Circ Cardiovasc Qual Outcomes. 2019;12:e000057. DOI: 10.1161/HCQ.0000000000000057 November 2019 1 Developed in Collaboration With the American Medical Association and the Preventive Cardiovascular Nurses Association Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Association of Clinical Endocrinologists, American Nurses Association, American Society for Preventive Cardiology, American Society of Health-System Pharmacists, and Association of Black Cardiologists ACC/AHA Task Force Members, see 2019 by the American Heart Association, Inc., and the American College of Cardiology Foundation. WRITING COMMITTEE MEMBERS Donald E. Casey Jr, MD, MPH, MBA, FAHA, Chair Randal J. Thomas, MD, MS, FACC, FAHA, Vice Chair* Vivek Bhalla, MD, FAHA Yvonne Commodore-Mensah, PhD, RN, FAHA, FPCNA Paul A. Heidenreich, MD, MS, FACC, FAHA Dhaval Kolte, MD, PhD Paul Muntner, PhD, FAHA Sidney C. Smith Jr, MD, MACC, FAHA John A. Spertus, MD, MPH, FACC, FAHA John R. Windle, MD, FACC Gregory D. Wozniak, PhD Boback Ziaeian, MD, PhD, FACC Key Words: AHA Scientific Statements high blood pressure hypertension performance measures quality measures quality indicators Circulation: Cardiovascular Quality and Outcomes https://www.ahajournals.org/journal/ circoutcomes *ACC/AHA Task Force on Performance Measures Liaison. Preventive Cardiovascular Nurses Association Representative. American Medical Association Representative. The American Heart Association requests that this document be cited as follows: Casey DE Jr, Thomas RJ, Bhalla V, Commodore-Mensah Y, Heidenreich PA, Kolte D, Muntner P, Smith SC Jr, Spertus JA, Windle JR, Wozniak GD, Ziaeian B. 2019 AHA/ACC clinical performance and quality measures for adults with high blood pressure: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes. 2019;12:e000057. doi: 10.1161/HCQ.0000000000000057. PERFORMANCE AND QUALITY MEASURES 2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures 2 TABLE OF CONTENTS 1.1. Scope of the Problem 5 1.2. Disclosure of Relationships With Industry and Other Entities 6 1.3. Abbreviations and Acronyms 7 2.2. Definition and Selection of Measures 8 3. ACC/AHA HBP Measure Set Performance Measures 8 3.1. Discussion of Changes to 2011 Hypertension 4. Areas for Further Research 10 Appendix A. HBP Measure Set 20 Performance Measures for HBP 20 Short Title: PM-1a: ACC/AHA Stage 2 HBP Control SBP <140 mmHg Short Title: PM-1b: ACC/AHA Stage 2 HBP Control SBP <130 mmHg Short Title: PM-2: ACC/AHA Stage 1 HBP Control SBP <130 mmHg Short Title: PM-3: ACC/AHA Stage 2 and Stage 1 HBP Control SBP <130 mmHg (Composite Measure Combining Short Title: Interventions for ACC/AHA Stage Short Title: PM-5: Use of HBPM for Management of ACC/AHA Stage 2 HBP 25 Process Quality Measures 26 Short Title: Interventions for ACC/AHA Stage Short Title: Interventions for ACC/AHA Stage Short Title: Interventions for All ACC/AHA Stages of HBP (Composite Measure Short Title: QM-4: Medication Adherence to Drug Therapy for ACC/AHA Stage 1 With ASCVD Risk 10% or ACC/AHA Short Title: QM-5: Use of HBPM for Management of ACC/AHA Stage 1 HBP 30 Short Title: QM-6: Use of HBPM for Management of ACC/AHA Stage 1 HBP or ACC/AHA Stage 2 HBP (Composite Measure Structural Quality Measures 32 Diagnosis, Assessment and Accurate Use of a Standard Protocol to Consistently and Correctly Measure BP in the Ambulatory Setting 32 Use of a Standard Process for Assessing ASCVD Risk 34 Use of a Standard Process for Properly Screening All Adults 18 Years and Older for HBP (USPSTF) 35 Use of an EHR to Accurately Diagnose and Assess HBP Control 36 A Patient-Centered Approach for Controlling HBP 37 Use of a Standard Process to Engage Patients in Shared Decision-Making, Tailored to Their Personal Benefits, Goals and Values for Evidence-Based Interventions to Improve Control Demonstration of Infrastructure and Personnel That Assesses and Addresses Social Determinants of Health of Patients With HBP 38 Implementation of a System of Care for Patients With HBP 40 Use of Team-Based Care to Better Manage HBP 40 Use of Telehealth, m-Health, e-Health and Other Digital Technologies to Better Diagnose and Manage HBP 42 Use of a Single, Standardized Plan of Care for All Patients With HBP 44 Use of Performance Measures to Improve Care for HBP 45 Use of Performance and Quality Measures to Improve Quality of Care for Patients With HBP 45 Appendix B. Author Listing of Relationships With Industry and Other Entities (Relevant) 46 Appendix C. Reviewer Listing of Relationships With Industry and Other Entities PREAMBLE The American College of Cardiology (ACC) and the American Heart Association (AHA) performance mea- surement sets serve as vehicles to accelerate translation of scientific evidence into clinical practice. Measure sets developed by the ACC and AHA are intended to pro- vide practitioners and institutions that deliver cardiovas- cular services with tools to measure the quality of care provided and identify opportunities for improvement. Writing committees are instructed to consider the methodology of performance measure development1,2 and to ensure that the measures developed are aligned with ACC/AHA clinical guidelines. The writing commit- tees also are charged with constructing measures that maximally capture important aspects of quality of care, including timeliness, safety, effectiveness, efficiency, 3 equity, and patient-centeredness, while minimizing, when possible, the reporting burden imposed on hos- pitals, practices, and practitioners. Potential challenges from measure implementation may lead to unintended consequences. The manner in which challenges are addressed is dependent on several factors, including the measure design, data collection method, per- formance attribution, baseline performance rates, report- ing methods, and incentives linked to these reports. The ACC/AHA Task Force on Performance Measures (Task Force) distinguishes quality measures from perfor- mance measures. Quality measures are those metrics that may be useful for local quality improvement but are not yet appropriate for public reporting or pay- for-performance programs (uses of performance mea- sures). New measures are initially evaluated for poten- tial inclusion as performance measures. In some cases, a measure is insufficiently supported by the guidelines. In other instances, when the guidelines support a mea- sure, the writing committee may feel it is necessary to have the measure tested to identify the consequences of measure implementation. Quality measures may then be promoted to the status of performance mea- sures as supporting evidence becomes available. Gregg C. Fonarow, MD, FACC, FAHA Chair, ACC/AHA Task Force on Performance Measures In 2018, the Task Force convened the writing commit- tee to begin the process of revising the existing per- formance measures set for hypertension that had been released in 2011.3 The writing committee also was charged with the task of developing new measures to evaluate the care of patients in accordance with the 2017 Hypertension Clinical Practice Guidelines.4 The writing committee developed a comprehensive measure set for the diagnosis