Quality indicators for cardiovascular primary care

doi:10.1016/S0828-282X(07)70772-9

Canadian Journal of Cardiology

Volume 23, Issue 5, April 2007, Pages 383-388

https://doi.org/10.1016/S0828-282X(07)70772-9 Get rights and content

Background

The Canadian Cardiovascular Outcomes Research Team was established in 2001 to improve the quality of cardiovascular care for Canadians. Initially, quality indicators (QIs) for hospital-based care for those with acute myocardial infarctions and congestive heart failure were developed and measured. Qualitative research on the acceptability of those indicators concluded that indicators were needed for ambulatory primary care practice, where the bulk of cardiovascular disease care occurs.

Objectives

To systematically develop QIs for primary care practice for the primary prevention and chronic disease management of ischemic heart disease, hypertension, hyperlipidemia and heart failure.

Methods

A four-stage modified Delphi approach was used and included a literature review of evidence-based practice guidelines and previously developed QIs; the development and circulation of a survey tool with proposed QIs, asking respondents to rate each indicator for validity, necessity to record and feasibility to collect; an in-person meeting of respondents to resolve rating and content discrepancies, and suggest additional QIs; and recirculation of the survey tool for rating of additional QIs. Participants from across Canada included family physicians, primary care nurses, an emergency room family physician and cardiologists.

Results

31 QIs were agreed on, nine of which were for primary prevention and 22 of which were for chronic disease management.

Conclusions

A core set of QIs for ambulatory primary care practice has been developed as a tool for practitioners to evaluate the quality of cardiovascular disease care. While the participants rated the indicators as feasible to collect, the next step will be to conduct field validation.

Contexte

L’Équipe canadienne d’analyse de résultats en matière de maladies cardiovasculaires a été fondée en 2001 afin d’améliorer la qualité des soins cardiovasculaires offerts au Canada. Au départ, des indicateurs de qualité (IQ) visant les soins fournis aux patients hospitalisés pour un infarctus aigu du myocarde ou pour de l’insuffisance cardiaque ont été élaborés, puis mesurés, mais une recherche qualitative sur l’acceptabilité des indicateurs a révélé la nécessité d’élaborer des indicateurs de qualité en soins primaires ambulatoires, là où est fournie la majeure partie des soins cardiovasculaires.

But

L’exercice avait pour but d’élaborer systématiquement des IQ pour la prestation de soins primaires liés à la prévention primaire et à la prise en charge de maladies chroniques comme les cardiopathies ischémiques, l’hypertension, l’hyperlipidémie et l’insuffisance cardiaque.

Méthode

Nous avons eu recours à une analyse Delphi modifiée, en quatre étapes, qui comportait un examen de la documentation sur des lignes directrices de pratique clinique, fondées sur des preuves, et sur des IQ déjà existants; l’élaboration et la distribution d’un outil d’enquête dans lequel on demandait aux répondants de coter, pour chacun des IQ proposés, la validité, la nécessité de la consignation et la faisabilité de la collecte de données; une entrevue personnelle avec des répondants afin de mieux comprendre certains écarts d’évaluation et de contenu et de leur permettre de suggérer des IQ; une redistribution de l’outil d’enquête pour l’évaluation d’autres IQ. Les participants, qui provenaient de toutes les régions du Canada, comprenaient des omnipraticiens, des infirmiers en soins primaires, un généraliste urgentologue et des cardiologues.

Résultats

Les répondants se sont mis d’accord sur 31 indicateurs de qualité : 9 d’entre eux portaient sur la prévention primaire et 22, sur la prise en charge de maladies chroniques.

Conclusions

Un ensemble de base d’IQ visant la prestation de soins primaires ambulatoires a été élaboré à l’intention des praticiens comme outil d’évaluation de la qualité des soins cardiovasculaires. Pendant que les participants évalueront les indicateurs du point de vue de la faisabilité de la collecte de données, la prochaine étape consistera en une enquête de validation sur le terrain.

