2010

Cardiac Rehabilitation
Performance Measures Toolkit

American Association of Cardiovascular and

Pulmonary Rehabilitation
The Cardiac Rehabilitation Performance Measures toolkit is designed for members to
gain knowledge and provide resources for use to encourage enrollment of appropriate
patients into cardiac and peripheral vascular rehabilitation programs.

Table of Contents
Introduction to Cardiac Rehabilitation Performance Measures Page 3 – 4

Top Ten Things To Know AACVPR/ACCF/AHA 2010 Update: Performance

Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation
Secondary Prevention Services Page 5

Example of how to implement Performance Measures in Cardiac Rehabilitation Page 6-7

Performance Measures Letter for physicians and providers Pages 8-9

Sample spread sheet for enrollment rates of Cardiac Rehabilitation Page 10

ACC Cardiac Rehabilitation Video/DVD Page 11

Discussion Forum for Utilizing Performance Measures Link Page 12-13

JACC AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac

Rehabilitation for Referral to Cardiac Rehabilitation/Secondary
Prevention Services Page 14-25
 Cardiac Rehabilitation
Performance Measures
December 2010

What are performance measures? Why cardiac rehabilitation performance

measures?
 Performance measures (PMs) are used to identify and correct gaps in care.  There is clear evidence that cardiac
 PMs are often utilized by external agencies and third party payers. rehabilitation (CR) services are associated
 One such group is the National Quality Forum (NQF), which reviews and with significant benefits to patients who
endorses performance measures that are considered for use by the Centers have had a recent cardiac event.
for Medicare and Medicaid Services (CMS).
 Unfortunately, only a small percentage of
 Performance measures refer to processes or structures of care that have
patients receive those services.
been rigorously tested and have been defined as such for public reporting
and benchmarking  The CR Performance Measures are aimed at
improving the utilization and benefits of CR
The National Quality Forum is a nonprofit organization that aims to improve the for eligible patients.
quality of healthcare for all Americans through fulfillment of its three-part
mission:  Some PMs that are endorsed by the NQF
 Setting national priorities and goals for performance improvement and utilized by CMS are reported publicly
 Endorsing national consensus standards for measuring and public (i.e., public report cards on service
reporting on performance outcomes) and some are also used as part
 Promoting the attainment of national goals through education and of the assessment for “pay for
outreach programs. performance” initiatives from third party
AACVPR in conjunction with AHA and ACC submitted two sets of Performance payers.
Measures on Cardiac Rehabilitation to NQF in 2010.
NQF website: www.qualityforum.org

“The gap in referral of patients to cardiac rehabilitation represents the largest gap in care for patients
following a cardiac event”
To increase the appropriate and timely referral of patients to outpatient cardiac rehabilitation programs the American Association
of Cardiovascular and Pulmonary Rehabilitation (AACVPR), the American College of Cardiology Foundation and the American Heart
Association issued updated performance measures. These measures are intended to help hospitals, doctors and other health care
providers more easily track referral rates, adopt tools to improve enrollment (e.g., automatic ordering sets, education materials to
promote enrollment), and assess and improve the quality of care provided.

Measure One- Referral from an Inpatient Setting

All patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina (CSA), or who
during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI),
cardiac valve surgery, or cardiac transplantation are to be referred to an early outpatient cardiac rehabilitation/secondary
prevention program. (*See full measure to learn about exceptions and other details)
http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.06.006

Measure Two – Referral from an Outpatient Setting

Patients evaluated in an outpatient setting have experienced an acute myocardial infarction, coronary artery bypass graft surgery, a
percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina and have
not already participated in an early outpatient cardiac rehabilitation/secondary prevention program for the qualifying
event/diagnosis are to be referred to such a program. (*See full measure to learn about exceptions and other details.)
 How do you implement performance measures into your practice?
 PLAN:
 Meet with those who oversee quality improvement efforts in your hospital or clinic and explain the rationale behind the CR
Performance Measures.
 Explain that the CR Performance Measures have been endorsed by NQF and are being considered by CMS for use in
hospital systems performance tracking.
 Explain that hospitals and physician clinics will be responsible for reporting performance in referring eligible patients to CR
following a qualifying cardiac event.
 DO:
 Offer to help design and implement a quality improvement (QI) project in your hospital or clinics.
 Develop consensus by discussing project with all pertinent “shareholders”—administrators, department managers,
referring providers, inpatient discharge coordinators, etc.
 Consider ways to improve referral rates. Effective methods include automatic referral orders sets for all eligible patients,
post-discharge telephone follow-up, etc.
 Emphasize the importance of face-to-face discussions between health care providers and patients of CR benefits and
referrals.
 Provide materials to assist patients in understanding the importance of CR and specific steps needed for them to
participate, keeping health-literacy issues in mind.
 Exchange referral data between the CR program and the referring hospital(s) or clinics.
 STUDY:
 Devise measurement system to assess current referral rates to CR.
 Continue to reassess performance and new methods to improve referral rates.
 ACT:
 Help keep hospitals and clinics notified on new developments regarding the CR Performance
Measures, such as CMS reviews and updates, etc.

What is the latest status of the CR performance measures?

