Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Measure Summary
Title
Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period.
Source(s)
American College of Cardiology, American Heart Association, Physician Consortium for Performance Improvement. Atrial fibrillation and atrial flutter physician performance measurement set. Chicago (IL): American Medical Association; 2007 Dec. 21 p. [1 reference]

Measure Domain

Primary Measure Domain
Clinical Quality Measures: Process
Secondary Measure Domain
Does not apply to this measure

Brief Abstract

Description

This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period.

Rationale

Adjusted-dose warfarin is highly efficacious in preventing thromboembolism in patients with atrial fibrillation (AF) and should be prescribed for all high risk patients except those with contraindications to anticoagulation. Aspirin is preferred in patients without risk factors or in those with contraindications to anticoagulation, and is an alternative to anticoagulation in those with only one moderate risk factor.

The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure:

2006 American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) Guidelines for the Management of Patients with Atrial Fibrillation

Chronic Anticoagulation Therapy
(Recommendations other than those listed below pertain to antithrombotic therapy for patients with AF undergoing cardioversion)

  1. Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF, except those with lone AF or contraindications.
  2. The selection of the antithrombotic agent should be based upon the absolute risks of stroke and bleeding and the relative risk and benefit for a given patient.
  3. Anticoagulation with a vitamin K antagonist is recommended for patients with more than one moderate risk factor. Such factors include age 75 years or greater, hypertension, heart failure (HF), impaired left ventricular (LV) systolic function (ejection fraction 35% or less or fractional shortening less than 25%), and diabetes mellitus.
  4. For patients without mechanical heart valves at high risk of stroke, chronic oral anticoagulant therapy with a vitamin K antagonist is recommended in a dose adjusted to achieve the target intensity international normalized ratio (INR) of 2.0 to 3.0, unless contraindicated. Factors associated with highest risk for stroke in patients with AF are prior thromboembolism (stroke, transient ischemic attack [TIA], or systemic embolism) and rheumatic mitral stenosis.
  5. The INR should be measured at least weekly during initiation of therapy and monthly when anticoagulation is stable.
  6. Aspirin, 81 to 325 mg daily, is recommended as an alternative to vitamin K antagonists in low-risk patients or in those with contraindications to anticoagulation.
  7. Antithrombotic therapy is recommended for patients with atrial flutter as for those with AF.
Evidence for Rationale
American College of Cardiology, American Heart Association, Physician Consortium for Performance Improvement. Atrial fibrillation and atrial flutter physician performance measurement set. Chicago (IL): American Medical Association; 2007 Dec. 21 p. [1 reference]

Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee [trunc]. J Am Coll Cardiol. 2006;48:e149-246.
Primary Health Components

Nonvalvular atrial fibrillation (AF); atrial flutter; high risk for thromboembolism (prior stroke, transient ischemic attack [TIA], age greater than or equal to 75 years, hypertension, diabetes mellitus, heart failure, impaired left ventricular [LV] systolic function); warfarin therapy

Denominator Description

All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter at high risk for thromboembolism (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Patients who were prescribed warfarin during the 12 month reporting period

Evidence Supporting the Measure

Type of Evidence Supporting the Criterion of Quality for the Measure
  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use of the Measure

State of Use
Current routine use
Current Use
Internal quality improvement
Pay-for-reporting
Public reporting

Application of the Measure in its Current Use

Measurement Setting
Ambulatory/Office-based Care
Professionals Involved in Delivery of Health Services
Physicians
Least Aggregated Level of Services Delivery Addressed
Individual Clinicians or Public Health Professionals
Statement of Acceptable Minimum Sample Size
Does not apply to this measure
Target Population Age

Age greater than or equal to 18 years

Target Population Gender
Either male or female

National Strategy for Quality Improvement in Health Care

National Quality Strategy Aim
Better Care
National Quality Strategy Priority
Prevention and Treatment of Leading Causes of Mortality

Institute of Medicine (IOM) National Health Care Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness

Data Collection for the Measure

Case Finding Period

Unspecified

Denominator Sampling Frame
Patients associated with provider
Denominator (Index) Event or Characteristic
Clinical Condition
Patient/Individual (Consumer) Characteristic
Denominator Time Window
Does not apply to this measure
Denominator Inclusions/Exclusions

Inclusions
All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter at high risk for thromboembolism

Note: Patients are identified by American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) 2006 guidelines by the following risk levels for thromboembolism:

