Guidelines For Congestive Heart Failure Research Articles

931. Congestive Heart Failure in Persons Living with HIV: Are we providing standard of care?

BackgroundWith antiretroviral therapy, Human Immunodeficiency Virus (HIV) infection has become a life-long chronic condition. Persons Living with HIV (PLWH) have increased risk of cardiovascular diseases including congestive heart failure (CHF) and increased morbidity and mortality from these diseases due to factors such as HIV-induced chronic inflammation. This study will assess if providers at University Hospital in Newark, NJ are providing standard of care for CHF in PLWH.MethodsThis study was approved by Rutgers IRB (Pro2020000391). A database of 154 charts including all patients with diagnoses of both HIV and CHF was generated using ICD-10 codes for HIV and CHF. After screening, 79 patient charts were eligible. Patients were excluded if their CHF was managed elsewhere, if they were misdiagnosed or deceased. Nine were diagnosed with heart failure with preserved ejection fraction (HFpEF) defined as an ejection fraction above 50%. Seventy were diagnosed with heart failure with reduced ejection fraction (HFrEF) defined as an ejection fraction below 40%. Treatment was assessed using the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines.Recommendations for treatment of HFrEF Recommendations for treatment of HFpEF ResultsFor patients with HFrEF, 10% of eligible patients were not prescribed aldosterone antagonists due to an incorrect contraindication. Thirty eight percent of patients requiring consideration for device therapy were not considered. Fourteen percent of patients did not have NYHA/ACC/AHA class documented. Three additional charts were found to not follow class-based management. Thirty five percent of patients with hypertension did not have guideline-based titrated therapy. In terms of HFpEF, 43% of patients did not have proper hypertension treatment.Heart Failure with Reduced Ejection Fraction Heart Failure with Preserved Ejection Fraction ConclusionAdherence to evidence-based guidelines for CHF in PLWH is important due to their increased risk of mortality and morbidity. Improvements such as documentation of heart failure class, contraindications to medications, and consideration for devices may improve outcomes going forward.Disclosures All Authors: No reported disclosures

A Medical Director’s Perspective: Influencing Rehospitalization Rates

A Medical Director’s Perspective: Influencing Rehospitalization Rates

Sepsis mandates: improving inpatient care while advancing quality improvement.

Sepsis mandates: improving inpatient care while advancing quality improvement.

Rate Control Is a Better Initial Treatment for Patients With Atrial Fibrillation and Heart Failure - Rhythm Control vs. Rate Control: Which Is Better in the Management of Atrial Fibrillation? (Rate-Side) -

Congestive heart failure (CHF) and atrial fibrillation (AF) often coexist, and each increase the morbidity and mortality associated with the other. Until now, many studies have reported that a strategy of rate control, in combination with anticoagulation in patients at risk of thromboembolic events, appears to be at least equivalent to a strategy of maintaining sinus rhythm with currently available pharmacological therapeutic options. As compared to rhythm control therapy, rate control treatment is simple and relatively easy. Therefore, pharmacological rate control should be considered initially in patients with AF associated with CHF. However, cardiac symptoms associated with AF may continue after achieving reasonable ventricular rate control. Either pharmacological or non-pharmacological rhythm control needs to be considered at that time. Amiodarone is the only recommended antiarrhythmic drug in the recent therapeutic guidelines for CHF, and can be used for both rhythm and rate control of AF. However, there is no question that some patients require early non-pharmacological rhythm control instead of long-lasting rate control. Catheter ablation (CA) can be applicable even in AF associated with CHF, but the results of CA are closely associated with the clinical and electrophysiological characteristics in each patient, as well as with the experience with this procedure in each institution. Indications for and the appropriate period of CA need to be carefully examined in each individual.