 Set A was endorsed by NQF in May 2010 for time-limited (2 year) endorsement, at which time the measures will once again
reviewed for endorsement
 Set B of performance measures are currently under review by NQF for endorsement
 Published originally in 2007 in the journals of AACVPR, ACC, and AHA, and endorsed by 9 other national and international
organizations
 Updated and published in September 2010
 Included in the ACC/AHA STEMI/NSTEMI performance measures published in 2010
 CMS is considering the use of the CR referral performance measures for their quality reporting initiatives
 The use and impact of the performance measures will be tested over the next 2 years in order to see if they reduce the
treatment gap that currently exists for CR utilization and improve subsequent patient outcomes

Paying for Performance: The CR referral performance measure is included in the ACC PINNACLE data registry available for
outpatient cardiology practices, and as a result practices that report such data are getting reimbursed at a slightly higher
rate by CMS for the patient services they are providing (part of the Physician Quality Reporting Initiative, or PRQI).
 Top Ten Things To Know
AACVPR/ACCF/AHA 2010 Update: Performance Measures
on Cardiac Rehabilitation for Referral to Cardiac
Rehabilitation/Secondary Prevention Services

1. Cardiac rehabilitation is associated with a 20-30% reduction in all-cause mortality rates

2. Cardiac rehabilitation promotes other significant health benefits after a cardiac event, including
myocardial infarction, coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention,
heart valve surgery, and heart transplantation surgery.

3. Cardiac rehabilitation is underused in the United States, with only about 20% of eligible patients
receiving therapy.

4. There is a large gap between actual care and care that should be provided, stimulating the
development of measures of quality of care for quality improvement and accountability.

5. System-based approaches including automatic ordering sets for referring eligible patients improve
referral and enrollment rates in cardiac rehabilitation programs.

6. The cardiac rehabilitation performance measure set includes a first a set of measures for the referral
of patients from the inpatient and outpatient settings.

7. Healthcare providers and healthcare systems report the percentage of eligible patients they refer
to cardiac rehabilitation programs.

8. The second set of measures is for the delivery of cardiac rehabilitation services; cardiac
rehabilitation programs will report on these measures.

9. The cardiac rehabilitation referral measures are endorsed by the National Quality Forum and are
being considered by the Centers for Medicare and Medicaid Services.

10. The cardiac rehabilitation performance measures include an online data supplement for easy
access to details.

Thomas RJ et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac
rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the
American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to
Develop Clinical Performance Measures for Cardiac Rehabilitation). J Cardiopulom Rehabil Prev. 2010;30:279–288.
http://circ.ahajournals.org/cgi/reprint/CIR.0b013e3181f5185b
Example of application Performance Measures in Cardiac Rehabilitation:
The Really Good Cardiac Rehabilitation Program.
Jane Doe, director of the Really Good Cardiac Rehabilitation, is committed to implement the new Cardiac
Rehabilitation Performance Measures in her local hospital and in her program. She plans a strategy to do so,
using the following steps.

1. Jane sits down with her operations team to give a background on the cardiac rehabilitation
performance measures and to ask for their support in implementing the measures locally. She receives
and implements her team’s suggestions and helps them work toward a consensus on how they will
implement the performance measures.

2. Assessment: Before Jane and her team can implement the performance measures, they first make an
assessment of what is currently happening in their hospital and in their program.

In-patient:

 How are in-patients being referred to cardiac rehabilitation now?

 What percentages are being referred?
 Who are the key people to work with in the hospital to implement a strategy to improve referrals
and to track referrals with the performance measures?
 Is there a quality of care committee that could help?
 What are the potential barriers to implementing the measures in the in-patient setting?

Out-patient cardiology practices:

 Are the cardiology out-patient practices currently collecting performance measure information?
 Do they know about performance measures?
 Are they part of the ACC Registry network (NCDR-PINNACLE)?
 Do they know how many of their eligible patients have participated in cardiac rehabilitation?

Out-patient cardiac rehabilitation program:

 What is the flow of process steps that occur for each patient who is enrolled in the program,
starting with the referral and ending with their completion of Phase 2 cardiac rehabilitation
sessions?
 Is the program staff currently collecting data that are included in the Cardiac Rehabilitation
Program Performance Measures?
 What percentages of patients are receiving care that meets the standards that are included in the
performance measures?
 What are potential barriers to full implementation of the measures in the out-patient program?
 3. Plan: Once Jane and her team have an understanding of the current status of the in-patient and out-
patient practices, and of their own program, they start making a plan to implement the performance
measures, in coordination with the people they have identified as potential collaborators in the hospital
and out-patient practices. These plans might include:

A. Awareness campaign:

Letters, notices, articles, and other messaging options could be circulated to leaders and staff
members so that they understand the purpose and importance of performance measures.

B. Implementation steps:

Identify who will be collecting performance measure data, how it will take place, and how it will
be reported. Get approval by appropriate committees and leaders. Start collecting data, and
provide regular feedback of results to appropriate committees and leaders. Use results to help
identify ongoing barriers to quality of care, and ways to overcome those barriers.

4. Re-assess: As implementation takes place, new and better ways of carrying out data collection will be
identified and implemented. This might include the use of quality assurance steps to make sure the data
being collected is being collected in an accurate and reproducible way.

5. Re-vise: Continue with the ongoing cycle of continuous improvement.

Jane and her team stayed flexible, yet committed as they went through these steps. Barriers and unexpected
twists and turns occurred during the process of implementing the performance measures. Through their
persistence, they gained added respect and appreciation from their colleagues in the hospital and cardiology
practice settings. Cardiac rehabilitation referrals increased gradually, and the quality of their rehabilitation
services also increased. Finally, they are able to now document the improvements that have occurred and that
will occur, using the data collection steps they have implemented.

Life is good at the Really Good Cardiac Rehabilitation Program!

Plan Do Study Act

Date

[All Hospital Cardiologists, PCPs and Hospitalists]

[address]

Dear Colleague,

Since 2001 the evidence has been clear that comprehensive exercise-based cardiac rehabilitation services are associated
with a reduction in cardiac mortality for patients with cardiovascular disease.1-3 The 2001 data have since been
supplemented by papers and reviews in 2004 (ACC/AHA 2004 & 2007).The overwhelming evidence qualifies the provision
of a comprehensive cardiac rehabilitation program as best practice for these patients.

