Impact of a guideline-based disease management team on outcomes of hospitalized patients with congestive heart failure

Hyperkalemia and management of renin-angiotensin-aldosterone system inhibitors in chronic heart failure with reduced ejection fraction: A systematic review

INTRODUCTION AND OBJECTIVES

Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). RAASi optimization in real-life care is challenged by hyperkalemia, a potentially fatal adverse event, which can necessitate downtitration or discontinuation of RAASi and negatively impact survival in HFrEF. The literature on this problem is sparse. We performed a systematic review of studies on HFrEF to investigate the prevalence, incidence, and risk factors of hyperkalemia, RAASi prescription rates, frequency of RAASi downtitration or discontinuation due to hyperkalemia, and the potential negative effect of the latter on prognosis.

METHODS

We conducted a MEDLINE (PubMed) search including observational and interventional studies published between January 1987 and May 2018.

RESULTS

A total of 30 observational and 18 interventional studies were included in the review. The incidence of hyperkalemia reported was between 0% and 63% in observational studies and was between 0% and 30% in clinical trials. Risk factors for hyperkalemia included RAASi prescription, older age, diabetes, and chronic kidney disease. In real-life studies, RAASi were downtitrated or discontinued in 3-22% of HFrEF patients; hyperkalemia was the reported cause in 5% of cases. No reports were found on the impact on prognosis of RAASi downtitration or discontinuation due to hyperkalemia.

CONCLUSIONS

Hyperkalemia and RAASi downtitration or discontinuation are frequent, particularly in real-life HFrEF studies. Further research is needed to clarify the role of RAASi downtitration or discontinuation due to hyperkalemia and to assess its long-term prognostic impact in HFrEF patients.

Effect of a double nutritional intervention on the nutritional status, functional capacity, and quality of life of patients with chronic heart failure: 12-month results from a randomized clinical trial

Introduction

Introduction: malnutrition is commonly associated with, and worsens the prognosis of heart failure. The management of chronic heart failure and its complications based only on the application of pharmacologic guidelines is incomplete. The benefits of interventions to improve nutritional status may be limited by the multifactorial nature of malnutrition. The objective of the present study was to determine whether nutritional advice and nutritional supplementation can improve the nutritional status of patients with chronic heart failure. Methods: we performed a randomized clinical trial on an intention-to-treat basis with blinded observers. We divided a sample of 76 patients into 2 groups: one that received structured advice combined with nutritional supplements for 12 weeks (test group), and one that received treatment as usual (control group). The outcome measure was nutritional status as evaluated using the Subjective Global Assessment and the Mini Nutritional Assessment tools. After 12 weeks of treatment the test group received a leaflet that served as a reminder. No further interventions were applied in either group. Patients were followed for 1 year. Results: at 3 months of follow-up nutritional status improved 4-fold in the test group, whereas no change was observed in the control group. At 9 months nutritional status in the intervention group had improved 2-fold with respect to the baseline visit, whereas no differences were recorded in the control group. Differences in mortality and length of stay at 1 year did not reach statistical significance.

Disease management interventions for heart failure

BACKGROUND

Despite advances in treatment, the increasing and ageing population makes heart failure an important cause of morbidity and death worldwide. It is associated with high healthcare costs, partly driven by frequent hospital readmissions. Disease management interventions may help to manage people with heart failure in a more proactive, preventative way than drug therapy alone. This is the second update of a review published in 2005 and updated in 2012.

OBJECTIVES

To compare the effects of different disease management interventions for heart failure (which are not purely educational in focus), with usual care, in terms of death, hospital readmissions, quality of life and cost-related outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL for this review update on 9 January 2018 and two clinical trials registries on 4 July 2018. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least six months' follow-up, comparing disease management interventions to usual care for adults who had been admitted to hospital at least once with a diagnosis of heart failure. There were three main types of intervention: case management; clinic-based interventions; multidisciplinary interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Outcomes of interest were mortality due to heart failure, mortality due to any cause, hospital readmission for heart failure, hospital readmission for any cause, adverse effects, quality of life, costs and cost-effectiveness.

MAIN RESULTS

We found 22 new RCTs, so now include 47 RCTs (10,869 participants). Twenty-eight were case management interventions, seven were clinic-based models, nine were multidisciplinary interventions, and three could not be categorised as any of these. The included studies were predominantly in an older population, with most studies reporting a mean age of between 67 and 80 years. Seven RCTs were in upper-middle-income countries, the rest were in high-income countries.Only two multidisciplinary-intervention RCTs reported mortality due to heart failure. Pooled analysis gave a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.23 to 0.95), but the very low-quality evidence means we are uncertain of the effect on mortality due to heart failure. Based on this limited evidence, the number needed to treat for an additional beneficial outcome (NNTB) is 12 (95% CI 9 to 126).Twenty-six case management RCTs reported all-cause mortality, with low-quality evidence indicating that these may reduce all-cause mortality (RR 0.78, 95% CI 0.68 to 0.90; NNTB 25, 95% CI 17 to 54). We pooled all seven clinic-based studies, with low-quality evidence suggesting they may make little to no difference to all-cause mortality. Pooled analysis of eight multidisciplinary studies gave moderate-quality evidence that these probably reduce all-cause mortality (RR 0.67, 95% CI 0.54 to 0.83; NNTB 17, 95% CI 12 to 32).We pooled data on heart failure readmissions from 12 case management studies. Moderate-quality evidence suggests that they probably reduce heart failure readmissions (RR 0.64, 95% CI 0.53 to 0.78; NNTB 8, 95% CI 6 to 13). We were able to pool only two clinic-based studies, and the moderate-quality evidence suggested that there is probably little or no difference in heart failure readmissions between clinic-based interventions and usual care (RR 1.01, 95% CI 0.87 to 1.18). Pooled analysis of five multidisciplinary interventions gave low-quality evidence that these may reduce the risk of heart failure readmissions (RR 0.68, 95% CI 0.50 to 0.92; NNTB 11, 95% CI 7 to 44).Meta-analysis of 14 RCTs gave moderate-quality evidence that case management probably slightly reduces all-cause readmissions (RR 0.92, 95% CI 0.83 to 1.01); a decrease from 491 to 451 in 1000 people (95% CI 407 to 495). Pooling four clinic-based RCTs gave low-quality and somewhat heterogeneous evidence that these may result in little or no difference in all-cause readmissions (RR 0.90, 95% CI 0.72 to 1.12). Low-quality evidence from five RCTs indicated that multidisciplinary interventions may slightly reduce all-cause readmissions (RR 0.85, 95% CI 0.71 to 1.01); a decrease from 450 to 383 in 1000 people (95% CI 320 to 455).Neither case management nor clinic-based intervention RCTs reported adverse effects. Two multidisciplinary interventions reported that no adverse events occurred. GRADE assessment of moderate quality suggested that there may be little or no difference in adverse effects between multidisciplinary interventions and usual care.Quality of life was generally poorly reported, with high attrition. Low-quality evidence means we are uncertain about the effect of case management and multidisciplinary interventions on quality of life. Four clinic-based studies reported quality of life but we could not pool them due to differences in reporting. Low-quality evidence indicates that clinic-based interventions may result in little or no difference in quality of life.Four case management programmes had cost-effectiveness analyses, and seven reported cost data. Low-quality evidence indicates that these may reduce costs and may be cost-effective. Two clinic-based studies reported cost savings. Low-quality evidence indicates that clinic-based interventions may reduce costs slightly. Low-quality data from one multidisciplinary intervention suggested this may be cost-effective from a societal perspective but less so from a health-services perspective.