and treatment of high blood pressure (HBP) that includes 22 new measures: 6 performance measures, 6 process quality measures, and 10 structural quality measures. In conceptualizing these measures, the writing committee paid very close attention to the current Class of Recommendation (COR) and Level of Evidence (LOE) guideline classification scheme used by ACC and AHA in all of its guidelines, as shown in Table 1. Generally, performance measures are developed from Class 1 CORs and Level A and B LOEs (ie, strong recommendations based on the highest quality of evi- dence), but quality measures are generally based on lower ranges of CORs and LOEs. This distinction is important to remember throughout the present docu- ment, given that performance measures are most com- monly designed to be considered for use in national quality payment and reporting programs by entities such as the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assur- ance (NCQA), whereas quality measures are typically designed to support quality improvement initiatives and activities at the national or microsystem levels. The effective implementation of this measure set by clinicians, care teams, and health systems will lead to significant improvements in effective detection and treatment of HBP for millions of people across the Unit- ed States. Specifications for these new measures take into full account the revised classification taxonomy of HBP from the 2017 Hypertension Clinical Practice as noted in Table 2. The writing committee felt that it was critically impor- tant to incorporate this revised classification into the con- struction of each of the new performance and quality measures presented in this document. The writing com- mittee believed that the former HBP classification scheme previously published by the Joint National Committee5 was now out of date and needed replacement with that of the 2017 Hypertension Clinical Practice Guidelines,4 described in Table 2, to reduce confusion in the field. The current International Classification of Diseases, 10th edi- tion, codes have not yet been modified to reflect the new classification from the 2017 Hypertension Clinical Prac- which may create some initial challenges with implementation. The writing committee is sensitive to the fact that the current version (2019 at the time of this writing) of the performance measures for controlling HBP developed by the NCQA for the Healthcare Effective- ness Data and Information Set6 and currently in use in also does not incorporate the 2017 Hyper- tension Clinical Practice Guidelines classification scheme. It is well understood that these measures are already in widespread use, especially for quality-related payment programs promulgated by CMS, such as the Medicare Advantage Stars ratings, the Medicare Shared Savings Program, and the Physician Quality Payment Program, as well as many other programs promoted by commercial health insurers. In particular, the widespread use of the 2017 Hypertension Clinical Practice Guidelines4 classi- fication scheme will also help to guide decision-making about when to prescribe antihypertensive medications in accordance with its current recommendations for the ACC/AHA stages of HBP (ie, stage 2, stage 1, and elevat- ed blood pressure [BP]), as outlined in Table 3. In the 2017 Hypertension Clinical Practice Guide- the authors emphasized the critical importance of measuring atherosclerotic cardiovascular disease (ASCVD) risk for all patients with HBP, regardless of stage. Therefore, it will be important for the end users of the new ACC/AHA performance measure set to incorporate this risk assessment process in order to achieve successful implementation as a key component of quality improvement for patients with HBP. Because the current NCQA and CMS performance measures for controlling HBP assess only the population with ACC/AHA stage 2 HBP,6 the writing committee 4 also felt that it was important to emphasize the 2017 Hypertension Clinical Practice Guidelines4 recommen- dations to lower BP below the 130/80-mmHg threshold for both ACC/AHA stage 2 and stage 1 patients. In for- mulating these new performance measures, the writing committee was sensitive to the fact that there is cur- rently not complete consensus among other guidelines from the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP)8 and also the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH).9 Nonetheless, despite this ongoing debate, the writing committee felt strongly that it is now time to move the US healthcare system ahead to reflect these differing points of view and expects that widespread use of this new measure set will help to achieve this goal. In addition, the writing committee was concerned that NCQA and CMS would be less likely to consider testing and adopting performance measures with denominator specifications different from those of the Controlling High Blood Pressure measure currently in widespread use (and recently revised in 2019).10 Therefore, the writ- ing committee chose to promote flexible denominator congruity and harmonization (as defined by the National Quality Forum [NQF]) with both NCQA and CMS mea- sure specifications in the new ACC/AHA performance measure set to promote its initial widespread use by cli- nicians and entities who support the treatment recom- mendations for ACC/AHA stage 1 HBP as emphasized in the 2017 Hypertension Clinical Practice Guidelines.4 This new performance measure set also includes a new com- posite measure for control of HBP for both ACC/AHA Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated August 2015)* 5 stage 2 and ACC/AHA stage 1 to a systolic goal of <130 mmHg. Furthermore, the new Process Quality Measures are intended for use in quality improvement initiatives that are designed to take into account management and control for all ACC/AHA stages of HBP without creat- ing controversy or conflict with CMS, NCQA, NQF, and professional societies with differing recommendations and points of view about treatment of ACC/AHA stage 2 and stage 1 HBP. CMS recently determined that the evi- dence is sufficient to cover ambulatory BP monitoring for the diagnosis of hypertension in Medicare beneficiaries with suspected white coat or masked hypertension.11,12 Annals of Internal Medicine also published an In the Clinic section for screening, prevention, diagnosis, and treatment of hypertension, citing the 2017 Hypertension Clinical Practice Guidelines.13 The writing committee was also interested in trans- lating some of the 2017 Hypertension Clinical Practice Guidelines recommendations for systematic strategies that support the consistent and accurate diagnosis and treatment of populations of patients with HBP.4 In its deliberations on this challenge, the writing committee felt that it would be cumbersome and challenging to collect data at the patient and individual clinician levels, thereby limiting the use and utility of measures speci- fied at these levels. With these potential constraints in mind, the writing committee created 10 new structural quality measures designed to evaluate the capability and capacity of