1. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. Quality of Care of and Outcomes for African Americans Hospitalized With Heart Failure: Findings From OPTIMIZE-HF (Organized Program To Initiate life-saving treatMent In hospitaliZEd patients with Heart Failure) Clyde W. Yancy MD, FACC, William T. Abraham MD, FACC, Nancy M. Albert PhD, RN, Robert Clare, MS, Wendy Gattis Stough PharmD, Mihai Gheorghiade MD, FACC, Barry H. Greenberg MD, FACC, Christopher M. O'Connor MD, FACC, Jie Lena Sun MS, James B. Young MD, FACC and Gregg C. Fonarow MD, FACC for the OPTIMIZE-HF Investigators and Hospitals

2. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 2 Disclosures Funding Support –GlaxoSmithKline funded the OPTIMIZE-HF registry under the guidance of the OPTIMIZE-HF Steering Committee and funded data collection and management by Outcome Sciences, Inc (Cambridge, MA) and analysis of registry data at Duke Clinical Research Institute (Durham, NC) Individual author disclosures are listed in the manuscript

3. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 3 Quality of Care of and Outcomes for African American with HF Heart failure in African Americans is characterized by variations in natural history, lesser response to evidence based therapies, and disparate health care. We hypothesized that a performance improvement program will achieve similar adherence to quality measures in African Americans admitted with HF compared with non–African Americans.

4. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 4 HF in African American Patients African Americans have a greater prevalence of HF and a higher rate of HF hospitalization and mortality than the general population 1 HF in African Americans presents at an earlier age, with more advanced LVSD and worse clinical class at the time of diagnosis 2 A-HeFT has suggested that among African American patients with HF and LVSD there is frequently a nonischemic etiology with a high prevalence of obesity and hypertension 2,3 African American patients may be less likely to receive guideline- recommended, evidence-based therapies due to less access to care 4 or due to misconceptions from clinical trials 5 that therapy is less effective in this population 1. American Heart Association. 2007 Heart and Stroke Disease Statistical Update. Dallas, Tex: American Heart Association; 2007. 2. Yancy C. Ethn Dis. 2002;12:S1  S26. 3. Taylor AL, et al. N Engl J Med. 2004;351:2049  2057. 4. Yancy CW, Sica DA. J Clin Hypertens (Greenwich). 2004;6:54  58. 5. Shekelle O. J Am Coll Cardiol. 2003;4141:1529-1538.

5. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 5 Study Objective We sought to examine the characteristics, quality of care, and clinical outcomes for a large cohort of African-American patients hospitalized with heart failure (HF) in centers participating in a quality improvement initiative.

6. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 6 OPTIMIZE-HF Program Objectives OPTIMIZE-HF is a national performance improvement initiative to improve guidelines adherence in patients hospitalized with HF Overall OPTIMIZE-HF program objectives: –Improve medical care and education of patients hospitalized with HF –Accelerate initiation of HF evidence-based, guideline- recommended therapies by starting these therapies before hospital discharge in appropriate patients without contraindications –Increase understanding of barriers to use of ACEIs,  -blockers, and other guideline-recommended therapies in eligible HF patients

7. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 7 OPTIMIZE-HF Process-of-Care Intervention and Registry “Process-of-care” intervention –Enhanced inpatient HF care and education –Enhanced discharge planning –Care maps, pathways, and standardized order sets that encouraged adoption of evidence-based therapies ACEI and  -blocker initiation before discharge JCAHO performance indicators –Educational programs to encourage adoption by providers Web-based registry –Tracks treatment rates and changes following performance interventions –Captures JCAHO/ORYX Quality of Care indicators –Benchmarks comparisons between institutions –Enhances understanding of barriers to uptake

8. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 8 OPTIMIZE-HF Performance Improvement Registry Protocol Eligibility –Adults hospitalized for episode of new or worsening HF as primary cause of admission, or with significant HF symptoms that develop during hospitalization when the initial reason for admission was not HF –Includes patients with systolic dysfunction and/or isolated diastolic dysfunction (HF with preserved systolic function) –Any admission satisfying JCAHO HF core measure criteria Prespecified subgroup (10%) with 60–90-day follow-up data –Survival, readmissions, and medical regimen –Informed consent required for follow-up The registry coordinating center was Outcome Sciences, Inc

9. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 9 OPTIMIZE-HF Hospital Characteristics Total Hospitals (N=259), n (%) Follow-Up Hospitals (N=91), n (%) Bed size: 0 to 9931 (12)9 (10) 100 to 24958 (22)21 (23) 250 to 499103 (40)40 (44) 500 to 74938 (15)13 (14)  750 13 (5)4 (4) Unknown16 (6)4 (4) Academic*118 (48)48 (55) Transplant program*34 (14)9 (10) Interventional † (CABG/PCI)163 (67)62 (70) Region ‡ : Midwest68 (27)27 (30) Northeast44 (17)14 (16) South87 (34)34 (38) West56 (22)15 (17) * N=246, n=88; † N=245, n=88; ‡ N=255, n=90. CABG/PCI = coronary artery bypass graft/percutaneous coronary intervention.

10. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 10 OPTIMIZE-HF Patient Characteristics Hospital Cohort (N=48,612) Follow-Up Cohort (N=5,791) Age, mean (years)73.172.0 Male (%)4851 Caucasian (%)7478 Ischemic etiology (%)4642 LVEF, mean (%)39.036.9 LVSD (% of those assessed)48.853.2 Insulin-treated diabetes (%)17 Non–insulin-treated diabetes (%)2526 Hypertension (%)7172 Rales (%)6462 Mean SBP (mmHg)143140 Mean heart rate (bpm)8786 Mean sodium (mEq/L)136.7136.8 Mean serum creatinine (mg/dL)1.81.7 Mean hemoglobin (g/dL)12.112.2

11. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 11 HF Etiology by Race Hypertensive Etiology Other*Ischemic Etiology *Other etiologies include postpartum, valvular, familial, alcohol/other drug, other, chemotherapy, unknown/idiopathic, and viral. P .0001 between both groups for each etiology.

12. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. Patient Characteristics by Race Characteristic African American (n=8,608) Non-African American (n=38,581)P Value Mean Age, years (SD) 63.6 (15.4)75.3 (12.7)  0.0001 Female (%) 52.751.40.0287 Hypertensive Etiology (%) 39.219.3  0.0001 Ischemic Etiology (%) 29.549.4  0.0001 Mean LVEF % (SD) 35.4 (17.8)39.7 (17.5)  0.0001 LVSD (LVEF <40% or moderate/severe LVD; %) 56.947.1  0.0001 Hyperlipidemia (%) 24.733.8  0.0001 Cigarette Smoker Within Past Year % 27.314.2  0.0001

13. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 13 Patient Lab and Exam Findings by Race Characteristic African American (n=8,608) Non–African American (n=38,581)P Value Mean admission weight, kg (SD) 90.7 (30.0) 80.8 (25.0) .0001 Mean weight change, kg (SD)  2.59 (5.33)  2.53 (4.67).4332 Mean admission SBP, mmHg (SD) 153.06 (35.98)140.34 (31.73) .0001 Mean admission HR, bpm (SD) 90.27 (20.85)85.76 (21.48) .0001 JVD (%) 36.931.6 .0001 Rales (%) 63.764.0.5493 Mean serum creatinine (mg/dL) 1.8 (1.3)1.6 (1.0) .0001 Mean hemoglobin (g/dL) 12.0 (2.1)12.1 (2.0) .0001

14. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 14 Diagnostic Studies and Procedures by Race Characteristic African American (n=8,608) Non–African American (n=38,581) P Value Patients with BNP measured (%) 4,349 (50.5)26,086 (67.6) .0001 Median BNP, pg/mL (IQR) 965 (450, 2130)785 (403, 1,600) .0001 Median troponin I, ng/mL (IQR) 0.2 (0.1, 0.5)0.1 (0.0, 0.3) .0001 Left heart catheterization (%) 10.18.5 .0001 Coronary artery bypass graft (%) 0.41.0 .0001 Dialysis (%) 9.04.2 .0001

15. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 15 P=.0003 P<.0001 P .0001 Complete Discharge Instructions LVEF Assessed Discharge ACEI Smoking Cessation Advice HF Measures at Hospital Discharge by Race African American Non  African American

16. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 16 Use of Evidence-Based HF Therapy at Discharge by Race P=.1178 P<.0001 P=.2250 P<.0001 P=.6744 P<.0001 ACEI/ ARB  -Blocker StatinAldosterone Antagonist WarfarinHydralazineNitrate ACEI/ARB, β-blocker, aldosterone antagonist, hydralazine, and nitrate use in eligible patients with LVSD; statin in coronary artery disease, cerebrovascular accident/transient ischemimc attack, diabetes, hyperlipidemia, and/or peripheral vascular disease; and warfarin use in patients with atrial fibrillation. Hydralazine/ Isosorbide Dinitrate P=.0001 African American Non  African American

17. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. Independent Association of African American Race and Quality of Care Performance MeasureOdds Ratio 95% Confidence IntervalP Value HF-1 Delivery of HF discharge instructions 1.020.94-1.100.701 HF-2 Left ventricular function assessment 1.191.05-1.340.007 HF-3 ACEI at discharge1.181.01-1.390.039 HF-4 Smoking cessation counseling 0.870.75-1.020.093 ACEI or ARB at discharge1.160.97-1.390.104  -Blocker 0.890.71-1.110.292

18. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 18 In-Hospital and Follow-Up Outcomes in HF Patients With LVSD by Race P=.0025 P<.0001 Length of Stay (days) In-Hospital Mortality (%) 93/ 4,212 670/ 15,365 60- to 90-Day Rehospitalization 60- to 90-Day Mortality P=.0164 P=.0549 Patients (%) 191/ 560 616/ 2,133 35/ 553 183/ 2,060 African American Non  African American

19. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 19 In-Hospital and Follow-Up Outcomes in HF Patients Without LVSD by Race P=.2532 P<.0001 Length of Stay (days) In-Hospital Mortality (%) 60- to 90-Day Rehospitalization 60- to 90-Day Mortality P=.1166 P=.2918 Patients (%) 49/ 3,187 539/ 17,283 93/ 360 603/ 2,015 23/ 353 159/ 1,947 African American Non  African American

20. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. Multivariable Mortality Analyses by Race In-Hospital Mortality Odds Ratio 95% Odds Ratio Confidence LimitsP Value Race (African American)0.710.570.87<0.001 Follow-Up Mortality Hazard Ratio 95% Odds Ratio Confidence LimitsP Value Race (African American)1.120.801.580.508

21. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 21 Limitations The present observations include only hospitalized patients with HF, a population known to be at increased risk of adverse outcomes Race was not a self-reported variable but rather was determined as that documented in the medical record, thus errors in racial determination could have occurred. Follow-up data were collected only from a pre-specified subset of patients and extended only 60 to 90 days Despite extensive covariate and propensity adjustment, residual confounding cannot be excluded, thus may only be demonstrating associations, rather than cause-and- effect relationships

22. Yancy et al. J Am Coll Cardiol. 2008;51:1675  84. 22 Conclusions African-American HF patients, when exposed to a process-of-care improvement initiative, had better-than- previously observed treatment with evidence-based therapies. African-American HF patients when treated according to guidelines had similar or better outcomes compared with non–African-American patients. The OPTIMIZE-HF program suggests that an in-hospital process-of-care improvement program might help to achieve similar conformity with quality measures for African Americans with HF.