In 2007 the American Association of Cardiovascular and Pulmonary Rehabilitation, in collaboration with the ACC/AHA,
proposed a performance measure that tracks the percentage of eligible patients hospitalized with a primary diagnosis who
are referred to an outpatient cardiac rehab/secondary prevention program prior to discharge or have a documented
patient-centered reason why such a referral was not made. In 2008 & 2010 the ACC/AHA jointly proposed a performance
measure that tracks the percentage of eligible patients hospitalized with a qualifying event (MI, CSA, PCI, CABG, cardiac
valve surgery or cardiac transplantation) who are referred to an outpatient cardiac rehab/secondary prevention program
prior to discharge.4

(Name of Hospital) Hospital goal is to ensure patients eligible for cardiac rehabilitation services are set up for this
therapy frequently and regularly, to ensure we provide a clear “best practice” status. In order to help physicians caring
for eligible patients ensure that the patient receives cardiac rehabilitation services, if appropriate, we are establishing a
new process that will be patient and physician friendly. It will consist of the following steps:

1. Eligible patients will be identified during their hospital stays and provided educational information about the benefits
and availability of cardiac rehabilitation.
2. Immediately following discharge, a “fax-back” referral will be sent to your office if you have not already referred the
patient for rehab. With a few simple check-offs you will be able to (a) refer the patient, or (b) document the reason the
patient is not appropriate for referral.
3. We will track all potential referrals and report your statistics to you individually; we will report overall organizational
performance as part of hospital-wide QA initiative to ensure that ___________ (name of hospital) patients are being
referred for cardiac rehabilitation services in an appropriate manner.

Thank you, in advance, for your help with this important Quality Improvement initiative. We are confident that, with your
help, we can quickly and accurately identify eligible patients and get them enrolled in a comprehensive cardiac
rehabilitation program.

If you have questions about this initiative, please contact ___________MD (questions related to standards of care and
patient eligibility),_____________ MD (questions related to the operation of this initiative, forms or outcomes data).

Collegially, Chief Quality Officer

Head, Division of Cardiology,
Department of Medicine
References:

1. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience
of randomized clinical trials. JAMA. 1988;2060:945-50.

2. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation in secondary prevention of coronary heart disease: American
Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac
Rehabilitation and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on
Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
Circulation. 2005; 111:369-376.

3. Witt BJ, Jacobsen SJ, Weston SA, et al. Cardiac rehabilitation after myocardial infarction in the community. J Am Coll
Cardiol. 2004; 44:988-996.

4. Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus, J. AACVPR/ACCF/AHA 2010 Update: Performance Measures on
Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services: A Report of the American
Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology
Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical
Performance Measures for Cardiac Rehabilitation) J Cardiopulom Rehabil Prev. 2010;30:279–288.

5. Suaya, J.A., Stason, W.B., Ades, P.A., Normand, S.T., Shepard, D.S. (2009). Cardiac rehabilitation and survival in older
coronary patients. Journal of the American College of Cardiology, 54(1), 25-33.
 Sample spread sheet to collect enrollment rates of a CR program.

January - June 2010 Cardiac Rehab Stats

Not Referred to
Percent Not
Month Total Referrals Enrolled interested, Off-site Phase III Can't Afford
Enrolled appropriate
declined Location

January

February

March

April

May

June

# of Days
# of Days # of Days
Percent Avg. Avg. between
Orients. Avg. First between between
Orients. Event Orient. Event and
Completed Call Date Event and First call
Complete Date Date Orient.
First Call and Orient.
Month Date

January

February

March

April

May

June

6.
The link below is to a 10 minute video developed by the American College of Cardiology in conjunction with Duke
University to promote enrollment in cardiac rehabilitation. It describes the core components of cardiac rehabilitation –
exercise, education and counseling about modifiable cardiovascular risk factors, and including psychosocial support.
Although it depicts a high volume university program, it is an excellent overview of cardiac rehabilitation, with convincing
arguments about why it is important for patients to enroll. Consider using this video as one of your strategies to promote
enrollment in your program, perhaps on your hospital patient education TV network or in physician waiting rooms.

http://www.cardiosmart.org/cardiacrehab.aspx

CARDIAC REHABILITATION: YOUR JOURNEY BACK TO HEART HEALTH

For people diagnosed with heart disease or a heart condition, finding a way back to health can be the biggest
challenge they've ever faced.

This video player requires you to upgrade or install Adobe Flash Player
The AACVPR web site http://www.aacvpr.org/ has a member discussion forum.

 To access this location select Resources

 Under Resources select Member Discussion Forum
 Scroll topics for Utilizing Performance Measures.

Below is the link to the forum. Members are encouraged to post “frequently asked
questions” here and can find information regarding access to materials relating to
performance measures.
http://www.aacvpr.org/Resources/DiscussionForum/tabid/111/view/topics/forumid/29/Default.aspx

Recent News Articles and Links:

Physician Consortium for Performance Improvement®
American College of Cardiology Foundation (ACCF)
American Heart Association (AHA)

Chronic Stable Coronary Artery Disease

Performance Measurement Set
Measure #9: Cardiac Rehabilitation Patient Referral From an
Outpatient Setting (NQF-Endorsed™)

http://www.ama-assn.org/ama1/pub/upload/mm/pcpi/cadminisetjune06.pdf
 Performance Measures on Cardiac Rehabilitation

