Impact of quality improvement initiatives in patients hospitalized for heart failure






José Luis ZAMORANO,MD, PhD
Head of Cardiology
University Hospital Ramón y Cajal
Madrid, SPAIN

Vanesa Cristina LOZANOMD
University Hospital Ramón y Cajal
Madrid, SPAIN

Impact of quality improvement initiatives in patients hospitalized for heart failure


by J. L. Zamorano and V. C. Lozano, Spain



Heart failure has become a serious and expensive epidemic in the Western world, with hospitalization contributing to the greatest proportion of spending. Many strategies to improve quality of care can be implemented during or after hospitalization to ensure optimal outcomes and reduce readmission rates. In-hospital strategies include promoting the use of management protocols based on clinical practice guidelines and the use of checklists, as well as developing methods that deliver feedback to clinicians on care provided and outcomes. A variety of follow-up measures can be planned on hospital discharge. Patients who are seen early after hospitalization have better outcomes and fewer readmissions, and this benefit appears to be greater if the follow-up is carried out by a familiar physician and shared between the cardiologist and the primary care physician. Apart from the routine medical follow-up, other effective strategies include referral to day hospitals or heart failure clinics, structured telephone support, or telemonitoring of patient health status by way of different telemedical solutions, and last, but not least, patient empowerment through self-care activities that help them maintain physiological stability. All of the above can be effectively implemented through disease management programs aimed at improving the quality of care and patient outcomes while reducing health care expenditures.

Medicographia. 2015;37:163-169 (see French abstract on page 169)



Heart failure has become a severe and expensive epidemic in the Western world, with an estimated prevalence of 1%-2% in Europeans, reaching over 10% in those aged 85 or older.1 Given the rapidly progressing aging of the population, the need for complex pharmacotherapy, specific treatment procedures, and frequent readmissions, it is not surprising that heart failure has long been considered a major public health problem and a growing burden on the health care system. Taking this into account, the American Heart Association published a policy statement in which an estimated increase of 240% in direct cost burden of the disease by the year 2030 was foreshadowed.2 Hospitalization contributes to the greatest proportion of expenditure in heart failure, accounting for over 60% of the total cost to the health service,3 which in turn represents between 1% and 2% of the total health care budget in developed countries.4

Readmission rates have been shown to be very high among patients with heart failure, especially during the first months after diagnosis, with a quarter of patients returning within 30 days, a third of patients returning within 2 months, and more than half within 18 months after discharge from hospital.5,6 In addition, in the United States, a recently launched collaborative tool that provides information on how well hospitals perform in all-kind quality-of-care–related statistical analysis shows that the national 30-day readmission rate for heart failure has had limited improvement in recent years.7 A reduction in this carefully scrutinized hospital-performance–related parameter is a desirable objective, as it not only helps decrease the overall cost of medical care, but it also contributes to better quality of life for our patients.

Many strategies regarding quality of care could be implemented during hospitalization to improve care and ensure optimal patient outcomes (Figure 1), as it is well documented that a substantial proportion of patients admitted with heart failure receive less-than-optimal treatment, especially when they are hospitalized for other causes.8

In-hospital strategies

Management protocols
A written, updated, and shared document that clinicians can consult when difficult decisions or clinical scenarios arise is desirable. Management protocols can be an initial step in improving quality of care in hospitalized patients, providing for standardized care and reducing undesired variation in clinical practice. Individual clinical expertise should only influence clinical management when scientific evidence is lacking or of insufficient quality.

These management protocols should be based on the best scientific evidence available, often found in clinical practice guidelines; it has been shown that their implementation results in significant improvement in outcome of care.9,10


Figure 1
Figure 1. Schematic showing various in-hospital and postdischarge follow-up strategies
to ensure optimal patient outcomes.



Checklists
Using something as simple and inexpensive as a checklist when patients are about to be discharged can greatly boost quality of care and decrease patient readmissions. A checklist can be of great help to attending physicians, as well as nurse practitioners and other house staff involved in patient care, reminding them about the convenience of applying various evidence-based pharmacologic (medications that should be prescribed or uptitrated during a patient’s stay, according to guidelines) and nonpharmacologic therapeutic measures (eg, the need to provide education, counseling, and followup instructions) (Figure 2).

