Quality Improvement for Institutions

Metrics and Measures

Metrics and measures in NCDR reports provide information on hospital and outpatient practice performance compared with aggregate benchmarks of all registry participants to guide internal quality improvement efforts. The NCDR follows the American College of Cardiology Foundation (ACC)/American Heart Association (AHA) classifications:

Performance Measures are those process, structure, efficiency, or outcome measures that have been developed using ACC/AHA methodology, including the process of public comment and peer review and which have been specifically designated as performance measures by the ACC/AHA Task Force on Performance Measures.

Quality Metrics are those measures that have been developed to support self-assessment and quality improvement at the provider, hospital, and/or healthcare system level.

Performance measures, endorsed by the ACC/AHA Task Force on Performance Measures and the National Quality Forum (NQF), are appropriate for consideration for additional quality programs, including public reporting and recognition programs by third parties.

Metrics and measures are developed with expert guidance using clinical guidelines (including guidelines developed by the ACCF in collaboration with other specialty societies) and evidence. In developing metrics and measures, the NCDR uses the leading methodology to identify and test metrics and measures that are scientifically valid and meaningful to providers for quality improvement benchmarking. When appropriate, this includes the development of composite metrics and risk-adjusted outcome metrics that can provide more usable information about quality of care than unadjusted individual metrics.

View a list of NCDR hospital based risk-adjusted and composite measures and metrics.

NQF Endorsement

The National Quality Forum (NQF) endorses national consensus standards for measuring and publicly reporting on performance. Several measures that are reported in the NCDR have received NQF endorsement, indicating that they are appropriate for consideration for public reporting and other accountability programs. The following NCDR measures have received NQF Endorsement:

Chest Pain – MI Registry

  • Defect Free Care for acute myocardial infarction

CathPCI Registry

  • Composite: Therapy with aspirin, P2Y12 inhibitor, and statin at discharge following percutaneous coronary intervention (PCI) in eligible patients
  • PCI  In-Hospital Risk-Adjusted Mortality (all patients)
  • PCI Risk Adjusted Bleeding (RAB)
  • 30-Day Risk-Standardized Readmission Rate Following PCI Measure
  • 30 Day Risk Adjusted Mortality post PCI for patients with STEMI or with cardiogenic shock
  • 30 Day Risk Adjusted Mortality post PCI for patients without STEMI or without cardiogenic shock

EP Device Implant Registry

  • Composite: Therapy with ACE/ARB and beta blocker at discharge following ICD implantation in eligible patients
  • 30-90 day Risk-Standardized Complication Rate following Implantation of ICD

STS/ACC TVT Registry

  • 30 Day All-Cause Risk Standardized Mortality Odds ratio following TAVR 

For more information about NQF and the endorsed measures reported in the NCDR, visit www.qualityforum.org.

Temp Styles

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