Adoption of Order Entry with Decision Support for Chronic Care by Physician Organizations

ObjectiveThis study sought to explore physician organizations’ adoption of chronic care guidelines in order entry systems and to investigate the organizational and market-related factors associated with this adoption. DesignA quantitative nationwide survey of all primary care medical groups in the United States with 20 or more physicians; data were collected on 1,104 physician organizations, representing a 70% response rate. MeasurementsMeasurements were the presence of an asthma, diabetes, or congestive heart failure guideline in a physician organization’s order entry system; size; age of the organization; number of clinic locations; type of ownership; health maintenance organization market penetration; urban/rural location; and presence of external incentives to improve quality of care. ResultsOnly 27% of organizations reported access to order entry with decision support for chronic disease care. External incentives for quality is the only factor significantly associated with adoption of these tools. Organizations experiencing greater external incentives for quality are more likely to adopt order entry with decision support. ConclusionBecause external incentives are strong drivers of adoption, policies requiring reporting of chronic care measurements and rewarding improvement as well as financial incentives for use of specific information technology tools are likely to accelerate adoption of order entry with decision support.

Strengthening condition-specific evidence-based home healthcare practice.

The home health industry has lagged in adopting evidence-based care but is now well positioned to adopt such practices. However, few clinical practice guidelines have been developed for the home healthcare setting. This paper reviews the existing evidence base for prevalent home healthcare diagnoses and conditions and the progress made in applying those practices in home healthcare. Existing guidelines for congestive heart failure, diabetes, chronic obstructive pulmonary disease, falls, osteoarthritis, depression, and medication management could be modified for applicability to home healthcare. The evidence for a number of home healthcare practices is robust enough to argue for widespread dissemination and implementation.

What factors influence provider knowledge of a congestive heart failure guideline in a national health care system?

Provider knowledge is a potential barrier to adherence to clinical guidelines. The purpose of this study is to assess the impact of organizational, provider, and guideline factors on provider knowledge of a congestive heart failure (CHF) clinical practice guideline (CPG) in the Veterans Health Administration (VHA) health care system. We developed a survey to investigate institution-level factors influencing the effectiveness of guideline implementation, including characteristics of the guideline, providers, hospital culture and structure, and regional network. Survey participants were quality managers, primary care administrators, and other individuals involved in primary care CPG implementation at 143 VHA hospitals with ambulatory care clinics. Potential explanatory variables were grouped into 11 factors. Multivariate regression models assessed the association between these factors and reported levels of provider knowledge regarding the CHF guideline at the hospital level. Two hundred forty surveys from 126 of 143 (88%) VHA hospitals were returned. Provider knowledge of the CHF guideline was estimated as "great" or "very great" by 58% of respondents. Three predictor factors (dissemination approaches, use of technology in guideline implementation, and hospital culture) were independently associated (P < or = .05) with provider knowledge. Specific variables within these categories that were related to greater knowledge included physician belief that guidelines were applicable to their practice, distribution of guideline summaries, use of guideline storyboards in clinic areas, the use of technology (eg, electronic patient records) in CPG implementation, and establishment of implementation checkpoints and deadlines. Provider knowledge of guidelines is affected by factors at various organizational levels: dissemination approaches, use of technology, and hospital culture. Guideline implementation efforts that target multiple organizational levels may increase provider knowledge.

Specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure; the OSCUR study. Oucome dello Scompenso Cardiaco in relazione all'Utilizzo delle Risore.

This study was designed to identify potential specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for congestive heart failure in departments of cardiology or internal medicine. From 1 July to 31 December 1998, we prospectively recorded epidemiological and clinical data from patients with congestive heart failure consecutively admitted to 11 departments of cardiology and 12 departments of internal medicine in Liguria, a northern area of Italy. The overall study population included 749 patients; 22% were treated by cardiologists and 78% by internists (P<0.0001). Patients managed by cardiologists were more likely to undergo echocardiography (92% vs 37%), Holter monitoring (25% vs 3%) and exercise stress testing (20% vs 0.5%) than those managed by internists (P=0.001). At discharge, patients treated by cardiologists were more likely to be prescribed beta-blockers (41% to 4%) and ACE inhibitors (100% to 74%) than those treated by internists (P<0.0001), and the latter medication at higher dosages by cardiologists than internists. In addition, patients followed by cardiologists were younger (70+/-9 to 79+/-1 years;P<0.0001), more likely to be male (61% to 50%;P=0.011) and to have coronary artery disease (57% to 45%;P<0.006) than those followed by internists. Conversely, patients followed by internists were more likely to have diabetes, chronic obstructive pulmonary disease, atrial fibrillation and renal failure (P<0.03). In the overall study population, 53 patients (7%) died during hospitalization. Patients treated by cardiologists had a mortality not significantly different from that of patients treated by internists (10% and 6%, respectively;P=0.067), although congestive heart failure was more severe on admission in patients treated by cardiologists. Cardiologists follow published guidelines for congestive heart failure more strictly than internists, but treat a smaller number of patients who are younger, have more severe congestive heart failure and fewer co-morbidities than those managed by internists.

