(1)
The Society of Cardiovascular Patient Care, An Institute of the American College of Cardiology, Dublin, OH, USA
(2)
Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
(3)
Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
Keywords
RevisitsHospitalizationHeart FailureDataQualityMetricsLength of StayFinancialReportingQuality and Its Measurement
Quality in health care is an idealized yet elusive goal. This can, in large part, be attributed to the inherent difficulty associated with establishing a precise definition of quality—a circumstance derived from the existence of multiple stakeholders (e.g., health-care providers, local administrators, patients, community, insurers, government) each with differing perspectives on what constitutes the deliverables of “good” health care. At its core, however, quality is generally regarded as an attribute of provider care, specifically technical performance (or lack thereof) as viewed through the lens of “best-practice” medicine [1]. The latter represents the summation of those actions (or inactions) that have either proven effective or are, by virtue of consensus expert opinion, considered de facto to contribute to better outcomes (e.g., smoking cessation).
Quality is thus a comparative construct which measures variance from a benchmark set by what is considered to be best care as identified by a consensus standard. But what exactly is being measured and how can one be sure that the metric is relevant at the individual patient level and attributable to the provider (or system) in question? Moreover, to what standard is the assessment held: maximal, which does not consider health benefits within the context of related cost or optimal, which places a cost-effective value on care? Understanding these issues in an era of performance measures [2] and increased accountability for health outcomes is critical.
More than two decades ago, Avedis Donabedian championed the notion that quality can and should be assessed as a function of the relationship between three essential elements termed “structure,” “process,” and “outcome” [1]. As shown in Fig. 4.1, each can exist as both a precondition for (e.g., identification of a disparate outcome at an institution leading to a change in culture or practice) and a consequence of (e.g., inability to meet time-dependent goals for therapeutic intervention because of resource limitations) the others. These relationships, however, are far from linear and can be strongly influenced by confounding variables, especially case mix.
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Fig. 4.1
Relationship between structure, process, and outcome in health care
All of this has particular relevance to acute heart failure (HF), where, despite significant advances in medicine, postdischarge outcomes remain poor [3–5]. In the following pages, we discuss the specifics of quality as they relate to HF and highlight, using the Donabedian framework, those measures being used to differentiate performance.
Structure and Process: The Language of Operational Metrics
Structure
The definition for health-care structure is broad, including everything from geographic location and physical layout of health-care facilities, medical equipment and information technology systems, and personnel qualifications, certification, and training. This breadth leads to a lack of consensus and evidence as to what structural elements contribute to high-quality health-care process and thus high-quality outcomes. Based primarily on expert opinion, a former American College of Cardiology/American Heart Association (ACC/AHA) Heart Failure Working Group [6] recommended four structural elements be considered as indicators of quality: clinical practice guidelines, monitoring of patient care and outcomes, disease management programs, and coordinated systems of care. Initially published in 2000, excellence in these areas, particularly the latter two, has come to define centers that consistently provide high-quality HF care.
Disease Management Programs
These are multidisciplinary, patient-focused programs that cover matters such as education about the disease and its treatment, dietary counseling, efforts to improve patients’ compliance with medical regimens, and interventions to help patients achieve and maintain control of their volume status. These programs have been shown to reduce readmissions and improve functional status but not necessarily affect mortality rates [7, 8]. Further study is needed to define their overall cost-effectiveness and the optimal strategy [9, 10], as not all approaches (e.g., postdischarge telemonitoring in those recently hospitalized with acute HF) appear to provide clinical benefit [11].
Coordinated Systems of Care
As originally written by the ACC/AHA HF Working Group, this element involved the specific decision to refer medically refractory HF patients to specialty and transplant centers. It called for health-care facilities to establish a relationship with a specialty center and coordinate a plan for transfer that is predetermined and not in response to patient crisis. In such coordinated systems, patients would be referred based on their overall prognosis and response to medical care. Indeed, the literature has shown that patients with symptoms for >3 months and a more severe initial presentation are less likely to respond to therapy and may benefit from referral to specialty centers, including transplant centers [12]. Moreover, in medically refractory patients, referral to specialty centers has been reported to result in a 98 % 1-year survival rate [13, 14] and reduce readmissions by 50 %.
