Associations between practice-level compliance with cardiac performance measures and clinical outcomes in US cardiovascular ambulatory care

Clinical question: Is practice-level compliance with cardiac performance measures associated with clinical outcomes in ambulatory care?

Main findings: Heart failure composite and individual performance measure compliance related to beta-blocker and ACEi/ARB use were associated with reduced likelihood of death or hospitalization and death alone.

Cardiac performance measures are key aspects of clinical care quality identified by the American College of Cardiology and American Heart Association given their strong evidence base, reproducibility, and evaluability. They may be used for purposes of public reporting, external comparisons, and pay-for-performance programs. They have been defined for a number of cardiovascular disease states central to ambulatory cardiovascular care quality inclusive of atrial fibrillation (AF), coronary artery disease (CAD), heart failure (HF), and hypertension (HTN). Linking real-world clinical outcomes to performance measures has the potential to direct improvement initiatives toward actionable care gaps on a practice level. A prior analysis demonstrated that achievement of performance measures varied significantly across cardiovascular practices. However, associations of real-world outcomes with practice-level performance in outpatient cardiovascular care are currently unknown. Accordingly, we sought to characterize real-world outcomes associated with practice-level performance by individual performance metrics as well as by composite measures integrating performance across all metrics for a given condition.

The ambulatory, prospective National Cardiovascular Data Registry’s PINNACLE registry linked with Centers for Medicare and Medicaid Services (CMS) served as the data source. Patients ≥65 years with a diagnosis of AF, CAD, HF, and/or HTN at practices participating in the PINNACLE registry between Jan 1st, 2016, to Dec 31st, 2016, and eligible for a cardiac performance measure endorsed by the American College of Cardiology and American Heart Association ,, were included. Patient encounters were linked to CMS outcomes of death and hospitalization through December 31, 2017. Primary exposures were composites of achievement of AF, CAD, HF, and HTN cardiac performance measures. These were defined as opportunity-based measures, calculated for each practice by dividing the total number of individual measures achieved across all patients by the total number of “opportunities” for achievement across all measures and patients. Secondary exposures were achievement of the individual measures. For each measure, practices were stratified according to quartile of performance. Associations between performance measures and clinical outcomes of death, hospitalization and combined death or hospitalization were assessed using mixed-effect Cox proportional hazards models, using the lowest-performing practice group as the referent and treating practice as the random effect. Reported P -values assess the significance of linear trends by quartiles ( Table 1 ).

Table 1

Association of death or hospitalization, death, and hospitalization with cardiovascular disease composite and individual performance measures

