Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association.

The introduction of Mission: Lifeline significantly increased timely access to percutaneous coronary intervention for patients with ST-segment-elevation myocardial infarction (STEMI). In the years since, morbidity and mortality rates have declined, and research has led to significant developments that have broadened our concept of the STEMI system of care. However, significant barriers and opportunities remain. From community education to 9-1-1 activation and emergency medical services triage and from emergency department and interfacility transfer protocols to postacute care, each critical juncture presents unique challenges for the optimal care of patients with STEMI. This policy statement sets forth recommendations for how the ideal STEMI system of care should be designed and implemented to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness.

American Heart Association's Call to Action for Payment and Delivery System Reform.

The healthcare system is undergoing a transition from paying for volume to paying for value. Clinicians, as well as public and private payers, are beginning to implement alternative delivery and payment models, such as the patient-centered medical home, accountable care organizations, and bundled payment arrangements. Implementation of these new models will necessitate delivery system transformation and will actively involve all fields of medical care, in particular medicine and surgery. This call to action, on behalf of the American Heart Association's Expert Panel on Payment and Delivery System Reform, serves to offer support and direction for further involvement by the American Heart Association. In doing so, it (1) provides baseline review and definition of the present models and some of the early results of these delivery models, including outcomes; (2) initiates a conversation within the American Heart Association on the impact of payment and delivery system reform, as well as how the American Heart Association should engage in the interest of patients; (3) issues a call to action to our organization and to cardiovascular and stroke health professionals across the country to become educated about these models so to as to understand their impact on patient care; and (4) asks the government and other funding agencies, including the American Heart Association, to begin supporting and prioritizing meaningful research endeavors to further evaluate these models.

Current quality of cardiovascular prevention for Million Hearts: an analysis of 147,038 outpatients from The Guideline Advantage.

BACKGROUND: Million Hearts is a national initiative to prevent 1 million heart attacks and strokes over 5 years. The degree to which outpatient providers are controlling risk factors has not been fully described. METHODS: We examined adherence to the Million Hearts clinical quality measures using The Guideline Advantage, a nationwide quality improvement program for outpatient care. Specifically, we determined the proportion of patients with (1) ischemic vascular disease who were prescribed an antiplatelet drug; (2) hypertension whose blood pressure was controlled; (3) diabetes mellitus whose most recent low-density lipoprotein cholesterol level was <100 mg/dL; and 4) a tobacco use screening and who received a smoking cessation intervention as needed. RESULTS: From January 1, 2010, to March 31, 2012, there were 147,038 patients enrolled from 25 US practices. At the practice level, antiplatelet prescription ranged from 50.0% to 82.3% (median 71.9%, interquartile range [IQR] 66.7-82.1), hypertension control ranged from 48.6% to 75.3% (median 66.6%, IQR 60.1-70.9), hyperlipidemia control among patients with diabetes mellitus ranged from 53.3% to 100.0% (median 75.8%, IQR 65.8-83.0), and tobacco use screening and intervention ranged from 31.0% to 98.8% (median 79.8%, IQR 72.0-83.2). Black and people of color races were associated with a lower likelihood of blood pressure control and cholesterol control. Female gender was associated with a lower likelihood of antiplatelet prescription and cholesterol control. CONCLUSIONS: Compliance with quality measures for the Million Hearts initiative varies widely and is notable for racial and gender disparities. Our findings identify multiple opportunities to improve the quality of cardiovascular prevention.

Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association.

Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post-cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.

Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative.

Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.

Standards for measures used for public reporting of efficiency in health care: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research and the American College of Cardiology Foundation.

The assessment of medical practice is evolving rapidly in the United States. An initial focus on structure and process performance measures assessing the quality of medical care is now being supplemented with efficiency measures to quantify the "value" of healthcare delivery. This statement, building on prior work that articulated standards for publicly reported outcomes measures, identifies preferred attributes for measures used to assess efficiency in the allocation of healthcare resources. The attributes identified in this document combined with the previously published standards are intended to serve as criteria for assessing the suitability of efficiency measures for public reporting. This statement identifies the following attributes to be considered for publicly reported efficiency measures: integration of the quality and cost; valid cost measurement and analysis; minimal incentive to provide poor quality care; and proper attribution of the measure. The attributes described in this statement are relevant to a wide range of efforts to profile the efficiency of various healthcare providers, including hospitals, healthcare systems, managed-care organizations, physicians, group practices, and others that deliver coordinated care.

