BOSTON — Using a performance improvement intervention for the outpatient care of heart failure patients increases the use of evidence-based, guideline-recommended processes and therapies, Dr. Clyde W. Yancy said at the annual meeting of the Heart Failure Society of America.
Providing physicians with prompts, pocket cards, check lists, and guidelines-based decision-support algorithms significantly increases the likelihood that they will use evidence-based therapies, devices, and patient education, according to the primary findings from the large-scale, prospective IMPROVE-HF (Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting) study.
To assess conformity with established heart failure performance measures based on class I recommendations of the national heart failure guidelines published jointly by the American College of Cardiology and the American Heart Association in 2005 (Circulation 2005;112:e154-235), the IMPROVE-HF investigators reviewed the charts of about 35,000 heart failure outpatients who were being treated at the study's 167 sites at baseline and then at 12 months and 24 months after the implementation of the practice-specific process-of-care initiative, said Dr. Yancy of Baylor University Medical Center at Dallas.
The baseline findings suggested suboptimal conformity with performance measures for all of the practices considered, as well as significant variation in the utilization of evidence-based, guideline-recommended therapies, especially for women and the elderly. In particular, large variations were observed in the use of anticoagulation for atrial fibrillation, implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy (CRT), and heart failure education.
In all, only 27% of patients who were assessed with a heart failure indication at baseline were receiving the treatments for which they were eligible, based on the guidelines, Dr. Yancy said.
But 24 months after the introduction of the performance improvement program, significantly more patients were receiving the treatments for which they were eligible across nearly all measures, Dr. Yancy reported, noting that the largest changes were observed in the use of ICDs, aldosterone receptor antagonists, and CRT, which went from being used in 39%, 35%, and 50% of eligible patients, respectively, to 68%, 60%, and 56%.
The use of ACE inhibitors or angiotensin receptor blockers and beta-blockers, as well as the provision of heart failure education, also improved significantly, but the use of anticoagulation therapy in the setting of atrial fibrillation remained the same.
The findings are promising in that they suggest that systematic process improvement is a real possibility, although the study is limited both by the absence of patient outcome data related to the improved adherence to quality measures and by the fact that it was conducted among cardiologists, whereas the majority of outpatient heart failure patients in actual practice are managed in the primary care setting, Dr. Yancy said.
“We don't know yet if we can scale the other 80% of the patient population” who are treated in a primary care setting, he said. Even so, he added, offering practical information and practice-specific disease management tools can help close gaps in heart failure treatment.
Dr. Yancy reported having no financial disclosures relative to his presentation. The IMPROVE-HF study is supported by Medtronic Inc.
The findings suggest that systematic process improvement is a real possibility.
Source DR. YANCY