References (38)

S.M. Campbell et al.
Defining quality of care
Soc Sci Med
(2000)
The Growing Burden of Heart Disease and Stroke in Canada, 2003. Heart and Stroke Foundation Canada....
J.V. Tu et al.
Canadian Cardiovascular Outcomes Research Team. Introduction to the Canadian Cardiovascular Outcomes Research Team's (CCORT) Canadian Cardiovascular Atlas project
Can J Cardiol
(2003)
C.T. Tran et al.
Canadian Cardiovascular Outcomes Research Team/Canadian Cardiovascular Society; Acute Myocardial Infarction Quality Indicator Panel. CCORT/CCS quality indicators for acute myocardial infarction care
Can J Cardiol
(2003)
D.S. Lee et al.
Canadian Cardiovascular Outcomes Research Team/Canadian Cardiovascular Society Heart Failure Quality Indicator Panel. CCORT/CCS quality indicators for congestive heart failure care
Can J Cardiol
(2003)
B. Chan
Access to physician services and patterns of practice
K. Tu et al.
Canadian Cardiovascular Outcomes Research Team. An overview of the types of physicians treating acute cardiac conditions in Canada
Can J Cardiol
(2004)
F. Burge et al.
Physician characteristics in relation to cardiovascular drugs commonly prescribed for hypertension in Nova Scotia
Can J Clin Pharmacol
(2001)
A.D. Brown et al.
Hospitalization for ambulatory care-sensitive conditions: A method for comparative access and quality studies using routinely collected statistics
Can J Public Health
(2001)
W. Putnam et al.
Quality indicators for cardiac care: National standards in a community context
J Health Serv Res Policy
(2006)

R.J. Romanow

Building on Values: The Future of Health Care in Canada

(2002)

The Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians – The federal role....

S.A. Buetow et al.

New Zealand and United Kingdom experiences with the RAND modified Delphi approach to producing angina and heart failure criteria for quality assessment in general practice

Qual Health Care

(2000)

S.M. Campbell et al.

Research methods used in developing and applying quality indicators in primary care

Qual Saf Health Care

(2002)

M.N. Marshall et al.

Can health care quality indicators be transferred between countries?

Qual Saf Health Care

(2003)

Marshall MN, Roland MO, Campbell SM, et al. Measuring general practice: A demonstration project to develop and test a...

Katz A, De Coster C, Bogdanovic B, Soodeen R-A, Chateau D. Using administrative data to develop indicators of quality...

S.A. Kirk et al.

Assessing the quality of care of multiple conditions in general practice: Practical and methodological problems

Qual Saf Health Care

(2003)

E.A. McGlynn

Selecting common measures of quality and system performance

Med Care

(2003)

Cited by (29)

