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  • Measure Summary
  • NQMC:008332
  • Nov 2012

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with AMI with referral to an appropriate cardiac rehabilitation program (Phase 2 or Phase 3) post-discharge who enroll in the program.

Davis T, Bluhm J, Burke R, Iqbal Q, Kim K, Kokoszka M, Larson T, Puppala V, Setterlund L, Vuong K, Zwank M. Diagnosis and treatment of chest pain and acute coronary syndrome (ACS). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Nov. 91 p. [159 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients age 18 years and older with acute myocardial infarction (AMI) with referral to an appropriate cardiac rehabilitation program (Phase 2 or Phase 3) post-discharge who enroll in the program - Phase Two Programs: electrocardiogram-monitored, outpatient, and Phase Three Programs: non-monitored, outpatient.

Rationale

The priority aim addressed by this measure is to increase the percentage of patients with acute myocardial infarction (AMI) using cardiac rehabilitation.

Studies by the National Heart, Lung, and Blood Institute estimate that each year approximately 785,000 Americans will have a new coronary attack and approximately 470,000 will have a recurrent attack.

Outpatient cardiac rehabilitation/secondary prevention programs are recommended for patients diagnosed with ST-elevation or non-ST-elevation myocardial infarction. Of particular concern are those patients who carry a moderate or high risk or have multiple modifiable risk factors for coronary artery disease and for whom supervised exercise training is deemed appropriate. There is strong evidence to suggest that cardiac rehabilitation programs have been shown to decrease mortality rates in all populations, including younger, more selective populations, as well as the socioeconomically and clinically diverse older population (age 65 and older).

Phase Two Cardiac Rehabilitation

The U.S. Public Health Service described Phase Two cardiac rehabilitation as a "comprehensive, long-term program including medical evaluation, prescribed exercise, cardiac risk factor modification, education and counseling. Phase Two refers to outpatient, medically supervised programs that are typically initiated one to three weeks after hospital discharge and provide appropriate electrocardiographic monitoring." In the past, the main emphasis was exercise based, but today the focus includes risk factor modification, education and counseling.

Research shows that a cardiac rehabilitation program based on regular exercise and education focused on risk factor reduction is both efficient and effective in altering the course of coronary heart disease. The initial outpatient phase includes a comprehensive evaluation, education and treatment for outpatients who have experienced a cardiac-related event. Phase Two patients are monitored with continuous electrocardiogram, blood pressure, heart rate and subjective Rating of Perceived Exertion. For certain patients, referral to a Phase Two program may facilitate earlier hospital discharge by providing emotional support in the outpatient hospital setting.

Phase Three Cardiac Rehabilitation

Phase Three is a maintenance program based on the continuation of a heart healthy lifestyle. The program is designed for patients who have completed a Phase Two cardiac rehabilitation program or for individuals with a cardiac history or significant cardiac risk factors. Patients are not continually monitored by electrocardiogram, but spot-check electrocardiograms and daily blood pressures and heart rates are often recorded. Trained staff, when available, continues to provide support and education for risk factor modification and exercise progression. Warm-up, aerobic exercise, stretching and strength training (when appropriate) are included in Phase Three.

Evidence for Rationale

Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med. 2001 Sep 20;345(12):892-902. [109 references] PubMed External Web Site Policy

Davis T, Bluhm J, Burke R, Iqbal Q, Kim K, Kokoszka M, Larson T, Puppala V, Setterlund L, Vuong K, Zwank M. Diagnosis and treatment of chest pain and acute coronary syndrome (ACS). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Nov. 91 p. [159 references]

Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Roger VL, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J, American Heart Association Statistics Committee and Stroke Statistics, Writing Group Members. Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010 Feb 23;121(7):e46-e215. PubMed External Web Site Policy

Suaya JA, Stason WB, Ades PA, Normand SL, Shepard DS. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. 2009 Jun 30;54(1):25-33. PubMed External Web Site Policy

Primary Health Components

Acute myocardial infarction (AMI); cardiac rehabilitation

Denominator Description

Number of patients with acute myocardial infarction (AMI) who are referred to an appropriate cardiac rehabilitation program post-discharge - Phase Two Programs: electrocardiogram-monitored, outpatient, and Phase Three Programs: non-monitored, outpatient (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients with acute myocardial infarction (AMI) who enroll in an appropriate cardiac rehabilitation program post-discharge - Phase Two Programs: electrocardiogram-monitored, outpatient, and Phase Three Programs: non-monitored, outpatient

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence

Additional Information Supporting Need for the Measure

  • With recent evidence-based changes in both interventional percutaneous coronary intervention (PCI) and pharmacological interventions in patients with acute coronary syndromes (ACS), the Global Registry of Acute Coronary Events (GRACE) found that in the United States, adhering to these new changes, rates of in-hospital death, cardiogenic shock, and new myocardial infarctions in patients with non-elevation myocardial infarction (non-STEMI) events have significantly decreased. Similarly, in the STEMI population there has been a significant decrease in rates of in-hospital death, cardiogenic shock, heart failure and pulmonary edema.
  • The National Quality Improvement Initiative found that the guidelines and treatments recommended by the American College of Cardiology/American Heart Association (ACC/AHA) were only followed 74% of the time in 350 of the U.S. hospitals it studied. Not adhering to the ACC/AHA guidelines for recommended care of patients with ACS/NSTEMI has been associated with increased in-hospital mortality.

