Performance Metrics Revised for Statins Post-MI, After PCI, and in CAD Patients
The American College of Cardiology/American Heart Association (ACC/AHA) has updated performance measures related to the use of statins in secondary prevention, including patients who have had an acute MI, have undergone PCI, or who have established coronary and peripheral artery disease.
And for the first time the performance measures acknowledge shared decision-making between physicians and patients, with the ACC/AHA measures not penalizing physicians if a statin-eligible patient decides against the prescription.
“We thought it was inappropriate to punish a clinician or a clinician group when a patient has decided not to take a medication based on their own personal preferences,” Joseph Drozda, MD, of Mercy Health (St. Louis, MO), told TCTMD.
Drozda, who chaired the writing committee, said this is the first time the ACC and AHA have attempted to incorporate shared-decision making into performance measures and that the process is likely to become more refined in future iterations. The goal will be to “actually reward physicians who take the time to go through the shared-decision making process,” he said.
Published December 14, 2015, in the Journal of the American College of Cardiology, the ACC/AHA focused update on secondary-prevention lipid performance measures includes multiple clinical areas. Performance measures typically address clinical care in specific fields, such as PCI or PAD. However, with the release of the 2013 ACC/AHA cholesterol guidelines, the group revised 4 previously published performance measures that dealt with lipid management. The aim was to ensure each set of performance measures was aligned with the new guidelines.
In total, the 2015 ACC/AHA focused update of lipid performance measures addresses the use of statins in PAD, STEMI/NSTEMI, PCI, and CAD. In addition, the performance measures include the recommendations for the use of statins in patients with atherosclerotic cardiovascular disease (ASCVD) as outlined by the cholesterol guidelines.
Derived From the Strongest Evidence
To TCTMD, Drozda explained that the performance measures are based on recommendations in the clinical guidelines with the strongest level of evidence, which is typically derived from data based on RCTs. With the 2013 cholesterol guidelines, they devised performance measures in secondary prevention given the strength of evidence supporting the use of statins in this population.
“We took a look at those 1a recommendations and turned them into performance measures under the assumption that what they’re saying with those recommendations is that physicians really should be doing this,” said Drozda. “Whatever the recommendation is, it’s beyond a strong suggestion.”
Performance measures can then be used for accountability purposes, pay-for-performance programs, and public reporting. They can be used to assess the performance of the cardiovascular team or cardiovascular health system in order to determine how well they adhere to the guidelines, said Drozda. They are typically created to address inadequacies in care.
“You put in performance measures in programs where there is actually a gap, where things aren’t happening the way they should happen,” Drozda noted. “We took a look to see how things were going with prescriptions of statin medication in these patient populations—those with established cardiovascular disease—and we found that the numbers are not particularly impressive. In recent studies, it would be somewhere in the neighborhood of 40% to 83% of patients with established disease actually get a prescription for statins.”
The performance measures now take into account statin dose, as recommended by the clinical guidelines. For PAD and CAD, hospital teams or healthcare systems will be measured on how many patients are offered moderate-to-high intensity statins. In STEMI/NSTEMI, the performance measure will track the percentage of patients offered moderate-to-high intensity statin at discharge. In PCI, the metric is the percentage of patients offered optimal medical therapy, which includes statins.
“This is what the guidelines
say,” said Drozda. “One of the gaps is that patients might actually be on
statins, but they are on doses that are too low to achieve the mortality
Drozda JP, Ferguson TB, Jneid H, et al. 2015 ACC/AHA focused update of secondary prevention lipid performance measures. J Am Coll Cardiol. 2015;Epub ahead of print.
- Drozda reports no conflicts of interest.