Clinical Indicators Clinical Indicators

Below are some examples of performance indicators suitable for cardiac rehabilitation (CR) or heart failure (HF) disease management programs adapted from key national and international sources. [#national-heart-foundation-of-australia.-multidisciplinary-care...-2010,#scott-i-denaro-c-flores-j-et-al.-2003,#bonow-ro-ganiats-tg-beam-ct-et-al.-2012,#american-college-of-cardiology-foundation-american-heart-association...-201]

In terms of calculating each indicator:

  • The denominator for each indicator is the number of patients in the program over a given time period
  • All indicators below describe the numerator, and should be expressed as a percentage of the denominator

Behavioural indicators

Percentage of eligible patients who are:

  • Physically active for 30 minutes daily or adhere to a recommended level of exercise
  • Smokers who stop smoking
  • Satisfied with care received and progress toward defined goals

Clinical indicators

Percentage of eligible patients:

  • Whose functional and/or exercise capacity is assessed (risk factor profile)
  • Who resume appropriate daily activities, or work, as specified at entry assessment

Psychosocial indicators

  • Patients who have been screened for depression†
  • Patients who have been assessed on a quality of life measure

Access and utilisation of services

Percentage of eligible patients who are:

  • Referred to a CR or a multidisciplinary HF care team
  • Referred to a CR/HF exercise program
  • Referred to start a programmed intervention
  • Completing a programmed intervention
  • Discharged from hospital following admission for HF and are followed up by the HF multidisciplinary team by phone, clinic visit, home visit or group program within 14 days of discharge

Self-care and education

Percentage of eligible patients:

  • For whom all relevant lifestyle risk factors (e.g., smoking, poor nutrition, salt intake, alcohol intake, physical inactivity, unhealthy body weight) have been assessed and recorded during one visit within a 12-month period
  • With a personalised written action plan
  • Assessed for the ability to self-care. For example see the Self-Care of Heart Failure Index

Exercise

Percentage of eligible patients:

Additional assessment where clinical judgements suggests further investigations

Percentage of eligible patients in whom:

  • Health literacy has been assessed†
  • Cognitive function has been assessed†
  • Depression has been assessed†
  • There is an advanced care plan (See Advance Care Planning Australia for further information)

Health outcomes

Percentage:

  1. Deaths within 30 days of discharge (cardiac and non-cardiac causes)
  2. 30-day re-admission rates (all cause, cardiac-specific, heart failure related)
  3. Risk adjusted average length of hospital stay
  4. Change in quality of life over 6 months measured on a validated tool
  5. Change in NYHA class over 6 months (HF only)

In addition to the general indicators, the following relate only to patients with HF.

Diagnosis of heart failure

  • Patients receiving an assessment of left ventricular function by echocardiography or other left ventricular imaging within the last 2 years or during a hospital admission

Medication prescription for heart failure on hospital discharge‡

NB. Denominators for medications ideally should exclude patients for whom the medications are not indicated, contra-indicated or not tolerated; however, in practice this is often poorly documented.

  • Patients with current or prior LVEF <40% prescribed one of the following beta-blockers (bisoprolol, carvedilol, sustained-release metoprolol or nebivolol)
  • Patients with current or prior LVEF <40% prescribed an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB)
  • Patients with current or prior LVEF <40% prescribed a mineralocorticoid receptor antagonist (MRA)
  • Patients with HF with chronic or paroxysmal atrial fibrillation (AF) or flutter with no documented reason for exclusion who are prescribed an oral anticoagulant

Medication titration

  • Patients with medication doses recommended in evidence-based guidelines (or at an optimal dose with reasons stated for no further up titrating) for:
    • ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB)‡
    • Beta-blocker‡
    • Mineralocorticoid receptor antagonist (MRA) ‡

† Assessed using an appropriate instrument that is reliable and validated for clinical group, where available.
‡ Except where contraindicated or not tolerated.