2. Target: Heart Failure Building on Success
A national initiative of the American Heart Association that provides healthcare professionals with content-rich resources and materials designed to help advance heart failure awareness, prevention, and treatment.
Building on Success
GWTG-Heart Failure
Mission: Lifeline
OPTIMIZE-HF
Joint Commission/AHA Heart Failure Advanced Certification Program
The Guideline Advantage
4/13/2017
©2010, American Heart Association

3. The Need
5.7 million Americans are currently living with heart failure, and 670,000 new cases are diagnosed each year- up significantly from 500,000 cases annually just a few years ago.
As our population ages, this epidemic of heart failure will only continue to grow. The cost of providing heart failure ranks among the leading U.S. healthcare expenditures.
Additionally, the toll of heart failure on life, both in quality and longevity, is sobering.
4/13/2017
©2010, American Heart Association

4. What is Target: Heart Failure ?
A national initiative of the American Heart Association that provides healthcare professionals with content-rich resources and materials designed to help advance heart failure awareness, prevention, and treatment.
4/13/2017
©2010, American Heart Association

5. Target: Heart Failure Vision:
To improve quality, care transitions, and outcomes for patients with heart failure with a targeted initiative and leveraging the American Heart Association’s premier quality improvement suite of resources including Get With The Guidelines-Heart Failure.
4/13/2017
©2010, American Heart Association

6. Target: Heart Failure Mission:
Increase 3 key patient-centered care domains with very well established or emerging evidence-base:
Medication optimization
Early follow-up and care coordination
Enhanced patient education
4/13/2017
©2010, American Heart Association

7. Target: HF Optimal Care Transitions and Patient Education:
Discharge use of ACEI/ARB, evidence-based beta blocker, and aldosterone antagonist in all eligible heart failure patients with reduced LVEF, in absence of documented contraindications, intolerance, or patient/system reasons
Early post-discharge follow-up with visit or contact within 48 hours of discharge scheduled
Enhanced patient education as evidenced by referral to heart failure disease management program, provision of at least 60 minutes of heart failure education by a qualified heart failure educator, or provision of AHA heart failure interactive workbook
4/13/2017
©2010, American Heart Association

8. Building on Success GWTG-Heart Failure Mission: Lifeline
Joint Commission/AHA Heart Failure Advanced Certification
OPTIMIZE-HF
The Guideline Advantage
4/13/2017
©2010, American Heart Association

9. Background on Heart Failure
Population Group
Prevalence
Incidence
Mortality
Hospital Discharges
Cost
Total population
5,700,000
670,000
277,193
990,000
$39.2 billion
Heart failure (HF) is a major public health problem resulting in substantial morbidity and mortality
Despite recent advances a substantial number of patients are not receiving optimal care
2Jones DL et al. Heart Disease and Stroke Statistics 2011 Update. Report from the AHA . Circulation.2011. 9 9

10. Heart Failure Hospitalizations
1.0 Million Hospitalizations a Year and Rising
30-Day
Rehospitalization
Rates in HF
24.8%
(Medicare)
The majority of patients hospitalized with HF were previously hospitalized with HF 10
United States: Source: NHDS/NCHS , NHLBI. Hospital Compare

11. 30-Day Rehospitalization Rates in HF Vary Widely Between Hospitals
X axis, hospital decile, 0-9
Y axis, mean hospital observed rates for 30-day rehospitalization from 0 to .40 11
Keenan PS et al. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.

12. All-Cause Mortality After Each Subsequent Hospitalization for HF
1.0 HF
1st admission (n = 14,374)
2nd admission (n = 3,358)
3rd admission (n = 1,123)
4th admission (n = 417)
P<0.0001
0.8
0.6
Cumulative mortality
0.4
0.2
1st hospitalization: 30-day mortality = 12%; 1-year mortality = 34%
0.0
0.0
0.5
1.0
1.5
2.0
Time since admission
Setoguchi S, et al. Am Heart J. 2007;154: 12

13. Estimated Direct and Indirect Costs of HF in US
Total Cost $39.2 billion
Hospitalization $20.9
53.3%
Nursing Home $4.7
11.9%
6.4%
10.5%
Physicians/Other Professionals $2.5
8.2%
Lost Productivity/ Mortality* $4.1
9.7%
Drugs/Other Medical Durables $3.2
Home Healthcare $3.8 13
Heart Disease and Stroke Statistics—2010 Update: A Report From the American Heart Association Circulation, Feb 2010; 121: e46 - e215. 13

14. Causes of Hospital Readmission for Heart Failure
Over 2/3 of HF Hospitalizations Preventable
Diet Noncompliance
24%
Rx Noncompliance
24%
16%
Inappropriate Rx
17%
Other
19%
Failure to Seek
Care 14
Annals of Internal Medicine 122:415-21, 1995 14