  • High risk: prior stroke or transient ischemic attack (TIA) OR two or more of the following factors: age greater than or equal to 75 years, hypertension, diabetes mellitus, and heart failure or impaired left ventricular systolic function
  • Intermediate risk: one of the following factors: age greater than or equal to 75 years, hypertension, diabetes mellitus, and heart failure or impaired left ventricular systolic function
  • Low risk: none of the following factors: prior stroke or TIA, age greater than or equal to 75 years, hypertension, diabetes mellitus, and heart failure or impaired left ventricular systolic function

Exclusions

  • Documentation of medical reason(s) for not prescribing warfarin (e.g., patients with transient or reversible causes of AF (e.g., pneumonia or hyperthyroidism), postoperative patients, patients who are pregnant, allergy to warfarin, risk of bleeding)
  • Documentation of patient reason(s) for not prescribing warfarin (e.g., economic, social, and/or religious impediments, noncompliance or other reason for refusal to take warfarin)
Exclusions/Exceptions
Medical factors addressed
Patient factors addressed
Numerator Inclusions/Exclusions

Inclusions
Patients who were prescribed warfarin during the 12 month reporting period

Exclusions
None

Numerator Search Strategy
Fixed time period or point in time
Data Source
Administrative clinical data
Electronic health/medical record
Paper medical record
Type of Health State
Does not apply to this measure
Instruments Used and/or Associated with the Measure

Unspecified

Computation of the Measure

Measure Specifies Disaggregation
Does not apply to this measure
Scoring
Rate/Proportion
Interpretation of Score
Desired value is a higher score
Allowance for Patient or Population Factors
Unspecified
Standard of Comparison
Internal time comparison

Identifying Information

Original Title

Measure #2: chronic anticoagulation therapy.

Submitter
American Medical Association on behalf of the American College of Cardiology, American Heart Association, and Physician Consortium for Performance Improvement® - Medical Specialty Society
Developer
American College of Cardiology Foundation - Medical Specialty Society
American Heart Association - Medical Specialty Society
Physician Consortium for Performance Improvement® - Clinical Specialty Collaboration
Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

N. A. Mark Estes, III, MD, FACC, FAHA, FHRS (Co-Chair); Jonathan L. Halperin, MD, FACC, FAHA (Co-Chair); Hugh Calkins, MD, FACC, FAHA; Michael D. Ezekowitz, MB, ChB, DPhil, FACC; Paul Gitman, MD, MACP; Alan S. Go, MD; Robert L. McNamara, MD, MHS, FACC; Joseph V. Messer, MD, MACC, FAHA; James L. Ritchie, MD, FACC, FAHA; Sam J. W. Romeo, MD, MBA; Albert L. Waldo, MD, FACC, FAHA, FHRS; D. George Wyse, MD, PhD, FACC, FAHA, FHRS

Mark S. Antman, DDS, MBA, American Medical Association; Joseph Y. Gave, MPH, American Medical Association; Karen S. Kmetik, PhD, American Medical Association

Joseph M. Allen, MA, American College of Cardiology; Susan L. Morrisson, American College of Cardiology

Gayle Whitman, PhD, American Heart Association

Rebecca A. Kresowik, Facilitator; Timothy F. Kresowik, MD, Facilitator

Financial Disclosures/Other Potential Conflicts of Interest

Conflicts, if any, are disclosed in accordance with the Physician Consortium for Performance Improvement® conflict of interest policy.

Measure Initiative(s)
Physician Quality Reporting System
Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC
2007 Dec
Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The Physician Consortium for Performance Improvement reaffirmed the currency of this measure in November 2011.

Source(s)
American College of Cardiology, American Heart Association, Physician Consortium for Performance Improvement. Atrial fibrillation and atrial flutter physician performance measurement set. Chicago (IL): American Medical Association; 2007 Dec. 21 p. [1 reference]
Measure Availability

The individual measure, "Measure #2: Chronic Anticoagulation Therapy," is published in the "Atrial Fibrillation and Atrial Flutter Physician Performance Measurement Set." This document and technical specifications are available in Portable Document Format (PDF) from the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement® Web site: www.physicianconsortium.org External Web Site Policy.

For further information, please contact AMA staff by email at cqi@ama-assn.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on June 9, 2008. The information was verified by the measure developer on August 13, 2008. This NQMC summary was retrofitted into the new template on May 6, 2011. The information was reaffirmed by the measure developer on November 30, 2011.

Copyright Statement

© 2007 American College of Cardiology, American Heart Association and American Medical Association. All Rights Reserved.

CPT® Copyright 2006 American Medical Association

Disclaimer

NQMC Disclaimer

The National Quality Measures Clearinghouse™ (NQMC) does not develop, produce, approve, or endorse the measures represented on this site.

Read full disclaimer...