Payers for Performance, Beware!
Abstract & Commentary
By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips reports no financial relationship to this field of study.
Synopsis: With the exception of prescription of ACE inhibitors or blockers, performance measures for heart failure do not predict mortality or rehospitalization in the first 60 to 90 days after discharge.
Source: Fonarow GC, et al and the OPTIMIZE-HF Investigators and Hospitals. JAMA. 2007;297:61-70.
This was a prospective application of the American College of Cardiology/American Heart Association (ACC/AHA) performance measures to 5791 patients in 91 US hospitals. Patients included in the study were recruited from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) registry. The following indicators in the ACC/AHA performance measures1 and the fraction of patients in this cohort whose care included meeting this standard were:
1. discharge instructions about diet, activity, medications, weight, and follow up (66% of the study cohort had this documented in their records);
2. evaluation of left ventricular systolic function (89% received this);
3. angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (83% of eligible patients received this);
4. adult smoking cessation advice (62%);
5. anticoagulation for those with atrial fibrillation (53%)
In addition, 84% of the cohort received prescriptions for beta blockers at discharge, even though this is not a performance measure in the ACC/AHA recommendations for patients hospitalized with heart failure.
The OPTIMIZE-HF registry gathers data on patient characteristics, in-hospital and discharge management via a web-based report form. For the current study, follow-up data about survival, readmission and medical management were prospectively collected for a prespecified, representative cohort of the OPTIMIZE-HF registry. This data collection occurred 60-90 days after hospitalization for congestive heart failure. The mean age of the cohort was 72 years, 51% were men, and 78% were white. Ischemia was the cause of the CHF in 42%; 43% of the patients had diabetes, and 53.2% had left ventricular systolic dysfunction with a mean left ventricular ejection fraction (LVEF) of 37%. During the 60-90 day follow-up, the cohort had a death rate of 8.6% and a re-admission rate of 29.6%. As noted, the percentages of eligible patients whose care included each of the 5 performances measures are given above in association with each measure.
After statistical analysis of outcomes adjusted for risk factors, none of the performance measures was associated with reduced 60-90 day mortality, but use of beta blockers (not currently a performance standard) was. With regard to the combined outcome of reduced mortality or readmission, only the prescription of ACE inhibitors or ARBs for those with left ventricular systolic dysfunction, or beta blockers (again, not part of the performance standards) was associated with reduced re-admission/mortality.
Pay for performance (P4P) is gaining acceptance among physicians and medical institutions, but the findings of this paper serve to remind us that, as is true of many things, the devil is in the details. The authors note in their discussion: "As this limited set performance measures is being used to publicly report the quality of heart failure care delivery at the hospital level and is beginning to affect financial payments to medical centers and individual physicians, it is essential that measures be prioritized to include those that are proven to be closely associated with patient outcomes."
It is distressing to note that only 1 of 5 P4P outcomes predicted mortality and/or hospitalization in the short run in this study, and that the strongest predictor was not included in the P4P measures. As the authors point out in their discussion, "smoking cessation counseling" can be meaningful or trivialized, depending on the commitment and the time constraints of the clinician, as can "discharge instructions.
In doing background reading on this paper, I came across an AMA statement published in 20052 that DOES include beta blockers in the performance measure for those with HF. I was confused about this discrepancy and contacted the first author of this paper, Dr Gregg Fonarow, who promptly and graciously replied:
"The ACC/AHA did release outpatient performance measures for patients with heart failure in late 2005/early 2006 … However the hospital performance measures released by the ACC/AHA at the same time excluded beta blockers… .
"As internal medicine physicians care for patients in both the inpatient and outpatient setting, it is important for them to recognize that there are other therapies beyond those covered by the JCAHO/CMS and ACC/AHA performance measures in the hospital setting that are strongly linked to clinical outcomes, such as beta blockers. Improving the use of beta blockers at hospital discharge in eligible heart failure patients who are stable and without contraindications would be expected to substantially reduce the risk of rehospitalization and mortality in the first 60-90 days post discharge as well as long term."
Point well taken. Simply complying with performance measures may get you paid, but it may not serve your patients well! As P4P continues to evolve, it will be important for clinicians to "evaluate the evaluators," (as the cardiologists are doing3) and to continue to think critically about application of performance measures as we care for patients, one by one.
1. Bonow RO, et al. ACC/AHA clinical performance measures for adults with chronic heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart Failure Clinical Performance Measures) endorsed by the Heart Failure Society of America. J Am Coll Cardiol. 2005;46:1144-1178.
2. http://www.ama-assn.org/ama/pub/category/15777.html (Heart failure measurement set from AMA website, last accessed 1/7/2007)
3. Bufalino V, et al and the American Heart Association's Reimbursement, Coverage, and Access Policy Development Workgroup. Payment for quality: guiding principles and recommendations: principles and recommendations from the American Heart Association's Reimbursement, Coverage, and Access Policy Development Workgroup. Circulation. 2006;113:1151-1154.