Non-pharmacological interventions for older patients with hypertension: A systematic review and network meta-analysis
2022, Geriatric Nursing
Citation Excerpt :
Older patients are more likely to benefit from continuous educational courses and tailored educational programs than one-time interventions that do not provide such tailoring.62 For this reason, repeated group education and tailored counseling based on personal needs and preferences are crucial for older patients with hypertension and significantly increase their adherence to lifestyle changes.63,64 Lifestyle modification, including improving treatment adherence, adhering to healthy dietary patterns, and increasing physical activity, can enhance the effectiveness of medical methods and BP control.65,66
Objective: To determine the most effective non-pharmacological interventions to control the blood pressure variation in older hypertensive patients.
Methods: Primary endpoints were office systolic blood pressure (SBP) and diastolic blood pressure (DBP). The quality of evidence was assessed using the “risk of bias 2″ tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. We performed a Bayesian network meta-analysis using R-4.0.2 software to compare the efficacy of interventions.
Results: 36 eligible studies (3,531 patients) with a median follow-up of 12 weeks, assessing 18 non-pharmacological interventions, were included. The percentages of high, moderate, low, and very low certainty evidence were 16.7%, 38.9%, 33.3%, and 11.1%, respectively.
Conclusion: High certainty evidence suggests that self-management education is most effective in lowering SBP and DBP in older patients with hypertension, followed by moderate-intensity aerobic exercise. Moderate-intensity resistance training is the most effective exercise for lowering SBP.
Registration: PROSPERO, #CRD42020209850.
Measuring Cardiovascular Quality in Primary Care Using Canadian Cardiovascular Harmonization of National Guidelines Endeavour and Electronic Medical Record Data in Ontario
2019, CJC Open
Citation Excerpt :
This is consistent with previous research that highlights gaps in treatment and management of vascular risk factors, particularly for patients with comorbidities such as diabetes.25-28 While most studies focus on one area of vascular management or adherence to specific treatment type,29-31 our QIs provide insights on multiple aspects of CVD and can give guidance on what areas of vascular management have wider gaps than others.29 Only 23 of the 74 2014 C-CHANGE guidelines recommendations could be developed into QIs.
This project uses electronic medical record (EMR) data to assess performance by family physicians (FPs) in the screening for, diagnosis, and management of cardiovascular disease (CVD) and risk factors against national harmonized guidelines by the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE).
A retrospective cohort study using the Electronic Medical Record Administrative Data Linked Database (EMRALD) was conducted. A set of quality indicators (QIs) were developed on the basis of the 2014 C-CHANGE guidelines. Twenty-three readily measurable QIs were used to measure performance in the screening for and management of CVD, and to identify gaps in performance.
Our study population consisted of 324 Ontario FPs and 284,959 patients. We assessed 23 of the 74 recommendations. There was variance in rates of adherence to QIs related to screening rates for CVD. Highest adherence to C-CHANGE guidelines was related to laboratory testing for patients with hypertension and prescription of antihypertensive therapies (≥ 91.4%). Lowest adherence to the guidelines was seen in administration of oral glucose tolerance tests for assessing prediabetic patients (4.4%).
FP EMR data can be used to measure adherence to one-third of the C-CHANGE recommendations. There are varying levels of adherence among the measurable C-CHANGE recommendations, and there is room for improvement in quality of primary care management of CVD in Ontario. There is potential to use EMR data to assess changes to CVD management in FP practice using guidelines if recommendations are quantifiable and measurable.
Ce projet consiste à utiliser les données de dossiers médicaux électroniques (DME) pour faire l’évaluation de la performance des médecins de famille (MF) dans le dépistage, le diagnostic et la prise en charge des maladies cardiovasculaires (MCV) et des facteurs de risque par rapport aux lignes directrices nationales harmonisées de l’Initiative canadienne d’harmonisation des lignes directrices nationales (C-CHANGE pour Canadian Cardiovascular Harmonization of National Guidelines Endeavour).
Nous avons mené une étude de cohorte rétrospective à l’aide de la banque de données EMRALD (Electronic Medical Record Administrative data Linked Database). Nous avons élaboré un ensemble d’indicateurs de qualité (IQ) à partir des lignes directrices de la C-CHANGE de 2014. Nous avons utilisé 23 IQ facilement mesurables pour évaluer la performance dans le dépistage et la prise en charge des MCV, et pour déterminer les lacunes de la performance.
La population de notre étude consistait en 324 MF de l’Ontario et 284 959 patients. Nous avons évalué 23 des 74 recommandations. Il y avait un écart dans les taux d’observation des IQ liés aux taux de dépistage des MCV. La plus grande observation des lignes directrices de la C-CHANGE était liée aux épreuves de laboratoire des patients atteints d’hypertension et ayant des ordonnances d’antihypertenseurs (≥ 91.4%). La plus faible observation des lignes directrices était notée dans l’administration des épreuves d’hyperglycémie provoquée par voie orale lors de l’évaluation des patients prédiabétiques (4,4 %).
Les données des DME des MF peuvent être utilisées pour mesurer l’observation du tiers des recommandations de la C-CHANGE. Il existe des niveaux variés d’observation des recommandations mesurables de la C-CHANGE, et il y a une marge d’amélioration de la qualité de la prise en charge en soins primaires des MCV en Ontario. Il est possible d’utiliser les données des DME pour faire l’évaluation des changements dans la prise en charge des MCV dans la pratique des MF à l’aide des lignes directrices si les recommandations sont quantifiables et mesurables.
An expert system for financial performance assessment of health care structures based on fuzzy sets and KPIs
2016, Knowledge-Based Systems
Citation Excerpt :
They focused on effectiveness and safety KPIs, and developed a set of indicators with the aim of monitoring the quality of the care delivered by providers, enhancing the transparency of the hospital sector, and prompting individual hospitals to improve their scores. Burge et al., [8] developed a set of quality indicators (QIs) for primary care practice, for the primary prevention and chronic disease management of ischemic heart disease, hypertension, hyperlipidemia, and heart failure using a four-stage modified Delphi approach. Bradley et al., [6] determined a set of 33 indicators to assess the quality of a childhood cancer system.
Interest in the field of performance assessment of health care structures has grown in recent decades. In fact, the possibility of determining overall performances of health care structures plays a key role in the optimization of resource allocation and investment planning, as it contributes to reducing the uncertainty of future performance. In this context, key performance indicator (KPI) tools have been developed to assess the performance of health care structures from process, organizational, cost, financial, and output points of view. In practice, they are periodically calculated, and the effect of several KPIs on the overall performance of health care structures is determined by management through human judgment or software that provides synthetic dashboards. Given their non-stationary nature, performance assessment and forecasting are generally tackled by employing adaptive models, but these approaches cannot reflect the holistic nature of performance itself, nor take into account the impact of KPIs on the overall performances. In order to overcome these shortcomings, this study presents an expert system whose engine relies on fuzzy sets, in which the input–output relations and correlations have been modeled through inference rules based on time-series trends. The focus is on the financial performance assessment of a health care structure, such as a hospital. The approach is of an interdisciplinary kind, as several indicators were taken as inputs that relate to output, process, and cost KPIs, and their impact on the output measure, which is of a financial kind (namely the total reimbursement). The output measure calculated by the expert system was then compared with that predicted using only adaptive forecasting models, and the error with respect to the actual value was determined. Results showed that measures determined by fuzzy inference, able to effectively model actual input–output relations, outperform those of adaptive models.
