AHRQ prevention quality indicators
Primary diagnosis (% of total; N)
Secondary diagnosis (% of total; N)
Heart failure
34 % (6514)
55 %(10,589)
Hypertension
0.14 % (27)
34 %(6588)
COPD
2.6 % (494)
32 % (6184)
Infections
1.6 % (312)
11.5 % (2214)
Dehydration
2.2 % (431)
10.6 % (2041)
Bacterial Pneumonia
4.7 % (913)
6.8 % (1305)
Diabetes, long-term
1.3 % (244)
6.4 % (1235)
Angina without procedure
0.2 % (47)
4.4 % (847)
Diabetes, uncontrolled
0.12 % (23)
1.67 % (311)
In light of the potentially avoidable hospitalizations for home health-care patients and the large percent of those related to HF symptoms, a solid partnership with a HF program can be invaluable by providing an evaluation early into the home health care course, even providing transportation or physician home visits to curb growing symptoms and administering guideline driven therapy by an expert HF team.
Thus, the rehospitalization issue for HF patients is complex and less likely to improve with only a narrow focus. We must target instead the integration of various approaches, including partnering with primary care providers and nurse-driven home health care, as well as with skilled nursing facilities.
The Guideline-Practice GAP
It is a constant and iterative process to encourage practices, whether academic or community-based, to apply the peer-reviewed guidelines for medical and device therapy [21]. The gap still exists in HF registries and is especially guideline-recommended medication doses are still marginal [22, 23]. Gaps in therapy also exist with respect to gender and race; for example, hydralazine and nitrates are used in fewer than ¼ of eligible African American patients with symptomatic HF [24]. Importantly, it has been shown that patients who need admission but are already on HF medical therapy are more likely to be discharged on evidence-based therapies [5].
The source of the inability to uptitrate drugs to their guideline or clinical trial levels is probably multifaceted but includes lack of self-efficacy with uptitration, physician pride that he/she needs no further training or counsel, fears of side effects, and clinical inertia. Educational programs that target quality improvement in applying HF GDMT should be multifactorial [13]. Current requirements for recertification will hopefully help to close the gap as clinicians look internally into their own practice and find places for improvement. Yet, the literature is replete with examples of decreases in poor outcomes, including mortality when GDMT is applied appropriately and consistently [25]. Patients deserve the best of treatment and the best of care.
Nonetheless, programs that focus on targeted and directed quality improvement have been shown to raise the level of care significantly [5, 26]. Some of these programs are directed to the inpatient stay and others to the transition to outpatient care [27, 28]. Heart failure programs can add a great deal of benefit by actively and vocally supporting such programs within a healthcare system and becoming the champions of quality care as groups that are respected for their clinical quality efforts. Programs are most successful when carried out at a system level and with buy-in from clinicians throughout [29–31].
There are multiple health care delivery settings for heart failure. Prevention of HF would be best and would avoid all the costs and patient burden that follows a HF diagnosis. Prevention is most likely to be delivered by the patient’s primary care provider, requires an awareness of the risk factors leading to HF (Stage A), andrequires aggressive interventions to improve them, e.g., hypertension or hyperlipidemia. Acute care in the emergency room or hospital observation unit, chronic care in a heart failure clinic, home care with specialized heart failure nurses are all potential sites of therapy. Palliative care can be a partner in all of these settings, except for the Stage A patients.
Why Are Heart Failure Programs Needed?
The disease epidemic of HF results in high utilization and costs of health care. There are several potential causes of high utilization and costs. These include deviation from evidence-based care, poor communication between primary care providers and specialists, poor communication between health-care providers and patients, failure to address psychosocial issues and patient adherence, a lack of coordinated long-term management, and ineffective transitional management from the hospital to home or skilled nursing facility (See Table 34.2). A well-structured specialized heart failure program can address some or most of these problems. Cost reduction is not the only issue driving the establishment of specialized HF programs. Clinical care and continuity of care should constitute top priority. Other issues driving the development of HF programs include research and the reputation of a hospital as a specialized care center.
