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Quality Measurement and Accountability in Cardiovascular Medicine: An Incomplete Revolution.

The rise of quality measurement and the proliferation of programs that require accountability for quality are among the most dramatic developments in cardiovascular medicine in the past 2 decades. The quality revolution now affects the daily practice of virtually every cardiovascular clinician and has influenced national health policy. Over time, however, both the successes and limitations of the quality movement have become apparent. As is often the case with revolutionary changes, quality measurement and the uses of these measures merit reflection and consideration of further change.

For years, quality measurement played an insignificant role in medicine. This changed with a growing appreciation of substantial unexplained variation in healthcare practice in parallel with seemingly unrestrained increases in care costs. The actions of the Health Care Financing Administration, now the Centers for Medicare & Medicaid Services, are illustrative of this evolution. Having employed the ineffectual approach of performing individual case review (quality assurance) of negative outliers, the Health Care Financing Administration adopted the relatively radical approach of measuring quality nationally in the hopes of stimulating improvement for all institutions and providers in the early 1990s.1 The Health Care Financing Administration’s Cooperative Cardiovascular Project measured the quality of care for acute myocardial infarction; subsequent efforts expanded to other high-impact conditions, including heart failure. Although these programs focused entirely on measuring processes of care (eg, rates of use of evidence-based therapies for acute myocardial infarction and heart failure) and did not address strategies for quality improvement, they introduced clinicians and hospitals to formal …