Performance Score, median (Q1, Q3) Adjusted Hazard Ratio, 95% Confidence interval
Cardiovascular disease Performance measure Q1 Q2 Q3 Q4 Outcome Q1 Q2 Q3 Q4 P -value
Atrial fibrillation Oral anticoagulation 0.45 (0.37, 0.49) 0.56 (0.54, 0.59) 0.64 (0.62, 0.66) 0.74 (0.70, 0.78) Death or hospitalization 1 (Reference) 0.98 (0.90, 1.07) 0.98 (0.90, 1.07) 0.97 (0.89, 1.06) .9141
Death 1 (Reference) 0.98 (0.88, 1.09) 0.95 (0.85, 1.06) 0.97 (0.87, 1.08) .8394
Hospitalization 1 (Reference) 0.98 (0.90, 1.08) 1.00 (0.91, 1.10) 0.97 (0.88, 1.07) .9158
Coronary artery disease Composite performance 0.49 (0.43, 0.52) 0.58 (0.56, 0.59) 0.65 (0.63, 0.66) 0.75 (0.72, 0.78) Death or hospitalization 1 (Reference) 1.02 (0.94, 1.11) 1.07 (0.98, 1.16) 1.02 (0.94, 1.11) .6426
Death 1 (Reference) 1.10 (0.96, 1.25) 1.13 (0.98, 1.29) 1.11 (0.97, 1.26) .7846
Hospitalization 1 (Reference) 1.02 (0.93, 1.12) 1.07 (0.97, 1.18) 1.02 (0.93, 1.12) .7349
Component performance
Beta-blocker 0.60 (0.46, 0.66) 0.74 (0.72, 0.76) 0.80 (0.78, 0.82) 0.89 (0.86, 0.92) Death or hospitalization 1 (Reference) 0.98 (0.88, 1.09) 0.92 (0.83, 1.02) 0.88 (0.79, 0.99) .0763
Death 1 (Reference) 0.97 (0.85, 1.10) 0.87 (0.77, 0.99) 0.86 (0.75, 0.98) .0413
Hospitalization 1 (Reference) 1.01 (0.89, 1.14) 0.96 (0.85, 1.08) 0.90 (0.79, 1.02) .224
ACEi/ARB 0.60 (0.54, 0.63) 0.69, 0.67, 0.71) 0.76 (0.74, 0.79) 0.85 (0.82, 0.88) Death or hospitalization 1 (Reference) 0.97 (0.88, 1.07) 0.92 (0.84, 1.02) 0.94 (0.85, 1.04) .376
Death 1 (Reference) 0.91 (0.82, 1.02) 0.91 (0.82, 1.02) 0.98 (0.87, 1.09) .2319
Hospitalization 1 (Reference) 0.99 (0.89, 1.09) 0.93 (0.84, 1.03) 0.95 (0.86, 1.06) .5281
Statin therapy use 0.03 (0.00, 0.07) 0.18 (0.14, 0.20) 0.39 (0.33, 0.43) 0.56 (0.51, 0.64) Death or hospitalization 1 (Reference) 1.01 (0.93, 1.09) 1.01 (0.94, 1.10) 0.97 (0.89, 1.06) .7247
Death 1 (Reference) 0.99 (0.89, 1.09) 1.04 (0.94, 1.15) 1.04 (0.93, 1.15) .6374
Hospitalization 1 (Reference) 1.02 (0.94, 1.12) 1.01 (0.93, 1.10) 0.95 (0.87, 1.04) .3922
Antiplatelet therapy 0.67 (0.57, 0.73) 0.80 (0.78, 0.82) 0.86 (0.85, 0.88) 0.93 (0.91, 0.95) Death or hospitalization 1 (Reference) 0.98 (0.91, 1.05) 0.95 (0.88, 1.02) 0.97 (0.90, 1.04) .5077
Death 1 (Reference) 1.00 (0.90, 1.10) 0.92 (0.83, 1.01) 1.01 (0.92, 1.12) .1619
Hospitalization 1 (Reference) 0.96 (0.88, 1.06) 0.95 (0.87, 1.04) 0.95 (0.87, 1.04) .6915
Smoking cessation 0.63 (0.47, 0.70) 0.83 (0.81, 0.85) 0.91 (0.90, 0.93) 0.96 (0.95, 0.98) Death or hospitalization 1 (Reference) 1.01 (0.93, 1.10) 1.05 (0.97, 1.15) 1.04 (0.96, 1.14) .5838
Death 1 (Reference) 0.95 (0.86, 1.05) 1.03 (0.94, 1.14) 0.93 (0.84, 1.03) .1485
Hospitalization 1 (Reference) 1.00 (0.92, 1.09) 1.04 (0.95, 1.13) 1.08 (0.99, 1.18) .2485
Cardiac rehab referral N/A 0 (0.00, 0.02) 0.08 (0.06, 0.10) 0.20 (0.16, 0.42) Death or hospitalization 1 (Reference) 0.99 (0.91, 1.07) 1.01 (0.92, 1.10) 0.9068
Death 1 (Reference) 0.94 (0.83, 1.06) 1.08 (0.94, 1.23) 0.1768
Hospitalization 1 (Reference) 1.00 (0.91, 1.09) 0.99 (0.90, 1.10) 0.9904