various levels of the US healthcare system to implement 2017 Hypertension Clinical Practice Guide- lines recommended strategies, such as standardized BP measurement protocols, electronic health record surveil- lance, telehealth, team-based care, a single plan of care, and performance measurement.4 These new measures are intended for qualitative evaluation of process and infrastructure for these strategies at the care delivery unit (CDU) level (including solo/small physician offices, group practices, health systems, public health sites, accountable care organizations, and clinically integrated networks). Summaries for these measures are displayed in Tables 4 and 5, which provide information on each measure. Tables 4 and 5 also list each of the new measures and which ACC/AHA classes of HBP are addressed for each. More detailed descriptive and technical specifications for each measure are listed in Appendix A, which pro- vides additional details for each measure description, numerator, denominator (including denominator exclu- sions and exceptions), rationale for the measure, guide- line recommendations that support the measure, mea- surement period, source of data, and attribution. 1.1. Scope of the Problem Failing to correctly diagnose and control HBP can put people at increased risk for cardiovascular disease, stroke, and renal failure. Recent analyses suggest that >100 million Americans currently have HBP, and the 2011 2014 US National Health and Nutrition Exami- nation Survey estimated that 46% of US adults have An additional 12% of US adults have elevated BP and are at high risk of developing HBP. Among US adults taking antihypertensive medication, 53% have Of US adults with hypertension, 20% were unaware they had the condition.17 In a large cohort study of US adults 45 years of age, the inci- dences of ASCVD and all-cause death were 20.5 and 29.6 per 1000 person-years, respectively, among par- ticipants with ACC/AHA stage 1 HBP who had been recommended to initiate antihypertensive medication, and 22.7 and 32.9 per 1000 person-years, respec- tively, among participants with ACC/AHA stage 2 HBP. Among participants taking antihypertensive medication with above-goal BP (ie, systolic BP 130 mmHg or dia- stolic BP 80 mmHg), the incidences of ASCVD and all-cause death were 33.6 and 42.5 events per 1000 In addition, individuals with HBP face on average nearly $2000 more in annual healthcare expenses than those without HBP.19 Table 3. Guideline Recommendation for BP-Lowering Medications: ACC/AHA COR/LOE ASCVD Risk Stage 2 High BP Stage 1 High BP mmHg) Elevated BP mmHg) ASCVD Risk COR: 1, LOE: A COR: 1, LOE: A Not recommended ASCVD Risk COR: 1, LOE: C-LD Not recommended Not recommended All require intensive lifestyle modification (COR: 1, LOE: A) (applies to the entire table). For older adults ( 65 years of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit are reasonable for decisions about intensity of BP lowering and choice of antihypertensive drugs (COR: 2a, LOE: C-EO). ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; COR, Class of Recommendation; and LOE, Level of Evidence. Table 2. BP Classification (JNC 7 and the 2017 Hypertension Clinical Practice Guidelines) SBP (mmHg) and/or DBP (mmHg) <120 and <80 Normal BP Normal BP 120 129 and <80 Prehypertension Elevated BP hypertension hypertension hypertension hypertension hypertension BP should be based on an average of 2 careful readings on 2 occasions. Adults with SBP or DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure; DBP, diastolic blood pressure; GL, guideline; JNC, Joint National Committee; and SBP, systolic blood pressure. 6 Two studies have projected large reductions in ASCVD and all-cause death among US adults through the achieve- ment of the BP goals in the 2017 Hypertension Clinical In 1 study, it was estimated that 3 million ASCVD events could be averted over the next 10 years through achievement and maintenance of the 2017 ACC/AHA BP goals (systolic/diastolic BP <130/80 mmHg; <130 mmHg for adults 65 years of age with low ASCVD risk), as compared with maintaining current BP and treatment and control levels.20 Overall, 33% of all ASCVD events prevented would be in those initiating antihypertensive treatment, and 67% would be in those intensifying current antihypertensive treatment.20 Despite the evidence-based recommendations for lower BP goals (<130/80 mmHg) in the 2017 Hyperten- sion Clinical Practice Guidelines,4 existing quality mea- sures from the NCQA for controlling HBP (for hyperten- sive adults 18 59 years of age whose BP was <140/90 have not changed substantially over the past several years for various insured populations, including commercial, Medicaid, Medicare Fee for Service, and Re-examining both the targets and processes of managing HBP are thus warranted to help support the use of the latest evidence in optimizing the quality of care and outcomes for patients with HBP. 1.2. Disclosure of Relationships With Industry and Other Entities The Task Force makes every effort to avoid actual, poten- tial, or perceived conflicts of interest that could arise as a result of relationships with industry or other entities (RWI). Detailed information on the ACC/AHA policy on RWI can be found at http://www.acc.org/guidelines/about-guide- lines-and-clinical-documents/relationships-with-industry- policy. All members of the writing committee, as well as those selected to serve as peer reviewers of this docu- ment, were required to disclose all current relationships and those existing within the 12 months before the initia- tion of this writing effort. ACC/AHA policy also requires Table 4. Summary of 2019 ACC/AHA Performance and Quality Measures for the Diagnosis and Management of HBP Measure No. Measure Title/Description ACC/AHA Stage 2 HBP ACC/AHA Stage 1 HBP ACC/AHA Elevated BP COR/LOE Performance Measures* PM-1a ACC/AHA stage 2 HBP control SBP <140 mmHg + - - COR: 1, LOE: A PM-1b ACC/AHA stage 2 HBP control SBP <130 mmHg + - - COR: 1, LOE: A / COR: 2a, LOE: C-EO PM-2 ACC/AHA stage 1 HBP control SBP <130 mmHg - + - COR: 1, LOE: A PM-3 ACC/AHA stage 2 and stage 1 HBP control SBP <130 mmHg (composite measure combining PM- + + - COR: 1, LOE: A / COR: 2a, LOE: C-EO PM-4 Nonpharmacological interventions for ACC/AHA stage 2 HBP + - - COR: 1, LOE: A PM-5 Use of HBPM for management of ACC/AHA stage + - - COR: 1, LOE: A Process Quality Measures* QM-1 Nonpharmacological interventions for ACC/AHA stage elevated BP - - + COR: 1, LOE: A QM-2 Nonpharmacological interventions for ACC/AHA stage 1 HBP - + - COR: 1, LOE: A QM-3 Nonpharmacological interventions for all ACC/AHA stages of HBP (composite measure + + + COR: 1, LOE: A QM-4 Medication adherence to drug therapy for ACC/ AHA stage 1 with ASCVD risk 10% or ACC/AHA stage 2 HBP + + - COR: 1, LOE: A QM-5 Use of HBPM for management of ACC/AHA stage - + - COR: 1, LOE: A QM-6 Use of HBPM for management of ACC/AHA stage 1 or ACC/AHA stage 2 (composite measure + + - COR: 1, LOE: A *Performance measures are used in national quality payment and reporting programs, whereas process quality measures support quality improvement initiatives and activities at the national or microsystem levels. +Indicates the corresponding ACC/AHA stage for the measure. -Indicates that the ACC/AHA stage does not correspond to the measure. ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; COR, Class of Recommendation; HBP, high blood pressure; HBPM, home blood pressure monitoring; LOE, Level of Evidence; PM, performance measure; QM, quality measure; and SBP, systolic blood pressure. 7 that the writing committee chair and at least 50% of the writing committee have no relevant RWI. Any writing committee member who develops new RWI during his or her tenure on the writing committee is required to notify staff in writing. These statements are reviewed periodically by the Task Force and by members of the writing committee. Author and peer reviewer RWI that are pertinent to the document are included in the appendixes: Appendix B for relevant writing committee RWI and Appendix C for comprehensive peer reviewer RWI. Additionally, to ensure complete transparency, the writing committee members comprehensive disclosure information, including RWI not relevant to the present document, is available online. Disclosure information for the Task Force is also available online at http://www. acc.org/guidelines/about-guidelines-and-clinical-docu- ments/guidelines-and-documents-task-forces. The work of the writing committee was supported exclusively by the ACC and the AHA without commercial support. Members of the writing committee volunteered their time for this effort. Meetings of the writing com- mittee were confidential and attended only by writing committee members, staff from the ACC and AHA, and representatives of the American Medical Association (AMA) and Preventive Cardiovascular Nurses Association (PCNA), which served as collaborators on this project. 1.3 Abbreviations and Acronyms Abbreviation/Acronym Meaning/Phrase ASCVD atherosclerotic cardiovascular disease BP blood pressure CDU care delivery unit CMS Centers for Medicare & Medicaid Services COR Class of Recommendation HBP high blood pressure LOE Level of Evidence NCQA National Committee for Quality Assurance NQF National Quality Forum Table 5. Summary of 2019 ACC/AHA Structural Measures for the Diagnosis and Management of HBP Measure No. Measure Title/Description ACC/AHA Stage 2 HBP ACC/AHA Stage 1 HBP ACC/AHA Elevated BP COR/LOE Diagnosis, Assessment, and Accurate Measurement SM-1 Use of a standard protocol to consistently and correctly measure BP in the ambulatory setting + + + COR: 1, LOE: C-EO SM-2 Use of a standard process for assessing ASCVD ) + + + COR: 1, LOE: B-NR SM-3 Use of a standard process for properly screening all adults 18 years of age for HBP (USPSTF15 ) + + + Grade A (USPSTF) SM-4 Use of an EHR to accurately diagnose and assess HBP control + + + COR: 1, LOE: B-NR Patient-Centered Approach for Controlling HBP SM-5 Use of a standard process to engage patients in shared decision-making, tailored to their personal benefits, goals, and values for evidence-based interventions to improve control of HBP (2019 ) + + + COR: 1, LOE: B-R SM-6 Demonstration of infrastructure and personnel that assess and address social determinants of health of patients with HBP (2019 Prevention ) + + + COR: 1, LOE: B-NR Implementation of a System of Care for Patients With HBP SM-7 Use of team-based care to better manage HBP + + + COR: 1, LOE: A SM-8 Use of telehealth, m-health, e-health, and other digital technologies to better diagnose and manage HBP + + + COR: 2a, LOE: A / COR: 1, LOE: A SM-9 Use of a single, standardized plan of care for all patients with HBP + + + COR: 1, LOE: C-EO Use of Performance Measures to Improve Care for HBP SM-10 Use of performance and quality measures to improve quality of care for patients with HBP + + - COR: 2a, LOE: B-NR +Indicates the corresponding ACC/AHA stage for the measure. -Indicates that the ACC/AHA stage does not correspond to the measure. ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; COR, Class of Recommendation; e-health, healthcare services provided electronically via the Internet; EHR, electronic health record; HBP, high blood pressure; LOE, Level of Evidence; m-health, practice of medicine and public health supported by mobile devices; SM, structural measure; and USPSTF, US Preventive Services Task Force. 8 2.1. Literature Review In developing the updated HBP measure set, the writ- ing committee reviewed evidence-based guidelines and statements that would potentially impact the construc- tion of the measures. The clinical practice guidelines and scientific statements that most directly contributed to the development of these measures are shown in Table 6. 2.2. Definition and Selection of Measures In constructing the measure set, the writing committee recognized that other organizations (eg, CMS, NCQA) have developed or are continuing to develop HBP perfor- mance measures in response to the release of the 2017 Hypertension Clinical Practice Guidelines.4 Hence, the committee created performance measures for ACC/AHA stage 2 HBP that are aligned with these other groups, called harmonizing measures. In addition, the committee created enhancing measures that incorporate emerging evidence showing improved outcomes with more aggres- sive BP control (ie, for ACC/AHA stage 1 HBP). When defining harmonization, the writing committee followed the NQF Guidance for Measure Harmonization report, which states measure harmonization should be con- sidered when measures are intended to address either the same measure focus the target process, condition, event, outcome (eg, numerator) or the same target pop- ulation (eg, denominator). 23 The enhancing performance and quality measures are intended to promote the wide- spread application in clinical practice of the current recom- mendations from the 2017 Hypertension Clinical Practice to improve care and outcomes for all patients with HBP, including those with ACC/AHA stage 1 HBP and elevated BP. The writing committee acknowledges that adding new performance measures may not be initially feasible in the current regulatory environment, in which many healthcare entities already have a high burden to collect and report existing quality measures. Nonetheless, it is imperative that national quality improvement efforts urgently incorporate high-quality, evidence-based recom- mendations into practice, especially given the recent lack of significant progress in controlling HBP with national measures in current use by CMS, NCQA, state Medicaid agencies, NQF, and other entities (Figure 1).6 The writing committee reviewed clinical practice guidelines and other clinical guidance documents recently published by other entities, in addition to ACC/ AHA documents. The writing committee also exam- ined available information on gaps in care to address which new measures might be appropriate as perfor- mance measures or quality measures for this measure set update, based on the attributes for performance measures outlined in Table 7. 