1. Quality of care, part 2: heart failure Kim A Eagle MD Albion Walter Hewlett Professor of Internal Medicine Chief, Clinical Cardiology Co-Director, Heart Care Program University of Michigan Ann Arbor, MI William T Abraham MD, FACP, FACC Professor of Medicine Chief, Division of Cardiology University of Kentucky College of Medicine Lexington, KY

2. Heart failure is the most rapidly growing form of cardiovascular disease in the US and in developed countries. Hospitalization for heart failure has become a major issue for the practitioner and for the healthcare planner. Heart failure (DRG 127) is now the most common discharge diagnosis for those over 55 years. Heart failure has recently become the fourth leading cause of hospitalization for all US adults. Hospitalization Heart failure

3. Primary goals of acute hospitalization for decompensated heart failure are not routinely measured in clinical trials or surveys of hospitalized patients for heart failure alleviation of symptoms achievement of a more compensated state Measures that can be objectively assessed from the medical record are used to assess quality of care use of appropriate medical therapy for the treatment of heart failure where the index drug has been an ACE inhibitor length of stay early (30–90 day) readmission rate Measuring quality-of-care indicators

4. In-hospital treatment Many of the drugs used in the treatment of heart failure (AIIAs for patients intolerant to ACE, beta blockers and aldactone) are more appropriate in outpatient settings. An optimal drug regimen cannot be achieved during a 5- or 6-day hospitalization for heart failure. Diuretics and ACE inhibitors are an appropriate therapy for hospitalized patients. Additional medications that take time to initiate and titrate to target doses are more appropriate in the outpatient environment. Appropriate drug therapy

5. Improving documentation LVEF helps distinguish systolic heart failure from heart failure associated with preserved LVF. EF documentation should be included in the medical record. In a survey sponsored by the University Health Systems Consortium evaluating more than 1450 hospitalized patients with heart failure, disease severity as assessed by NYHC and LVEF was rarely included in the medical record during index hospitalization. Ejection fraction

6. In-hospital treatment The 2 most important benchmarks during hospitalization for heart failure are EF and whether the patient was placed on an ACE inhibitor. Ideally, more patient-oriented measures of quality of care should be used  disease-specific measures of quality of life  patient satisfaction  specific scales for assessing improvement in symptoms Patient-specific benchmarks

7. Outpatient care The simplest measure for assessing quality of care for outpatients is appropriateness of drug therapy. There is a growing list of effective pharmacologic therapies for heart failure. Nonpharmacologic treatments are as important as drug therapy  adequate patient education  self-monitoring of daily weight by patients  tracking patient compliance with pharmacologic and nonpharmacologic treatment  understanding and complying with a low- sodium diet Assessing quality

8. Heart failure management Pharmacologic therapy  diuretic therapy, particularly for patients retaining fluid  ACE inhibitors  beta blockers Process of care issues  patient education  low-sodium diet  self-monitoring of daily weight Practical strategies

9. Improving quality Develop a structured approach to heart failure care that includes an advocate for the patient who can help integrate their care. There are many examples of heart failure care that substantially reduce the incidence of hospitalization or rehospitalization and improve care  pharmacist-directed initiatives  nurse-directed initiatives  nurse-practitioner-directed initiatives  primary-care-directed initiatives  cardiologist-directed initiatives Do something

10. Improving quality Heart failure clinics providing specialized or focused care for heart failure patients Community-based case management for outpatients with heart failure Tele-management — improve patient satisfaction and quality of life and reduce the need for hospitalization Hospital-sponsored cardiac rehabilitation A multidisciplinary team approach to disease management Process-of-care improvements

11. Creating partnerships Advantages of partnering with local or community hospitals to provide services  better patient care  benchmarks in heart failure care are more easily achieved  length of stay and early readmission rates are reduced  infrastructure necessary for heart failure management can be established Pooling resources

12. The electronic age Physician performance will be increasingly scrutinized as healthcare moves into the electronic arena. In the future, everything physicians do will be tracked electronically in real time and immediate feedback will be provided. Continual feedback will lead to a better standard of care. Access to computer-based programs, protocols, and algorithms for care will be patient-specific rather than general. Increased scrutiny

13. The future of care Tele-management or remote management of patients will be more common. New devices will allow monitoring of patients in their homes either in an episodic or a moment-to- moment fashion. New schemes for reimbursing remote management and data management services will be required. Process-of-care improvements will be rewarded. In the long run, process-of-care improvements may be a better (more economical) fit even to community practices. Changes in process

14. Evolution of care Heart failure is going to continue to be a growing problem and burden for the healthcare system. Changes to the management of patients are inevitable. Process-of-care improvements should be put into practice before they are mandated. If physicians want to influence the system for defining and measuring quality in the future, participation in developing processes is essential. Participation is key