Heart Failure Core Measures Research Articles

Management of Chemotherapy-Induced Left Ventricular Dysfunction and Heart Failure in Patients With Cancer While Undergoing Cancer Treatment: The MD Anderson Practice.

Chemotherapy-induced cardiotoxicity resulting in heart failure (HF) is one of the most dreaded complications of cancer therapy that can significantly impact morbidity and mortality. With a high prevalence of cardiovascular disease in cancer patients, the risk of developing HF is significantly increased. A new discipline of Onco-Cardiology has evolved to address the cardiovascular needs of patients with cancer, however, there is limited evidence-based data to guide clinical decision-making in the management of the cardiovascular complications of cancer therapy. The department of cardiology at MD Anderson Cancer Center initiated the MD Anderson Practice (MAP) project and developed algorithms to guide the management of the cardiovascular complications of cancer therapy. For chemotherapy-induced HF, we initiated the Heart Success Program (HSP), a patient-centered program that promotes interdisciplinary collaboration for the management of concurrent HF resulting from chemotherapy-induced cardiotoxicity. After one year of HSP implementation, compliance with the Center for Medicare and Medicaid Services HF core measures has significantly improved. The measurement of LVEF and initiation of recommended pharmacologic therapy for HF (angiotensin converting enzyme inhibitor [ACE-I] or angiotensin receptor blocker for ACE-I intolerant patients) has improved to 100%; provision of discharge instruction has improved from 50 to 94%; and the 30-day hospital readmission rate decreased from 40 to 27%. This article will describe the MD Anderson Practice in the management of chemotherapy-induced cardiomyopathy and HF in cancer patients through the HSP. The novelty of the HSP has raised clinician’s awareness of the magnitude of the clinical problem of HF in cancer and the

Individualizing heart failure core measures and use of beta blockers in severe pulmonary hypertension?a teachable moment

A 73-year old African-American woman with history of hypertension, diabetes mellitus, liver cirrhosis, atrial fibrillation and diastolic heart failure presented with a one-week history of shortness of breath, increasing dyspnea, eight-pound weight gain, and progressive weakness. She had associated orthopnea, paroxysmal nocturnal dyspnea, and leg swelling. She denied fevers, cough, chills, hemoptysis, recent hospitalization or wheezing. Her initial vitals were: blood pressure 194/127 mmHg, heart rate 74 beats per minute (bpm), respiratory rate 22 and she was afebrile. Examination revealed elevated jugular venous pressure 15 cm above sternal notch at 45 degrees, loud P2, right ventricular heave but regular rate and rhythm. There was a holosystolic murmur grade II/VI present at the left lower sternal border consistent with regurgitation murmur, which increased with inspiration. Initial electrocardiogram showed sinus rhythm with occasional premature ventricular complexes with predominant rightward axis and echocardiogram demonstrated elevated right ventricular systolic pressure of 102 mmHg indicative of severe pulmonary hypertension. The left ventricular ejection fraction was preserved.

Development of a collaborative transitions-of-care program for heart failure patients.

The development and implementation of a pharmacy-led transitions-of-care program to reduce the risk of readmission and increase satisfaction for heart failure (HF) patients are described. A transitions-of-care committee was established at Providence St. Peter Hospital, a 390-bed community teaching facility in Olympia, Washington, and focused on implementing standardized workflow processes for conducting admission medication review and discharge medication review and providing discharge counseling for patients with HF. All HF patients were to have admission medication reconciliation performed within 48 hours of admission. All HF patients were assigned a readmission risk complexity score after being admitted to the medical floor. The pharmacist, resident, and student performed daily patient medication profile reviews on all HF patients to ensure the use of optimal doses of appropriate HF medication regimens. The pharmacist proactively monitored for patient discharges using reports available in the electronic medical record. The pharmacist, resident, student, or HF nurse navigator counseled each patient on the discharge medications and answered any questions or addressed concerns regarding medications. Input from the quality-improvement specialist and data abstracter was used to ensure compliance with HF core measures. The program has resulted in an increase in core measure compliance and a reduction of HF, 30-day, and all-cause readmissions, and patient satisfaction scores have improved. For each avoided readmission, there was an associated decrease of $5652 in variable costs. The implementation of a pharmacy-led transitions-of-care program improved patient care by prioritizing those who needed medication reconciliation and led to increases in HF core measure compliance and patient satisfaction scores.

