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ABSTRACT. It is unclear whether peritoneal dialysis (PD) compared with hemodialysis (HD) confers a survival advantage in end-stage renal disease (ESRD) patients with coronary artery disease (CAD). This hypothesis was tested in a national cohort of 107,922 patients starting dialysis therapy between May 1, 1995, and July 31, 1997. Data on patient characteristics were obtained from the Center for Medicare and Medicaid Services Medical Evidence Form (CMS) and linked to mortality data from the United States Renal Data System (USRDS). Patients were classified on the basis of CAD presence and followed until death or the end of 2 yr. Nonproportional Cox regression models estimated the relative risk (RR) of death for patients with and without CAD by dialysis modality using primarily the intent-to-treat but also the as-treated approach. Diabetic patients (DM) and nondiabetic patients (non-DM) were analyzed separately. Among DM, patients with CAD treated with PD had a 23% higher RR (95% CI, 1.12 to 1.34) compared with similar HD patients, whereas patients without CAD receiving PD had a 17% higher RR (CI, 1.08 to 1.26) compared with HD. Among non-DM, patients with CAD treated with PD had a 20% higher RR (CI. 1.10 to 1.32) compared with HD patients, whereas patients without CAD had similar survival on PD or HD (RR = 0.99; CI, 0.93 to 1.05). The mortality risk for new ESRD patients with CAD differed by treatment modality. In both DM and non-DM, patients with CAD treated with PD had significantly poorer survival compared with HD. Whether differences in solute clearance and/or cardiac risk profiles between PD and HD may explain these findings deserves further investigation. E-mail: Austin.Stack@uth.tmc.edu

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Abstract-The ability to quantify the quality of cardiovascular care critically depends on the translation of recommendations for high-quality care into the measurement of that care. As payers and regulatory agencies increasingly seek to quantify healthcare quality, the implications of the measurement process on practicing physicians are likely to grow. This statement describes the methodology by which the American College of Cardiology and the American Heart Association approach creating performance measures and devising techniques for quantifying those aspects of care that directly reflect the quality of cardiovascular care. Methods for defining target populations, identifying dimensions of care, synthesizing the literature, and operationalizing the process of selecting measures are proposed. It is hoped that new sets of measures will be created through the implementation of this approach, and consequently, through the use of such measurement sets in the context of quality improvement efforts, the quality of cardiovascular care will improve. M edicine is experiencing an unprecedented increased focus on quantifying and improving the quality of health care. Although healthcare quality is a multidimensional construct that, as articulated by the Institute of Medicine, 1 encompasses concepts of safety, equity, evidencebased medicine, timeliness of care, efficiency, and patientcenteredness, the foundation of efforts to improve care is predicated on measurement. Without the ability to quantify quality, the opportunity to identify practices that lead to higher-quality care, and the opportunity to learn how such care was delivered, quality cannot be improved. Therefore, developing a framework to measure components of the quality of health care is of paramount importance.The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multifaceted strategy to facilitate the process of improving the quality of cardiovascular care. The initial phase of this effort was to create clinical practice guidelines that carefully review and synthesize the available evidence to better guide patient care. As articulated in a recent overview of the guidelines process, the creation of guidelines is but one component of the ACC's and the AHA's commitment to improving the

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