AUTHORS' CONCLUSIONS

We found limited evidence for the effect of disease management programmes on mortality due to heart failure, with few studies reporting this outcome. Case management may reduce all-cause mortality, and multidisciplinary interventions probably also reduce all-cause mortality, but clinic-based interventions had little or no effect on all-cause mortality. Readmissions due to heart failure or any cause were probably reduced by case-management interventions. Clinic-based interventions probably make little or no difference to heart failure readmissions and may result in little or no difference in readmissions for any cause. Multidisciplinary interventions may reduce the risk of readmission for heart failure or for any cause. There was a lack of evidence for adverse effects, and conclusions on quality of life remain uncertain due to poor-quality data. Variations in study location and time of occurrence hamper attempts to review costs and cost-effectiveness.The potential to improve quality of life is an important consideration but remains poorly reported. Improved reporting in future trials would strengthen the evidence for this patient-relevant outcome.

A perioperative care map improves outcomes in patients with morbid obesity undergoing major surgery

BACKGROUND

The surgical management of patients with morbid obesity (body mass index ≥ 40) is notable for a relatively high risk of complications. To address this problem, a perioperative care map was developed using precautions and best practices commonly employed in bariatric surgery. It requires additional medical assessments, sleep apnea surveillance, more stringent guidelines for anesthetic management, and readily available bariatric operating room equipment, among other items. This care map was implemented in 2013 at 4 major urban teaching hospitals for use in patients undergoing all types of nonambulatory surgery with a body mass index greater than 40 kg/m². The impact on patient outcomes was evaluated.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to compare 30-day outcomes of morbidly obese patients before the year 2013 and after the years 2015 care-map implementation. In addition, trends in 30-day outcomes for morbidly obese patients were compared with those for non-obese patients.

RESULTS

Morbidly obese patients, between 2013 and 2015, saw an adjusted decrease in the rate of unplanned return to the operating room (OR = 0.49; P = .039), unplanned readmission (OR = 0.57; P = .006), total duration of stay (-0.87 days; P = .009), and postoperative duration of stay (-0.69 days; P = .007). Of these, total duration of stay (-0.86 days; P = .015), and postoperative duration of stay (-0.69 days; P = .012) improved significantly more for morbidly obese patients than for nonmorbidly obese patients.

CONCLUSION

Outcomes in morbidly obese patients improved from 2013 to 2015. Implementation of a perioperative care map may have contributed to these improvements. The care map should be further investigated and considered for more widespread use.

Integrating Care Across Disciplines

Interdisciplinary care teams are important in managing older patients. Geriatric patients with cardiovascular problems represent a unique paradigm for interdisciplinary teams, and patients benefit from the assistance of physicians, nurses, social workers, pharmacists, and therapists collaborating on treatment plans. Teams work on the inpatient and outpatient sides and at patients' homes to maximize function and prevent readmissions to the hospital.

Single subject design: Use of time series analyses in a small cohort to understand adherence with a prescribed fluid restriction

PURPOSE

This paper presents a secondary in-depth analysis of five persons with heart failure randomized to receive an education and behavioral intervention on fluid restriction as part of a larger study.

METHODS

Using a single subject analysis design, time series analyses models were constructed for each of the five patients for a period of 180 days to determine correlations between daily measures of patient reported fluid intake, thoracic impedance, and weights, and relationships between patient reported outcomes of symptom burden and health related quality of life over time.

RESULTS

Negative relationships were observed between fluid intake and thoracic impedance, and between impedance and weight, while positive correlations were observed between daily fluid intake and weight.

CONCLUSIONS

By constructing time series analyses of daily measures of fluid congestion, trends and patterns of fluid congestion emerged which could be used to guide individualized patient care or future research endeavors. Employment of such a specialized analysis technique allows for the elucidation of clinically relevant findings potentially disguised when only evaluating aggregate outcomes of larger studies.

The effectiveness of chronic care management for heart failure: meta-regression analyses to explain the heterogeneity in outcomes

OBJECTIVE

To support decision making on how to best redesign chronic care by studying the heterogeneity in effectiveness across chronic care management evaluations for heart failure.

DATA SOURCES

Reviews and primary studies that evaluated chronic care management interventions.

STUDY DESIGN

A systematic review including meta-regression analyses to investigate three potential sources of heterogeneity in effectiveness: study quality, length of follow-up, and number of chronic care model components.

PRINCIPAL FINDINGS

Our meta-analysis showed that chronic care management reduces mortality by a mean of 18 percent (95 percent CI: 0.72-0.94) and hospitalization by a mean of 18 percent (95 percent CI: 0.76-0.93) and improves quality of life by 7.14 points (95 percent CI: -9.55 to -4.72) on the Minnesota Living with Heart Failure questionnaire. We could not explain the considerable differences in hospitalization and quality of life across the studies.

