood pressure. Materials and Methods: The study included 268 602 physicians participating in the Medicare Electronic Health Record Incentive Program between 2011 and 2014. Independent variables included delivery reform participation and physician, practice level, and area characteristics. Successful technical performance was a reported eCQM with non-zero values in both the numerator and denominator. Successful clinical performance was a reported eCQM value of ≥70% hypertension control. Results: Physicians with longer experience using certified health information technology, participants in delivery reform programs, and specialists that traditionally manage hypertension were 5%-15% more likely to achieve 70% control. Physicians in smaller and rural practices and a subset of physicians unlikely to primarily manage hypertension were more likely to submit measures with a zero value in either the numerator or denominator. Discussion: More physicians are using eCQMs to track and report their quality improvement efforts. This research presents the first examination of national eCQM data to identify physician and practice-level characteristics associated with performance. Conclusion: With careful selection of measures relevant to the clinician's specialty, complete data entry, and support for continuous quality improvement, health care professionals can excel technically and clinically. As care delivery transitions from fee-for-service to quality- and value-based models, high performers may realize financial gains and better patient outcomes. These analyses suggest patterns that may inform steps to improve performance.

Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool: A Special Report From the American Heart Association and American College of Cardiology.

The Million Hearts Initiative has a goal of preventing 1 million heart attacks and strokes-the leading causes of mortality-through several public health and healthcare strategies by 2017. The American Heart Association and American College of Cardiology support the program. The Cardiovascular Risk Reduction Model was developed by Million Hearts and the Center for Medicare & Medicaid Services as a strategy to assess a value-based payment approach toward reduction in 10-year predicted risk of atherosclerotic cardiovascular disease (ASCVD) by implementing cardiovascular preventive strategies to manage the "ABCS" (aspirin therapy in appropriate patients, blood pressure control, cholesterol management, and smoking cessation). The purpose of this special report is to describe the development and intended use of the Million Hearts Longitudinal ASCVD Risk Assessment Tool. The Million Hearts Tool reinforces and builds on the "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" by allowing clinicians to estimate baseline and updated 10-year ASCVD risk estimates for primary prevention patients adhering to the appropriate ABCS over time, alone or in combination. The tool provides updated risk estimates based on evidence from high-quality systematic reviews and meta-analyses of the ABCS therapies. This novel approach to personalized estimation of benefits from risk-reducing therapies in primary prevention may help target therapies to those in whom they will provide the greatest benefit, and serves as the basis for a Center for Medicare & Medicaid Services program designed to evaluate the Million Hearts Cardiovascular Risk Reduction Model.

Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool: A Special Report From the American Heart Association and American College of Cardiology.

The Million Hearts Initiative has a goal of preventing 1 million heart attacks and strokes-the leading causes of mortality-through several public health and healthcare strategies by 2017. The American Heart Association and American College of Cardiology support the program. The Cardiovascular Risk Reduction Model was developed by Million Hearts and the Center for Medicare & Medicaid Services as a strategy to assess a value-based payment approach toward reduction in 10-year predicted risk of atherosclerotic cardiovascular disease (ASCVD) by implementing cardiovascular preventive strategies to manage the "ABCS" (aspirin therapy in appropriate patients, blood pressure control, cholesterol management, and smoking cessation). The purpose of this special report is to describe the development and intended use of the Million Hearts Longitudinal ASCVD Risk Assessment Tool. The Million Hearts Tool reinforces and builds on the "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" by allowing clinicians to estimate baseline and updated 10-year ASCVD risk estimates for primary prevention patients adhering to the appropriate ABCS over time, alone or in combination. The tool provides updated risk estimates based on evidence from high-quality systematic reviews and meta-analyses of the ABCS therapies. This novel approach to personalized estimation of benefits from risk-reducing therapies in primary prevention may help target therapies to those in whom they will provide the greatest benefit, and serves as the basis for a Center for Medicare & Medicaid Services program designed to evaluate the Million Hearts Cardiovascular Risk Reduction Model.

Using electronic clinical quality measure reporting for public health surveillance.

By June 2013, three fourths of office-based practicing physicians in the United States had adopted some form of electronic health record (EHR) system. With greater EHR use, more health data are linked with available patient demographic information in a format that is easily retrievable and collected at the point of care. This highlights the potential of electronic clinical quality measure (CQM) reporting data for use in monitoring population health for those receiving health care services. To assess this possibility, electronic CQM data that were submitted to the Medicare EHR Incentive Program were analyzed to assess provider progress toward achieving blood pressure control among their patients with hypertension. Approximately 63,000 health care providers reported at least 1 time over 3 years, representing approximately 17 million patients with hypertension. On average, 62% of patients with hypertension had controlled blood pressure. Use of EHR data for public health surveillance could streamline reporting, facilitating more timely and possibly more complete data collection in key areas of public health concern.

Characteristics of medical professional liability claims in patients with cardiovascular diseases.

This report presents data describing a large cohort of closed cardiovascular medical professional liability (MPL) claims. The Physician Insurers Association of America established a registry of closed MPL claims in 1985. This registry contains data describing 230,624 closed claims for 28 medical specialties through 2007. The registry is maintained to support educational programs designed to improve the quality of care and to reduce patient injury and MPL claims. In this report, descriptive techniques are used to present summary information for the medical cardiovascular claims in the registry. Of 230,624 closed claims, 4,248 (1.8%) involved cardiovascular medical physicians. Of the 4,248 closed cardiovascular medical claims, 770 (18%) resulted in indemnity payments, and the average indemnity payment was $248,291. In the entire database, 30% of closed claims were paid, and the average indemnity payment was $204,268. The most common allegation among cardiovascular closed claims was diagnostic error, and the most prevalent diagnosis was coronary atherosclerosis. Claims involving cardiac catheterization and coronary angioplasty represented 12% and 7% of the cardiovascular closed claims. Aortic aneurysms and dissections, although relatively infrequent as clinical events, represent a substantial MPL risk because of the high percentage of paid claims (30%) and the very high average indemnity payment of $417,298. In conclusion, MPL issues are common and are important to all practicing cardiologists. Detailed knowledge of risks associated with liability claims should assist practicing cardiologists in improving the quality of care, reducing patient injury, and reducing the incidence of claims.