Table 34.2
Why we need HF programs
Realization: It is impossible for a single practitioner to care for a large number of HF patients using cutting-edge evidence-based care in the current practice environment |
It is equally impossible for a single HF physician to care for the ever growing number of patients |
Other providers of care are essential |
Teams must be created |
In hospital care is fragmented |
Measures of quality are being collected by hospitals and systems |
Transitions of care are not consistent across episodes |
Payment is linked to quality |
Penalties exist |
Other penalties at the level of the provider are inevitable |
Planning a HF program needs to take into consideration the social and cultural milieu of the local patient population, which can differ from an inner-city setting to an urban population. The geographic distribution of the target population will dictate the ease to which patients can access clinical care services and prioritize initiatives such as telehealth or home-based visits. The incidence of heart failure, medical co-morbidities and age can also differ by geographic location. Other demographic factors, such as socioeconomic characteristics, health literacy, and ethnicity should be taken into consideration to ensure that care is provided within a culturally appropriate paradigm.
There are multiple goals for a HF clinic, such as improved access to appropriate cost-effective health care, improving patient quality of life and survival while decreasing hospitalizations, control of health care costs, and a means to track quality outcomes. There should be a seamless integration of medical care, pharmacologic intervention, patient education, and patient support.
Criteria have been proposed to identify those patients who could gain most benefit from care in a HF clinic [32]. High-risk markers include recent HF hospitalizations, renal insufficiency, or multiple active comorbidities. Clinics that cannot provide all facets of advanced HF care should partner with a facility that can offer options such as mechanical support and heart transplantation in eligible patients, recognizing that these constitute a small percentage of the total HF population.
Heart Failure Care as Disease Management
Disease management programs have been described as a means to improve the quality of care for patients with chronic illnesses under a multidisciplinary framework in a cost-effective manner. Disease management may be an effective way to treat patients with or at risk for heart failure by increasing quality of care, enhancing adherence to practice guidelines, and expediting accessibility to healthcare services. Disease management may also improve efficiency of delivery of healthcare services by promoting quality while reducing costs. It can do this for the HF population by preventing or minimizing the effects of heart failure through integrative and proactive care. The definition of disease management by the Care Continuum Alliance (formerly the Disease Management Association of America) has helped to standardize the terminology related to the practice of disease management. They define disease management as a multidisciplinary, continuum-based approach to health care delivery that proactively identifies populations with, or at risk for, established medical conditions that: supports the physician/patient relationship and plan of care; emphasizes prevention of exacerbations and complications utilizing cost-effective evidence-based practice guidelines and patient empowerment strategies such as self-management education; and continuously evaluates clinical, humanistic, and economic outcomes with the goal of improving overall health. In addition, they recommend that all of the following components be in place in order for a program to be considered a disease management program: population identification process; evidence-based practice guidelines; collaborative practice model to include physician and support-service providers; risk identification and matching of interventions with need; patient self-management education (may include behavior modification programs); process and outcomes measurement, evaluation, and management; routine reporting (may include communication with patient, physician and other care providers); and appropriate use of information technology (may include data registries, telehealth and automated decision support tools).
There is a considerable body of clinical evidence supporting the use of disease management strategies for the treatment of patients with heart failure [33–38]. Disease management programs utilize strategies designed to improve adherence to scientific guidelines and established treatment plans. These disease management principles should be practiced consistently in order to maximize the efficiency of resource use within the healthcare system. Ultimately, the goal of disease management programs in HF is to augment quality of patient care while concurrently reducing the public health burden. A team of experts dedicated to the same goal, i.e., the patient’s overall well-being, may also improve patient engagement and self-care. The patient is seen as an active member of the team.
The American Heart Association Expert panel on Disease Management recommends the following principles for the development, implementation, and evaluation of disease management programs [39]
The main goal of disease management should be to improve the quality of care and patient outcomes.
Scientifically derived, peer-reviewed guidelines should be the basis of all disease management programs. These guidelines should be evidence based and consensus driven.
Disease management programs should help increase adherence to treatment plans based on the best available evidence.
Disease management programs should include consensus-driven performance measures.
All disease management efforts must include ongoing and scientifically based evaluations, including clinical outcomes.
Disease management programs should exist within an integrated and comprehensive system of care in which the patient-provider relationship is central.
To ensure optimal patient outcomes, disease management programs should address the complexities of medical comorbidities.
Disease management programs should be developed for all populations and should particularly address members of the underserved or vulnerable populations.
Organizations involved in disease management should scrupulously address potential conflicts of interest.
There are a large number of studies that give evidence of some improved outcomes with the use of disease management strategies for the treatment of patients with heart failure. One publication describing 10 observational studies of disease management in HF showed improved symptoms and functional class, reduced hospitalizations and length of stay, improved adherence to HF therapies and improved patient and physician satisfaction [40]. Another study of 9 randomized controlled trials of HF disease management programs showed reduced hospitalizations, readmissions and length of stay, that translated into cost savings but no appreciable impact on mortality [41]. Several other studies showed an improvement in functional class and quality of life, increased adherence to guideline-directed medical therapy and reduced readmission rates [42–45].