CONCLUSION

Chronic care management significantly reduces mortality. Positive effects on hospitalization and quality of life were shown, however, with substantial heterogeneity in effectiveness. This heterogeneity is not explained by study quality, length of follow-up, or the number of chronic care model components. More attention to the development and implementation of chronic care management is needed to support informed decision making on how to best redesign chronic care.

Clinical service organisation for heart failure

BACKGROUND

Chronic heart failure (CHF) is a serious, common condition associated with frequent hospitalisation. Several different disease management interventions (clinical service organisation interventions) for patients with CHF have been proposed.

OBJECTIVES

To update the previously published review which assessed the effectiveness of disease management interventions for patients with CHF.

SEARCH METHODS

A number of databases were searched for the updated review: CENTRAL, (the Cochrane Central Register of Controlled Trials) and DARE, on The Cochrane Library, ( Issue 1 2009); MEDLINE (1950-January 2009); EMBASE (1980-January 2009); CINAHL (1982-January 2009); AMED (1985-January 2009). For the original review (but not the update) we had also searched: Science Citation Index Expanded (1981-2001); SIGLE (1980-2003); National Research Register (2003) and NHS Economic Evaluations Database (2001). We also searched reference lists of included studies for both the original and updated reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with at least six months follow up, comparing disease management interventions specifically directed at patients with CHF to usual care.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently extracted data and assessed study quality. Study authors were contacted for further information where necessary. Data were analysed and presented as odds ratios (OR) with 95% confidence intervals (CI).

MAIN RESULTS

Twenty five trials (5,942 people) were included. Interventions were classified by: (1) case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); (2) clinic interventions (follow up in a CHF clinic) and (3) multidisciplinary interventions (holistic approach bridging the gap between hospital admission and discharge home delivered by a team). The components, intensity and duration of the interventions varied, as did the 'usual care' comparator provided in different trials.Case management interventions were associated with reduction in all cause mortality at 12 months follow up, OR 0.66 (95% CI 0.47 to 0.91, but not at six months. No reductions were seen for deaths from CHF or cardiovascular causes. However, case management type interventions reduced CHF related readmissions at six month (OR 0.64, 95% CI 0.46 to 0.88, P = 0.007) and 12 month follow up (OR 0.47, 95% CI 0.30 to 0.76). Impact of these interventions on all cause hospital admissions was not apparent at six months but was at 12 months (OR 0.75, 95% CI 0.57 to 0.99, I(2) = 58%).   CHF clinic interventions (for six and 12 month follow up) revealed non-significant reductions in all cause mortality, CHF related admissions and all cause readmissions. Mortality was not reduced in the two studies that looked at multidisciplinary interventions. However, both all cause and CHF related readmissions were reduced (OR 0.46, 95% CI 0.46-0.69, and 0.45, 95% CI 0.28-0.72, respectively). 

AUTHORS' CONCLUSIONS

Amongst CHF patients who have previously been admitted to hospital for this condition there is now good evidence that case management type interventions led by a heart failure specialist nurse reduces CHF related readmissions after 12 months follow up, all cause readmissions and all cause mortality.  It is not possible to say what the optimal components of these case management type interventions are, however telephone follow up by the nurse specialist was a common component.Multidisciplinary interventions may be effective in reducing both CHF and all cause readmissions. There is currently limited evidence to support interventions whose major component is follow up in a CHF clinic.

Patient-centered medical homes: will health care reform provide new options for rural communities and providers?

Many are calling for the expansion of the patient-centered medical home model into rural and underserved populations as a transformative strategy to address issues of access, efficiency, quality, and sustainability in the delivery of health care. Patient-centered medical homes have been touted as a promising cost-saving model for comprehensive management of persons with chronic diseases and disabilities, but it is unclear how rural practitioners in medically underserved areas will implement the patient-centered medical home. This article examines how the Patient Protection & Affordable Care Act of 2010 will enhance rural providers' ability to provide patient-centered care and services contemplated under the Act in a comprehensive, coordinated, cost-effective way despite leaner budgets and health workforce shortages.

ACEi/ARB for systolic heart failure: closing the quality gap with a sustainable intervention at an academic medical center

BACKGROUND

National guidelines recommend angiotensin converting enzyme inhibitor (ACEi) or angiotensinogen receptor blocker (ARB) therapy for patients with left ventricular systolic dysfunction (LVSD), including those with symptomatic heart failure (HF). However, guideline adherence has not been optimal. The goal of this quality improvement project is to devise and implement a sustainable care-delivery model in a 920-bed academic hospital center that would improve ACEi/ARB adherence before hospital discharge.

METHODS

The Model of intervention is: (1) a computer-based daily screening program; (2) inpatient pharmacist e-flag message; and (3) alerts for inpatient care teams. Its operating algorithm: If eligible adult HF/LVSD inpatients are not on ACEi or ARB nor documentation of contraindications, a flag alert is generated; deficiency is confirmed by a pharmacist and conveyed to the patient-care teams; if alert is acted on and care brought into adherence, the screening program would not re-flag the same patients the succeeding day; if not, the patients would be re-flagged daily until reaching adherence. We compared ACEi/ARB adherence before, during, and after the intervention.

RESULTS

Baseline performance (percentage of eligible HF/LVSD patients receiving ACEi/ARB) was 87.5%. After implementation of the Model the ACEi/ARB adherence rate at the time of hospital discharge rose to 96.7% (P < 0.002) and was sustained for 21 months without needing additional personnel.

CONCLUSIONS

A carefully designed, computer-based care-delivery model is highly efficient and sustainable for enhancing ACEi/ARB adherence.

Factors associated with potentially preventable hospitalization among nursing home residents in New York State with chronic kidney disease

OBJECTIVE

Identify clinical and organizational factors associated with potentially preventable ambulatory care sensitive (ACS) hospitalization among nursing home residents with chronic kidney disease.

METHODS

New York State Nursing home residents (n = 5449) age 60+ with chronic kidney disease and were hospitalized in 2007. Data included residents' sociodemographic and clinical characteristics, nursing home organizational factors, and ACS hospitalizations. Multivariate logistic regression quantified the association between potential determinants and ACS hospitalizations (yes versus no).