AACVPR's Past President, Dr. Randal Thomas, Blog on Increasing Referrals

http://blog.cardiosource.org/post/How-We-Can-Increase-Cardiac-Rehab-Referrals.aspx

http://www.medpagetoday.com/Cardiology/MyocardialInfarction/21966
 ACC/AHA Issue First Set of Performance Measures to Improve Diagnosis and
Treatment of Adults with PAD
http://circ.ahajournals.org/cgi/reprint/CIR.0b013e3182031a3cv1

Cardiosource articles related to Performance Measures

http://blog.cardiosource.org/search.aspx?q=cardiac%20rehabilitation%20performance%20measures

Journal of Cardiopulmonary Rehabilitation and Prevention

Journal of Cardiopulmonary Rehabilitation & Prevention:

September/October 2010 - Volume 30 - Issue 5 - p 279–288

Authors and Disclosures

Writing Committee Members
Randal J. Thomas, MD, MS, FAACVPR, FACC, FAHA, Chair
Marjorie King, MD, FAACVPR, FACC
Karen Lui, RN, MS, FAACVPR
Neil Oldridge, PHD, FAACVPR, FACSM
Ileana L. Pia, MD, FACC
John Spertus, MD, MPH, FACC

ACCF/AHA Task Force on Performance Measures

Frederick A. Masoudi, MD, MSPH, FACC, FAHA, Chair
Elizabeth DeLong, PHD
John P. Erwin, III, MD, FACC
David C. Goff, JR, MD, PHD, FAHA, FACP
Kathleen Grady, PHD, RN, FAHA, FAAN
Lee A. Green, MD, MPH
Paul A. Heidenreich, MD, FACC
Kathy J. Jenkins, MD, MPH, FACC
Ann R. Loth, RN, MS, CNS
Eric D. Peterson, MD, MPH, FACC, FAHA
David M. Shahian, MD, FACC

AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac

Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention
Services: A Report of the American Association of Cardiovascular and Pulmonary
Rehabilitation and the American College of Cardiology Foundation/American
Heart Association Task Force on Performance Measures (Writing Committee to
Develop Clinical Performance Measures for Cardiac Rehabilitation)
Writing Committee Members; ACCF/AHA Task Force on Performance Measures
Preamble

Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its
seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered
medical care, the Institute of Medicine described a quality "chasm". [1] Recognition of the magnitude of the gap between the care that is
delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such
measures for the purposes of quality improvement and accountability.

Consistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart
Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical
areas (Table 1). The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the
clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and
methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical
topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to
construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate,
incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data
standards to encourage uniform measurements of cardiovascular care. The writing committees are also instructed to evaluate the extent to
which existing nationally recognized performance measures conform to the attributes of performance measures described by the ACCF/AHA
and to strive to create measures aligned with acceptable existing measures when this is feasible.

Table 1. ACCF/AHA Performance Measure Sets

Original
Topic Partnering Organizations Status
Publication Date

Currently undergoing
ACC/AHA—Inpatient measures update
Chronic heart failure (2) 2005
ACC/AHA/PCPI—Outpatient measures Currently undergoing
update

Chronic stable coronary artery Currently undergoing

2005 ACC/AHA/PCPI
disease (3) update

Currently undergoing
Hypertension (4) 2005 ACC/AHA/PCPI
update
ST-elevation and non–ST-
elevation myocardial infarction 2006 ACC/AHA Updated 2008 (6)
(5)

Updated 2010 (referral

Cardiac rehabilitation (7) 2007 AACVPR/ACC/AHA
measures only)

Atrial fibrillation (8) 2008 ACC/AHA/PCPI

Primary prevention of
2009 ACCF/AHA
cardiovascular disease (9)

Peripheral artery disease 2010* ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS Under development

Percutaneous coronary
2011* ACCF/AHA/SCAI/PCPI/NCQA Under development
intervention

* Planned publication date.

AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; ACR, American College of Radiology; NCQA, National
Committee for Quality Assurance; PCPI indicates American Medical Association—Physician Consortium for Performance Improvement; SCAI,
Society for Cardiac Angiography and Interventions; SIR, Society for Interventional Radiology; SVM, Society for Vascular Medicine; SVN, Society
for Vascular Nursing; and SVS, Society for Vascular Surgery.

The initial measure sets published by the ACCF/AHA focused primarily on processes of medical care or actions taken by healthcare providers,
such as the prescription of a medication for a condition. These process measures are founded on the strongest recommendations contained in
the ACCF/AHA clinical practice guidelines, delineating actions taken by clinicians in the care of patients, such as the prescription of a particular
drug for a specific condition. Specifically, the writing committees consider as candidates for measures those processes of care that are
recommended by the guidelines either as Class I, which identifies procedures/treatments that should be administered, or Class III, which
identifies procedures/treatments that should not be administered (Table 2). Class II recommendations are not considered as candidates for
performance measures. The methodology guiding the translation of guideline recommendations into process measures has been explicitly
delineated by the ACCF/AHA, providing guidance to the writing committees.[10]

Table 2. Applying Classification of Recommendations and Level of Evidence

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of
diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C
does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to
clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is
useful or effective. †For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the
use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

Although they possess several strengths, processes of care are limited as the sole measures of quality. Thus, current ACCF/AHA performance
measures writing committees are instructed to consider measures of structures of care, outcomes, and efficiency as complements to process
measures. In developing such measures, the committees are guided by methodology established by the ACCF/AHA. [11] Although
implementation of measures of outcomes and efficiency is currently not as well established as that of process measures, it is expected that
such measures will become more pervasive over time.

Although the focus of the performance measures writing committees is on measures intended for quality improvement efforts, other
organizations may use these measures for external review or public reporting of provider performance. Therefore, it is within the scope of the
writing committee's task to comment, when appropriate, on the strengths and limitations of such external reporting for a particular CVD state
or patient population. Thus, the metrics contained within this document are categorized as either performance measures or test measures.
Performance measures are those metrics that the committee designates as appropriate for use for both quality improvement and external
 reporting. In contrast, test measures are those appropriate for the purposes of quality improvement but not for external reporting until further
validation and testing are performed.