Symptoms and activity assessment N/A 0 (0.00, 0.00) 0.18 (0.07, 0.34) 0.98 (0.92, 1.00) Death or hospitalization 1 (Reference) 1.00 (0.93, 1.08) 1.00 (0.93, 1.08) 0.9987
Death 1 (Reference) 0.96 (0.86, 1.07) 1.00 (0.90, 1.11) 0.7132
Hospitalization 1 (Reference) 1.02 (0.93, 1.10) 0.99 (0.91, 1.08) 0.8904
Blood pressure control 0.79 (0.72, 0.82) 0.88 (0.86, 0.89) 0.92 (0.91, 0.92) 0.95 (0.94, 0.96) Death or hospitalization 1 (Reference) 1.06 (0.98, 1.14) 0.96 (0.89, 1.04) 0.98 (0.91, 1.05) .074
Death 1 (Reference) 1.06 (0.93, 1.19) 0.93 (0.82, 1.05) 0.99 (0.88, 1.13) .2165
Hospitalization 1 (Reference) 1.06 (0.97, 1.16) 0.97 (0.89, 1.06) 0.97 (0.89, 1.06) .1446
Heart failure Composite performance 0.64 (0.56, 0.67) 0.74 (0.72, 0.75) 0.83 (0.81, 0.86) 0.92 (0.89, 0.95) Death or hospitalization 1 (Reference) 0.95 (0.83, 1.09) 0.86 (0.75, 0.99) 0.87 (0.76, 1.01) .0041
Death 1 (Reference) 0.86 (0.74, 0.99) 0.78 (0.67, 0.91) 0.80 (0.68, 0.94) <.0001
Hospitalization 1 (Reference) 0.98 (0.86, 1.12) 0.87 (0.76, 1.00) 0.89 (0.77, 1.02) .0605
Component performance
Beta blocker 0.60 (0.50, 0.68) 0.76 (0.73, 0.77) 0.83 (0.81, 0.86) 0.92 (0.89, 0.95) Death or hospitalization 1 (Reference) 0.98 (0.89, 1.08) 0.97 (0.87, 1.07) 0.87 (0.78, 0.97) .0425
Death 1 (Reference) 0.83 (0.73, 0.94) 0.86 (0.75, 0.97) 0.80 (0.70, 0.92) .0072
Hospitalization 1 (Reference) 1.01 (0.87, 1.17) 1.03 (0.89, 1.20) 0.91 (0.78, 1.07) .3971
ACEi/ARB 0.61 (0.54, 0.66) 0.72 (0.71, 0.74) 0.80 (0.78, 0.82) 0.92 (0.89, 0.96) Death or hospitalization 1 (Reference) 0.82 (0.73, 0.92) 0.81 (0.72, 0.91) 0.77 (0.68, 0.86) <.0001
Death 1 (Reference) 0.80 (0.68, 0.94) 0.77 (0.65, 0.92) 0.69 (0.58, 0.83) .0005
Hospitalization 1 (Reference) 0.82 (0.72, 0.93) 0.82 (0.72, 0.94) 0.78 (0.68, 0.89) .0017
Hypertension Blood pressure control 0.76 (0.68, 0.79) 0.86 (0.84, 0.87) 0.90 (0.89, 0.91) 0.94 (0.93, 0.95) Death or hospitalization 1 (Reference) 1.05 (0.97, 1.13) 1.02 (0.95, 1.10) 1.02 (0.94, 1.09) .7070
Death 1 (Reference) 1.02 (0.90, 1.17) 0.97 (0.85, 1.11) 0.94 (0.83, 1.08) .6243
Hospitalization 1 (Reference) 1.05 (0.96, 1.15) 1.04 (0.95, 1.14) 1.03 (0.93, 1.13) .7704
Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Study design for an emulated trial of a 2 arm, parallel, stratified, adaptive, RCT of CABG versus PCI in people requiring myocardial revascularization at high risk (High-Risk REVASC)
  2. STrategies for antithrombotic tRreatment following transcatheter edge-to-edge repair in patients with severe mitral regurgitation: Rationale and design of STAR-TEER trial
  3. Association between atherosclerosis and atrial fibrillation progression in patients with paroxysmal atrial fibrillation: Data from the RACE V study
  4. Design and rationale of RECOVER-AUTONOMIC: A randomized platform trial evaluating interventions for Long COVID postural orthostatic tachycardia syndrome

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 27, 2026 | Posted by in CARDIOLOGY | Comments Off on Associations between practice-level compliance with cardiac performance measures and clinical outcomes in US cardiovascular ambulatory care

Full access? Get Clinical Tree
Get Clinical Tree app for offline access