RESULTS

Prevalence of chronic kidney disease among nursing home residents is 24%. Potentially avoidable ACS hospitalization among older nursing home residents with chronic kidney disease is 27%. Three potentially modifiable factors associated with significantly higher odds of ACS hospitalization include the following: presence of congestive heart failure (OR = 1.4; 95% CI 1.24-1.65), excessive medication use (OR = 1.3; 95% CI 1.11-1.48), and the lack of training provided to nursing staff on how to communicate effectively with physician about the resident's condition. (OR = 1.3; 95% CI 0.59-0.96).

CONCLUSION

To reduce potentially preventable ACS hospitalization among chronic kidney disease patients, congestive heart failure and excessive medication use can be kept stable using relatively simple interventions by periodic multidisciplinary review of medications and assessing appropriate response to therapy; and communication training be provided to nursing staff on how to articulate to the responsible physician important changes in the patients' condition.

Medical homes: "where you stand on definitions depends on where you sit"

The medical home is a potentially transformative strategy to address issues of access, quality, and efficiency in the delivery of health care in the United States. While numerous organizations support a physician-driven definition, it is by no means the universally accepted definition. Several professional groups, payers, and researchers have offered differing, or nuanced, definitions of medical homes. This lack of consensus has contributed to uncertainty among providers about the medical home. We conducted a systematic review of the literature on the medical home and identified 29 professional, government, and academic sources offering definitions. While consensus appears to exist around a core of selected features, the medical home means different things to different people. The variation in definitions can be partly explained by the obligation of organizations to their members and whether the focus is on the patient or provider. Differences in definitions have implications at both the policy and practice levels.

Clinical impact of adherence to guidelines on the outcome of chronic heart failure in Japan

The impact of guideline adherence on clinical outcomes in the management of chronic heart failure (CHF) has never been evaluated in Japan. We investigated outcomes in 92 consecutive CHF patients admitted to Kitasato University Hospital in 2004-2006 for HF exacerbation with a left ventricular ejection fraction < or = 40% by the use of class I drugs for pump-failure, as recommended in the Japanese Circulation Society guideline. Drugs, namely angiotensin-converting enzyme inhibitors (ACEI), beta-blockers (BB), spironolactone, diuretics, and cardiac glycosides were administered to 64.1%, 59.8%, 28.2%, 96.7%, and 68.0% of patients, respectively. Patients for whom adherence to the prescription of ACEI and BB as first-line agents was high had significantly and independently better prognostic outcomes for cardiac events (P = 0.0036) as well as subsequent improvements in clinical surrogate markers for HF status such as NYHA class and BNP. Addition of the 3 latter drugs to the prescription of ACEI and BB did not affect the superiority of ACE plus BB in improving the long-term prognosis. We have demonstrated that adherence to treatment guidelines for CHF is a significant predictor of subsequent cardiac events in actual practice in Japan. An effective means of improving adherence to current guideline standards of care for CHF has yet to be established.

Assessment of attitudes of intensive care unit staff toward clinical practice guidelines

Although studies on the implementation and adherence to specific practice guidelines have been proliferating, research examining the attitude of healthcare workers toward practice guidelines in general has been lacking. This study is a secondary analysis of data collected from 39 volunteer hospitals participating in the National Nosocomial Infection Surveillance System on attitudes of intensive care unit staff regarding practice guidelines in general. Age, profession, type of intensive care unit, and race were identified as significant predictors of attitude scores in this study. Understanding the differences in perceived barriers is important for the adherence to practice guidelines.

The impact of patient-specific quality-of-care report cards on guideline adherence in heart failure

BACKGROUND

It is unknown if physician education through heart failure (HF) patient-specific quality-of-care report cards (HFRC) impacts outpatient HF guideline adherence.

METHODS

A prospective pre-post design study was performed to test the hypothesis that a one-time, patient-specific HFRC delivered to physicians after HF patient (ejection fraction < or = 40%) discharge would lead to improved HF guideline adherence compared with control practitioners. Patients were contacted at 1, 3, and 6 months after discharge to assess medication usage and intolerances. Six month quality score (QS) was the primary end point, calculated as the sum of adherence to 4 medication performance measures (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, aldosterone inhibitors, and warfarin for atrial fibrillation).

RESULTS

The mean QS at discharge was 3.10 +/- 0.78 in controls (n = 189) and 3.25 +/- 0.79 in the HFRC group (n = 76, P = .11). Controlling for discharge QS, the HFRC resulted in a significantly improved QS at 3 months (beta = .11, P = .023) but not at the 6-month primary end point (beta = .084, P = .14). Controlling for baseline medication use, patients of practitioners receiving the HFRC were 32.5 (P = .019) and 8.5 (P = .030) times more likely to receive, or have a documented contraindication to, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker at 3 and 6 months, respectively. There were no significant differences in indicated beta-blocker, aldosterone inhibitor, or warfarin prescriptions at any follow-up.

CONCLUSIONS

Although one-time patient-specific report cards result in short-term statistically significant improvements in outpatient evidence-based HF care, the gain does not translate into sustained improvements in quality of care.

Patient complexity: more than comorbidity. the vector model of complexity

BACKGROUND

The conceptualization of patient complexity is just beginning in clinical medicine.

OBJECTIVES

This study aims (1) to propose a conceptual approach to complex patients; (2) to demonstrate how this approach promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans; and (3) to examine availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients.

METHODS/RESULTS

The Vector Model of Complexity portrays interactions between biological, socioeconomic, cultural, environmental and behavioral forces as health determinants. These forces are not easily discerned but exert profound influences on processes and outcomes of care for chronic medical conditions. Achieving congruence between patient, physician, and healthcare system is essential for effective, patient-centered care; requires assessment of all axes of the Vector Model; and, frequently, requires trade-off decisions to develop a tailored treatment plan. Most evidence-based guidelines rarely provide guidance for trade-off decisions. Quality measures often exclude complex patients and are not designed explicitly to assess their overall healthcare.

CONCLUSIONS/RECOMMENDATIONS

We urgently need to expand the evidence base to inform the care of complex patients of all kinds, especially for the clinical trade-off decisions that are central to tailoring care. We offer long- and short-term strategies to begin to incorporate complexity into quality measurement and performance profiling, guided by the Vector Model. Interdisciplinary research should lay the foundation for a deeper understanding of the multiple sources of patient complexity and their interactions, and how provision of healthcare should be harmonized with complexity to optimize health.