15. Measuring and Improving the Quality of HF Care
Heart failure remains a major public health problem resulting in substantial morbidity and mortality.
A number of evidence-based, guideline-recommended therapies are available to treat patients with heart failure.
However, study after study shows the large gaps, variations, and disparities in the use of these evidence based therapies in eligible patients. 15 15

16. ADHERE Quality of Care Conformity to The Joint Commission HF Performance Indicators
Lagging Centers
Leading Centers
All P<0.0001
% Utilization
Discharge
Instructions
LV Function
Measurement
ACEI use
Smoking
Cessation
Length of Stay
(median)
Mortality
admissions between 6/2002 – 12/2003 at 223 hospitals
Grouped by Leading (90th percentile) and Lagging (10th percentile) 16
Fonarow GC et al. Arch Intern Med 2005;165:

17. Risk-Treatment Mismatch in HF: Canadian EFFECT Study
At Hospital Discharge
90-Day Follow-Up
1-Year Follow-Up 90 80 70 60
Patients, % 50 40 30 20 10
ACEI
ACEI or ARB
-Blocker
ACEI
ACEI or ARB
-Blocker
1-Year Mortality Rate
Low Risk
Average Risk
High Risk
Use rates in absence of contraindications. For all drug classes, P < .001 for trend.
EFFECT, Enhanced Feedback for Effective Cardiac Treatment. Lee D. JAMA. 2005;294: 17

18. Evidence-Based Treatment for Heart Failure with Reduced LVEF
Reduce Mortality
Control Volume
ACEI
or ARB
Aldosterone
Antagonist
Sodium Restriction*
Diuretics*
-Blocker
Treat Residual Symptoms
CRT 
an ICD*
ICD*
Hyd/ISDN*
Digoxin*
Enhance Adherence
Treat Comorbidities
Education
Disease Management
Performance Improvement Systems
Aspirin*
Warfarin*
Statin* 18
*For select indicated patients.

19. Established Benefits of Guideline-Recommended HF Therapies
Guideline Recommended Therapy
Relative Risk Reduction in Mortality
Number Needed to Treat for Mortality
NNT for Mortality (standardized to 36 months)
Relative Risk Reduction in HF Hospitalizations
ACEI/ARB
17%
22 over 42 months 26
31%
Beta-blocker
34%
28 over 12 months 9
41%
Aldosterone Antagonist
30%
9 over 24 months 6
35%
Hydralazine/Nitrate
43%
25 over 10 months 7
33%
CRT
36%
12 over 24 months 8
52%
ICD
23%
14 over 60 months 23 NA
Fonarow GC, et al. Am Heart J 2011;161: 19

20. Improved Adherence to ACC/AHA HF Guidelines Translates to Improved Clinical Outcomes in Real World HF Patients
Each 10% improvement in ACC/AHA guideline- recommended composite care was associated with a 13% lower odds of 24-month mortality (adjusted OR 0.87; 95% CI, 0.84 to 0.90; P<0.0001).
Fonarow GC, et al. Circulation. 2011;123:

21. Bridging the Gap Between Knowledge and Routine Clinical Practice
ACC/AHA/HFSA Guidelines
Systems
Clinical Practice
Clinical guidelines, implemented through critical pathways in the hospital and at discharge, help bridge any potential gaps and provide a smooth transition between acute care and long-term management. Implementing guideline-based critical pathways will:
Optimize patient triage
Ensure appropriate use of proven medications and treatments
Facilitate communication between specialist physicians and PCPs during hospitalization and after discharge
Enhance patient compliance and outcomes
Reduce the potential for medical errors
Reduce costs by limiting length of stay and unnecessary testing
Improve compliance with national standards (such as the Joint Commission on Accreditation of Healthcare Organizations [JCAHO])
Cannon CP, O’Gara PT. Critical Pathways in Cardiology. Lippincott Williams & Wilkins; 2001.
Implement evidence-based care
Improve communications
Ensure compliance
Clinical trial evidence
National guidelines
Improve quality of care
Improve outcomes
Adapted from the American Heart Association. Get With The Guidelines; 2001. 20

22. ACC/AHA 2005 HF Guidelines: Implementation of Guidelines
Academic detailing or educational outreach visits are useful to facilitate the implementation of practice guidelines
Multidisciplinary disease-management programs for patients at high risk for hospital admission or clinical deterioration are recommended
Chart audit and feedback of results can be effective to facilitate implementation of practice guidelines
The use of reminder systems can be effective to facilitate implementation of practice guidelines
The use of performance measures based on practice guidelines may be useful to improve quality of care I
IIa
IIb
III A I
IIa
IIb
III B
Hunt SA, et al. ACC/AHA 2005 Practice Guidelines. Available at 21