Although there are several studies that support disease management programs in the treatment of HF, there still needs to be more scrutiny into what practices and components constitute the most successful of programs. In a more recent study, the Medicare Health Support Pilot Program was a large, randomized study of eight commercial programs for disease management that used nurse-based call centers [46]. The program randomly assigned patients with heart failure to disease management versus usual care to evaluate the effects of the commercial programs on the quality of clinical care, acute care utilization, and Medicare expenditures. This was a large study, enrolling 242,417 patients (163,107 in the intervention group and 79, 310 in the control group). Ultimately, the commercial disease-management programs did not reduce hospital admissions or emergency room visits, as compared with usual care. However, they did observe 14 significant improvements in process-of-care measures, but these modest improvements came at substantial cost, with no demonstrable savings in Medicare expenditures. The authors concluded that commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality-of-care measures, with no demonstrable reduction in the utilization of acute care or the costs of care. The authors further suggested that the findings might be explained by the severity of chronic disease among the patients studied, delays in patients receiving protocol-driven disease management care after hospitalizations, and the lack of integration between specialists and the primary care providers of the patients. Clearly more study is required to determine which components of disease management practice build the more successful programs.
Barriers to adequate HF care include patient-related issues and problems in the care system delivery. Patient barriers include inability to sustain complex self-care management, lack of motivation due to depression or poor functional capacity, and financial concerns. Issues with the delivery of disease management health care include the lack of capacity of high-frequency patient follow-ups (usually 1 week post discharge, then every 1–2 weeks for medication titration and to maintain effective diuresis), and lack of shared communication between multiple health care providers.
Multidisciplinary Structure
HF is a progressive disease characterized by clinical exacerbations that result in the utilization of acute healthcare services. Effective treatment for these patients involves complex drug management, time-consuming patient education and frequent clinical visits [19]. The lack of careful management of patient symptoms results in excessive use of acute emergency and hospital services; indeed, as many as 50 % of HF admissions may be preventable [47]. The goal of HF care is to prevent episodes of clinical exacerbations so as to ensure better quality of life and survival for the patient and offer more efficient use of healthcare resources. HF treatment requires significant adjustments in lifestyle. The prevention of clinical deterioration and maintenance of a good quality of life require the patient to actively participate in the disease management process. For the healthcare provider, successful management of symptomatic HF patients requires frequent follow-up visits and determined efforts to improve patient adherence to medical treatment and lifestyle changes. While current research supports the benefits of some elements of care delivery processes in disease management programs for HF, it does not specify a single, specific healthcare delivery model as the most successful system. In truth, it is likely that a variety of approaches should be tailored to the specific needs of the local patient population and resource availability [40]. In general, care for the HF patient can be improved by a system that emphasizes comprehensiveness of care while preserving efficient healthcare delivery.
Many of the different models of chronic HF care incorporate the following important elements: coordination of care across different providers, patient/caregiver education, patient/caregiver support with a focus on patient self-management and adherence, medication management, rigorous clinical monitoring, and implementation of guideline-directed protocols [48]. The ACC/AHA guidelines state that optimal care is best delivered by a team that includes both a primary care physician and a cardiologist [7] and there is strong evidence supporting the benefit of multidisciplinary programs for the management of HF. For example, in one meta-analysis of 30 randomized-controlled trials of multidisciplinary programs for HF showed a reduction in all-cause hospitalization (13 % lower risk), HF-related admissions (30 %) and mortality (20 %) compared with individuals receiving usual care; interventions involved a physician and at least one other type of health professional such as a nurse, pharmacist, dietician, or social worker [49]. Multiple other studies show that multidisciplinary interventions for HF management may improve patient adherence, functional status, reduce risk of hospital admissions, reduce length of hospital stay, confer improved survival, and reduce healthcare costs [30, 41, 48–58].
In 2008, the Heart Failure Society of America published a consensus statement that described the integral elements of a HF clinic, which focused on the systems and procedures that would provide the most consistent application of evidence-based guidelines and, ultimately, ensure optimal patient care [59]. The authors specified the follow areas: disease management, functional assessment, quality of life assessment, medical therapy and drug evaluation, device evaluation, nutritional assessment, follow-up, advance planning, communication, provider education, and quality assessment. The authors acknowledged that these areas had not been subjected to standard trial methodology and that few studies had adequate power or statistical design to show that specialized HF clinics decreased mortality for HF patients. As described above, however, there are many studies demonstrating improved quality of life, functional status, and patient satisfaction, with reduced hospitalizations for patients followed in HF clinics [41]. The current era of Patient Centered Outcomes Research (PCORI) may be able to compare strategies of HF care using patient reported outcomes, such as quality of life and satisfaction with the care.