3. AHA/ACC HBP MEASURE SET PERFORMANCE MEASURES 3.1. Discussion of Changes to 2011 Hypertension Measure Set After reviewing the existing guidelines and the 2011 hypertension measure set,3 the writing committee dis- cussed which measures required revision to reflect updat- ed science related to HBP and identified which guideline recommendations could serve as the basis for new per- formance or quality measures. The writing committee also reviewed existing publicly available measure sets. These subsections serve as a synopsis of the revisions that were made to previous measures and a description of why the new measures were created for both the inpatient and outpatient settings. 3.1.1. Retired Measures The writing committee decided to retire the BP Control Measure because it was not concordant with the 2017 Hypertension Clinical Practice Guidelines.4 3.1.2. New Measures On the basis of the 2017 Hypertension Clinical Practice and the 2019 Prevention Guideline,14 the writing committee created a comprehensive list of mea- sures intended to be used to improve important gaps in the quality of care for patients with HBP.4,14 This set includes 22 new measures: 6 performance measures, 6 process quality measures, and 10 structural quality mea- sures. Table 8 includes a list of the measures with infor- mation on the attribution and a brief rationale. Perfor- mance measures are typically outcome measures that target meaningful gaps in the quality of care, are based on Class 1 clinical practice guideline recommendations, and are appropriately designed for use in accountability in programs that rely on public reporting and pay-for- value initiatives promoted by organizations such as CMS, commercial payers, the NCQA, and the NQF. The writ- ing committee believes that it is important to confirm its Table 6. Associated Clinical Practice Guidelines and Other Clinical Guidance Documents Clinical Practice Guidelines Performance Measures and Scientific Statements 2 NQF Measure 0018 Controlling High Blood Pressure (NCQA)22 3 ACC/AHA Performance Measures Methodology1 ACC indicates American College of Cardiology; AHA, American Heart Association; NCQA, National Committee for Quality Assurance; NQF, National Quality Forum; and USPSTF, US Preventive Services Task Force. 9 full support of the performance measure for BP control in current widespread use by CMS and NCQA for HBP (ie, the proportion of stage 2 patients with HBP with control below the Joint National Committee5 traditional target of 140/90 mmHg). In addition, the writing committee unanimously feels it important to include new harmoniz- ing measures for stage 1 HBP and a composite measure (ie, for ACC/AHA stage 2 and ACC/AHA stage 1 com- bined) that emphasize the importance of controlling HBP below the new ACC/AHA target of 130/80 mmHg, as recommended by the 2017 Hypertension Clinical Practice Because of the importance of the promo- tion of intensive nonpharmacological healthy lifestyle modifications and home BP monitoring for patients with stage 2 HBP (as emphasized in the 2017 Hypertension Clinical Practice Guidelines,4 new performance measures to assess quality of care in this regard have been included. These new performance measures are also intended to harmonize with the performance measure for stage 2 HBP currently in use by CMS and NCQA. Quality measures, on the other hand, are intended to be deployed in collaborative quality improvement initia- tives (such as those promoted by the ACC and AHA) that do not require the degrees of technical rigor required for performance measures. The writing committee decided to include 6 new process quality measures based on Class 1 recommendations from the 2017 Hypertension Clini- cal Practice Guidelines4 recommendations that address important gaps in care for patients with HBP. If additional evidence evolves that demonstrates significant impact on the quality of care and meets NQF requirements for reliability, feasibility, usability, validity, and acceptable burden of data collection for these measures, then they may be considered as potential future performance mea- sures by the writing committee and other entities, such as CMS, NCQA, state Medicaid agencies, and NQF. Given the extensive emphasis on developing more effective systems of care for patients with HBP, the writ- ing committee also feels it is important to present a new concept of structural measures, which are designed to improve these systems. This category of quality measure is intended to evaluate care at the aggregate care deliv- ery unit (CDU) level, as opposed to the performance and quality measures, which are designed to summarize the evaluation of care of prespecified populations with HBP at the individual, group clinician, or health plan levels. A CDU represents the organizational structure of the clinicians who are delivering care to these patients. This measurement includes a hierarchical scale of the health delivery infrastructure for optimal management of patients with HBP that is available to organizations such as a small medical practice, a multispecialty clinic, a community-based health center (eg, a Federally Quali- fied Health Center), a hospital-owned ambulatory care site, or even a large, geographically dispersed health system (eg, the US Department of Veterans Affairs). Figure 1. Performance of HEDIS Controlling HBP Measure 1999 2017 (percent of patients with hypertension treated in accordance with the HEDIS Controlling HBP Measure). The HEDIS Hypertension Measure6 assesses adults 18 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled according to the following criteria: 1) Adults 18 59 years of age whose blood pressure was <140/90 mmHg. 2) Adults 60 85 years of age, with a diagnosis of diabetes mellitus, whose blood pressure was <140/90 mmHg. 3) Adults 60 85 years of age, without a diagnosis of diabetes mellitus, whose blood pressure was <150/90 mmHg (likely to be lowered in 2018 to <140/90 mmHg). Data in graph from National Committee for Quality Assurance (NCQA).6 HBP indicates high blood pressure; HEDIS, Healthcare Effectiveness Data and Information Set; HMO, health maintenance organization; and PPO, preferred provider organization. 10 The writing committee developed this new category of 10 structural measures in hopes that they could be imple- mented within a CDU at any level of the health system to assess strengths and weaknesses of available infrastructure designed to improve accurate diagnosis and management of patients with HBP, again in accordance with relevant rec- ommendations from the 2017 Hypertension Clinical Prac- The writing committee emphasizes that expecting the structural measures to be interpreted as rigid requirements for CDUs would not permit the high level of flexibility these diverse entities need to use these mea- sures for their own self-assessment and collaborative qual- ity improvement implementation initiatives. Hence, these new measures are currently not designed or intended to be used for accountability standards but rather to be used as a roadmap for solo/small physician offices, group practices, health systems, public health sites, accountable care organizations, and clinically integrated networks, etc., in their collective journeys to establish better and more standardized