Some studies have shown that the use of this kind of clinical tool can have a significant impact on improving quality of care by leading to a higher proportion of patients being treated with evidence-based therapies and correctly uptitrated drugs, which in turn leads to decreasing readmission rates and better clinical outcomes.11

Feedback
A critical element for improving quality of care lies in providing clinicians with methods for monitoring care and outcomes of patients. Each facility should have a quality assessment and improvement program specific for heart failure where the extent to which clinicians practice in accordance with clinical guidelines can be assessed. The most powerful method appears to be the sharing of feedback on data comparing clinicians with their colleagues and education carried out at the local level by respected fellows.12

A prospective registry, whether local or national, can be a useful tool. By collecting patient characteristics and performance measures during hospitalization and capturing postdischarge outcomes during follow-up, clinicians can receive feedback on their adherence to evidence-based guideline recommendations and quality of care provided.

Several national and local initiatives have been undertaken in this field using a variety of mechanisms, including national tracking and reporting of quality indicators through health plan claims and reviews of medical records. These initiatives provide feedback to practitioners on quality indicator adherence through peer review, require hospitals to submit performance measure data, and provide performance-improvement tools to enhance adherence.13,14





Figure 2
Figure 2. Example of a simple, inexpensive heart failure checklist, which can have a significant impact on patient quality of care.

Hospital discharge and follow-up strategies

Early follow-up
The days following discharge are a vulnerable period for patients suffering from heart failure because of their advanced age, the presence of comorbid conditions that could hinder the complete resolution of episodes of decompensation (eg, chronic kidney disease), the complexity of pharmacological regimens employed, and the great number of physicians who may be involved in their subsequent care. It is usually necessary to rely on new medical therapies or to make changes in previous ones that could worsen their clinical condition, cause secondary effects, or even destabilize other comorbidities. In a retrospective cohort study conducted in Canada involving patients discharged from acute care hospitals with the diagnosis of new-onset congestive heart failure, those who received a regular cardiovascular follow-up had fewer visits to the emergency department (38% vs 80%; P<0.001), fewer admissions to hospital (13% vs 94%; P<0.001), and showed a lower 1-year mortality (22% vs 37%; P<0.001) compared with those with no follow-up visit.15

Although aftercare tracking on a 6-monthly basis may seem adequate for patients with stable disease, current guidelines recommend an early follow-up after certain circumstances, such as a recent hospital admission,16 given that prompt follow- up of patients hospitalized for heart failure has been associated with lower rates of death and readmission. In a study carried out in 225 hospitals in the United States among Medicare beneficiaries hospitalized for heart failure, patients discharged from centers with a greater proportion of early follow- up (defined as an outpatient evaluation visit with a physician within 7 days after discharge) had lower rates of all-cause 30-day readmissions.17

Physician continuity
Physician continuity has been demonstrated to positively influence postdischarge outcomes beyond the sole effect of an early follow-up. In a recently published observational study conducted in Canada regarding risk of death or urgent all cause readmission over 6 months in 24 373 patients discharged from hospital with a first-time diagnosis of heart failure, patients who had follow-up visits with a familiar physician (defined as one who had seen the patient at least once during the index admission or at least twice in the year before the index admission) had a lower risk of death or unplanned readmission (hazard ratio [HR] 0.91; 95% confidence interval [CI], 0.85-0.98) than those followed by an unfamiliar physician, whether specialist or not.18 Moreover, another observational study revealed that the benefit is not limited to patients discharged from hospitalization, but has also been observed to extend to patients treated and released from emergency departments, a population known to have worse 30-day outcomes than those actually admitted.19 In a cohort of 12 285 patients treated and released directly from various emergency departments in Canada, the risk of death or hospitalization was lower in patients followed by a familiar physician compared with those followed by an unfamiliar physician, at 3 months (HR 0.79; 95% CI, 0.71-0.89) as well as at 12 months (HR 0.87; 95% CI, 0.80-0.96).20 The previous observations raise the question of whether we could be achieving suboptimal outcomes by sacrificing physician continuity in order to meet early follow-up deadlines.

Collaborative care
Although many patients suffering from heart failure receive care only by a primary care physician, being the gatekeeper of referrals to specialist care, a lot of patients in the postemergency setting (that is, after discharge from hospital or after visiting the emergency department) are only seen by a cardiologist. However, patients who receive concurrent care by both a primary care physician and a cardiologist show better results. In a population-based study including 10 599 patients, those patients who visited both a primary care physician and a specialist within 30 days from discharge showed a lower rate of death at 1 year (7.2%) compared with those who only visited a primary care physician (10.4%; P<0.001). Moreover, patients with shared care had the highest rates of left ventricular ejection fraction evaluation, noninvasive testing for ischemia detection, and cardiac catheterization.21

Some studies suggest that collaborative care entails a tradeoff between lower mortality and higher rates of hospitalization,15 whereas others found no impact of specialist care.