Management strategies to meet the core heart failure measures for acute decompensated heart failure: a nursing perspective

Despite enormous advances in the medical management of heart disease, heart failure (HF) persists as a leading cause of hospitalization in our elderly. In 2001, the American Heart Association and the American College of Cardiology published Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease. The guidelines proactively responded to a growing body of evidence confirming that comprehensive risk factor management and risk reduction improve quality of life and survival, while reducing recurrent cardiovascular events. In spite of the well-crafted, comprehensive HF guidelines, morbidity, mortality, and hospital readmission rates for acute decompensated heart failure remain high, and adherence to HF guidelines is not always optimal. The Joint Commission has implemented a number of quality care performance indicators based on the Guidelines for Secondary Prevention; among them are the Core HF Measures for hospitalized HF patients. The Core HF Measures are endorsed by the Center for Medicare and Medicaid and has been adopted as a national benchmark for measurement and public reporting of healthcare performance and for Medicare payments (Joint Commission). The implementation and monitoring of Core HF Measures has prioritized attention toward patient education and risk factor modification to prevent future hospitalization. Critical care nurses are on the frontline to champion uptake and adherence of Core HF Measures. The purpose of this article is to highlight the critical component that nursing care, guided by the Core HF Measures, can offer to improve the quality of patient care in acute decompensated heart failure.

Predictors of delivery of hospital-based heart failure patient education: a report from OPTIMIZE-HF

BACKGROUND

Although recent heart failure (HF) management guidelines recommend delivery of patient education and discharge instructions, little is known about predictors of delivery of these materials or how such materials relate to outpatient disposition postdischarge. This report assesses the degree to which the full set of HF discharge instructions and education comprising the Joint Commission on Accreditation of Healthcare Organizations process-of-care measure (HF-1) was provided, identifies factors predictive of use of HF-1, and determines if HF-1 predicts postdischarge outcome disposition in a registry and performance improvement (PI) program for patients hospitalized for HF.

METHODS AND RESULTS

In the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (ie, OPTIMIZE-HF), of 33,681 patients from 259 US hospitals, 54% received HF-1. Some patient and site characteristics, such as symptoms on admission and performance of coronary angiography, were positively associated with delivery of the full set of HF-1 components, and others, such as African-American or Hispanic race and Midwest site location, were negatively associated with HF-1 delivery. However, delivery of the full set of HF-1 components was significantly more likely in the 46% of patients receiving PI tools (OR 2.23, 95% CI 2.12-2.35; P < .0001). Delivery of the full set of HF-1 components was significantly associated with use of specialty referral programs after discharge (P < .0001).

CONCLUSIONS

Despite recommendations that complete instructions be given to patients with HF before hospital discharge, both PI tools to facilitate HF-1 and HF-1 itself are underused. Efforts should focus on strengthening processes and structures that will improve consistent delivery of HF-1 to all patients.

[Health economics from the physician's point of view]

Physicians should be aware that overall resources in health care are limited. Thus, available funds should be allocated in a fair and efficient manner. Although the daily work at the bedside or in the physician's office create many direct and even more indirect costs to the health care system, many physicians believe that cost-benefit considerations should not be part of the daily work because they are viewed as a disturbing factor in the patient-physician relationship. However, due to the limited resources, strategic measures that reduce health care costs but maintain quality are unavoidable. Physicians must be involved in the design and implementation of these measures, and the administrative burden to document progress must be kept as small as possible. As an example we would like to discuss the pay for performance programme of the National Health Service in the United Kingdom, launched in 2004. Physicians could improve their income by about 25% if they were able to accomplish a number of well-defined quality indicators. As much as 97% of the primary care physicians reached the pre-defined goals, and there was no indication for manipulation. This example shows that through the implementation of quality improvement programmes, the position of primary care medicine can even be strengthened. Sponsors of the health care system should continue to look for measures that maintain a high quality standard in primary care medicine. However, before this system can be widely implemented, active research is needed to evaluate whether privileging some quality indicators over others has negative consequences on overall societal health. Only through an open-minded discussion among all participants of the health care system including the general population will a solution be found that is capable of winning a majority and that takes into account the limited availability of resources.

A taxonomy for disease management: a scientific statement from the American Heart Association Disease Management Taxonomy Writing Group

BACKGROUND

Disease management has shown great promise as a means of reorganizing chronic care and optimizing patient outcomes. Nevertheless, disease management programs are widely heterogeneous and lack a shared definition of disease management, which limits our ability to compare and evaluate different programs. To address this problem, the American Heart Association's Disease Management Taxonomy Writing Group developed a system of classification that can be used both to categorize and compare disease management programs and to inform efforts to identify specific factors associated with effectiveness.

METHODS

The AHA Writing Group began with a conceptual model of disease management and its components and subsequently validated this model over a wide range of disease management programs. A systematic MEDLINE search was performed on the terms heart failure, diabetes, and depression, together with disease management, case management, and care management. The search encompassed articles published in English between 1987 and 2005. We then selected studies that incorporated (1) interventions designed to improve outcomes and/or reduce medical resource utilization in patients with heart failure, diabetes, or depression and (2) clearly defined protocols with at least 2 prespecified components traditionally associated with disease management. We analyzed the study protocols and used qualitative research methods to develop a disease management taxonomy with our conceptual model as the organizing framework.

RESULTS

The final taxonomy includes the following 8 domains: (1) Patient population is characterized by risk status, demographic profile, and level of comorbidity. (2) Intervention recipient describes the primary targets of disease management intervention and includes patients and caregivers, physicians and allied healthcare providers, and healthcare delivery systems. (3) Intervention content delineates individual components, such as patient education, medication management, peer support, or some form of postacute care, that are included in disease management. (4) Delivery personnel describes the network of healthcare providers involved in the delivery of disease management interventions, including nurses, case managers, physicians, pharmacists, case workers, dietitians, physical therapists, psychologists, and information systems specialists. (5) Method of communication identifies a broad range of disease management delivery systems that may include in-person visitation, audiovisual information packets, and some form of electronic or telecommunication technology. (6) Intensity and complexity distinguish between the frequency and duration of exposure, as well as the mix of program components, with respect to the target for disease management. (7) Environment defines the context in which disease management interventions are typically delivered and includes inpatient or hospital-affiliated outpatient programs, community or home-based programs, or some combination of these factors. (8) Clinical outcomes include traditional, frequently assessed primary and secondary outcomes, as well as patient-centered measures, such as adherence to medication, self-management, and caregiver burden.