Though initially centered on referral, the concept of coordinated systems has morphed into one increasingly focused on greater linkage throughout the entire continuum of HF care [15, 16]. Such systems, termed accountable care organizations (ACOs), would provide continuity for patients across different institutional settings (including ambulatory and inpatient hospital visits) and, if possible, during episodes of acute decompensation. While prospective experience with structured, shared accountability, and related outcome data in HF is lacking, there is relatively strong evidence from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry which suggests a relationship between readmission rate and early outpatient follow-up after an index HF hospitalization [17]. Among patients with acute HF who were discharged from the emergency department (ED) in the Canadian National Ambulatory Care Reporting System, an association between early collaborative HF care and increased use of drug therapies, cardiovascular diagnostic testing, and better outcomes has also been reported [18].
Process
Processes of care are the interventions made in the hospital or outpatient setting that will lead to a desired health-care outcome. They can be pharmacologic (e.g., the use of angiotensin-converting enzyme inhibitors [ACEI], beta-adrenergic blockers), diagnostic (the assessment of left ventricular dysfunction), or patient-focused (providing discharge instructions and encouraging daily weight measurement). Ideal process measures have a well-defined outcome link, are broadly applicable to a defined group of patients, and are easily measured. Adherence to such interventions serves as a marker of quality of care and forms a foundation for quality improvement.
There are several challenges in defining ideal process of care measures for HF patients. First, HF is a clinical syndrome rather than a single disease entity. Patients’ symptoms and left ventricular (LV) function can vary greatly and with minimal apparent correlation. This makes it difficult to define process measures that are applicable to all HF patients. For instance, the majority of HF patients are known to have preserved systolic function; however, most diagnostic and therapeutic interventions have not been studied in this population [6]. In addition, patients at more advanced stages of disease are less likely to be receiving evidence-based therapy [19]. This is largely due to increased contraindications to therapy as mortality risk rises and decreased use of medication in eligible patients. More research is needed to define which therapies are beneficial to patients with early versus advanced stages of disease.
A second challenge is the lack of consensus as to what constitutes the ideal processes of care. A number of leading health-care organizations, including The Society of Cardiovascular Patient Care (SCPC), an institute of the American College of Cardiology, have attempted to define processes (Table 4.1) which, based on the best available evidence or, in its absence, consensus opinion should either be utilized in every patient (unless contraindicated) or at the least be tracked. While there is a considerable amount of overlap in the recommendations, there are also differences that make it difficult to set national or international goals and benchmarks for quality care. For instance, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), ACC/AHA, and SCPC each recommends ACEI or angiotensin receptor blocker (ARB) therapy for patients with LVEF <40 %, evaluation of LV function, detailed discharge instructions incorporating activity level, diet, discharge medications, follow-up appointments, weight monitoring, and what to do if symptoms worsen, and smoking cessation counseling. In addition to the aforementioned metrics, many other metrics are tracked in the SCPC Heart Failure Accreditation tool which focuses on the daily patient level processes that apply to the management of the HF population.
Table 4.1
Society of cardiovascular patient care heart failure accreditation calculated measures
Heart failure admission rate – observation |
Heart failure admission rate – inpatient |
Heart failure specific length of ED, observation, inpatient stay |
Hospital 7, 15, 30, 60, 90-day HF specific readmission rate following Heart Failure hospitalization |
Heart failure-specific readmission rates from a location other than home at 7, 15, 30, 60, 90 days |
Heart failure-specific return to observation rates at 7, 15, 30, 60, 90 days |
Heart failure-specific return to observation rates at 15 days |
Proportion of heart failure patients requiring an increased level of care |
Heart failure in hospital mortality rate |
Evaluation of left ventricular systolic function |
Median time to ECG |
Proportion of patients receiving NIPPV while in the ED |
Assessment of objective data – heart failure patients (process) |
Proportion of patients undergoing evaluation of current level of activity and clinical symptoms (NYHA) |
Proportion of patients having documented daily assessment of electrolytes and renal function |
Proportion of African Americans given Hydralazine/ISDN at discharge |
Proportion of heart failure appropriate patients given an approved Beta-Blocker at discharge |
Proportion of heart failure appropriate patients given an ACE/ARB at discharge |
Proportion of patients discharged on NSAIDS |
Proportion of patients discharged on Aldosterone Antagonists |
Detailed discharge instructions |