guideline-based systems of care for the many millions of patients with HBP across the United States. More detailed information on the specifications for these new performance, quality, and structural measures for care of patients with HBP is presented in Appendix A. 4. AREAS FOR FURTHER RESEARCH Several additional areas of research will potentially have an impact on HBP performance and quality measures: Further research is needed on devices for measur- ing BP for diagnosis and control, including con- tinuous measurements from digital devices and entering BP measurements into electronic health records. Further research is needed on improving the accu- racy of office BP measurements, including appro- priate technique, number of measurements, and training of healthcare providers in measuring BP to help standardize care and improve utilization of performance measures. Technology for measurement of BP continues to evolve. Several ambulatory BP monitoring and home BP monitoring devices, including cuffless devices that incorporate optical BP monitoring algorithms, are available, although out-of-office BP measurements using validated upper-arm devices with appropriately sized cuffs are recommended to confirm the diagnosis of HBP and for titration of BP-lowering medications. Additional data on accu- racy, reproducibility, costs, and device comparisons are needed. The field would benefit from further research on how improvement in HBP measurement, such as the use of home BP monitoring and use of a stan- dard protocol to measure BP accurately, as incor- porated into guideline-based clinical interventions (eg, AHA and AMA Target: BP), translates into improvement in BP care.26 Table 7. ACC/AHA Task Force on Performance Measures: Attributes for Performance Measures24 1. Evidence Based High-impact area that is useful in improving patient outcomes a. For structural measures, the structure should be closely linked to a meaningful process of care that in turn is linked to a meaningful patient outcome. b. For process measures, the scientific basis for the measure should be well established, and the process should be closely linked to a meaningful patient outcome. c. For outcome measures, the outcome should be clinically meaningful. If appropriate, performance measures based on outcomes should adjust for relevant clinical characteristics through the use of appropriate methodology and high-quality data sources. 2. Measure Selection Measure definition a. The patient group to whom the measure applies (denominator) and the patient group for whom conformance is achieved (numerator) are clearly defined and clinically meaningful. Measure exceptions and exclusions b. Exceptions and exclusions are supported by evidence. Reliability c. The measure is reproducible across organizations and delivery settings. Face validity d. The measure appears to assess what it is intended to. Content validity e. The measure captures most meaningful aspects of care. Construct validity f. The measure correlates well with other measures of the same aspect of care. 3. Measure Feasibility Reasonable effort and cost a. The data required for the measure can be obtained with reasonable effort and cost. Reasonable time period b. The data required for the measure can be obtained within the period allowed for data collection. Actionable a. Those held accountable can affect the care process or outcome. Unintended consequences avoided b. The likelihood of negative unintended consequences with the measure is low. Reproduced with permission from Thomas et al.25 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. ACC indicates American College of Cardiology; and AHA, American Heart Association. 11 Table 8. New Performance, Quality, and Structural Measures for the Diagnosis and Management of HBP in the Outpatient Care Setting* Measure No. Measure Title Attribution Rationale for Creating New Measure PM-1a ACC/AHA stage 2 HBP control SBP <140 mmHg (harmonizing measure) Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Harmonizes with current performance measure Controlling High Blood Pressure for ACC/AHA stage 2 HBP currently in widespread use. PM-1b ACC/AHA stage 2 HBP control SBP <130 mmHg (enhancing measure) Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Harmonizes with current performance measure Controlling High Blood Pressure for ACC/AHA stage 2 HBP currently in widespread use and adds lower target for further risk reduction. PM-2 ACC/AHA stage 1 HBP control SBP <130 mmHg (harmonizing measure) Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Harmonizes with current performance measure Controlling High Blood Pressure for ACC/AHA stage 2 HBP currently in widespread use. Adds emphasis on including the ACC/AHA stage 1 HBP population. PM-3 ACC/AHA stage 2 and stage 1 HBP control SBP <130 mmHg (composite measure combining PM-1b and Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Harmonizes with current performance measure Controlling High Blood Pressure for ACC/AHA stage 2 HBP currently in widespread use. Adds emphasis on including the ACC/AHA stage 1 HBP population and combines both ACC/AHA stage 2 and stage 1 HBP populations. PM-4 Nonpharmacological interventions for ACC/AHA stage 2 HBP Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Harmonizes with current performance measure Controlling High Blood Pressure for ACC/ AHA stage 2 HBP currently in widespread use. Adds new emphasis on high-quality evidence and strong recommendation for promoting lifestyle modification, as recommended in the 2017 Hypertension Clinical Practice Guidelines for this population as an important strategy for controlling HBP. PM-5 Use of HBPM for management of ACC/AHA stage 2 HBP Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Harmonizes with current performance measure Controlling High Blood Pressure for ACC/ AHA stage 2 HBP currently in widespread use. Adds new emphasis on correct measurement of BP by individuals at home or elsewhere outside the clinic setting, as recommended in the 2017 Hypertension Clinical Practice Guidelines for this population as an important strategy for evaluating control of HBP. QM-1 Nonpharmacological interventions for ACC/AHA stage elevated BP Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Adds new emphasis on high-quality evidence and strong recommendation for promoting lifestyle modification, as recommended in the 2017 Hypertension Clinical Practice Guidelines for ACC/ AHA elevated BP population as an important strategy for controlling HBP. QM-2 Nonpharmacological interventions for ACC/AHA stage 1 HBP Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Adds new emphasis high-quality evidence and strong recommendation for promoting lifestyle modification, as recommended in the 2017 Hypertension Clinical Practice Guidelines for ACC/ AHA stage 1 population as an important strategy for controlling HBP. QM-3 Nonpharmacological interventions for all ACC/AHA stages of HBP (composite measure combining PM-4, Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Adds new emphasis on high-quality evidence and strong recommendation for promoting lifestyle modification, as