CONCLUSIONS

This statement presents a taxonomy for disease management that describes critical program attributes and allows for comparisons across interventions. Routine application of the taxonomy may facilitate better comparisons of structure, process, and outcome measures across a range of disease management programs and should promote uniformity in the design and conduct of studies that seek to validate disease management strategies.

Heart failure disease management: implementation and outcomes

Millions of dollars are being spent to identify new therapies to improve mortality and morbidity for the growing epidemic of patients sustaining heart failure. However, in clinical practice, these therapies are currently underused. To bridge the gap between proven therapies and clinical practice, the medical community has turned to disease management. Heart failure disease management interventions vary from vital-sign monitoring to multidisciplinary approaches involving a pharmacist, nutritionist, nurse practitioner, and physician. This review attempts to categorize these inventions based on location. We compared the published results from randomized, controlled trials of the following types of heart failure disease management interventions: inpatient, clinic visits, home visits, and telephone follow up. Although research shows an improvement in the quality of care and a decrease in hospitalizations for patients sustaining heart failure, the economic impact of disease management is still unclear. The current reimbursement structure is a disincentive to providers wanting to offer disease management services to patients sustaining heart failure. Additionally, the cost of providing disease management services such as additional clinical visits, patient education materials, or additional personnel time has not been well documented. Most heart failure disease management studies do confirm the concept that providing increased access to healthcare providers for an at-risk group of patients sustaining heart failure does improve outcomes. However, a large-scale randomized, controlled clinical trial based in the United States is needed to prove that this concept can be implemented beyond a single center and to determine how much it will cost patients, providers, healthcare systems, and payers.

Clinical practice guidelines and organizational adaptation: a framework for analyzing economic effects

OBJECTIVES

The overall objective of this article was to review the theoretical and conceptual dimensions of how the implementation of clinical practice guidelines (CPGs) is likely to affect treatment costs.

METHODS

An important limitation of the extant literature on the cost effects of CPGs is that the main focus has been on clinical adaptation. We submit that the process innovation aspects of CPGs require changes in both clinical and organizational dimensions. We identify five organizational factors that are likely to affect the relationship between CPGs and total treatment costs: implementation, coordination, learning, human resources, and information. We review the literature supporting each of these factors.

RESULTS

The net organizational effects of CPGs on costs depends on whether the cost-reducing properties of coordination, learning, and human resource management offset potential cost increases due to implementation and information management.

CONCLUSIONS

Studies of the cost effects of clinical practice guidelines should attempt to measure, to the extent possible, the effects of each of these clinical and organizational factors.

The physician-hospital team: a successful approach to improving care in a large academic medical center

Initiatives to improve the quality and efficiency of care in academic medical centers (AMCs, teaching hospitals) can benefit the performance of academic departments as well as the hospital. However, the value of performance improvement programs in an AMC is often challenging. At Jefferson Medical College, clinical efficiency and bed availability are important priorities to the Department of Medicine. To this end, a multidisciplinary program was designed to (1) improve the quality and consistency of care by adapting and adopting national guidelines for patients with heart failure and acute coronary syndrome; (2) identify and improve hospital operational supports and maximize resource utilization; (3) increase hospital functional capacity to make way for increased volume; and (4) improve housestaff education and practice by using evidence-based approaches and by optimizing teaching relationships between housestaff and attending faculty. The eight-month project (November 2002 to July 2003) resulted in improvement in several quality measures including increased use of beta blockers and angiotensin converting enzyme inhibitors for heart failure patients, reduced length of stay for heart failure and acute coronary syndrome patients, and increased satisfaction of the clinicians involved in caring for these patients. However, the project was not without barriers including individual physician's unwillingness to embrace change and an inability to incentivize change. Development of faculty leadership skills and enhanced physician accountability helped in overcoming the challenges of change.

Barriers to providing osteoporosis care in skilled nursing facilities: perceptions of medical directors and directors of nursing

OBJECTIVES

The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs.

DESIGN

The authors conducted a cross-sectional national survey.

PARTICIPANTS

This study consisted of a random national sample of MED DIRs (n = 1300) and DONs (n = 1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care.

MEASUREMENTS

A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested.

RESULTS

Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses.

CONCLUSION

Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.

Temporal improvement in heart failure survival related to the use of a nurse-directed clinic and recommended pharmacological treatment

BACKGROUND

The use of recommended drugs for chronic heart failure (CHF) has been discouragingly low in clinical practice. The aim of this study was to prospectively evaluate to which extent a nurse-directed heart failure clinic could accomplish drug titration with modern heart failure treatments, with focus on beta-blockers.

METHODS

Outcome of drug titration was evaluated for 418 patients referred to the nurse-run clinic from 1995 through 2001, using a prospective, open, non-randomised quality control protocol.

RESULTS

Throughout the period, most of the patients were discharged on an ACE inhibitor (during 2001, 86%). The use of beta-blockers increased during the observation (from 43% to 88%). Patients started on an ACE-inhibitor treatment continued in 89% and in 95% when started on a beta-blocker. There was a significant decrease in mortality, relative risk per year 0.84 (95% CI, 0.75 to 0.94), P=0.002. Three-year mortality was reduced from 27% to 10%. In a multivariable analysis, survival was significantly associated with ejection fraction, renal function, the use of beta-blockers and ACE inhibitors, and negatively with digitalis treatment.

CONCLUSIONS

The nurse-directed titration succeeded in introducing more patients on beta-blockers than on ACE-inhibitors. Mortality was reduced during the study period, associated with more use of documented therapy, beta-blockers in particular. These findings suggest that the observed signs of improvement in CHF prognosis are likely caused by more efficient medical treatment.