Reconciled medication list received by discharged patients (Discharges from an inpatient facility to home/self care or any other site of care) |
Timely transmission of transition record (Discharges from an inpatient facility to home/self care or any other site of care) |
Percent of patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen |
Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of Heart Failure for whom a follow up appointment was scheduled and documented including location, date and time for a follow-up office visit, or home health visit (as specified) |
Door to IV therapy time for nitroglycerin or other vasodilator during early stabilization |
Door to IV therapy time for furosemide or other loop diuretic during early stabilization |
Proportion of patients who received a Social Work Consult |
Proportion of patients with diastolic dysfunction discharged with a BP >150 |
Proportion of patients with no past medical history of heart failure |
All cause readmission rate for heart failure population |
Rate of patients evaluated with NT-proBNP or BNP |
These metrics along with CMS Value Based Purchasing Scores (Length of stay, 30-day readmission and inpatient mortality) give insight into the process, quality, and outcomes of a HF disease management program. Previously, there had been little to no information regarding appropriate management of the HF patient in both the Emergency Department and Observations services areas. However, recently a statement released by Collins et al. (2015) has given much improved guidance of care in these areas. Previously proposed measures, such as door-to-treatment (i.e., diuretic) time, door to provider time, make empirical sense but have been insufficiently explored. In comparison, the quality metric associated with the utilization of standardized evidence-based order sets has been proven effective in the short stay management areas as well as inpatient level of care. The ideal processes of care, and thus the markers of quality, could be substantially different for patients with acute decompensation who are treated in a short-stay setting than for patients following a prolonged hospitalization, but at present, there are simply not enough data.
A final issue is ensuring that processes of care are carried out equally across socioeconomic, racial, ethnic, and gender groups. In OPTIMIZE-HF, it was found that African American patients admitted for HF were more likely to receive evidence-based medications while in hospital but less likely to receive discharge instructions or smoking cessation counseling [20]. Disparity in care such as this across different racial, ethnic, and social groups is commonly found and is often alleviated by the involvement of the Case Manager or Social Worker. The formation and utilization of the multidisciplinary care approach can also be associated with quality indicators and improved outcomes.
Outcomes: Quality in Action
Positive outcomes are the ultimate goal of any health-care system and the true essence of quality. Ideal outcome measures should be measurable, sensitive to modifications in the structure and process of care, practical to use and should take into account patients’ underlying risk for good or bad outcomes. The main challenge in using outcomes as a marker of quality is that they do not depend solely on the health care provided. Age, severity of cardiac dysfunction, presenting hemodynamic profile, degree of comorbidity, and socioeconomic status have all been shown to affect outcomes for acute HF patients [21].
An additional challenge specific to the ED setting is the relative absence of data linking ED or OU acute HF processes of care with postdischarge outcomes. Consequently, it is unknown which of the commonly used outcome measures (Table 4.2) constitute a meaningful representation of what can reasonably be attributable to ED and OU management of HF patients. Thus, while a recent review of more than 50,000 acute HF patients in Ontario, Canada, found a slightly higher 90-day mortality rate (11.9 % versus 9.5 %; log-rank P = 0.016) among those who were discharged from the ED versus admitted to the hospital, its interpretation within the context of health-care quality is difficult [22]. Moreover, while 90 days is a relatively short follow-up period, it is probably long enough to introduce substantial confounding. With the advent of CMS Value Based Purchasing, shorter (30-day) postdischarge event rates are now favored and may be more reflective of an ED, OU, or even inpatient treatment period. Perhaps of greater importance, 30-day mortality and readmission data for acute HF are publicly reported by the CMS as a measure of comparative hospital quality. Regardless of the sampling period, there may be added value through use of more time-sensitive metrics such as days out of hospital and alive [15], which provide a clearer signal of causality than measurement of dichotomous (and equally weighted) outcomes that occur at any point within a prespecified time frame.
Survival |
Mortality rates |
Quality-adjusted life years (QALYs) |
Days out of the hospital and alivea |
Resource utilization |
Index visit |
Admission rate |
Admission location (floor, telemetry, ICU) |
Length of stay |
Postdischarge |
Outpatient clinic visits |
Emergency department visits |
Hospital readmissions |
Symptom resolution |
Dyspnea scores |
Health status and quality of life |
Short form (SF) 8, 12, or 36 |
Minnesota living with heart failure |
Kansas City cardiomyopathy |
6-min walk test |
Patient knowledge and compliance
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