The impact of a Continuum of Care Resident Pharmacist on heart failure readmissions and discharge instructions at a community hospital.

Purpose:To examine the impact of a Continuum of Care Resident Pharmacist on (1) heart failure 30-day hospital readmissions and (2) compliance with Joint Commission Heart Failure core measure 1 at a community hospital.Methods:The Continuum of Care Network led by a Continuum of Care Resident Pharmacist was established in August 2011. The Continuum of Care Resident Pharmacist followed Continuum of Care Network patients and retrospectively collected data from August 2011 to December 2012. Thirty-day readmission rates for Continuum of Care Network heart failure patients versus non-Continuum of Care Network heart failure patients were compared and analyzed. Joint Commission Heart Failure core measure 1 compliance rates were retrospectively collected from January 2011 and compared to data after establishment of the Continuum of Care Network.Results:In all, 162 Continuum of Care Network patients and 470 non-Continuum of Care Network patients were discharged with a diagnosis of heart failure from August 2011 to December 2012. Continuum of Care Network heart failure patients had a lower 30-day all-cause readmission rate compared to non-Continuum of Care Network heart failure patients (12% versus 24%, respectively; p = 0.005). In addition, Heart Failure core measure 1 compliance rates improved from the 80th percentile to the 90th percentile after implementation of the Continuum of Care Network (p = 0.004). The top three interventions performed by the Continuum of Care Resident Pharmacist were discharge counseling (74.1%), providing a MedActionPlan™ (68.5%), and resolving medication reconciliation discrepancies (64.8%).Conclusion:The study findings suggest that a Continuum of Care Resident Pharmacist contributed to lowered heart failure readmission rates and improved Heart Failure core measure 1 compliance rates. Future randomized, controlled trials are needed to confirm these findings.

Pharmacist involvement at discharge with the joint commission heart failure core measure: challenges and lessons learned.

Pharmacists are vital health care providers to patients with heart failure (HF), but their compliance to the HF core measure has not been clearly defined. The objective of this study was to measure the impact of pharmacist involvement at discharge on compliance with The Joint Commission HF core measure. This prospective study was conducted at a 361-bed academic teaching institution. A pharmacist performed chart reviews just prior to discharge on adult patients with a preliminary diagnosis of HF (ie, clinical suspicion) to evaluate compliance with the HF core measure. The pharmacist then intervened as needed to ensure compliance. The primary outcome was HF core measure compliance rates with pharmacist involvement at discharge compared to rates during the same 3-month period during the previous year (without pharmacist involvement). Of 92 patients admitted with clinical suspicion of HF, the pharmacist was able to review 45 patient charts at discharge (49%). The majority of interventions made by the pharmacist were due to medication discrepancies within the discharge instructions found during medication reconciliation. Rates of compliance with the HF core measure did not differ between the period with pharmacist involvement at discharge and the previous period (without pharmacist involvement, P = .39). However, barriers to compliance related to discharge medication documentation, interdisciplinary communication, and manpower were identified through the process. Although pharmacist involvement at discharge did not translate into improved compliance with the HF core measure, systematic barriers to compliance were identified and are currently being addressed.

