Often confused with guideline recommendations, performance measurements are used to construct a framework for the boundaries of care. As outlined by the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA) task force on performance measures, “performance measures identify aspects of care for which the failure to provide a particular process of care is judged as poor clinical performance” whereas practice guidelines delineate “processes of care that should that should generally be used in patients with a given condition” [8]. As highlighted by the writing committee to develop heart failure clinical performance measures in 2005, development of quality metrics aims to capture implementation of those processes or structural aspects of care whose supporting evidence “is so strong that failure to perform such actions reduces the likelihood that optimal patient outcomes will occur” [9].

Once the goal of a quality improvement initiative has been identified, the individual(s) or group undertaking the initiative need tools to study existing processes and the outcomes they result in. Outcome measures quantify high level safety, patient care and financial endpoints that indicate how well an organization is meeting its goals. Ideally, outcome measures specify a population to study and a specific timeline over which the measure would be applied.

Process measures assess the specific steps or tasks in a pathway that lead to a specific outcome metric. Several process measures can be studied sequentially to codify the steps that lead to the outcome measure of interest (Fig. 32.2). While outcome measures can be used to measure the overarching goals and directions for a healthcare organization, process measures are used to steer granular interventions towards these goals.

Health care quality metrics are developed for a wide array of audiences and reasons. Patients and purchasers may use them when deciding on providers and plans, institutions and individual providers may use them as tools to drive performance improvement initiatives, assess resource utilization or compare themselves with competitors. Donabedian proposed in 1991 that the quality of healthcare could be assessed by assessing its structure, process and outcomes [10]. In the United States, the IOM defines healthcare quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” [11].

Process measures provide information about health care delivery that can be used to affect change within a system. Process measures carry the additional benefit of requiring littleDOUBLEHYPHENif any, risk adjustment for patient illness. The development of a process measure requires identification of an eligible population to which the measure is then applied [12]. An example would be to measure the percentage of all patients with left ventricular systolic dysfunction (eligible population) that have been prescribed and angiotensin converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB).

In Crossing the Quality Chasm, the IOM makes the case that focusing on specific conditions provides added meaning to patients as well as those involved in the utilization, delivery, strategic implementation or purchasing of health care [4]. In addition to aligning the multiple stakeholders involved in healthcare delivery and utilization, prioritizing disease conditions can help combat forces that fragment and misalign the health care system and stifle systematic quality improvement efforts.

Heart Failure is an important national public health issue with widespread prevalence, significant morbidity, mortality, and cost implications for patients, providers and payors (both public and private). Of all diagnoses, more Medicare dollars are spent on congestive heart failure diagnosis and treatment than any other in the United States. An estimated five million Americans live with the diagnosis and an additional 550,000 diagnoses are made each year [13]. Understanding of the pathophysiology of the disease has led to the development of non-invasive, pharmacologic and biomechanical tools to diagnose and treat heart failure. Despite these significant advances, evidence indicates that the implementation and use of these new tools falls below that which might be expected.

The NCQA describes the fragmentation of the United States health care system as one in which “episodic care is delivered by a range of providers who are not as well-connected to one another as they should be” [14]. Furthermore, “poorly coordinated care is frequently lower quality, more expensive and can result in poor health outcomes.”

In February 2000 the AHA/ACCF Task Force on Performance Measures was created to develop guidelines across the scope of cardiovascular disease care. In 2003 the ACC, AHA and Physician Consortium for Performance Improvement (PCPI) developed measures for heart failure patients that received care in the outpatient setting. The ACCF and AHA first developed inpatient clinical performance measures for adults with chronic heart failure in 2005 [9] Five inpatient measures and 11 outpatient measures were proposed based on 2005 ACCF/AHA class I and class III guideline recommendations for the diagnosis and management of heart failure as well as the Team Management of Patients with Heart Failure: A statement for Healthcare Professionals From the Cardiovascular Nursing Council of the American Heart Association. These measures were most recently updated in May 2012 by the Heart Failure workgroup and published in conjunction with the PCPI. This updated measure set expanded its scope to include guidelines from the European Society of Cardiology and the Heart Failure Society of America (HFSA) [15].

Measures put forth by the (ACCF/AHA/PCPI) in the 2012 update have been streamlined to include both the ambulatory and hospital care settings with the aim of quantifying processes (process measures) in patients with heart failure meant to favorably influence morbidity and mortality (outcome measures). Five outpatient measures and three inpatient measures from the 2005 version of the guidelines were retired with this update. Currently, nine measures exist divided into three groups- outcome measures, process measures and paired/bundled measures (Tables 32.1 and 32.2) [15].