Prior studies have shown that evidence-based, guideline-recommended therapies are significantly underutilized, and there is substantial variation in adherence to performance measures among hospitals caring for patients with HF (10,11,12,13,14). A well-documented treatment gap exists between national HF guidelines and the clinical management of HF. This HF treatment gap results from a variety of complex issues, including a lack of systems and disease management programs.

Despite the favorable effect on morbidity and mortality that has been demonstrated by the use of angiotensin-converting enzyme (ACE) inhibitors, studies indicate that only 48% of patients with previous HF were receiving these agents at the time of hospitalization (13), and that only 60% to 70% of eligible HF patients received ACE inhibitors at discharge (15,16). The Acute Decompensated Heart Failure National Registry (ADHERE) reported a similar statistic, with only 47% of chronic HF patients with previously diagnosed systolic dysfunction receiving a β-blocker on an outpatient basis before admission to the hospital (13).

Evidence-based clinical practice guidelines have been developed for the treatment of patients with HF (3,17,18,19), and components of these guidelines have been adapted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to create core performance measures for patients hospitalized with HF (Table 20-1) (20,21,22).

However, adherence to JCAHO core measures is variable. Data from more than 80,000 HF admissions to academic and nonacademic hospitals in the United States participating in the ADHERE registry were analyzed to determine the rates of conformity with the four core performance measures: discharge instructions (HF-1), assessment of left ventricular function (HF-2), use of ACE inhibitors in patients with left ventricular systolic dysfunction (LVSD) (HF-3), and smoking cessation counseling (HF-4) (23). Across all hospitals, the median rates of conformity with HF-1, HF-2, HF-3, and HF-4 were 24.0%, 86.2%, 72.0%, and 43.2%, respectively. Rates of conformity at individual hospitals varied from 0% to 100%, with statistically significant differences between academic and nonacademic hospitals. Figure 20-1 depicts the frequency distribution of conformity rates by hospital (23). For each measure, there were substantial clinically relevant differences in performance between hospitals at different percentile levels. These differences were most notable for the measures with the lowest overall conformity. For HF-1, there was a 100-fold difference in conformity between hospitals at the 10th and 90th percentiles. For HF-4, there was an 11.2-fold difference in conformity at these percentiles. In contrast, there was a 1.3- and a 1.5-fold difference in conformity between hospitals at the 10th and 90th percentiles for HF-2 and HF-3, respectively (23).

Median hospital length of stay varied from 2.3 to 9.5 days, and in-hospital mortality varied from 0% to 11.1%. Among the hospitals enrolled in ADHERE, there was significant individual variability in conformity to quality-of-care indicators and clinical outcomes and a substantial gap in overall performance. Academic and nonacademic hospitals differed in their conformity with the four performance measures. Nonacademic hospitals demonstrated significantly better median conformity with HF-1 than academic hospitals, whereas academic hospitals demonstrated slightly better median conformity than nonacademic hospitals with HF-2 and HF-3 (23).

The gaps in care that currently exist in the hospital suggest that new efforts targeting education and effective patient
intervention should be investigated to improve the overall quality of care for patients with HF. Hospital-based systems for HF have been demonstrated to improve the provision of evidence-based care. Previous studies have demonstrated the importance of hospital-based systems and in-hospital initiation of cardiovascular protective therapies for improving treatment rates and clinical outcomes in patients with atherosclerosis (12,24).

The setting in which HF therapy is initiated is an important factor influencing treatment and compliance/adherence rates. The care of HF patients while hospitalized is critical to their outcome. Therapy that is initiated in the hospital is likely to
have higher adherence rates due to both patient and physician behavior: the hospital is a patient “capture point.” Therapy recommended in the hospital carries more weight with the patient and will be viewed as a necessary, lifesaving medication. The hospital setting also provides a teachable moment, where the physician has the attention of both the patient and family members. Other physicians, nurses, and health care workers are also available to answer questions. The hospital structure can also provide a better setting for initiation of therapy, because the patient is monitored closely, and the physician uses standard protocols and guidelines for treatment.