A Phased Cluster-randomized Trial of Rural Hospitals Testing a Quality Collaborative to Improve Heart Failure Care

Use of evidence-based practices for heart failure (HF) patients has the potential to improve outcomes and reduce variations in care delivery. To evaluate the effect of a rural hospital quality collaborative and organizational context (nurse staffing and practice environment) on 4 HF core measures. Phased cluster-randomized trial with delayed intervention control group. The intervention included a HF toolkit, 2 onsite meetings, and a monthly phone call. Twenty-three rural eastern US hospitals, registered nurses who care for HF patients (N=591). Seven quarters of 4 HF core measures, nurse staffing (nursing skill mix, registered nurse hours per patient day, nurse-turnover), and a survey of practice environment. : Using regression models with generalized estimating equation autoregressive methods, no statistically significant changes were found during the intervention period on all 4 core measures for either group. Higher nurse-turnover was related to all 4 core measures: lower compliance with discharge instructions [β=-1.042; 95% confidence interval (CI): -1.777, -0.307], smoking cessation (β=-1.148; 95% CI: -2.180, -0.117), left ventricular ejection fraction (β=-0.893; 95% CI: -1.784, -0.002), and prescribing angiotensin converting enzyme inhibitors on discharge (β=-1.044; 95% CI: -1.820, -0.269). Better practice environment was related to higher left ventricular ejection fraction (β=0.217; 95% CI: 0.054, 0.379). Significant improvements in 4 core measures were realized in stable environments (less nurse-turnover). Assuring appropriate nurse staffing and stability is essential to increase organizational preparation for quality initiatives and adoption of best practices in HF care in rural hospitals.

Cancer therapy and heart failure: Successful management through collaborative interdisciplinary practice.

123 Background: Heart failure (HF) is a clinical problem of emerging importance in cancer care. The advances in cancer detection and complex treatment regimens have resulted in increased cancer treatment induced HF. The literature indicates that more than 50% of all patients exposed to anthracyclines will show some degree of cardiac dysfunction either acutely or 10 to 20 years after treatment, and 5% of those patients will develop overt HF. Successful management requires a collaborative, interdisciplinary approach. The purpose of this presentation is to discuss how the “Heart Success Program” (HSP) resulted in cost effective and clinical quality outcomes in patients with cancer and HF. Methods: The HSP was piloted in the emergency center and telemetry units with high volume admission of HF patients. The HSP includes comprehensive education of patients, families, and health care providers regarding HF management in cancer patients. HSP implementation includes a HF order set, patient education booklet, and educational videotape specific for patients with cancer and HF. Weekly interdisciplinary clinical rounds provide a forum for discussion of identified patient’s problems and formulation of solutions. Endpoint outcomes include compliance with the Center for Medicare and Medicaid Services (CMS) core measures for HF, as well as decreasing HF readmissions. Results: The pilot implementation of the HSP resulted in decreased hospital length of stay by 57%, and average hospital admission cost by 60%. Despite multiple co morbid conditions, patients were discharged with improved functional status and compliance with CMS HF core measures. Conclusions: The findings from this quality improvement project showed significant impact in clinical and cost outcomes for patients with cancer and HF. The multidisciplinary team approach that provided support to patients and their families and allowed for patients to continue their cancer treatment resulting in improved outcomes. As we move toward value-based purchasing, the HSP provides an example of how collaboration and standardized process improvement impacts cost and quality in the oncology population.

Does Systematic Adherence to Joint Commission and AHA Heart Failure Performance Measures Improve Patient Outcomes?

Author(s): Bender, M; Jaski, BE; Glaser, D; Thomas, V; Cary, DS; Smith, SC | Abstract: Introduction It is unclear whether inpatient heart failure (HF) performance measures reduce post-discharge adverse events. This exploratory study examined the association between systematic adherence to a set of performance measures and outcomes. Measures included all four Joint Commission (JC) HF core measures and AHA recommended beta blockade prescription on discharge. Methods A retrospective review of a 3-hospital system was performed for all patients discharged with a primary diagnosis of HF in 2008-2009. Patients were included if they met eligibility criteria for one or more measures (n=1270). ‘Perfect care’ was defined as compliance with all eligible measures. Subsequent all-cause 30-day readmission and 1-year mortality was determined via electronic records and social security national database. Results ‘Perfect care’ significantly reduced 30-day readmissions (19.2% vs. 24.9%, p=.045; OR=.72, 95% CI 0.52-0.99). ‘Perfect care’ did not influence 1-year mortality. Conclusions Adherence to this set of composite performance measures positively influenced short-term patient outcomes. Benefit of adherence was found despite the longer LOS and higher severity of illness on index admission for patients receiving ‘perfect care’. The data support the clinical value of a systematic approach towards HF care on patient care quality. ‘Perfect care’ did not influence long term outcomes, which may be because inpatient processes do not extend to long term outpatient medical management.