Most specialized HF clinics practice a multidisciplinary approach that may include physicians, nurses, pharmacists, nutritionists, social workers, exercise physiologists, and other health care professionals with specialized training and skills in HF management [60, 61]. With consistent application of GDMT and the common goals of improving patient well-being and increasing the efficiency of healthcare deliver, the multidisciplinary team establishes a long-term relationship with an individual patient to optimize medical therapy, provide frequent clinical follow-up with ready access to care in the case of decompensation, administer thorough patient and caregiver education, and create seamless coordination of care between multiple care providers. Comprehensive education of the patient and family with a focus on increasing adherence to therapy and self-care can improve HF outcomes. Numerous clinical studies provide strong evidence for the effectiveness of multidisciplinary disease management of HF and the components of HF management programs consistent across these studies include multidisciplinary teams of health professionals, intensive patient education and support for self-management, and ready access to providers.
A successful multidisciplinary HF clinic requires adequate financial resources to support provider training and the framework for coordinated healthcare delivery and quality assessment. This includes a provider to patient ratio that will support individualized and comprehensive patient care.
Management of the HF Patient
A systematic approach to the assessment of the HF patient provides the crux of effective HF management. The ongoing management of the HF patient should address the following components: etiology and ongoing factors contributing to myocardial dysfunction, circulatory status, related co-morbidities, goals for ongoing therapy, psychological and social vulnerabilities, patient preferences and end-of-life decisions (Table 34.3) [62]. Important elements of HF management include symptom review, medication titration, education of the patient, care provider and family, self-management support, management of comorbidities, telephone support, psychosocial and care provider support, and palliative care. The frequency of office visits and HF treatment should be guided by established protocols to ensure uniform practice and the attainment of optimal guideline-directed medical and device therapies. Patients should ideally be seen within a week of hospital discharge and every 2 weeks if they exhibit unstable symptoms. Stable HF patients should be followed at a minimum frequency of every 3 months. Recent evidence from GWTG implies that a visit that occurs early, within 1 week of discharge can lead to a decrease in hospitalizations [31].
Cause of and contributing factors to left ventricular dysfunction: |
Original cause (e.g. ischemia, alcohol) |
Additional exacerbating factors (e.g. tachycardia, anemia, infection, pulmonary emboli, obesity, excessive alcohol consumption, use of recreational drugs, use of nonsteroidal anti-inflammatory agents, thyroid disease) |
Current circulatory status: |
Resting profile – evidence of congestion or hypoperfusion |
Cardiovascular reserve – activity level, evidence of limitation |
Potential to improve current status with adjustment of therapy – therapy for fluid retention and symptomatic hypotension |
Related risks: |
Symptoms of dysrhythmias |
Risk or symptoms for embolic events |
Recurrent ischemic events |
Defining goals for ongoing therapy: |
Establishment of clinical stability |
Maintenance of clinical stability |
Modulation of disease progression – target dosages of ACE inhibitors and beta-blockers |
Behavioral, psychological, and social risks: |
Non-adherence and factors that contribute to it |
Anxiety and depression |
Social isolation |
Patient preferences and end-of-life decisions |
The assessment of functional capacity remains an important component of the initial and follow-up evaluation of HF patients. There are three well-validated methods to assess functional status in HF patients, New York Heart Association (NYHA) class, the 6-minute walk test (6MWT), and cardiopulmonary exercise stress (CPET) testing [63–66]. BNP testing may also be useful, but its purpose in guiding outpatient management of HF is currently undergoing study. Baseline NYHA functional classification should be assessed then reassessed with every visit. An objective assessment of functional status with either 6MWT or CPET should also be performed initially then serially to determine response to clinical interventions. CPET is also important to risk stratifying patients potentially needing advanced therapies such as mechanical assist device or cardiac transplantation. Peak oxygen uptake (VO2) obtained during CPET is one of the most powerful predictors of mortality in this population and may also serve to deliver an individualized exercise prescription. Serial measurements of health status, such as through the Minnesota Living with Heart Failure Questionnaire or Kansas City Cardiomyopathy Questionnaire, can also predict survival and hospitalization risk for patients with HF [67–69].