Evidence for Additional Information Supporting Need for the Measure

Davis T, Bluhm J, Burke R, Iqbal Q, Kim K, Kokoszka M, Larson T, Puppala V, Setterlund L, Vuong K, Zwank M. Diagnosis and treatment of chest pain and acute coronary syndrome (ACS). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Nov. 91 p. [159 references]

Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Roger VL, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J, American Heart Association Statistics Committee and Stroke Statistics, Writing Group Members. Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010 Feb 23;121(7):e46-e215. PubMed External Web Site Policy

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Hospital Inpatient

Hospital Outpatient

Rehabilitation Centers

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Case Finding Period

The time frame pertaining to the data collection can be monthly.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Institutionalization

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of patients with acute myocardial infarction (AMI) who are referred to an appropriate cardiac rehabilitation program post-discharge - Phase Two Programs: electrocardiogram-monitored, outpatient, and Phase Three Programs: non-monitored, outpatient

Population Definition: Patients 18 years and older.

Data Collection: This measure will involve chart review for appropriateness of referral and enrollment.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patients with acute myocardial infarction (AMI) who enroll in an appropriate cardiac rehabilitation program* post-discharge - Phase Two Programs: electrocardiogram-monitored, outpatient, and Phase Three Programs: non-monitored, outpatient

*Refer to the National Guideline Clearinghouse (NGC) summary of the Institute for Clinical Systems Improvement (ICSI) guideline Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS) External Web Site Policy.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Electronic health/medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of patients with AMI with referral to an appropriate cardiac rehabilitation program (Phase 2 or Phase 3) post-discharge who enroll in the program - Phase Two Programs: electrocardiogram-monitored, outpatient, and Phase Three Programs: non-monitored, outpatient.

Measure Collection Name

Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS)

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.

Composition of the Group that Developed the Measure

Work Group Members: Thomas Davis, MD (Work Group Leader) (Park Nicollet Health Services) (Cardiology); Qamar Iqbal, MD (HealthEast Care System) (Internal Medicine); V. Krishna Puppala, MD, MPH (HealthEast Care System) (Internal Medicine); Rynn Burke, MD (HealthPartners Medical Group and Regions Hospital) (Internal Medicine and Hospitalist); Kara Kim, MD (HealthPartners Medical Group and Regions Hospital) (Hospitalist); Khuong Vuong, MD (HealthPartners Medical Group and Regions Hospital) (Hospitalist); Michael Zwank, MD (HealthPartners Medical Group and Regions Hospital) (Emergency Medicine); Tonja Larson, PharmD, BCPS (Marshfield Clinic) (Pharmacy); Marek Kokoszka, MD (Park Nicollet Health Services) (Cardiology); Linda Setterlund, MA, CPHQ (Institute for Clinical Systems Improvement) (Clinical Systems Improvement Facilitator); Jim Bluhm, MPH (Institute for Clinical Systems Improvement) (Team Director)

Financial Disclosures/Other Potential Conflicts of Interest

The Institute for Clinical Systems Improvement (ICSI) has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols.

In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report Clinical Practice Guidelines We Can Trust (2011).

Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group.

The complete ICSI policy regarding Conflicts of Interest is available at the ICSI Web site External Web Site Policy.

Disclosure of Potential Conflicts of Interest

Rynn Burke, MD, Work Group Member
Internal Medicine Physician, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: MN Department of Health Pandemic Planning
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Thomas Davis, MD, Work Group Leader
Cardiologist, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Qamar Iqbal, MD, Work Group Member
Internal Medicine Physician, HealthEast Care System
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Kara S. Kim, MD, Work Group Member
Emergency Medicine, HealthPartners Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Marek J. Kokoszka, MD, Work Group Member
Cardiologist, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Tonja Larson, PharmD, BCPS, Work Group Member
Pharmacist, Marshfield Clinic
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Krishna Puppala, MD, Work Group Member
Internal Medicine and Hospitalist, HealthEast Care System
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Consulting for services provided as hospitalist practice.

Khuong M. Vuong, MD, Work Group Member
Hospitalist, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Michael D. Zwank, MD, Work Group Member
Emergency Medicine, HealthPartners Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2012 Nov

Measure Maintenance

Scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature.

Date of Next Anticipated Revision

The next scheduled revision will occur within 24 months.

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Source(s)

Davis T, Bluhm J, Burke R, Iqbal Q, Kim K, Kokoszka M, Larson T, Puppala V, Setterlund L, Vuong K, Zwank M. Diagnosis and treatment of chest pain and acute coronary syndrome (ACS). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Nov. 91 p. [159 references]

Measure Availability

Source available from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 12, 2013.

The information was reaffirmed by the measure developer on January 13, 2016.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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