All measures have limitations and pose challenges to implementation that could result in unintended consequences when used for
accountability. The implementation of measures for purposes other than quality improvement requires field testing to address issues related
but not limited to sample size, frequency of use of an intervention, comparability, and audit requirements. The manner in which these issues
are addressed is dependent on several factors, including the method of data collection, performance attribution, baseline performance rates,
incentives, and public reporting methods. The ACCF/AHA encourages those interested in implementing these measures for purposes beyond
quality improvement to work with the ACCF/AHA to consider these complex issues in pilot implementation projects, to assess limitations and
confounding factors, and to guide refinements of the measures to enhance their utility for these additional purposes.

By facilitating measurements of cardiovascular healthcare quality, ACCF/AHA performance measurement sets may serve as vehicles to
accelerate appropriate translation of scientific evidence into clinical practice. These documents are intended to provide practitioners and
institutions that deliver care with tools to measure the quality of their care and identify opportunities for improvement. It is our hope that
application of these performance measures will provide a mechanism through which the quality of medical care can be measured and
improved.

Frederick A. Masoudi, MD, MSPH, FACC, FAHA

Chair, ACCF/AHA Task Force on Performance Measures

1. Update of Performance Measures for Referral to Cardiac Rehabilitation

1.1 Background

The AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary
Prevention Services were published in October 2007.[7] This document updates the 2 measures that articulate the opportunities to improve
referrals to outpatient Cardiac Rehabilitation that were embodied in Measure Set A from that 2007 paper (Appendix A in[7]). Measure A-1
(Cardiac Rehabilitation Patient Referral From an Inpatient Setting) and measure A-2 (Cardiac Rehabilitation Patient Referral From an Outpatient
Setting) have been revised to clarify several aspects of the measures and to facilitate their implementation. The updated measures (Appendix
B) have been revised as described in the following text. The measures in Measure Set B from the 2007 paper related to the structure and
processes of care for cardiac rehabilitation programs remain unchanged and are not included in this update.

1.2 Measure A-1. Cardiac Rehabilitation Patient Referral from an Inpatient Setting

Numerator Exclusion Criteria:

 "Patient-oriented barriers" was revised to "patient-oriented factors," and the example provided was changed. Patient refusal, which was
listed as an example in the 2007 paper, should not be considered a reason not to provide a referral. Whether the patient chooses to act upon
the referral or not is beyond the provider's control. The example provided in this update clarifies that patients discharged to a nursing care
facility for long-term care can be excluded.
 "Provider-oriented barriers" was revised to "medical factors," and the examples provided were changed. The 2007 measures listed "patient
deemed to have a high-risk condition or a contraindication to exercise" as an example. This was revised to specify "medically unstable, life-
threatening condition" as an example of an appropriate medical exclusion. The rationale reflects the capacity of cardiac rehabilitation
programs to modify their program to the medical needs of individual patients and that, other than life-threatening conditions, there are no a
priori reasons to presume that a patient might not be able to participate in a rehabilitation and secondary prevention program.
 "Health care system barriers" was revised to "healthcare system factors," and the examples provided were changed. "Financial barriers" was
deleted and "lack of CR programs near a patient's home" was clarified to specify no cardiac rehabilitation program available within 60 minutes
of travel time from the patient's home.

Denominator: A note was added to clarify that patients with a qualifying event who are to be discharged for a short-term stay in an inpatient
medical rehabilitation facility are still expected to be referred to an outpatient cardiac rehabilitation program by the inpatient team during the
index hospitalization. This referral should be reinforced by the care team at the medical rehabilitation facility.
 Corresponding Guidelines and Clinical Recommendations: The recommendations in this section were updated to reflect the most recent
iterations of the guidelines cited.

1.3 Measure A-2. Cardiac Rehabilitation Patient Referral from an Outpatient Setting

Numerator:

 The note describing what constitutes a referral has been expanded to clarify that standards of practice for cardiac rehabilitation programs
require care coordination communications to be sent to the referring provider, including any issues regarding treatment changes, adverse
treatment responses, or new nonemergency condition (new symptoms, patient care questions, etc.) that need attention by the referring
provider. These communications also include a progress report once the patient has completed the program.
 Exclusion criteria: The same revisions made to the patient, medical, and health system factors described for Measure A-1 in Section 1.2 were
made to this measure.

Denominator: The denominator statement was clarified to specify that only patients who have had a qualifying event/diagnosis during the
previous 12 months and have not participated in an outpatient cardiac rehabilitation program since the qualifying event/diagnosis should be
included.

Attribution/Aggregation: This section was added to clarify that 1) the measure should be reported by the clinician who provides the primary
cardiovascular-related care for the patient (In general, this would be the patient's cardiologist, but in some cases it might be a family physician,
internist, nurse practitioner, or other healthcare provider.); and 2) the level of aggregation (clinician versus practice) will depend upon the
availability of adequate sample sizes to provide stable estimates of performance.

1.4 Administrative Codes to Identify Denominator-eligible Populations

To facilitate implementation of these measures in a variety of systems, we have included administrative codes that may be useful in identifying
the population of patients who are eligible for inclusion in the denominator for each of the updated measures. See the online data supplement
for details.