11. Heart failure core measure analysis project and it's impact on transitional discharge plans and 30 day readmissions

Heart Failure is among the top five most prevalent diagnoses. The 30 day readmissions of HF patients are costly and a burden the health care system. Nursing staff‘s knowledge base increased thorough understanding of Heart Failure Performance Measures, Outcomes and need for transitional plans and it impact on reimbursement to the organization.Despite the focused on discharge instructions for heart failure with systolic dysfunction, the condition continues to cause readmission hospitalization in the elderly populations.

Abstract 268: Multidisciplinary Approach to the Heart Failure Patient Significantly Improves Adherence to Evidence-Based Medicine Beyond Core Measures

Background: Adherence to heart failure core measures has been a focus of all hospitals in the past several years and has become even more important with the advent of pay for performance. Core measures address basic heart failure care, but do not include utilization of all evidence-based therapies which improve long term outcomes. We hypothesized that an in-hospital multidisciplinary heart failure (HF) management program could improve adherence to evidence-based guidelines beyond core measures. Methods: As a quality improvement initiative, we formed a multidisciplinary team to improve compliance with HF evidence-based therapy. Interventions included multiple educational sessions, discharge and post-discharge transition improvements, concurrent and post-discharge chart abstraction, revised patient education, and real-time provider education. Charts were abstracted in 525 consecutive HF inpatients between Jul 2010 and Mar 2011. Data was collected in the GWTG-HF (Outcome Inc) Registry. Pre-intervention compliance data (Jul-Sep) was compared to post-intervention (Nov-Mar) data with a paired t test and the Mann-Whitney rank sum test. Direct variable cost was analyzed for defect-free cases versus cases with defects. Results: Baseline Demographics: Mean age was 69 years, 42% female, 20% black, 55% ischemic etiology, mean LVEF=37%. Prior to the multidisciplinary intervention, overall defect-free care was excellent at over 89% (see figure) but there was a relative underutilization of aldosterone antagonists, hydralazine/nitrate therapy, CRT-D and anticoagulation for AF. Post-intervention, adherence improved to over 90% for all 8 evidence based therapies including: evidence-based beta-blocker (p=0.002), aldosterone antagonist (p<0.001), hydralazine nitrate (p=0.04), ICD placed or prescribed (p<0.001), CRT-D (p=0.002), anticoagulation for afib (p=0.04), and DVT prophylaxis (p=0.04). Mean direct variable cost per case was higher at $8249 in defect cases versus $6951 in defect-free cases. Conclusions: In this single center experience, interventions led by a HF multidisciplinary team can significantly improve adherence to evidence-based therapies, beyond core HF measures. A multidisciplinary approach to inpatient HF care has the potential to decrease HF related costs.

Abstract P145: Implementation of a Simple Computerized Heart Failure Discharge Instruction Tool Lead to Increased Adherence to JCAHO Heart Failure Core Measures and Reduced Heart Failure Readmission Rate

