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AMERICAN COLLEGE OF CARDIOLOGY AGREES
Core Measure Criteria Are Wrong

Ever since the new code sets for Heart Failure (and acute MI) came out in 2003, I learned more and more about the conditions the represent heart failure, the modeling changes of the left ventricle, the functional abnormalities and what they really meant in developing an understanding of stroke volume, left ventricular end diastolic pressure, diastolic filling and ejection fraction.  When CMS and JCAHO came out with separate and later unified criteria sets for Core Measures - of compliance with clinical criteria in dealing with heart failure, I realized that there was something wrong.
The initial publication was as follows:
(Circulation. 2001;104:2996.)
© 2001 American Heart Association, Inc.

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure)

The goal of this publication was to point out to practicing physicians that patients who have heart failure states due to chronic left ventricular dysfunction have two major types:  left ventricular systolic dysfunction and left ventricular diastolic dysfunction.  And most patients with chronic left ventricular diastolic dysfunction are easier to treat and have had better survival statistics.  But patients with chronic left ventricular systolic dysfunction leading to the chronic heart failure conditions are harder to control, more frequently suffer sudden cardiac death and have worse survival statistics.  So they, through research, recommended use of ACE inhibitors in their care, which has been shown to increase survival.  A republication of the chronic heart failure criteria in 2003 added the use of ARBs (angiotensin receptor blockers) for patients with heart failure due to chronic left ventricular systolic dysfunction.

Well guess what’s missing from the Heart Failure Core Measure criteria sets?

CHRONIC!  There is NO reference to identification of the patients with chronic systolic failure.  All they ask for is LVSD (which can mean failure or not failure) and a measurement of ejection fraction (which can represent acute or chronic and you don’t know which – and they don’t know to care).

In addition, the Acute Myocardial Infarction criteria set asks for identification of the same wrong things: LVSD (with no consideration of acute of chronic) and EF under 40%.  Well, patients with acute MI may have “stunning” of the myocardium, with lowered ejection fractions for minutes to hours and return to total normalcy.  And, unless there is other reason to start ACE inhibitors or ARBs in these patients, to subject them to life-long medication for a condition that ended yesterday is inappropriate.

Well, the folks at the American College of Cardiology, who deal with the Core Measures and are quite aware of the risk factors of chronic systolic failure patients, agree whole heartedly that the current Core Measure criteria sets are inaccurate because they don’t ask for chronic in either Heart Failure or Acute MI and they don’t ask for heart failure at all in the Acute MI set.  Additionally, the JCAHO project authorities also agree with the above observation and recognize that it is the chronic heart failure patient with LV systolic dysfunction that requires the attention.  And they have both agreed to institute action to correct this situation.  Both also told me that it will likely take several months before anyone sees the change, but it must happen.

Amazing how many patients have been placed within the cohorts of Heart Failure and Acute MI groups and nobody ever picked this up.

HIM folks will be happier when they see documentation that supports the assignment of 428.22 in these patients.  Physicians will be happy when their mortality statistics show the increased risk of mortality these patients have that will positively affect their mortality profiles.  Hospitals will be happy when a Major Cardiovascular Diagnosis appears that they’re just not used to expecting.  And you know what’s most important?  It’s the right thing to do!