Staff

American Association of Cardiovascular and Pulmonary Rehabilitation

P. Joanne Ray, CFRE, Executive Director
Abigail Lynn, Senior Coordinator

American College of Cardiology Foundation

John C. Lewin, MD, Chief Executive Officer
Charlene May, Senior Director, Clinical Policy and Documents
Melanie Shahriary, RN, BSN, Associate Director, Performance Measures and Data Standards
Jensen S. Chiu, MHA, Specialist, Clinical Performance Measurement
Erin A. Barrett, MPS, Senior Specialist, Clinical Policy and Documents

American Heart Association

Nancy Brown, Chief Executive Officer
Rose Marie Robertson, MD, FACC, FAHA, Chief Science Officer
Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations
Dorothea K. Vafiadis, MS, Science and Medicine Advisor

Appendix A. Author Relationships with Industry and Other Entities—AACVPR/ACCF/AHA 2010 Update: Performance Measures on
Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services

Instituti Exp
Na Employme Consu Ownership/Partnershi Researc
Speaker onal, ert
me nt ltant p/Principal h
Organiza Wit
tional, or nes
 Other s
Financial
Benefit

 Blue
Cross/Bl
ue
Shield  AACVP
of R
Ran Minnes (Preside
ota* nt)
dal
 Mayo  Marrio  Stratis No
J. None None None
Clinic tt Health ne
Tho Family (Commu
mas Progra nity
m in Health
Individu Award)*
alized
Medicin
e*

 Helen
Mar Hayes
Hospital
jori
and No
e None None None None None
Hudson ne
Kin Heart
g Associate
s

Kar
No
en  GRQ, LLC None None None None None
ne
Lui

 Universit
y of
Neil Wisconsin
Old School of  Copyright for No
None None None None
ridg Medicine MacNew ne
e and
Public
Health

 Food
and
Ilea  Universit Drug
y Admi  AstraZen
na
Hospitals nistra eca No
L. None None None
Case tion  Merck ne
Piñ Medical  Sano  Novartis
a Center fi-
Aventi
s

Joh  MidAme  St. None  Copyright for  Americ  CV No

n rica Heart Jude Seattle Angina an Outcom
Spe Institute Medic Questionnaire, College es, Inc. ne
rtus of St. al Kansas City of (Preside
Luke's  Unit Cardiomyopathy Cardiolo nt of
Hospital ed Questionnaire, and gy this
Healt Peripheral Artery Foundat 501(C)3
hcare Questionnaire* ion* organiza
Scient  PRISM Technology  Amgen tion)
ific *  Health
Advis  Bristol- Outcom
ory Myers es
Board Squibb/ Sciences
Sanofi- , LLC
Aventis (owners
Partner hip
ship* interest)
 Johnso  Outco
n& mes
Johnson Instrum
* ents, LLC
 Eli Lilly (owners
& Co.* hip
interest)

This table represents the relationships of committee members with industry and other entities that were reported by authors to be relevant to
this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing
committee during the document development process. The table does not necessarily reflect relationships with industry at the time of
publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting
stock or share of the business entity, or ownership of $10,000 or more of the fair market value of the business entity; or if funds received by
the person from the business entity exceed 5% of the person's gross income for the previous year. A relationship is considered to be modest if
it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted. * Significant (greater
than $10,000) relationship.

Appendix B. AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac
Rehabilitation/Secondary Prevention Services

Performance Measure A-1

A-1. Cardiac Rehabilitation Patient Referral From an Inpatient

All patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina (CSA), or who during
hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve
surgery, or cardiac transplantation are to be referred to an early outpatient cardiac rehabilitation/secondary prevention (CR) program.

Number of eligible patients with a qualifying event/diagnosis who have been referred to an outpatient CR program
prior to hospital discharge or have a documented medical or patient-centered reason why such a referral was not
made.
(Note: The program may include a traditional CR program based on face-to-face interactions and training sessions or
may include other options such as home-based approaches. If alternative CR approaches are used, they should be
Numerator
designed to meet appropriate safety standards.)
A referral is defined as an official communication between the healthcare provider and the patient to recommend
and carry out a referral order to an early outpatient CR program. This includes the provision of all necessary
information to the patient that will allow the patient to enroll in an early outpatient CR program. This also includes a
written or electronic communication between the healthcare provider or healthcare system and the cardiac
rehabilitation program that includes the patient's enrollment information for the program. A hospital discharge
 summary or office note may potentially be formatted to include the necessary patient information to communicate
to the CR program (e.g., the patient's cardiovascular history, testing, and treatments). All communications must
maintain appropriate confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act
(HIPAA).
Exclusion criteria:

 Patient factors (e.g., patient to be discharged to a nursing care facility for long-term care).
 Medical factors (e.g., patient deemed by provider to have a medically unstable, life-threatening condition).
 Health care system factors (e.g., no cardiac rehabilitation program available within 60 minutes of travel time from
the patient's home).

Number of hospitalized patients in the reporting period hospitalized with a qualifying event/diagnosis who do not
meet any of the exclusion criteria mentioned in the Numerator section.
(Note: Patients with a qualifying event who are to be discharged for a short-term stay in an inpatient medical
Denominator
rehabilitation facility are still expected to be referred to an outpatient cardiac rehabilitation program by the in-
patient team during the index hospitalization. This referral should be reinforced by the care team at the medical
rehabilitation facility.)

Period of
Inpatient hospitalization.
Assessment

Method of Proportion of healthcare system's patients with a qualifying event/diagnosis who had documentation of their referral
Reporting to an outpatient CR program.

