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Clinical Updates
Program helps physicians implement heart failure treatment guidelines
UCLA researchers have developed tools to help physicians implement treatment guidelines that have been shown to improve survival among heart-failure patients.
The UCLA-led IMPROVE HF Performance Improvement Initiative includes clinical decision support and checklists with prompts and reminders that physicians can follow in considering treatment options, thus helping match patients with the best therapies to treat their heart failure.
Heart failure affects nearly 6 million people in the United States and has a high mortality rate - about 250,000 patients die each year and nearly 1,000,000 hospitalizations annually are primarily due to heart failure. And while strict adherence to evidence-based treatment guidelines can save an estimated 68,000 lives a year, improve patient quality of life, reduce the need for hospitalization and reduce medical costs, research has shown that many patients don't receive guideline-recommended care.
The UCLA Cardiac Hospitalization Atherosclerosis Management Program (CHAMP), which was among the first performance-improvement systems to implement protective therapies for those with coronary atherosclerosis or diabetes, served as a model for the IMPROVE HF initiative. The purpose is to help physicians provide treatment that adheres to the evidence-based guidelines and improves clinical outcomes.
Treatment guidelines
Heart failure occurs when the heart can no longer pump enough blood through the body. Causes include coronary heart disease, congenital heart disease, heart valve disease, high blood pressure, certain infections and some types of abnormal heart rhythms. Symptoms include shortness of breath, cough, foot and ankle swelling, weight gain, irregular or rapid pulse, fatigue or weakness and loss of appetite.
Evidence-based therapies for heart failure include several medications, such as ACE inhibitors, beta blockers and aldosterone antagonists; select device therapies, such as cardiac resynchronization therapy to help coordinate heart contractions and implanted cardioverter-defibrillator devices to correct heart rhythm abnormalities; and patient education.
Discrepancies in following the guidelines
Despite evidence of the efficacy of the guideline-recommended therapies, researchers found underuse, variation and disparities between what was recommended guidelines and what was actually happening in clinical practices. There were also treatment disparities among various patient groups, including women, certain ethnic groups and those with comorbid conditions. The gaps may be explained by some of the challenges physicians face in following the guidelines: they are sometimes as long as 100 to 200 pages, with many different therapies; it is difficult to keep up with changing guidelines; patients' health complaints don't always fit a specific protocol and the physician may not know enough about background issues, past treatments, etc.
The IMPROVE HF initiative examined 167 cardiology and specialty practices across the United States - enrolling a total of 35,000 heart-failure outpatients - to study the practical application of heart-failure guidelines. Researchers looked
at six evidence-based therapies for heart failure using data collected from quality-of-care studies, patient registries and clinical trials.
Use of IMPROVE HF tools substantially improved patient care in six of seven key quality measures. In addition, the UCLA research demonstrated that guideline-recommended heart-failure therapies were associated with improved survival in real-world clinical practice. The survival benefits were cumulative: patients treated with each of the guideline-directed therapies experienced a 24-month mortality rate that was 83 to 90 percent lower — a remarkable improvement in survival for these patients.
Systems of Care
This innovative heart-failure system of care helps physicians put the recommended therapies into practice. Besides the checklist, prompts and reminders, the system includes sequences to be followed when starting certain therapies, providing physicians a systematic approach to treating their patients.
The clinical decision-support materials also includes focused algorithms, pocket cards, a discharge checklist, patient education materials and tools to help with transition of care.
Continuing work to improve outcomes
Following evidence-based guidelines for treating heart-failure patients saves lives, improves patient quality of life, prevents hospitalizations and reduces medical costs. UCLA's innovative IMPROVE-HF Performance Improvement Initiative helps doctors follow those guidelines.
Researchers examined 167 cardiology and specialty practices across the U.S. to see how the treatment guidelines were being followed and they found gaps in how therapies were being applied. "We saw a prime opportunity for improvement," says Gregg C. Fonarow, M.D., director of the Ahmanson-UCLA Cardiomyopathy Center and co-chief of the UCLA Division of Cardiology.
The IMPROVE HF initiative provides support tools, including focused algorithms, pocket cards, patient education materials and transition of care tools.
"We proved that using these evidence-based therapies works in the real world," Dr. Fonarow says. "It's a challenge to follow the heart-failure treatment guidelines. Utilizing the IMPROVE HF checklist helps ensure nothing is overlooked."
Participating Physicians
Gregg C. Fonarow, M.D.
Director, Ahmanson-UCLA Cardiomyopathy Center
Co-chief, Cardiology
Professor of Clinical Medicine
Reza Ardehali, M.D.
Assistant Professor of Medicine in Residence
Arnold Baas, M.D.
Associate Clinical Professor of Medicine
Martin Cadeiras, M.D.
Clinical Instructor of Medicine
Daniel Cruz, M.D., Ph.D.
Assistant Clinical Professor of Medicine
Mario Deng, M.D.
Medical Director, Advanced Heart Failure, Mechanical Circulatory Support and Heart Transplant Program
Professor of Medicine in Residence
Eugene DePasquale, M.D.
Clinical Instructor of Medicine
Ann Hickey, M.D.
Clinical Instructor of Medicine
Tamara Horwich, M.D.
Assistant Professor of Medicine in Residence
Allison Kean, M.D.
Assistant Clinical Professor of Medicine
Ali Nsair, M.D.
Assistant Professor of Medicine in Residence
Contact Information
UCLA Cardiovascular Center
100 UCLA Medical Plaza, Suite 630
Los Angeles, CA 90095
Phone: (310) 825-9011
Fax: (310) 825-9012
chf@mednet.ucla.edu
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