Background: Suboptimal adherence to JCAHO (Joint Commission on the Accreditation of Healthcare Organizations) heart failure (HF) core measures have been reported in various hospital settings. Non- adherence to JCAHO HF core measures have been associated with decreased survival. The purpose of this study was to evaluate the impact of implementation of a discharge instruction tool on the adherence to JCAHO HF measures and analyze HF outcomes. Methods: A simple computerized discharge instruction tool (DIT) included an electronic check list of four JCAHO HF core measures to be completed and verified by all physicians who discharged acute HF patients; and got implemented at Catholic Medical Center (CMC), New Hampshire from January 2008. We compared the patient data before (January to December 2007; n=219)) and after (January 2008 to June 2009; n=326) implementation of DIT for adherence to four JCAHO HF core measures. All patients were followed for six months to analyze HF readmission rate and cardiac related death. Results: Total eligible patients (n=545) with their adherence to the HF core measures and improvement in the adherence to discharge instructions are shown in Table 1 and Figure 1-a/b. Reduction of six-month readmission rate (36.2 vs 27.8%; p=0.03) recognized an approximate saving of $6500.00 per case accounting to a total annual savings of approximately $176,000; with no significant change in the hospital length of stay and cardiac related death. Conclusions: A simple DIT achieved an improved adherence to JCAHO HF core measures and CMC acquired a local and regional recognition. Similar DIT could be shared in other hospitals across the nation to achieve improved HF outcomes.

Abstract P142: A Statistically Significant Reduction in Heart Failure Length of Stay: Moving the Mean Through Process Improvement

Background: The burden of acute heart failure (HF) remains formidable. Length of stay (LOS) must be minimized to control costs, while still maintaining positive outcomes. Inappropriate diagnoses and the lack of coordinated care remain impediments to achieving a target LOS. Care process redesign affords an opportunity to improve LOS. Method: The HF program at Christiana Care Health System implemented a process improvement (PI) project in June 2009 on our 31 bed heart failure unit (HFU) to identify and correct barriers to timely discharge. Markers for increased LOS were identified based on historical data and included: O2 use, skilled nursing facility referral, IV vasoactive therapy use, absence of ACC/AHA guideline-based HF therapy, multiple co-morbidities, poor social support and depression. The HFU multi-disciplinary team engaged the nursing staff in twice daily case review rounds to identify and remedy outstanding care issues. The HFU team was proactive and developed individual care plans. Social Work and Case Management addressed options for the transition to home (+/- home healthcare), rehabilitation, or extended care. A HF Clinical Psychologist was consulted for patients with depression and/or poor social support. Providers were engaged where ACC/AHA HF guideline and HF Core measure compliance was lacking or when prolonged O2, IV diuretics, or IV vasoactive drug use was identified. Results: LOS on the HFU (6 months Pre and Post project initiation) was compared via Student's t-Test for unpaired data. PI Project implementation resulted in LOS reduction of 0.86 days. Pre vs post project initiation: p= 0.028. (See Table ). Conclusion: A dedicated multi-disciplinary team, rounding twice daily on HF patients in a dedicated HFU, was able to significantly reduce LOS through the systematic identification of barriers to a timely discharge, and application of targeted interventions in a large volume medical center. Christiana Care Health System Heart Failure Unit Time Period HF Admissions Male Female Mean Age LOS LOS Range Pre- PI Project Intervention Dec ’08 - May ’09 358 45.00% 55.00% 73.3 yrs 6.24 ± 0.49 5.42 - 6.90 PI Project Intervention Jun ’09 - Nov ’09 346 51.00% 49.00% 72.9 yrs 5.38 ± 0.66 4.55 - 6.20 Pre versus Post PI Project Intervention LOS: p= 0.028

The Importance of Consistent, High-Quality Acute Myocardial Infarction and Heart Failure Care: Results From the American Heart Association’s Get With The Guidelines Program