Day hospitals
Day hospitals allow evaluation and management of mild to moderate decompensations by short therapeutic interventions, arising as an efficient alternative in maintaining continuity of care while preventing readmissions, improving accessibility, increasing patient comfort, and reducing costs. Compared with other strategies, day hospitals or heart failure clinic-based disease management models can deliver more options in diagnostic tools and equipment, facilitating acute care.22

In a study aimed at assessing and comparing the effectiveness and cost utility between a heart failure management program delivered by day hospital or usual care, patients referred to one of these facilities (with a staff consisting of a cardiologist, 4 trained nurses, and 2 physiotherapists, as well as other part-time collaborators)—where a series of interventions including cardiovascular risk stratification, correction of causes of instability, and continuous optimization of therapy could be applied—showed better results in management outcomes as well as in hard outcomes. A smaller percentage of patients referred to day hospitals experienced readmission compared with patients in the usual care group (8% vs 35%; P<0.05%) or suffered cardiac death (2.7% vs 17.2%; P<0.05). This model also showed a better cost-utility ratio than community management.23

Structured telephone support
It is feasible to educate, monitor, and give support to patients through self-management programs after discharge using simple telephone technology in a structured format. Through a series of scheduled calls with a specific goal and thoughtful questioning, a clinician can assess medication adherence, input- output balance, abrupt changes in body weight, and the convenience of medication adjustment, among other things. Although 2 large meta-analyses of randomized clinical trials24,25—one meta-analysis focusing on telemonitoring and structured telephone support and the other covering a broader range of transitional care interventions—showed a reduction in congestive heart failure–related hospitalizations and a trend toward reduction in all-cause mortality, this did not correlate with a reduction in all-cause hospitalizations. Furthermore, individual randomized clinical trials showed mixed results.26 Therefore, the available evidence is insufficient to support a clear recommendation.

Compared with other strategies, telephone-support disease management models are low cost and time efficient, and have been shown to be convenient for both the team and the patient. Nevertheless, it can be difficult to objectively assess symptoms and signs of heart failure by this strategy and implementation of large adjustments in treatment can be challenging.

Remote monitoring or telemedicine
Advances in telecommunication technologies have made possible the continuous care of patients at any place as an adjuvant to standard care, while contributing to the self-empowerment of patients. Through different telemedical solutions, some of them based on the use of implantable devices, selected physiological measurements can be collected and analyzed to ensure an early detection of disease deterioration, prompting medical intervention. The key to the effectiveness of telemedical management hence relies on the predictive value of the chosen monitored variables.26

As a noninvasive approach, body weight monitoring has been considered for many years the cornerstone in traditional telemedicine. Although it may seem a simple measurement at first glance, there are several shortcomings due to body weight being easily influenced by clinical status or changes in food or fluid intake. It is also possible to assess parameters such as oxygen saturation, body impedance, and physical activity. Other monitoring strategies involve special drug containers that are able to send a signal when opened, thus helping assess adherence.

Minimally invasive approaches include measurement of serum concentrations of certain biomarkers, such as blood glucose or brain natriuretic peptide, or utilization of already in-use devices, like implantable cardioverter defibrillators or pacemakers, to monitor device function and usage or even some physiological variables, such as heart rate or type of rhythm. More invasive approaches include the insertion of implantable devices specifically designed with telemonitoring purposes. Some of these tools, such as a wireless pulmonary artery hemodynamics monitoring system, have been shown to reduce hospitalizations,27 although data on efficacy in improving outcomes is still lacking.

Self-care promotion
Self-care promotion, defined as the encouragement of “a naturalistic decision-making process that patients use in the choice of behaviors that maintain physiological stability and the response to symptoms when they occur,” can be a very convenient ally for clinicians.28