Achieving rapid reperfusion with primary percutaneous coronary intervention remains a challenge: insights from American Heart Association's Get With the Guidelines program.

BACKGROUND: The speed of reperfusion (door-to-balloon [D2B] time) is a well established performance metric for patients with ST-elevation myocardial infarction. Although preferably D2B times should be or=65 years, 27% female, and 17% nonwhite). The overall median D2B time was 96 minutes (interquartile range [IQR] 69-140 minutes). Only 44.8% of cases had D2B or=65 years (103 [IQR 74-153] vs 93 [IQR 67-133] minutes), women (103 [IQR 73-154] vs 94 [IQR 68-135] minutes), and minorities (108 [IQR 77-162] vs 95 [IQR 68-136] minutes) had significantly longer median D2B times. These subgroup disparities in the D2B persisted over the study period as compared with their peers. CONCLUSION: The median D2B times with primary PCI have improved modestly in hospitals participating in the American Heart Association Get With the Guidelines program over the last few years but remain below ideal levels. The D2B times are particularly delayed in the elderly people, women, and minority populations; an issue that has persisted over time. These results highlight the ongoing need for national myocardial infarction quality improvement initiatives.

Effectiveness of the electronic medical record in improving the management of hypertension.

Clinical studies suggest that hypertension is often undiagnosed, undertreated, and poorly controlled. In 1997, the authors developed a comprehensive electronic medical record that interfaces with physicians during each outpatient visit and provides real-time feedback about patient care management, including the management of hypertension. The purpose of this study was to determine whether this interactive electronic medical record results in better detection and control of hypertension. During a 12-month study period, consecutive outpatients (n=1076) were seen for routine follow-up; patient care documentation relied solely on the electronic medical record. Quality indicators for hypertension included: 1) documentation of the diagnosis of hypertension; 2) use of blood pressure-lowering drugs; and 3) successful blood pressure lowering to < or =140/90 mm Hg. The authors compared the hypertension management of these patients to a control group of similar patients (n=723) with medical records consisting solely of traditional pen and paper charts. Baseline characteristics were similar between the two groups, including the prevalence of hypertension (73% vs. 70%; p=NS). However, the electronic medical record resulted in higher documentation rates of hypertension (90% vs. 77%; p<0.001), greater use of antihypertensive therapy (94% vs. 90%; p<0.01), and more successful blood pressure lowering to < or =140/90 mm Hg (54% vs. 28%; p<0.001). In conclusion, the electronic medical record with real-time feedback improves the physicians ability to detect, treat, and control hypertension.

Standards for measures used for public reporting of efficiency in health care: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes research and the American College of Cardiology Foundation.

The assessment of medical practice is evolving rapidly in the United States. An initial focus on structure and process performance measures assessing the quality of medical care is now being supplemented with efficiency measures to quantify the "value" of healthcare delivery. This statement, building on prior work that articulated standards for publicly reported outcomes measures, identifies preferred attributes for measures used to assess efficiency in the allocation of healthcare resources. The attributes identified in this document combined with the previously published standards are intended to serve as criteria for assessing the suitability of efficiency measures for public reporting. This statement identifies the following attributes to be considered for publicly reported efficiency measures: integration of the quality and cost; valid cost measurement and analysis; minimal incentive to provide poor quality care; and proper attribution of the measure. The attributes described in this statement are relevant to a wide range of efforts to profile the efficiency of various healthcare providers, including hospitals, healthcare systems, managed-care organizations, physicians, group practices, and others that deliver coordinated care.

Electronic health record systems: the vehicle for implementing performance measures.

Advances in information technology and recent national directives have the potential to support dramatic improvements in health care. Two key components are the implementation of functional electronic health record systems and widely accepted, evidence-based clinical performance measures for physicians. Midwest Heart Specialists, a 55-physician cardiovascular group at 14 locations in northern Illinois, has utilized an outpatient electronic health record system since 1997. Since 2003, the group has integrated cardiovascular measurement sets developed by the American Medical Association-convened Physician Consortium for Performance Improvement into its electronic health record system. With this integration, the group was able to capture data needed for internal quality assessment and improvement as part of routine outpatient care without the need for additional resources. Critical disease-management data for decision support are available continuously, resulting in improvements in health care. The reporting of these standardized data could be the foundation to support quality-based reimbursement strategies and physician office-based disease-management strategies.