23. American Heart Association’s Get With the Guidelines–Heart Failure
The AHA’s hospital based quality-improvement program aims at ensuring that every patient with HF receives the best possible care
Continuity of data and hospital tools with OPTIMIZE-HF
Launched January 2005; currently over 500 US hospitals participating, over 500,000 patient HF hospitalizations
Opportunity for hospitals to achieve national recognition through participation
Opportunity for advanced heart failure certification via The Joint Commission 22

24. GWTG-HF Performance Measures
All p<0.0001
May 2011
Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from 1/1/05-12/31/10 23

25. GWTG-HF Performance Measures
All p<0.0001
Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from 1/1/05-12/31/10
May 2011 24

26. GWTG-HF Performance Measures
All p<0.0001
Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from 1/1/05-12/31/10
May 2011 25

27. GWTG-HF Participation and Quality of Care for Heart Failure
Measure
GWTG
Hospitals
(n=355)
Non-GWTG Hospitals
(n=3909)
P-Value
LVEF documented
92.8%
83.0%
<0.0001
ACEI/ARB in LVSD
85.6%
81.4%
0.001
Discharge Instructions
67.7%
55.3%
<0.001
Smoking Cessation Counseling
85.7%
81.3%
0.04
Heidenreich PA et al Am Heart J 2009;158:546-53

28. Impact of Evidence-Based HF Therapy Use at Hospital Discharge on Treatment Rates During Follow-Up
60- to 90-Day Postdischarge Follow-Up
OR 30.6
(95% CI, )
P.0001
OR 10.22
(95% CI )
P.0001
-Blocker at Discharge
YES
-Blocker at Discharge NO
ACEI/ARB at Discharge
YES
ACEI/ARB at Discharge NO
(1,579/1,697)
(94/309)
(1,329/1,861)
(75/382) 26
Fonarow GC et al. J Card Fail 2007;13:722-31

29. Days After Hospital Discharge
Impact of Discharge Use of Beta Blocker on Early Clinical Outcomes in Heart Failure
30 day Survival
P<0.01
1.00
P=0.0003
0.95
0.90
Survival Probability
0.85
0.80
0.75
Beta-Blocker
No Beta-Blocker
0.70 10 20 30 40 50 60 70 80 90
100
110
120
130
Days After Hospital Discharge
Patients at Risk
Beta-blocker
1,946
1,855
1,649
333 68
No Beta-blocker
362
337
304 60 7
*Only subset of patients with 60- to 90-day follow-up are included. Patients with beta-blocker contraindications are excluded.
Fonarow et al. J Am Coll Cardiol. 2008;52: 27

30. In-Hospital and Follow-Up Outcomes Improve When Process of Care Tools are Used: OPTIMIZE-HF
60- to 90-Day Mortality and Rehospitalization
In-Hospital Mortality
P<.02
P.001
Patients (%)
PrCI Tool Use
No PrCI Tool Use
PrCI Tool Use
No PrCI Tool Use
Process of care tool use (admission order set or discharge checklist) was reported during hospitalization in 45.3% of patients (n=22,017/48,612)
Fonarow GC, et al. Arch Intern Med. 2007;167:14931502. 28

31. 4/13/2017
©2010, American Heart Association

32. GWTG-HF Results in Equitable Care
With few exceptions, individual HF core measures were similar for Black, Hispanic, and White patients. When there were differences in core measures, they predominantly favored nonwhite subgroups
Unadjusted
Thomas K et al. Am Heart J. 2011;161:746-54 30

33. GWTG-HF Resulted in Equitable Improvement by Race/
Ethnicity in HF Quality
Trends in “All-or-None HF Care Measure* by Race/Ethnicity
Unadjusted
Odds Ratio
Adjusted**
White (Year 1 vs. Baseline)
1.60
1.55
White (Year 2 vs. Baseline)
2.34
2.29
White (Year 3 vs. Baseline)
3.07
3.04
Black (Year 1 vs. Baseline)
1.70
1.74
Black (Year 2 vs. Baseline)
2.32
2.40
Black (Year 3 vs. Baseline)
3.18
3.28
Hispanic (Year 1 vs. Baseline)
1.43
1.39
Hispanic (Year 2 vs. Baseline)
2.00
Hispanic (Year 3 vs. Baseline)
2.48
2.46
*”All-or-None HF Care Measure” = 100% adherence to al 4 HF care measures plus B-Blocker use in patients with LV systolic dysfunction
**Adjusted variables include age, gender, body mass index, insurance, medical history, systolic blood pressure and hospital characteristics
Thomas K et al. Am Heart J. 2011;161:746-54 31

34. Hospital Variation in Early Follow-up After
Heart Failure Hospitalization
Median Follow-up
Visit within
7 days = 37.5%
225 Hospitals
Hernandez et al. JAMA 2010;303: 32