Sources of
Administrative data and/or medical records.
Data

Rationale

A key component to outpatient CR program utilization is the appropriate and timely referral of patients. Generally, the most important time for
this referral to take place is while the patient is hospitalized for a qualifying event/diagnosis (MI, CSA, CABG, PCI, cardiac valve surgery, or
cardiac transplantation).
This performance measure has been developed to help healthcare systems implement effective steps in their systems of care that will optimize
the appropriate referral of a patient to an outpatient CR program.
This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that
involve disease states or other conditions for which CR services have been found to be appropriate and beneficial (e.g., following MI, CABG
surgery). This performance measure is provided in a format that is meant to allow easy and flexible inclusion into such performance
measurement sets.
Effective referral of appropriate inpatients to an outpatient CR program is the responsibility of the healthcare team within a healthcare system
that is primarily responsible for providing cardiovascular care to the patient during the hospitalization.

Corresponding Guidelines and Clinical Recommendations

ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery. [12]
Class I
Cardiac rehabilitation should be offered to all eligible patients after CABG (Level of Evidence: B).
ACC/AHA 2007 Update of the Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction.[13]
Class I
Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or
revascularization, heart failure) is recommended (Level of Evidence: B).
ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction.[14]
Class I
Cardiac rehabilitation/secondary prevention programs are recommended for patients with unstable angina/non–ST-segment elevation MI,
particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is
particularly warranted (Level of Evidence: B).
Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with unstable angina/non–ST-segment
elevation MI, particularly those with multiple modifiable risk factors and those moderate- to high-risk patients in whom supervised or
monitored exercise training is warranted (Level of Evidence: B).
ACC/AHA 2007 Chronic Angina Focused Update of the Guidelines for the Management of Patients With Chronic Stable Angina. [15]
Class I
Medically supervised programs (cardiac rehabilitation) are recommended for at-risk patients (e.g., recent acute coronary syndrome or
revascularization, heart failure) (Level of Evidence: B).
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult.[16]
Class I
Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of
heart failure and reduced left ventricular ejection fraction (LVEF) (Level of Evidence: B).
AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update.[17]
Class I
A comprehensive risk-reduction regimen, such as cardiovascular or stroke rehabilitation or a physician-guided home- or community-based
exercise training program, should be recommended to women with a recent acute coronary syndrome or coronary intervention, new-onset or
chronic angina, recent cerebrovascular event, peripheral arterial disease (Level of Evidence: A), or current/prior symptoms of heart failure and
an LVEF <40% (Level of Evidence: B).
ACC/AHA/SCAI 2007 Focused Update of the Guidelines for Percutaneous Coronary Intervention. [18]
Class I
Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or
revascularization, heart failure) is recommended (Level of Evidence: B).

Challenges to Implementation

Identification of all eligible patients in an inpatient setting will require that a timely, accurate, and effective system be in place. Communication
of referral information by the inpatient hospital service team to the outpatient CR program represents a potential challenge to the
implementation of this performance measure. However, this task is generally performed by an inpatient cardiovascular care team member,
such as an inpatient CR team member or a hospital discharge planning team member.

Performance Measure A-2

A-2. Cardiac Rehabilitation Patient Referral From an Outpatient Setting

All patients evaluated in an outpatient setting who within the past 12 months have experienced an acute myocardial infarction (MI),
coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation,
or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary
prevention (CR) program for the qualifying event/diagnosis are to be referred to such a program.

Number of patients in an outpatient clinical practice who have had a qualifying event/diagnosis during the
previous 12 months, who have been referred to an outpatient CR program.
(Note: The program may include a traditional CR program based on face-to-face interactions and training
sessions or other options that include home-based approaches. If alternative CR approaches are used, they
Numerator should be designed to meet appropriate safety standards.)
A referral is defined as an official communication between the healthcare provider and the patient to
recommend and carry out a referral order to an outpatient CR program. This includes the provision of all
necessary information to the patient that will allow the patient to enroll in an outpatient CR program. This
also includes a written or electronic communication between the healthcare provider or healthcare system
and the cardiac rehabilitation program that includes the patient's enrollment information for the program. A
 hospital discharge summary or office note may potentially be formatted to include the necessary patient
information to communicate to the CR program (e.g., the patient's cardiovascular history, testing, and
treatments). According to standards of practice for cardiac rehabilitation programs, care coordination
communications are sent to the referring provider, including any issues regarding treatment changes,
adverse treatment responses, or new nonemergency condition (new symptoms, patient care questions,
etc.) that need attention by the referring provider. These communications also include a progress report
once the patient has completed the program. All communications must maintain an appropriate level of
confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA).
Exclusion criteria:

 Patient factors (e.g., patient resides in a long-term nursing care facility).

 Medical factors (e.g., patient deemed by provider to have a medically unstable, life-threatening condition).
 Health care system factors (e.g., no cardiac rehabilitation program available within 60 min of travel time
from the patient's home).

Number of patients in an outpatient clinical practice who have had a qualifying event/diagnosis during the
previous 12 months and who do not meet any of the exclusion criteria mentioned in the Numerator section,
Denominator
and who have not participated in an outpatient cardiac rehabilitation program since the qualifying
event/diagnosis.

Period of Assessment Twelve months following a qualifying event/diagnosis.

Proportion of patients in an outpatient practice who have had a qualifying event/diagnosis during the past
Method of Reporting
12 months and have been referred to a CR program.

Sources of Data Administrative data and/or medical records.

This measure should be reported by the clinician who provides the primary cardiovascular-related care for
the patient. In general, this would be the patient's cardiologist, but in some cases it might be a family
Attribution/Aggregation physician, internist, nurse practitioner, or other health-care provider. The level of "aggregation" (clinician
versus practice) will depend upon the availability of adequate sample sizes to provide stable estimates of
performance.