In a systematic review of randomized trials of multidisciplinary management programs in heart failure, those aimed at enhancing patient self-care activities effectively reduced heart failure–related hospitalizations (relative risk [RR] 0.66; 95% CI, 0.52 -0.83) and all-cause hospitalizations (RR 0.73; 95% CI, 0.57-0.93), without achieving an effect on mortality. The interventions led in the publications analyzed included nurse delivered patient education, mailed patient education materials, home visits after discharge to reinforce education and self-care, or regular telephone contact by a nurse educator to monitor for deterioration.29,30 Similarly, on another systematic review of randomized clinical trials focusing specifically on self-management interventions in which patients retained the primary role in managing their health condition (which included education sessions or educational software providing information about signs and symptoms of heart failure, importance of daily weighing, dietary restrictions, and importance of adherence to the medication prescribed), self-care activities reduced heart failure–related readmissions (odds ratio [OR], 0.44; 95% CI, 0.27-0.71) and all-cause hospital readmissions (OR 0.59; 95% CI, 0.44-0.80).31

Moreover, some studies show that self-care measures may provide a benefit in terms of reduction in risk of death. In a randomized controlled trial comparing a self-management program (consisting of a 1-hour educational session in which patients were given an educational booklet designed for low literacy patients and a digital scale, a personalized management plan centered on the patient’s ideal weight and modifications in dosage of diuretic medications, and scheduled follow-up phone calls) with usual care among outpatients with a diagnosis of heart failure, the intervention group had a lower rate of hospitalization or death (adjusted incident rate ratio [IRR] 0.52; 95% CI, 0.32-0.89).

Toward the era of integrated care and disease management programs

All of the above quality-of-care strategies have been accepted to be useful tools that by themselves can have an impact on patient outcomes, but this raises questions about which one would provide better outcomes, or to which one we should pool our efforts. Disease management programs have emerged in the past decade as a potential strategy to enhance the quality of care received by patients suffering from chronic conditions by bringing together some of the above components. It can not only increase the quality of care, the adherence to guidelines and care protocols, and the access to health services, but it can also be an effective way of improving the efficiency of health care services delivery by maintaining or improving quality while reducing costs.

Evidence regarding the characteristics and effectiveness of various interventions often used in disease management programs has been published. Provider-centered components, such as education and feedback, all of which can help to increase adherence to guidelines, as well as patient-centered components, such as reminders and financial incentives, have been associated with improvements in patient disease control.32 Moreover, a meta-analysis including 11 randomized clinical trials showed that disease management programs were cost effective and patients cared for by these were more likely to undergo fewer hospitalizations.33

The American Heart Association recommends a series of principles for guiding the development, implementation, and evaluation of disease management strategies.34 First, the main goal of disease management should be to improve the quality of care and patient outcomes, and should not be solely based on their efficacy in reducing health care expenditures. Second, these programs should be founded on scientifically based guidelines, focusing on encouraging patients and caregivers to follow treatment plans based on the best available evidence. Third, scientifically derived evaluations and consensus- driven performance measures should be included as a crucial component of any disease management program, to maximize benefit and facilitate its own refinement. Fourth, these strategies should support and enhance the patient provider relationship within an integrated and comprehensive system of care. And lastly, these programs should address potential handicaps, which include the complexity of medical comorbidities, the challenges of the underserved and vulnerable populations, and the potential conflicts of interest of the organizations involved.

A related and often inadvertently overlooked tool for improving quality of care and patient outcomes lies in providing our health professionals with the best available information on how to do so. In this regard, continuing medical education and promotional education programs can help us maintain competence and learn about old and new strategies in the developing field of quality of care. Some studies suggest that these kinds of activities can help improve physician performance, especially in resource utilization, counseling strategies, and preventive medicine, and can have a positive impact on patient health care outcomes.24

Although these programs are promising, there is a need for testing and demonstrating best practices and for sharing information on successful components across a wide range of scenarios and a variety of care settings.