Evidence-based practice guidelines for the pharmacologic and device therapy of HF have been published by several professional organizations [7, 70]. These guidelines are best put in protocol form for HF management clinics in order to ensure uniform practice across all healthcare providers and to expedite up-titration and optimization to the target dosages of guideline-directed HF medications. A comprehensive drug evaluation can reduce hospital admission rates and improve survival [51, 60, 71–74]. A look at adherence to the medication regimen should be done with each visit, with a focus on strategies to improve patient adherence and involvement in HF care.
Nutritional assessment and education can be done by a physician extender or nutritionist as part of the holistic approach to HF care. Sodium and fluid indiscretion accounts for at least 18 % of preventable readmissions for HF [75] and time should be spent devoted to teaching patients about salt and fluid restriction, especially those with frequent acute exacerbations of HF. Early identification and intervention for cachexia are also important since cachexia is a marker for poor outcomes in HF [76].
Effective communication is extremely important to improved patient outcomes. Shared decision-making between the healthcare provider and patient leads to better adherence and patient satisfaction [77]. In addition, clear communication between different healthcare providers decreases the incidence of medication errors and conflicting treatment plans. HF patients usually have many comorbidities and all of the care provided by their various providers should be well-coordinated to decrease discrepancies and improve patient outcomes and the efficiency of healthcare delivery.
Each HF patient should have an individualized care management plan for the long-term care of their disease. Components of the care management plan include HF management goals, treatment plans, a list of problems such as lifestyle changes, medication administration, and means of transportation, and clear contact information for their various healthcare providers. A copy of the care management plan should be given to the patient and his or her care provider, as well as each health care provider that is involved in the care of the patient. HF patient education should provide information on their medical condition, lifestyle changes that need to be made, medications, and the predicted course of their condition. The patients’ family member and care providers should also be educated on HF. Standardized HF educational resources, such as booklets or support group meetings, are very useful to meet the education objectives of patients and their care providers.
Patient self-management is a care model whereby the patient is actively engaged in and takes responsibility for their healthcare. This model requires an informed and motivated patient. By promoting self-management in the care of HF, patients are empowered to understand their disease and treatments, and to be able to recognize the signs of HF decompensation before they become emergent.
Telephone services to assess symptoms, up-titrate medications, provide education, or offer emotional support, complement the face-to-face clinical care of the HF patient. This should be delivered by a nurse proficient at HF care and these phone interactions should be guided by evidence-based protocols.
Advanced heart failure therapies are required for a relatively small proportion of people with HF and these patients should be managed intensively in a tertiary hospital with capability for mechanical support devices and/or heart transplantation. For those patients with end-stage HF for whom advanced therapies are not appropriate, involvement of palliative care services can improve the quality of life of patients with HF and their families facing death. Health professionals treating HF patients should have some training in palliative care philosophy.
Home Care and Telemonitoring
HF disease management programs can incorporate home care and telemonitoring into their systems of care [78]. Some studies have shown that multidisciplinary interventions that included home-based components were the most effective in the care of the HF patient [79]. Home care may be provided by home health care vendors that employ visiting nurses or other home health care professionals [80]. Home-based visitation by physicians has also been reported as another strategy to improve outcomes for HF patients [81]. Home care visits have been shown to decrease risk of all-cause and HF-related admissions [49].
The HF clinic can utilize telemonitoring technology to monitor patients who cannot make frequent visits, either due to geographic limitations or an inability to leave their homes [82, 83]. Telemonitoring is the use of telecommunications or other electronic information processing technologies to monitor patient health status at a distance. Telemonitoring devices include those that monitor vital signs and weight. Physiologic data such as body weight, blood pressure, and heart rate can be captured electronically on a scheduled or ad hoc basis for review and intervention, if needed. Remote analysis of intrathoracic impedance may also be used to monitor for worsening HF [84, 85]. Telemonitoring has been shown to improve outcomes in HF patients, such as decreased admissions and reduced risk of mortality [49]. Some of the published evidence suggests that telemonitoring may be as effective as other disease management programs for decreasing patient risk of hospitalization and increasing quality of life [86–88] while other studies show no difference in patient outcomes [89, 90]. Careful examination of some telemonitoring programs will show that beyond the early study time-period, adherence to the intervention drops off, making it nearly impossible to determine true efficacy in an intent-to-treat analysis. It may be more important, therefore, to examine the system in which telemonitoring is deployed, rather than the type of telemonitoring used.
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