Intervention program helps outpatient cardiology practices improve heart failure care
A UCLA-led study has found that a new performance-intervention program significantly improved adherence to national guideline–recommended therapies for heart failure patients in outpatient settings.
Heart failure is a chronic, progressive disease that impacts millions and results in morbidity, death, the use of significant health care resources, and substantial costs. And while scientific research and national guidelines have demonstrated the effectiveness of specific therapies for heart failure patients, these treatments are still underused.
Although several programs have helped improve heart-failure patient care in hospitals, the current intervention is the largest performance-improvement program on the use of national guideline–related therapies in outpatient clinic settings.
The findings are published in the July 26 online edition of the journal Circulation.
The new program, called the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF), provided key interventions, including clinical decision support tools, structured improvement strategies and medical-chart audits with feedback to help the clinics adhere to heart failure therapies — including the use of recommended medications and devices — that have been proven to help improve patient mortality and outcomes.
"We found substantial, clinically relevant improvement in the number of patients receiving key treatments after introducing this new performance-improvement intervention program at the clinics," said the study's first author, Dr. Gregg Fonarow, UCLA's Eliot Corday Professor of Cardiovascular Medicine and Science and director of the Ahmanson–UCLA Cardiomyopathy Center at the David Geffen School of Medicine at UCLA.
For the study, researchers utilized the IMPROVE HF program at 167 cardiology practice clinics in the United States. Participants included 34,810 patients diagnosed with a previous heart attack, weakening left heart ventricle function or chronic heart failure, a condition that occurs when the heart's left ventricle can no longer pump enough blood to the body's other organs.
The program applied interventions to help ensure that patients received seven nationally recommended standard-of-care treatments developed by the American College of Cardiology and the American Heart Association.
The IMPROVE HF program employed a tool kit designed to help clinicians make patient care decisions; the tool kit included educational outreach, performance profiling, reminder systems, practice-specific data, quality-of-care reports, guideline-based best-practice algorithms, standardized encounter forms, checklists, pocket cards and patient-chart stickers.
Medical-chart reviews performed at baseline, before adopting the program, and at several points over two years following the initiation of the IMPROVE HF program revealed significant improvement in the use of five of the seven national-level recommended heart failure treatments targeted in the study. Researchers found:
- The use of beta-blocker medication increased 6.2 percent, from 86 percent at baseline to 92.2 percent after the interventions.
- The use of aldosterone antagonist medication rose 25.1 percent, from 34.5 to 60.3 percent.
- The use of cardiac resynchronization therapy, a device that helps coordinate the heart's contractions, increased 29.9 percent, from 37.2 percent to 66.3 percent.
- The use of implantable cardioverter-defibrillator devices, which help regularly pace abnormal heartbeats, increased 27.4 percent, from 50.1 to 77.5 percent.
- Heart-failure patient education also rose 12.6 percent, from 59.5 to 72.1 percent.
"We reported increased use of the majority of the national treatment guideline therapies tested in the study," Fonarow said.
Fonarow noted that, overall, opportunities to provide national guideline-recommended therapies to eligible patients increased from 68.4 percent at baseline to 80.1 percent two years after the initiation of the IMPROVE HF interventions.
According to the researchers, this increase is significant, especially given the wide range of cardiology clinics across the country included in the study, the majority of which were community-based.
"The IMPROVE HF program may help establish a model and framework for future performance-improvement programs administered in an outpatient setting for cardiology practices," Fonarow said.
The demonstration of substantial change in the use of guideline-recommended therapies among practices participating in IMPROVE HF provides direct evidence in support of applying this, or programs of similar design, nationwide, Fonarow said.
"This study suggests that receipt of patient-level performance feedback that is actionable appears to be a particularly important component of the heart failure performance-improvement efforts," he said. "Because IMPROVE HF, with the exception of the practice-specific data collection, utilized existing personnel and resources within each practice, it may be more scalable and sustainable than alternative models to improve outpatient cardiovascular care."
No significant improvements were seen in the use of two of the national guideline treatments used in the study: a heart failure medication called angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and an anticoagulation medication for atrial fibrillation. Researchers suggest that this could be due to physician perceptions, inconvenience associated with monitoring certain drugs or other factors. Further study is needed to explore why the use of these two treatments did not improve.
Medtronic Inc., a manufacturer of cardiac resynchronization therapy and implantable defibrillator devices, provided financial and material support for the IMPROVE HF registry. The company had no role or input in the selection of end-points or quality measures used in the study.
Outcome Sciences Inc., a contract research organization, independently performed the practice-site chart abstractions for IMPROVE HF, stored the data, and provided benchmarked quality-of-care reports to practice sites. Outcome Sciences received funding from Medtronic. Individually identifiable practice-site data were not shared with either the steering committee or the sponsor.
Fonarow has received honoraria and consultant fees from Medtronic. Additional author financial disclosures are listed in the study manuscript.
Additional authors include: Nancy M. Albert, Ph.D., Cleveland Clinic Foundation; Anne. B. Curtis, University of South Florida College of Medicine; Wendy Gattis Stough, Pharm.D., Campbell University School of Pharmacy and Duke University Medical Center; Dr. Mihai Gheorghiade, Northwestern University; Dr. J. Thomas Heywood, Scripps Clinic; Mark L. McBride, Ph.D., and Patches Johnson Inge, Ph.D., Outcomes Science Inc. (Massachusetts); Dr. Mandeep R. Mehra, University of Maryland; Dr. Christopher M. O'Connor, Duke University Medical Center; Dr. Dwight Reynolds, University of Oklahoma Health Sciences Center; Dr. Mary Norine Walsh, the Care Group, LLC (Indiana); and Dr. Clyde W. Yancy, Baylor University Medical Center.