References
1. Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart. 2007;93(9): 1137-1146.
2. Heidenreich PA, Trogdon JG, Khavjou OA, et al; American Heart Association Advocacy Coordinating Committee; Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Cardiopulmonary; Critical Care; Perioperative and Resuscitation; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular Surgery and Anesthesia, and Interdisciplinary Council on Quality of Care and Outcomes Research. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American heart association. Circulation. 2011;123(8):933-944.
3. McMurray J, Hart W, Rhodes G. An evaluation of the cost of heart failure to the National Health Service in the UK. Br J Med Econ. 1993;6:99-110.
4. Berry C, Murdoch DR, McMurray JJ. Economics of chronic heart failure. Eur J Heart Fail. 2001;3(3):283-291.
5. Cowie MR, Fox KF, Wood DA, et al. Hospitalization of patients with heart failure: a population-based study. Eur Heart J. 2002;23(11):877-885.
6. Krumholz HM, Merrill AR, Schone EM, et al. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes. 2009;2(5):407-413.
7. Kocher RP, Adashi EY. Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011;306(16):1794-1795.
8. Blecker S, Agarwal SK, Chang PP, et al. Quality of care for heart failure patients hospitalized for any cause. J Am Coll Cardiol. 2014;63(2):123-130.
9. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993;342(8883):1317-1322.
10. Poelzl G, Altenberger J, Pacher R, et al. Dose matters! Optimisation of guideline adherence is associated with lower mortality in stable patients with chronic heart failure. Int J Cardiol. 2014;175(1):83-89.
11. Basoor A, Doshi NC, Cotant JF, et al. Decreased readmissions and improved quality of care with the use of an inexpensive checklist in heart failure. Congest Heart Fail. 2013;19(4):200-206.
12. Krumholz HM, Baker DW, Ashton CM, et al. Evaluating quality of care for patients with heart failure. Circulation. 2000;101(12):e122-e140.
13. Fonarow GC, Abraham WT, Albert NM, et al. Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Arch Intern Med. 2007; 167(14):1493-1502.
14. Smaha LA; American Heart Association. The American Heart Association Get With The Guidelines program. Am Heart J. 2004;148(5 suppl):S46-S48.
15. Ezekowitz JA, Van Walraven C, McAlister FA, Armstrong PW, Kaul P. Impact of specialist follow-up in outpatients with congestive heart failure. Can Med Assoc J. 2005;172(2):189-194.
16. McDonagh TA, Blue L, Clark AL, et al. European Society of Cardiology Heart Failure Association standards for delivering heart failure care. Eur J Heart Fail. 2011;13(3):235-241.
17. Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303(17):1716-1722.
18. McAlister FA, Youngson E, Bakal JA, Kaul P, Ezekowitz J, van Walraven C. Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure. CMAJ. 2013;185(14):E681-E689.
19. Lee DS, Schull MJ, Alter DA, et al. Early deaths in heart failure patients discharged from the emergency department: a population-based analysis. Circ Heart Fail. 2010;109.
20. Sidhu RS, Youngson E, McAlister FA. Physician continuity improves outcomes for heart failure patients treated and released from the emergency department. JACC Heart Fail. 2014;2(4):368-376.
21. Lee DS, Stukel TA, Austin PC, et al. Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department. Circulation. 2010;122(18):1806-1814.
22. Jaarsma T, Strömberg A. Heart failure clinics are still useful (more than ever?). Can J Cardiol. 2014;30(3):272-275.
23. Capomolla S, Febo O, Ceresa M, et al. Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by day-hospital and usual care. J Am Coll Cardiol. 2002;40(7):1259-1266.
24. Inglis SC, Clark RA, McAlister FA, Stewart S, Cleland JG. Which components of heart failure programmes are effective? A systematic review and meta-analysis of the outcomes of structured telephone support or telemonitoring as the primary component of chronic heart failure management in 8323 patients: Abridged Cochrane Review. Eur J Heart Fail. 2011;13(9):1028-1040.
25. Feltner C, Jones CD, Cené CW, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014;160(11):774-784.
26. Anker SD, Koehler F, Abraham WT. Telemedicine and remote management of patients with heart failure. Lancet. 2011;378(9792):731-739.
27. Abraham WT, Adamson PB, Bourge RC, et al. Wireless pulmonary artery hemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet. 2011;377(9766):658-666.
28. Riegel B, Moser DK, Anker SD, et al. State of the science promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation. 2009;120(12):1141-1163.
29. McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol. 2004;44(4):810-819.
30. Blue L, Lang E, McMurray JJ, et al. Randomised controlled trial of specialist nurse intervention in heart failure. BMJ. 2001;323(7315):715-718.
31. Jovicic A, Holroyd-Leduc JM, Straus SE. Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials. BMC Cardiovasc Disord. 2006;6(1):43.
32. Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness: which ones work? Meta-analysis of published reports. BMJ. 2002;325(7370):925.
33. Ahmed A. Quality and outcomes of heart failure care in older adults: role of multidisciplinary disease-management programs. J Am Geriatr Soc. 2002;50(9): 1590-1593.
34. Faxon DP, Schwamm LH, Pasternak RC, et al. Improving quality of care through disease management: principles and recommendations from the American Heart Association’s Expert Panel on Disease Management. Circulation. 2004; 109(21):2651-2654.



Keywords: heart failure, hospitalization, readmission, mortality, quality of care