Clinical Practice Guideline Adherence Before and After Implementation of the HEARTFELT (HEART Failure Effectiveness & Leadership Team) Intervention

HEART Failure Effectiveness & Leadership Team (HEARTFELT) is a multifaceted intervention designed to improve adherence with the American College of Cardiology/American Heart Association practice guidelines for heart failure (HF). The purpose of this study was to assess differences in clinician adherence with clinical practice guidelines before and after implementation of HEARTFELT. A quasi-experimental, untreated control group design with separate pretest/posttest samples was employed at a community hospital in Connecticut. The untreated historical control group included patients aged 65 years or older with HF and a nonequivalent comparison group of patients with stroke. The posttest samples included patients with the diagnosis of HF and stroke admitted after implementation of the HEARTFELT intervention. The HEARTFELT intervention included automated pathway in electronic medical record (order sets, interdisciplinary plan of care, self-management plan), access to evidence for clinicians and patients, HF self-management education tools, and ongoing discipline-specific feedback regarding adherence. Data were analyzed using parametric and nonparametric methods. The HEARTFELT intervention significantly improved clinician adherence with addressing all self-management categories in the electronic medical record (P = .000) and adherence with self-management education given to the patient in writing at discharge (P = .000). There were no significant differences in adherence with medical interventions (P = .39). While guideline adherence is associated with less practice variation and improved processes, methods of integration into practice in community hospital settings have been largely unexplored. The multifaceted HEARTFELT intervention is promising for its potential to integrate evidence at the point of care, to reduce unwarranted variation in practice, and ultimately to improve the outcomes of individuals with HF.

Economic effectiveness of disease management programs: a meta-analysis

The economic effectiveness of disease management programs, which are designed to improve the clinical and economic outcomes for chronically ill individuals, has been evaluated extensively. A literature search was performed with MEDLINE and other published sources for the period covering January 1995 to September 2003. The search was limited to empirical articles that measured the direct economic outcomes for asthma, diabetes, and heart disease management programs. Of the 360 articles and presentations evaluated, only 67 met the selection criteria for meta-analysis, which included 32,041 subjects. Although some studies contained multiple measurements of direct economic outcomes, only one average effect size per study was included in the meta-analysis. Based on the studies included in the research, a meta-analysis provided a statistically significant answer to the question of whether disease management programs are economically effective. The magnitude of the observed average effect size for equally weighted studies was 0.311 (95% CI = 0.272-0.350). Statistically significant differences of effect sizes by study design, disease type and intensity of disease management program interventions were not found after a moderating variable, disease severity, was taken into consideration. The results suggest that disease management programs are more effective economically with severely ill enrollees and that chronic disease program interventions are most effective when coordinated with the overall level of disease severity. The findings can be generalized, which may assist health care policy makers and practitioners in addressing the issue of providing economically effective care for the growing number of individuals with chronic illness.

The near absence of osteoporosis treatment in older men with fractures

The burden of osteoporotic fractures in older men is significant. The objectives of our study were to: (1) characterize older men with fractures associated with osteoporosis, (2) determine if medication treatment rates for osteoporosis are improving and (3) identify patient, healthcare benefit and utilization, and clinician characteristics that are significantly associated with treatment. This retrospective cohort study assessed 1,171 men aged 65 or older with any new fracture associated with osteoporosis between 1 January 1998 and 30 June 2001 in a non-profit health maintenance organization in the United States. Multiple logistic regression was used to evaluate pre-fracture factors for their association with osteoporosis treatment in the 6-month post-fracture period. The main outcome measure was pharmacologic treatment for osteoporosis in the 6 months after the index fracture. Subjects' average age was 76.7 years; 3.3% had a diagnosis of osteoporosis and 15.2% a diagnosis or medication associated with secondary osteoporosis. Only 7.1% of the study population and 16.0% of those with a hip or vertebral fracture received a medication for osteoporosis following the index fracture, and treatment rates did not improve over time. In the multivariate model, factors significantly associated with drug treatment were a higher value on the Charlson Comorbidity Index (odds ratio 1.26, 95% confidence interval 1.05-1.51), having an osteoporosis diagnosis (odds ratio 8.11, 95% confidence interval 3.08-21.3), chronic glucocorticoid use (odds ratio 5.37, 95% confidence interval 2.37-12.2) and a vertebral fracture (odds ratio 16.6, 95% confidence interval 7.8-31.4). Bone mineral density measurement was rare (n =13, 1.1%). Our findings suggest that there is under-ascertainment and under-treatment of osteoporosis and modifiable secondary causes in older men with fractures. Information systems merging diagnostic and treatment information can help delineate gaps in patient management. Interventions showing promise in other conditions should be evaluated to improve care for osteoporosis.

Clinical service organisation for heart failure

BACKGROUND

Chronic heart failure (CHF) is a serious, common condition associated with frequent hospitalisation. Several different disease management interventions (clinical service organisation interventions) for patients with CHF have been proposed.

OBJECTIVES

To assess the effectiveness of disease management interventions for patients with CHF.

SEARCH STRATEGY

We searched: Cochrane CENTRAL Register of Controlled Trials (to June 2003); MEDLINE (January 1966 to July 2003); EMBASE (January 1980 to July 2003); CINAHL (January 1982 to July 2003); AMED (January 1985 to July 2003); Science Citation Index Expanded (searched January 1981 to March 2001); SIGLE (January 1980 to July 2003); DARE (July 2003); National Research Register (July 2003); NHS Economic Evaluations Database (March 2001); reference lists of articles and asked experts in the field.

SELECTION CRITERIA

Randomised controlled trials comparing disease management interventions specifically directed at patients with CHF to usual care.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently extracted data information and assessed study quality. Study authors were contacted for further information where necessary.

MAIN RESULTS

Sixteen trials involving 1,627 people were included. We classified the interventions into three models: multidisciplinary interventions (a holistic approach bridging the gap between hospital admission and discharge home delivered by a team); case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); and clinic interventions (follow up in a CHF clinic). There was considerable overlap within these categories, however the components, intensity and duration of the interventions varied. Case management interventions tended to be associated with reduced all cause mortality but these findings were not statistically significant (odds ratio 0.86, 95% confidence interval 0.67 to 1.10, P = 0.23), although the evidence was stronger when analysis was limited to the better quality studies (odds ratio 0.68, 95% confidence interval 0.46 to 0.98, P = 0.04). There was weak evidence that case management interventions may be associated with a reduction in admissions for heart failure. It is unclear what the effective components of the case management interventions are. The single RCT of a multidisciplinary intervention showed reduced heart-failure related re-admissions in the short term. At present there is little available evidence to support clinic based interventions.