Rationale

Cardiac rehabilitation services have been shown to help reduce morbidity and mortality in persons who have experienced a recent coronary
artery disease event, but these services are used in less than 30% of eligible patients. [19] A key component to CR utilization is the appropriate
and timely referral of patients to an outpatient CR program. While referral takes place generally while the patient is hospitalized for a
qualifying event (MI, CSA, CABG, PCI, cardiac valve surgery, or heart transplantation), there are many instances in which a patient can and
should be referred from an outpatient clinical practice setting (e.g., when a patient does not receive such a referral while in the hospital, or
when the patient fails to follow through with the referral for whatever reason).
This performance measure has been developed to help healthcare systems implement effective steps in their systems of care that will optimize
the appropriate referral of a patient to an outpatient CR program.
This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that
involve disease states or other conditions for which CR services have been found to be appropriate and beneficial (e.g., following MI, CABG
surgery). This performance measure is provided in a format that is meant to allow easy and flexible inclusion into such performance
measurement sets.
Referral of appropriate outpatients to a CR program is the responsibility of the healthcare provider within a healthcare system that is providing
the primary cardiovascular care to the patient in the outpatient setting.
 Corresponding Guidelines and Clinical Recommendations

See Clinical Recommendations section from Performance Measure A-1.

Challenges to Implementation

Identification all eligible patients in an outpatient clinical practice will require that a timely, accurate, and effective system be in place.
Communication of referral information by the outpatient clinical practice team to the outpatient CR program represents a potential challenge
to the implementation of this performance measure.

References

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
2. Bonow RO, Bennett S, Casey DE Jr., et al. ACC/AHA clinical performance measures for adults with chronic heart failure: a report of the
American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart
Failure Clinical Performance Measures). J Am Coll Cardiol. 2005;46:1144–78.
3. American Medical Association. Physician Consortium for Performance Improvement. Clinical Performance Measures: Chronic Stable Coronary
Artery Disease. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/370/cadminisetjune06.pdf. Accessed January 5, 2010.
4. American Medical Association. Physician Consortium for Performance Improvement. Clinical Performance Measures: Hypertension. Available
at: http://www.ama-assn.org/ama1/pub/upload/mm/370/hypertension-8-05.pdf. Accessed January 5, 2010.
5. Krumholz HM, Anderson JL, Brooks NH, et al. ACC/AHA clinical performance measures for adults with ST-elevation and non–STelevation
myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures on ST-Elevation and Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol.
2006;47:236–65.
6. Krumholz HM, Anderson JL, Bachelder BL, et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non–STelevation
myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol.
2008;52:2046 –99.
7. Thomas RJ, King M, Lui K, et al. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac
rehabilitation/secondary prevention services. J Am Coll Cardiol. 2007;50:1400–33.
8. Estes NA, III, Halperin JL, Calkins H, et al. ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular
atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance
Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for
Atrial Fibrillation). J Am Coll Cardiol. 2008;51:865–84.
9. Redberg RF, Benjamin EJ, Bittner V, et al. ACCF/AHA 2009 performance measures for primary prevention of cardiovascular disease in adults: a
report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing
Committee to Develop Performance Measures for Primary Prevention of Cardiovascular Disease). J Am Coll Cardiol. 2009;54:1364–405.
10. Spertus JA, Eagle KA, Krumholz HM, et al. American College of Cardiology and American Heart Association methodology for the selection and
creation of performance measures for quantifying the quality of cardiovascular care. J Am Coll Cardiol. 2005;45:1147–56.
11. Krumholz HM, Brindis RG, Brush JE, et al. Standards for statistical models used for public reporting of health outcomes: an American Heart
Association Scientific Statement from the Quality of Care and Outcomes Research Interdisciplinary Writing Group: cosponsored by the Council
on Epidemiology and Prevention and the Stroke Council. Endorsed by the American College of Cardiology Foundation. Circulation.
2006;113:456–62.
12. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article. A report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines
for Coronary Artery Bypass Graft Surgery). J Am Coll Cardiol. 2004;44:e213–310.
13. Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-
elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J
Am Coll Cardiol. 2008;51:210–47.
14. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation
myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing
 Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction). J
Am Coll Cardiol. 2007;50:e1–157.
15. Fraker TD Jr., Fihn SD, Gibbons RJ, et al. 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients
with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Group to Develop the Focused Update of the 2002 Guidelines for the Management of Patients With Chronic Stable Angina). J Am Coll
Cardiol. 2007;50:2264–74.
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College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the
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17. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation.
2007;115:1481–501.
18. King SB, III, Smith SC Jr., Hirshfeld JW Jr., et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary
intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2008;51:172–209.
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review. Am Heart J. 2006;151:249–56.

This document was approved by the American College of Cardiology Foundation Executive Committee in April 2010, by the American Heart Association Science Advisory
and Coordinating Committee in April 2010, and by the AACVPR Document Oversight Committee and Board of Directors in June 2010.

The American College of Cardiology Foundation requests that this document be cited as follows: Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J.
AACVPR/ACC/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the
American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on
Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation). J Am Coll Cardiol 2010;56:1159–67.

This article is copublished in Circulation and the Journal of Cardiopulmonary Rehabilitation and Prevention.

Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Association
(my.americanheart.org). For copies of this document, please contact the Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail [email protected].

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the
American College of Cardiology Foundation. Please contact Elsevier's permission department at [email protected].

These measures and specifications are provided "as is" without warranty of any kind. Neither the AACVPR, the ACCF, nor the AHA shall be responsible for any use of these
performance measures.

Limited proprietary coding is contained in the measure specifications (online data supplement) for convenience. Users of the proprietary code sets should obtain all
necessary licenses from the owners of these code sets. The AACVPR, the ACCF, and the AHA disclaim all liability for use or accuracy of any Current Procedural Terminology
(CPT™) or other coding contained in the specifications.
J Am Coll Cardiol. 2010;56(14):1159-1167. © 2010 Elsevier Science, Inc.
© 2006 American College of Cardiology