A Practical Approach to Evidence Grading

The Institute for Clinical Systems Improvement (ICSI) is a collaboration of 17 Minnesota medical groups. Among other activities, ICSI develops health care guidelines and technology assessment reports. To maintain focus on the underlying evidence, ICSI has developed an evidence and conclusion grading system for use by the practicing clinicians who write the documents and use them in making decisions about patient care. THE EVIDENCE GRADING SYSTEM IN DETAIL: The centerpiece of the evidence grading system is the conclusion grading worksheet, which calls for statement of a conclusion, summarization of research reports that support or dispute the conclusion, assignment of classes and quality markers to the research reports, and assignment of a grade to the conclusion. The system has been used in the writing of more than 40 guidelines and numerous technology assessment reports. An example of a worksheet from the congestive heart failure guideline is presented. The system has helped the drafting groups to attend to the evidence. The methods have proven to be well accepted by practicing physicians and to be practical, although staff expertise in epidemiology is needed to support the system. Grading of conclusions appears to be reliable, although this characteristic of the system has not been rigorously tested. The outputs are valued by users of the documents. Although some residual problems remain to be solved, the system appears to be successful in overcoming the complexity of some published systems for grading evidence while still yielding a defensible classification of conclusions based on the strength of the underlying evidence.

Differences Between Primary Care Physicians and Cardiologists in Management of Congestive Heart Failure: Relation to Practice Guidelines

Objectives. This study was designed to characterize physician practices in the management of congestive heart failure (CHF) and to determine whether these practices vary by specialty and how they relate to guideline recommendations.Background. Congestive heart failure is responsible for considerable mortality, morbidity and health care resource utilization. Although there have been important advances in the diagnostic evaluation and treatment of CHF, little information is available on physician practices in this area.Methods. We surveyed physicians concerning their management of patients with CHF. The results were analyzed in multivariate models to determine the relation of diagnostic and treatment approaches to physician specialty, time since training, board certification and volume of patients with CHF. Surveys were sent to a sample of 2,250 family and general practitioners (FP/GPs), internists and cardiologists. Responses were examined in relation to guidelines issued by the Agency for Health Care Policy and Research that had been released 9 months previously.Results. Significant differences were found between physician groups with regard to each of the major guideline recommendations. For example, routine evaluation of left ventricular function, a point of emphasis in the guideline, is performed by 87% of cardiologists, but by only 77% of internists and 63% of FP/GPs (p < 0.001 between groups). Angiotensin-converting enzyme inhibitors were used by cardiologists, internists and FP/GPs in 80%, 71% and 60% of patients with mild to moderate CHF, respectively (p < 0.001 between groups). Larger differences were reported in the prescribed dosages of these drugs and their use in patients with renal dysfunction.Conclusions. Cardiologists report practices more in conformity with published guidelines for CHF than do internists and FP/GPs. Because of the large numbers of patients with CHF and their substantial mortality, morbidity and cost of care, these differences may have a major impact on outcomes and health care costs.

A cardiologist's perspective on evolving concepts in the management of congestive heart failure.

The conceptual framework for treatment of congestive heart failure has changed dramatically in the past 30 years. The 1950s and 1960s were characterized by manipulation of the left ventricular function curve by digitalis and diuretics. The 1970s focused on relief of symptoms by afterload reduction with vasodilators. Then stimulation of cardiac output with inotropes was shown to relieve symptoms, but patients died sooner. Now the focus is on the neurohumeral milieu and methods to counteract excess renin-angiotensin and sympathetic nervous system stimulation. Angiotensin-converting enzyme inhibitors are the drugs of choice because they also improve survival, but beta-blockers are becoming popular. The effect of molecular cardiology on practice guidelines for congestive heart failure is yet to be seen.