An International Environmental Scan of Quality Indicators for Cardiovascular Care
2012, Canadian Journal of Cardiology
Citation Excerpt :
The full texts of these abstracts were obtained for the review. Of these, 20 articles20–39 and 1 peer-reviewed monograph7 (identified from the screening of references) met the criteria for evaluation and were critically appraised using the AGREE II QI tool. The majority of excluded abstracts focused on the application of QIs or the impact of quality improvement activities on care processes and patient outcomes as opposed to QI development.
Quality indicators (QIs) are increasingly being used to measure and improve the quality of cardiac care. We conducted an international environmental scan to identify and critically appraise published QI development initiatives addressing cardiovascular disease (CVD). A review of the peer-reviewed and grey English-language literature was conducted to identify published CVD QI development initiatives. The quality of identified studies was assessed using a modified version of the Appraisal of Guidelines for Research and Evaluation (AGREE) II QI tool—an instrument originally developed for the assessment of the quality of clinical practice guidelines. An initial literature search identified 2314 potentially relevant abstracts of peer-reviewed articles. After a review of the abstracts, 120 full text articles were retrieved and reviewed. Of these, 20 articles and 1 peer-reviewed monograph were selected for critical appraisal (n = 21). Most of the initiatives were conducted in North America (76%) and were published after 2005 (62%). The majority (5 of 6) of the AGREE II QI domain scores were skewed toward higher values, including the median score for the ‘overall quality’ rating (83.3%). Of the CVD categories addressed within the 21 initiatives, heart failure was the most common (n = 10 QI indicator sets), followed by acute coronary syndromes (n = 8). Considerable variation was observed in the methods utilized and the degree of scientific rigour applied in the published international CVD QI development initiatives. Adoption of standardized methods could help improve the quality of QI development initiatives.
Les indicateurs de la qualité (IQ) sont de plus en plus utilisés pour mesurer et améliorer la qualité des soins cardiaques. Nous avons mené une analyse environnementale internationale pour définir et évaluer de manière critique les publications sur les initiatives de développement des IQ portant sur la maladie cardiovasculaire (MCV). Une revue de la littérature grise anglophone examinée par des pairs a été menée pour définir les publications sur les initiatives de développement des IQ portant sur les MCV. La qualité de ces études a été évaluée en utilisant une version modifiée de l'outil d'IQ Appraisal of Guidelines for Research and Evaluation (AGREE) II – un instrument conçu au départ pour l'évaluation de la qualité des lignes directrices de la pratique clinique. Une recherche initiale de littérature a déterminé 2 314 résumés potentiellement pertinents d'articles examinés par des pairs. Après une revue des résumés, 120 articles en texte intégral ont été extraits et revus. Parmi ceux-ci, 20 articles et 1 monographie examinée par des pairs ont été sélectionnés pour une évaluation critique (n = 21). La plupart des initiatives ont été menées en Amérique du Nord (76 %) et ont été publiées après 2005 (62 %). La majorité (5 de 6) des scores du domaine des IQ de AGREE II ont été faussées par des valeurs plus élevées, incluant le score médian pour la notation de la « qualité globale » (83,3 %). Des catégories de MCV dont il est question dans les 21 initiatives, l'insuffisance cardiaque a été la plus fréquente (ensembles d'indicateurs IQ, n = 10), suivie par les syndromes coronariens aigus (n = 8). Une variation importante a été observée dans les méthodes utilisées et le degré de rigueur scientifique appliquée aux publications des initiatives internationales de développement des IQ portant sur la MCV. L'adoption de méthodes standardisées aiderait à améliorer la qualité des initiatives de développement des IQ.
The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs
2010, Canadian Journal of Cardiology
Since 2006, the Canadian Cardiovascular Society heart failure (HF) guidelines have published annual focused updates for cardiovascular care providers. The 2010 Canadian Cardiovascular Society HF guidelines update focuses on an increasing issue in the western world – HF in ethnic minorities – and in an uncommon but important setting – the pregnant patient. Additionally, due to increasing attention recently given to the assessment of how care is delivered and measured, two critically important topics – disease management programs in HF and quality assurance – have been included. Both of these topics were written from a clinical perspective. It is hoped that the present update will become a useful tool for health care providers and planners in the ongoing evolution of care for HF patients in Canada.
Depuis 2006, la Société canadienne de cardiologie publie chaque année une mise à jour de ses Lignes directrices sur l’insuffisance cardiaque (IC) ciblées, à l’intention des professionnels de la santé cardiovasculaire. La mise à jour 2010 des Lignes directrices de la Société canadienne de cardiologie sur l’IC porte sur un problème croissant en Occident, l’insuffisance cardiaque chez les minorités ethniques, et sur un tableau rare mais important, l’insuffisance cardiaque chez la femme enceinte. En outre, comme on accorde depuis peu une plus grande attention à l’évaluation de la façon dont les soins sont prodigués et évalués, deux autres sujets d’une grande importance sont abordés : les programmes de prise en charge de l’IC et l’assurance de la qualité. Ces deux derniers volets ont été rédigés d’un point de vue clinique. Il est à espérer que la présente mise à jour deviendra un outil pratique pour les professionnels de la santé et les planificateurs, compte tenu de l’évolution constante des soins prodigués aux patients atteints d’IC au Canada.
Practical application of the care quality indicators in the hypertensive patient
2009, Hipertension y Riesgo Vascular
La hipertensión arterial es uno de los principales factores de riesgo de morbimortalidad cardiovascular, su elevada prevalencia y su escaso control la convierten en un problema que afecta a múltiples estamentos implicados en la salud de la población.
La actuación del médico ante el paciente hipertenso debe regirse por criterios de calidad asistencial que, como todos los órdenes de nuestra actuación, deben superar el mínimo exigido y alcanzar, siempre que sea posible, el máximo asumible. Además, la calidad asistencial deber ser sometida de forma continua a evaluación de cara a que se pueda mejorar. El principal método para medir la calidad asistencial son los indicadores de calidad, instrumento de medida que permite cuantificar la calidad de los procesos asistenciales.
Poner al alcance de los profesionales los criterios e indicadores de calidad exigibles en la atención a los pacientes con hipertensión arterial permitirá en un futuro evaluar la calidad de nuestra actuación y optimizar los resultados.
Arterial hypertension is one of the major risk factors for cardiovascular morbidity and mortality. Its high prevalence and poor control make it a major health problem that affects many health population stratums.
The performance of the physician regarding the hypertensive patient should be guided by quality of care criteria which, as all of orders of our performance, should exceed the minimum required and should reach, whenever possible, the maximum level. Moreover, to assure its improvement, the quality of care should be subjected to continuous assessment. The main method to measure quality of care are quality indicators, measurement instruments that makes it possible to quantify the quality of the care processes.
Making these quality criteria and indicators available to professionals in their care to patients with arterial hypertension will permit in the future to evaluate the quality of our performance and optimize our results.