This study examined the degree to which hospital performance for acute myocardial infarction (AMI) and heart failure (HF) care processes are correlated. Although AMI and HF care processes may be amenable to similar quality improvement interventions, whether these are indeed correlated and whether hospitals with consistently superior performance for both care metrics have the best outcomes remains unknown. We compared hospital performance of the Centers for Medicare & Medicaid Services AMI and HF core measures in 283 hospitals submitting 10 or more patients to the Get With The Guidelines AMI and HF programs between January 2005 and April 2009. Median hospital adherence to AMI and HF composite measures were 93% (interquartile range: 87% to 97%) and 92% (interquartile range: 85% to 96%), respectively, with only a modest correlation between hospital performance on these 2 composite metrics (r = 0.50; 95% confidence interval: 0.41 to 0.58). Hospitals with superior performance to both AMI and HF processes had significantly longer duration of Get With The Guidelines participation and lower adjusted in-hospital mortality (odds ratio: 0.79; 95% confidence interval: 0.63 to 0.99) for AMI and HF patients, whereas hospitals with superior adherence to either alone had similar mortality rates as hospitals with superior adherence to neither measure. Hospitals that had consistent, superior performance for both AMI and HF care had significantly lower risk-adjusted mortality than those with superior performance either alone or for neither measure. Whether a single scoring system to assess global, rather than condition-specific, quality of cardiovascular care would facilitate care quality improvement more consistently and would optimize patient outcomes merits further investigation.

8. Information technology improves heart failure core measure compliance and readmission rates

8. Information technology improves heart failure core measure compliance and readmission rates

Financial Impact of Pay for Performance on the US Hospitals

Background: In order to provide the optimum quality of care (QOC), the Centers for Medicare and Medicaid Services (CMS) implemented a program known as the heart failure core measures (HFCM) that will correlate with improved QOC for heart failure (HF) patients in hospitals across the country. The demonstration project, which began in October 2003, initially involves more than 260 hospitals and tracks process and outcome measures in five clinical areas including HF. On January 26, 2007, CMS announced second-year incentive payments of $8,690,447 to 115 top-performing hospitals in the project.

Leaning Toward Perfection in Heart Failure Care

Background: Heart Failure (HF) is the leading cause of hospitalization for those over age 65. Improvement efforts in Pursuing Perfection are aimed at providing reliable evidence-based care, and improving outcomes for patients with chronic illness, with a special focus on congestive heart failure. A hospital, part of a large healthcare system in the Midwest has identified Heart Failure Disease Management as a key initiative. In June and July of 2008, a decrease in two of the four Heart Failure Core Measures prompted the evaluation of our process.

Comparison of Heart Failure Core Measure Performance and Length of Stay among Teaching Hospitals in California

Comparison of Heart Failure Core Measure Performance and Length of Stay among Teaching Hospitals in California

Incremental Survival Benefit With Adherence to Standardized Heart Failure Core Measures: A Performance Evaluation Study of 2958 Patients

Background In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established four heart failure (HF) core measures to standardize and improve health care quality in the United States. Although adherence to these HF care processes may be improving, their collective impact on survival is not yet settled. Methods JCAHO HF measures were implemented within a 20-hospital health care system. Eligible patients had a principal discharge diagnosis of HF. Metrics representing compliance with these measures were derived and their relationship with 1-year survival was examined using an adjusted Cox proportional hazards regression. Results A total of 2958 patients met study criteria. The average age was 73 years, 50% were male, and 9.9% were smokers. One-year survival benefits were seen in an item-by-item evaluation of HF measures for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy (hazard ratio [HR] = 0.69), left ventricular function assessment (HR = 0.83), and patient education (HR = 0.79). When assessed collectively, improved survival was seen among patients eligible for two (HR = 0.53), three (HR = 0.36), or four HF measures (HR = 0.65). Further, we found a positive and incremental relationship between the degree of adherence and survival ( P = .008). Conclusion Adherence to JCAHO HF core measures is associated with improved 1-year survival after HF hospitalization. This validates these simple and effective performance measures and justifies efforts to implement them in all eligible patients with HF.

Improvement of Heart Failure Core Measures Compliance and Readmission Rates through a Multidisciplinary Approach

Our health system is a community-based teaching system privately owned with multiple provider groups and inpatient facilities, which admit 1200 HF patients yearly. Care is provided by 140 cardiologists, internists, and hospitalists. As a result of the need to better standardize care and address JCAHO quality parameters an interdisciplinary HF team was created. It has evolved to include representatives from all segments of the HF care process from the emergency department through discharge. Bimonthly meetings were held to analyze monthly data including, JCAHO core measures, and to devise methods of streamlining the care process and minimizing undesirable variations in care.