The importance of initiating therapy before a patient is discharged cannot be overemphasized. The implementation of comprehensive in-hospital HF disease management programs, which include management of medications, patient education, and medical staff guidelines, results in improvements in medication dosing and decreased hospitalization for HF patients (12). The Duke Heart Failure Program, for example, showed a significant increase in both the use of β-blockers and the percentage of patients reaching target doses of β-blockers and a decrease in cost of care throughout the hospital system (12).

Various hospitals have developed a number of tools to encourage physicians to initiate as many lifesaving therapies as possible before patient discharge. The use of preprinted orders, care maps, discharge forms, physician/nursing education, and treatment utilization reports may facilitate the implementation of therapy. These tools are designed to help health care providers identify and initiate guideline-recommended treatments in appropriate HF patients without contraindications. The tools also provide guidance in identifying and managing factors that may exacerbate HF, major comorbidities, and concomitant risk factors (e.g., sudden death risk, lipids, diabetes, anemia, chronic obstructive pulmonary disease, and depression). These critical pathways also aim to enhance patient education, assessment of social support, discharge planning, follow-up, and outpatient monitoring.

The continued persistence of suboptimal compliance in all hospitals and the significant variability between hospitals in both compliance and outcome variables provide a compelling rationale for the implementation of critical pathway tools that may improve hospital performance.

It is important to recognize why therapy is suboptimal in order to devise effective strategies to improve it. Some of the barriers that prevent the implementation of cardioprotective therapies in patients with HF are time constraints; lack of physician training, including inadequate appreciation of benefits and lack of prescription experience; a lack of resources; and lack of communication between specialists and generalists. In addition, the adherence to old guidelines that call for delaying initiation of therapy and including multiple steps, time points, and too many treatment options may deter physicians from using optimal care. The use of HF critical pathway tools that simplify care and clarify the roles of each caregiver may break down some of these barriers. Use of these tools may also eliminate the variability in care between hospitals and improve the overall treatment of hospitalized HF patients. The structure and education that these tools provide, in addition to improving coordination of care among staff in the hospital, make process-of-care programs invaluable.

Process-of-care programs are designed to implement a number of tools to check the treatment of the hospitalized HF patient at various stages, from admission, throughout hospital stay, and at discharge. An example of an HF admission checklist is shown in Figure 20-4. This tool will aid in diagnosis, prompt the appropriate laboratory work, and remind the physician of the importance of an echocardiogram in HF patients to evaluate EF. Use of this checklist can help the physician more accurately assess a patient’s needs for indicated therapy as well as facilitate identification of patients with contraindications to one or more therapies.

An example of standardized orders for HF is shown in Figure 20-5. This easy-to-read form serves as a guide for the physician, nurse, and other caregivers and allows each of them to follow standard HF treatment protocols and indicate each guideline-recommended therapy that has been initiated. These preprinted order sets can facilitate the identi-fication of patients with contraindications to one or more therapies and thus enhance patient safety, provide standard medication dosing, emphasize the need for monitoring certain laboratory tests, and help avoid medical errors of omission. The sets can also facilitate consultation and collaborative care.

In addition, a comprehensive HF critical pathway tool may be used throughout the patient’s hospitalization to monitor care (Fig. 20-6). This tool may help the physician recognize the signs of poor outcomes, higher in-hospital mortality, and rehospitalization. Deviations from the critical pathway



can be documented and later analyzed to better understand variations and patterns to facilitate the quality improvement process.

In addition to all the tools contained in this chapter, a number of critical pathway aids should be used in all hospitals to improve the quality of care. Algorithms, care paths, standing orders, and patient education materials can all aid the physician in the hospital. A discharge summary checklist may be an important component, as it forces physicians to evaluate the therapy on which a patient is discharged and—in light of data that show increased adherence to medications that are prescribed before discharge—may cause them to initiate additional therapy (Fig. 20-7). As discussed previously, patients that are discharged on therapy are more likely to remain on therapy.