View all citing articles on Scopus

View full text

Quality indicators for cardiovascular primary careIndicateurs de qualité pour la prestation de soins primaires en cardiologie

Background

Objectives

Methods

Results

Conclusions

Contexte

But

Méthode

Résultats

Conclusions

Soc Sci Med

Canadian Cardiovascular Outcomes Research Team. Introduction to the Canadian Cardiovascular Outcomes Research Team's (CCORT) Canadian Cardiovascular Atlas project

Can J Cardiol

Canadian Cardiovascular Outcomes Research Team/Canadian Cardiovascular Society; Acute Myocardial Infarction Quality Indicator Panel. CCORT/CCS quality indicators for acute myocardial infarction care

Can J Cardiol

Canadian Cardiovascular Outcomes Research Team/Canadian Cardiovascular Society Heart Failure Quality Indicator Panel. CCORT/CCS quality indicators for congestive heart failure care

Can J Cardiol

Access to physician services and patterns of practice

Canadian Cardiovascular Outcomes Research Team. An overview of the types of physicians treating acute cardiac conditions in Canada

Can J Cardiol

Physician characteristics in relation to cardiovascular drugs commonly prescribed for hypertension in Nova Scotia

Can J Clin Pharmacol

Hospitalization for ambulatory care-sensitive conditions: A method for comparative access and quality studies using routinely collected statistics

Can J Public Health

Quality indicators for cardiac care: National standards in a community context

J Health Serv Res Policy

Building on Values: The Future of Health Care in Canada

New Zealand and United Kingdom experiences with the RAND modified Delphi approach to producing angina and heart failure criteria for quality assessment in general practice

Qual Health Care

Research methods used in developing and applying quality indicators in primary care

Qual Saf Health Care

Can health care quality indicators be transferred between countries?

Qual Saf Health Care

Assessing the quality of care of multiple conditions in general practice: Practical and methodological problems

Qual Saf Health Care

Selecting common measures of quality and system performance

Med Care