Quality Measurement and Accountability in Cardiovascular Medicine

Circulation. 2016;134:632–634. DOI: 10.1161/CIRCULATIONAHA.116.021916 632 Frederick A. Masoudi, MD, MSPH The rise of quality measurement and the proliferation of programs that require accountability for quality are among the most dramatic developments in cardiovascular medicine in the past 2 decades. The quality revolution now affects the daily practice of virtually every cardiovascular clinician and has influenced national health policy. Over time, however, both the successes and limitations of the quality movement have become apparent. As is often the case with revolutionary changes, quality measurement and the uses of these measures merit reflection and consideration of further change. For years, quality measurement played an insignificant role in medicine. This changed with a growing appreciation of substantial unexplained variation in healthcare practice in parallel with seemingly unrestrained increases in care costs. The actions of the Health Care Financing Administration, now the Centers for Medicare & Medicaid Services, are illustrative of this evolution. Having employed the ineffectual approach of performing individual case review (quality assurance) of negative outliers, the Health Care Financing Administration adopted the relatively radical approach of measuring quality nationally in the hopes of stimulating improvement for all institutions and providers in the early 1990s.1 The Health Care Financing Administration’s Cooperative Cardiovascular Project measured the quality of care for acute myocardial infarction; subsequent efforts expanded to other high-impact conditions, including heart failure. Although these programs focused entirely on measuring processes of care (eg, rates of use of evidence-based therapies for acute myocardial infarction and heart failure) and did not address strategies for quality improvement, they introduced clinicians and hospitals to formal quality measurement on a national scale. Since that time, the number of measures, the domains of measurement, and the uses of measures in cardiovascular medicine have expanded substantially. The National Quality Measures Clearinghouse of the Agency for Healthcare Research and Quality now catalogs nearly 2000 different measures,2 many of which address cardiovascular disease. Although the preponderance are process measures, outcomes measures are becoming increasingly important. Simultaneously, the financial incentives associated with measurement have evolved substantially, from pay for participation to pay for reporting to pay for performance, increasing the extent to which quality measures will impact practice. As quality measurement has become inextricably embedded in clinical practice, and as the implications of accountability have intensified, many clinicians have become fatigued with the measurement process and are skeptical that it improves clinical outcomes.3 Indeed, some have suggested that the additional work arising as a consequence of the avalanche of quality measures has contributed to physician burnout. Many process measures are considered irrelevant, either because performance is now so high that residual variation is of little clinical importance (eg, aspirin use in patients with acute myocardial infarction) or because they are perceived to lack a causal link to relevant patient outcomes (eg, documenting provision of hospiQuality Measurement and Accountability in Cardiovascular Medicine