David W. Baker, MD, MPH; Stephen D. Persell, MD, MPH; Jason A. Thompson, BA; Neilesh S. Soman, MD, MBA; Karen M. Burgner, MD; David Liss, BA; Karen S. Kmetik, PhD
Acknowledgment: The authors thank Heidi Bossley for technical assistance.
Grant Support: This project was supported in part by grant number 5 U18 HS013690 from the Agency for Healthcare Research and Quality.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: David Baker, MD, MPH, 676 North St. Clair Street, Suite 200, Chicago, IL 60611-2927; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Baker, Persell, Soman and Mr. Thompson and Mr. Liss: Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 200, Chicago, IL 60611.
Dr. Burgner: Northwestern Memorial Hospital, 210 East Huron Road, Chicago, IL 60611.
Dr. Kmetik: American Medical Association, 515 State Street, Chicago, IL 60610.
Baker D., Persell S., Thompson J., Soman N., Burgner K., Liss D., Kmetik K.; Automated Review of Electronic Health Records to Assess Quality of Care for Outpatients with Heart Failure. Ann Intern Med. 2007;146:270-277. doi: 10.7326/0003-4819-146-4-200702200-00006
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Published: Ann Intern Med. 2007;146(4):270-277.
The Institute of Medicine and the Medicare Payment Advisory Commission have called for government payers to publicly report providers' clinical quality data and increase payments for health care providers who deliver higher-quality care (that is, pay-for-performance) (1–4). The Centers for Medicare & Medicaid Services (CMS) has already taken steps toward these goals with the Nursing Home Quality Initiative, the Home Health Quality Initiative, and the Hospital Quality Initiative (5, 6). More recently, the CMS announced the Physician Focused Quality Initiative, which will assess the quality of outpatient medical care for key illnesses and clinical conditions and “investigate the concept of payment for performance” (7). Assessing the quality of outpatient care, especially primary care, has unique challenges. Unlike quality-of-care assessment for hospitalized patients, information relevant to outpatient quality measures may be documented in past encounters and may not easily be identifiable, especially for patients with multiple comorbid conditions and many past visits (8, 9). In addition, patients often see several different physicians, and it may not be feasible to collect information for quality measurement from other providers.
April 11, 2007
II read the article by Baker et al with interest. I was concerned that end-stage renal disease and chronic renal insufficiency were listed as valid exclusions for why individuals are not receiving an ACEI or ARB in heart failure. This is not consistent with current guidelines and AHRQ recommendations state an elevated creatinine is not an exclusion (1). Subgroup analyses of studies do not suggest a lower benefit of ACEI/ARB (2) and as individuals with an elevated creatinine are at higher risk for events, the argument can be made that the potential benefit of ACEI is greater for those with an elevated creatinine.
Linda Fried, MD, MPH VAPHCS Linda.Fried@va.gov
1. http://www.ahrq.org/clinic/cpgarchv.htm 2. Frances CD, Noguchi H, Massie BM, Browner WS, McClellan M. Are we inhibited? Renal insufficiency should not preclude the use of ACE inhibitors for patients with myocardial infarction and depressed left ventricular function. Arch Intern Med 2000;160: 1645-2650.
David W. Baker
Feinberg School of Medicine, Northwestern University
May 2, 2007
The authors reply:
We agree that severe renal insufficiency is not a contraindication to the use of an ACEI or ARB for patients with heart failure. However, some of these patients will have a severe decline in renal function after starting an ACEI or ARB, requiring discontinuation of treatment. Note that if a patient with severe renal insufficiency tolerates an ACEI or ARB, the patient is represented in both the numerator and the denominator; a physician can "get credit" for treating such a patient successfully but does not "fail" the measure if a patient does not tolerate an ACEI or ARB.
How should performance measures account for comorbidities like renal insufficiency? Performance measures frequently allow patients not receiving guideline-concordant care to be excluded when certain comorbid conditions are present, even if these conditions are not absolute contraindications. Thus, in the case cited above, any patient not prescribed an ACEI or ARB with certain renal failure diagnosis codes would be excluded from the denominator of the quality measure, even though only a subgroup might have sufficient medical justification for withholding treatment. Similarly, heart failure patients not given a beta blocker would be excluded if asthma or chronic obstructive pulmonary disease were present even though only a minority of patients may have bronchospasm so severe as to outweigh the benefits of treatment. This approach is also problematic because listing a condition as an exclusion may be taken to imply that physicians should not even try to initiate a therapy.
Quality measures that rely on these kinds of simplifications are helpful up to a point. When care is only fair, there is room for improvement even among the simple cases. But as care improves, the utility of this kind of measure becomes more limited. To improve quality to very high levels, quality measurement needs to be able to determine if good care is given to more complex patients. In recognition of the problems of using comorbidities as absolute exclusion criteria, the Physician Consortium for Performance Improvement currently recommends using a general "medical reason" exclusion rather than a comprehensive list of relative contraindications or conditions requiring cautious prescribing. When reporting exclusions, physicians are encouraged to explicitly record in the medical record the reason why a therapy is not given. Electronic health record vendors should create standard methods for physicians to easily record justifications for their clinical decisions to improve the accuracy of quality measurement and minimize time burdens.
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Cardiology, Heart Failure.
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