35. Hospital Variation in Early Follow-up After HF
Hospitalization: Follow-up by Physician Type
Hernandez et al. JAMA 2010;303:

36. Relationship Between Early Physician Follow-up and 30-day Outcomes for Medicare Beneficiaries
30-Day Mortality p= 0.44
30-Day Readmission p <0.01
Hernandez et al. JAMA 2010;303:

37. Relationship Between Early Physician Follow-up and 30-day Readmission Among Medicare Beneficiaries Hospitalized for HF
Early Follow-up
Unadjusted HR
95% CI P
Value
Adjusted HR
Quartile 1
1.0 (REF)
Quartile 2
0.86
<.01
0.85
<01
Quartile 3
0.87
Quartile 4
0.91
.05
Hospitals in the lowest quartile of early physician follow-up had higher
rates of rehospitalization within 30-days, than those in the other 3 quartiles, independent of other factors 33
Hernandez et al. JAMA 2010;303:

38. Rehospitalizations in Heart Failure
Nearly one in four patients hospitalized with HF is rehospitalized within 30 days of discharge
Opportunity to Improve
30-day rates of rehospitalizations in HF have risen over the past 2 decades and vary widely by hospital, even after adjusting for case mix and other factors
Many HF hospitalizations are preventable, but effective strategies to prevent rehospitalizations are underutilized 34

39. Get With The Guidelines® Heart Failure Clinical Tools Library
Over 60 heart failure tools, including:
Discharge Orders/Instructions
Order Sets
Pathways/Algorithms
Patient Education Materials
Other Tools
All posted submissions were reviewed/evaluated by AHA volunteer workgroup.
AHA does not endorse any tools. Submissions are intended solely as examples that hospitals may want to consider using/modifying.
Heart failure clinical tools library: heart.org/hfclinicaltools.
Stroke clinical tools library: heart.org/strokeclinicaltools.
Submit tools you would like us to consider to 37

40. AHA Interactive Workbook to help educate patients
and help them manage Heart Failure.
Created for after the patients hospital stay, the interactive workbook focuses on preventing recurring events.  The workbook helps improve patient health and track recovery.  These workbook are designed to help the patient better understand their condition, how to maximize their recovery and provide the skills to the patient and their caregivers need to better manage heart failure. 

41. Challenges to Implement a HF Performance Improvement System
This will not work in a community practice or hospital.
The cardiologists will not agree to this.
We can not get a consensus.
The managed care organization will not pay for it.
Patients do not want to be on a lot of medications.
There is not enough time.
It will cost too much.
It may not be safe to start Beta Blocker medications in heart failure patients.
This will benefit the competition.
The administration will not pay for it.
What about the liability?
It will take too much time.
All my patients are too complex for this.
The patients should all be followed by someone else.
It is too hard to get things through the practice committee.
The physicians at my office do not like cookbook medicine.
We do not have anyone to do this. 38

42. Key Elements to Quality Improvement: Why Do Some Programs Succeed?
Access to current and accurate data on treatment and outcomes
Have stated goals
Administrative support
Support among clinicians
Use of care maps and pathways
Use of data to provide feedback
Bradley. JAMA. 2001;285: 39

43. Potential Impact of Optimal Implementation of Evidence-Based HF Therapies on Mortality
Guideline Recommended
Therapy
HF Patient Population Eligible for Treatment, n*
Current HF Population Eligible and Untreated, n (%)
Potential Lives Saved per Year
(Sensitivity Range*)
ACEI/ARB
2,459,644
501,767 (20.4)
6516
( ,260)
Beta-blocker
2,512,560
361,809 (14.4)
12,922
( ,329)
Aldosterone Antagonist
603,014
385,326 (63.9)
21,407
(10,960-36,991)
Hydralazine/Nitrate
150,754
139,749 (92.7)
6655
( ,500)
CRT
326,151
199,604 (61.2)
8317
( ,372)
ICD
1,725,732
852,512 (49.4)
12,179
( ,045)
Total -
67,996
(34, ,497)
Fonarow GC, et al. Am Heart J 2011;161:

44. Target: Heart Failure Honor Roll Recognition
Requirements: Documentation of all three care components for 50% or more of eligible patients with heart failure discharged to home. Hospitals must be GWTG-HF performance achievement award hospitals.
4/13/2017
©2010, American Heart Association

45. Target: Heart Failure Resources
Get With The Guidelines-Heart Failure
Patient Management Tool™
Get With The Guidelines Heart Failure Tool Kit
AHA patient education resources
Heart Failure Best Practices Center
Heart Failure Interactive Patient Education Workbook
Heart Failure guidelines, publications, and resources
Heart 360
4/13/2017
©2010, American Heart Association 41

46. For more information and to register for Target: Heart Failure, go to www.heart.org/targethf.
4/13/2017
©2010, American Heart Association