recommended in the 2017 Hypertension Clinical Practice Guidelines for all 3 ACC/AHA stages of HBP population as an important strategy for controlling HBP. Composite measure permits assessment of effectiveness for all stages combined. QM-4 Medication adherence to drug therapy for ACC/AHA stage 1 with ASCVD risk 10% or ACC/AHA stage Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Adds new emphasis on high-quality evidence and strong recommendation for assessing and promoting medication adherence, as recommended in the 2017 Hypertension Clinical Practice Guidelines for the combined ACC/AHA stage 1 with ASCVD risk 10% and ACC/AHA stage 2 HBP population as an important strategy for controlling HBP. (Continued) 12 QM-5 Use of HBPM for management of ACC/AHA stage 1 HBP Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Harmonizes with new performance measure PM-5 for ACC/AHA stage 2 HBP. Adds new emphasis on correct measurement of BP by individuals at home or elsewhere outside the clinic setting, as recommended in the 2017 Hypertension Clinical Practice Guidelines for this population as an important strategy for evaluating control of ACC/ AHA stage 1 HBP and ASCVD risk 10%. QM-6 Use of HBPM for management of ACC/AHA stage 1 or ACC/AHA stage 2 (composite measure combining Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Harmonizes with new measures PM-5 and QM-5 and adds new emphasis on correct measurement of BP by individuals at home or elsewhere outside the clinic setting, as recommended in the 2017 Hypertension Clinical Practice Guidelines for this population as an important strategy for evaluating control of ACC/AHA stage 2 and stage 1 HBP and ASCVD risk 10%. Composite measure permits assessment of effectiveness for these 2 stages combined. SM-1 Use of a standard protocol to consistently and correctly measure BP in the ambulatory setting CDU Accurate measurement and recording of BP are essential to categorize level of BP, ascertain BP-related CVD risk, and guide management of high BP. Office BP measurement is often unstandardized, despite the well-known consequences of inaccurate measurement. Errors are common and can result in a misleading estimation of an individual s true level of BP if staff are not trained and a protocol is not followed. SM-2 Use of a standard process for assessing ASCVD risk CDU To facilitate decisions about preventive interventions, it is recommended to screen for traditional ASCVD risk factors and apply the race- and sex-specific PCE (ASCVD Risk Estimator) to estimate 10-year ASCVD risk for asymptomatic adults 40 79 years of age. SM-3 Use of a standard process for properly screening all adults 18 y of age for HBP CDU The evidence on the benefits of screening for HBP is well established. In 2007, the USPSTF reaffirmed its 2003 recommendation to screen for HBP in adults 18 y of age. SM-4 Use of an EHR to accurately diagnose and assess HBP control CDU A growing number of health systems are developing or using registries and EHRs that permit large-scale queries to support population health management strategies to identify undiagnosed or undertreated HBP. SM-5 Use of a standard process to engage patients in shared decision-making, tailored to their personal benefits, goals, and values for evidence-based interventions to improve control of HBP CDU Decisions about primary prevention should be collaborative decisions made between a clinician and a patient. SM-6 Demonstration of infrastructure and personnel that assess and address social determinants of health of patients with HBP CDU It is important to tailor advice to an individual s socioeconomic and educational status, as well as cultural, work, and home environments. SM-7 Use of team-based care to better manage HBP CDU RCTs and meta-analyses of RCTs of team- based HBP care involving nurse or pharmacist intervention demonstrated reductions in SBP and DBP and/or greater achievement of BP goals when compared with usual care. SM-8 Use of telehealth, m-health, e-health, and other digital technologies to better diagnose and manage HBP CDU Meta-analyses of RCTs of different telehealth interventions have demonstrated greater SBP and DBP reductions and a larger proportion of patients achieving BP control than those achieved with usual care without telehealth. Table 8. Continued Measure No. Measure Title Attribution Rationale for Creating New Measure (Continued) 13 Field testing is needed to determine the utilization of new process and structural quality measures for the future development of new performance measures. This is especially true for lifestyle modifi- cations, shared decision making, and implementa- tion of a standardized protocol to consistently and correctly measure BP. Efforts to standardize BP data entry into electronic health records are needed to improve diagnosis and management of HBP. These include entering multiple readings and averages of readings, with electronic health record systems having the ability to perform the averaging function automatically for multiple BP readings within a visit and across 2 visits. Future HBP patient registries should include a broader range of races/ethnicities and incorporate data on other socioeconomic deter- minants of health, as well as patient engagement and activation, to better understand the impact of these variables on medication adherence and BP control. Continued research to examine temporal trends and disparities (with respect to sex, race/ethnic- ity, and socioeconomic status) in the achievement of performance and quality measures is critical for future revisions of these measure sets. Before adoption of behavioral and motivational strategies as new performance measures, prospective stud- ies evaluating their efficacy in achieving a healthy lifestyle and a standardized process for patient- centered shared decision making for BP control are needed. Utilization of new performance measures in public accountability and payment programs is needed. The impact of inclusion of HBP per- formance measures in pay-for-performance strategies on HBP diagnosis, management, and outcomes should be prospectively evalu- ated. The impact of compliance with some or all performance measures on hospital quality of care and short- and long-term clinical outcomes should be assessed. The HBP performance measures may further evolve on the basis of additional evidence, along with future focused updates and revisions to the 2017 Hypertension Clinical Practice Guidelines. ACC/AHA TASK FORCE MEMBERS Gregg C. Fonarow, MD, FACC, FAHA, Chair*; Biykem Bozkurt, MD, PhD, FACC*; Sandeep Das, MD, MPH*; Michael E. Hall, MD, MS, FAHA, FACC*; Hani Jneid, MD, FACC, FAHA*; Corrine Y. Jurgens, PhD, RN, ANP-BC, FAHA* ; Patricia Keegan, DNP, APRN, NP-C ; Rohan Khera, MD* ; Leo Lopez, MD, FACC ; Jeffrey W. Olin, DO, FACC, FAHA*; Manesh Patel, MD, FACC*; Faisal Rahman, BM BCh ; Matthew Roe, MD, FACC ; Alex Sandhu, MD, MS ; Randal J. Thomas, MD, MS, FACC, FAHA ; Muthiah Vaduganathan, MD, MPH ; Paul D. Varosy, MD, FACC ; Siqin Ye, MD, MS ; Boback Ziae- ian, MD, PhD, FACC STAFF American College of Cardiology Richard J. Kovacs, MD, FACC, President