Einstein/Montefiore Department of Medicine

Improving Appropriate Use of ACE Inhibitors and ARBs

A Case Study in Quality Improvement of CMS Core Measures 


Calie Santana, MD 


In 2003, the Center for Medicare and Medicaid Services (CMS) began publicly reporting data on “core measures”, or measures of care quality for prevalent hospital admissions such as heart attack, heart failure, and pneumonia. Since then, Montefiore Medical Center has collected and publicly reported data on measures such as the percentage of patients with acute myocardial infarction (AMI) who are discharged on aspirin.

Montefiore performs well in most CMS core measures. However, it has lagged behind its state and national peers in measures related to use of ACE inhibitors or ARBs (ACE/ARB), medications known to reduce mortality in patients with poor left ventriculular function after AMI or with systolic congestive heart failure (CHF).

A series of steps toward improvement have been undertaken since 2007:

  1. Chart review to identify practice patters
  2. Creation of an information technology tool to identify patients with CHF and AMI in real time
  3. Creation of a paper chart reminder with evidence of Montefiore’s performance on the ACE/ARB core measure
  4. Information sessions with hospitalists, housestaff and physician assistants about this opportunity for quality improvement
  5. Distribution of chart reminders in the charts of eligible patients starting in July 2009
  6. Distribution of a reminder to attendings and fellows (PDF) on the ACE/ARB initiative with detailed instructions on how to improve Montefiore’s performance on the ACE/ARB core measure
  7. Dissemination of the preliminary results of this initiative internally to the medicine service and externally via peer-reviewed abstracts

The work to improve this core measure offers evidence of Montefiore’s commitment to quality and of how CMS mandates impact the hospital’s quality improvement agenda.

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