Timothy W. Attebery, MBA, FACHE, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, FACP, Executive Vice President, Science, Education, Quality, and Publishing Lara Slattery, Team Lead/Division Vice President, Clinical Registry and Accreditation *American Heart Association Representative. Former Task Force member; current member during the writing effort. American College of Cardiology Representative. SM-9 Use of a single, standardized plan of care for all patients with HBP CDU Studies demonstrate that implementation of a plan of care for HBP can lead to sustained reduction of BP and attainment of BP targets over several years. SM-10 Use of performance and quality measures to improve quality of care for patients with HBP CDU A large observational study showed that a systematic approach to HBP control, including the use of performance measures, was associated with significant improvement in HBP control compared with historical control groups. *Including office, clinic, home, or ambulatory. Including, but not limited to, solo/small physician offices, group practices, ambulatory care centers, health systems, public health sites, accountable care organizations, and clinically integrated networks that diagnose and treat patients with HBP. ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CDU, care delivery unit; CVD, cardiovascular disease; DBP, diastolic blood pressure; e-health, healthcare services provided electronically via the Internet; EHR, electronic health record; HBP, high blood pressure; HBPM, home blood pressure monitoring; m-health, practice of medicine and public health supported by mobile devices; PCE, pooled cohort equations; PM, performance measure; QM, quality measure; RCT, randomized controlled trial; SBP, systolic blood pressure; SM, structural measure; and USPSTF, US Preventive Services Task Force. Table 8. Continued Measure No. Measure Title Attribution Rationale for Creating New Measure 14 Esteban Perla, MPH, Team Lead, Quality Measurement Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/ American Heart Association Abdul R. Abdullah, MD, Director, Guideline Science and Methodology Rebecca L. Diekemper, MPH, Guideline Advisor, Perfor- mance Measures American Heart Association Ivor J. Benjamin, MD, FAHA, President Nancy Brown, Chief Executive Officer Mariell Jessup, MD, FAHA, Chief Science and Medical Officer Rose Marie Robertson, MD, FAHA, Deputy Chief Sci- ence and Medical Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Radhika Rajgopal Singh, PhD, Director, Science and Medicine, Office of Science Operations Anne Leonard, MPH, RN, FAHA, Senior Science and Medicine Advisor, Office of Science Operations Melanie Shahriary, RN, BSN, Senior Manager, Perfor- mance Metrics, Quality and Health IT Jody Hundley, Production and Operations Manager, Sci- entific Publications, Office of Science Operations ARTICLE INFORMATION This Physician Performance Measurement Set (PPMS) and related data specifica- tions were developed by the Physician Consortium for Performance Improve- ment (the Consortium), including the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Medical Association (AMA), to facilitate quality-improvement activities by physicians. The perfor- mance measures contained in this PPMS are not clinical guidelines, do not es- tablish a standard of medical care, and have not been tested for all potential applications. Although copyrighted, they can be reproduced and distributed, without modification, for noncommercial purposes for example, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the performance measures for commercial gain, or incorporation of the performance measures into a product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the PPMS require a license agreement between the user and the AMA (on be- half of the Consortium) or the ACC or the AHA. Neither the AMA, ACC, AHA, the Consortium, nor its members shall be responsible for any use of this PPMS. The measures and specifications are provided as is without warranty of any kind. Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of the code sets. The AMA, the ACC, the AHA, the National Committee for Quality Assurance (NCQA), and the Physician Consor- tium for Performance Improvement (PCPI) and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT) or other cod- ing contained in the specifications. CPT contained in the measures specifications is copyright 2004 2012 American Medical Association. LOINC copyright 2004 2012 Regenstrief Insti- tute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT) copy- right 2004 2012 International Health Terminology Standards Development Organization. All rights reserved. This document underwent a 14-day peer review between March 18, 2019, and April 1, 2019, and a 30-day public comment period between March 18, 2019, and April 16, 2019. The American Heart Association and the American College of Cardiology make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or busi- ness interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential con- flicts of interest. This document was approved by the American College of Cardiology Clinical Policy Approval Committee and the American Heart Association Science Advisory and Coordinating Committee in June 2019; by the American Heart Association Executive Committee on August 9, 2019; and by the American Medical Associa- tion and the Preventive Cardiovascular Nurses Association on July 25, 2019. Supplemental materials are available with this article at https://www. ahajournals.org/doi/suppl/10.1161/HCQ.0000000000000057. This article has been copublished in the Journal of the American College of Cardiology. Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional. heart.org). A copy of the document is also available at https://professional.heart. org/statements by selecting the Guidelines & Statements button. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer. com. The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guide- lines development, visit https://professional.heart.org/statements. Select the Guidelines & Statements drop-down menu near the top of the webpage, then click Publication Development. Permissions: Multiple copies, modification, alteration, enhancement, and/ or distribution of this document are not permitted without the express permis- sion of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the Copyright Per- missions Request Form appears in the second paragraph (https://www.heart. org/en/about-us/statements-and-policies/copyright-request-form). REFERENCES 1. Spertus JA, Eagle KA, Krumholz HM, et al. American College of Cardiol- ogy and American Heart Association methodology for the selection and creation of performance measures for quantifying the quality of cardio- vascular care. Circulation. 2005;111:1703 12. 2. Spertus JA, Bonow RO, Chan P, et al. ACCF/AHA new insights into the methodology of performance measurement: a report of the American College of Cardiology Foundation/American Heart Association Task Force on performance measures. Circulation. 2010;122:2091 106. 3. 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