AUTHORS' CONCLUSIONS

The data from this review are insufficient for forming recommendations. Further research should include adequately powered, multi-centre studies. Future studies should also investigate the effect of interventions on patients' and carers' quality of life, their satisfaction with the interventions and cost effectiveness.

Psychometric testing of the self-care of heart failure index

BACKGROUND

Self-care is believed to improve outcomes in heart failure (HF) patients. However, research testing this assumption is hampered by difficulties in measuring self-care. The purpose of this study was to evaluate the psychometric properties of a revised instrument measuring self-care in persons with HF, the Self-Care of Heart Failure Index (SCHFI). The SCHFI is a self-report measure comprised of 15 items rated on a 4-point response scale and divided into 3 subscales.

METHODS AND RESULTS

Psychometric testing was done using data from 760 HF patients (age 70.36 +/- 12.3 years, 51% male) from 7 sites in the United States. Reliability of the SCHFI (alpha.76) was adequate. Reliability of the Self-Care Maintenance subscale was lower than desired (alpha.56) but the reliability of the other subscales was adequate: Self-Care Management (alpha.70) and Self-Care Self-Confidence (alpha.82). Construct validity was supported with satisfactory model fit on confirmatory factor analysis (NFI=.69, CFI.73). Construct validity was supported further with significant total and subscale (all P <.05) differences between patients experienced with HF and those newly diagnosed, consistent with the underlying theory.

CONCLUSION

Low reliability of the Self-Care Maintenance subscale was expected because the items reflect behaviors known to vary in individuals. The reliability and validity of the SCHFI are sufficient to support its use in clinical research.

Are there race/ethnicity differences in outpatient congestive heart failure management, hospital use, and mortality among an insured population?

OBJECTIVE

The objective of this study was to assess the quality of outpatient care received by patients with congestive heart failure (CHF) and whether differences in care and outcomes exist by race/ethnicity.

BACKGROUND

Appropriate outpatient CHF management can improve patient well-being and reduce the need for costly inpatient care. Yet, little is known regarding outpatient CHF management or whether differences in this care exist by race/ethnicity.

METHODS

Using automated data sources, we identified a cohort of insured patients seen in an outpatient setting for CHF between September 1992 and August 1993. Medical record abstraction was used to confirm diagnosis of CHF. Patients (N = 566) were followed until September 1998. Race/ethnicity differences in outpatient management and medical care utilization were assessed using generalized estimating equations. Differences in mortality and hospitalization for CHF, controlling for patient characteristics and outpatient management, were assessed using Cox and Andersen-Gill models, respectively.

RESULTS

With the exception of beta blocker use and primary care visit frequency, few differences by race/ethnicity in patient characteristics and CHF management were found. However, older black patients had more hospital use both at baseline and during follow up. These differences persisted after adjusting for patient characteristics and clinical management. No race/ethnicity differences were found in mortality.

CONCLUSIONS

In an insured population, older black patients with CHF have substantially more hospital use than older white patients. This increased use was not explained by differences in CHF outpatient management. Further research is needed to understand why race/ethnicity differences in hospital use are observed among older patients with CHF.

Medical decision-making and healthcare disparities: the physician's role

Widespread disparities in US healthcare have been documented with attendant speculation about their causes, including the potential role of the physician as a healthcare decision-maker. However, the current evidence on physician decision-making is inadequate to draw firm conclusions on how it relates to healthcare inequalities. In this article, we review the available evidence on physician decision-making as it relates to healthcare disparities, with an emphasis on its shortcomings, discuss potential sources of bias, including interpersonal factors and physician preferences, and make suggestions for further research in this area.

Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding

OBJECTIVES

Acute nonvariceal upper gastrointestinal (GI) bleeding is the most common medical emergency encountered by gastroenterologists resulting in high patient morbidity and cost. We sought to establish if a GI bleeding clinical care pathway could improve the quality and cost effectiveness of inpatient medical care.

METHODS

A disease management program for acute upper GI bleeding was established. Length of stay, time to endoscopy, utilization of potentially unnecessary radiological tests, acid suppression, and cost of care were compared between patients pre- and postinitiation of GI bleeding pathway guidelines.

RESULTS

The instituted GI bleeding management program significantly reduced the use of intravenous H2-blockade from 65.3% to 47.7% (p = 0.002). The use of radiological tests, time to endoscopy, and length of hospital of stay were unchanged. There was a trend toward a reduction in total cost and variable direct cost per patient admitted with acute upper GI bleeding, from $5,381 to $4,627 and from $2,269 to $1,952, respectively.

CONCLUSION

A clinical care pathway may affect the management of acute upper GI bleeding and reduce costs. However, there are significant limitations and barriers to the overall effectiveness of such a pathway in actual clinical practice.

Standard outcome metrics and evaluation methodology for disease management programs. American Healthways and Johns Hopkins Consensus Conference

Disease management is conceptually recognized as being a significant approach for closing the gaps in care identified by the Institute of Medicine as contributing to poor outcomes from our health care system. That conceptual credibility has been bolstered by the disease management industry through the adoption of an industry-standard definition of disease management and through the development and implementation of disease management accreditation programs by the National Committee for Quality Assurance, Utilization Review Accreditation Commission, and Joint Commission on Accreditation of Healthcare Organizations. The clinical and financial outcomes of disease management programs continue to be suspect, however, due to the lack of an industry standard set of outcomes metrics and a uniform methodology for evaluating those metrics. As a result, the ability to evaluate the effectiveness of any individual program is compromised, and the ability to effectively compare results across programs of different delivery designs is non-existent. To address this issue, American Healthways and Johns Hopkins convened a consensus conference of nearly 150 health care professionals representing health plans, hospitals, practicing physicians (both primary care and specialty), and other health care professionals. The conference purpose was to develop a "first-step" set of metrics and a uniform methodology that could be applied industry-wide to enable meaningful comparisons between programs and to allow evaluation of individual programs whether "homegrown" or "outsourced." The consensus conferees recognized that there were many paths to this objective, but that they had to land on a set of metrics and a methodology that was "doable" in light of today's technology and data availability. The results of their consensus effort follow.

Effects of Interdisciplinary Rounds on Length of Stay in a Telemetry Unit

Interdisciplinary rounds (IRs) have been proposed to improve staff communication and reduce LOS. There have been no studies of IRs on an inpatient telemetry ward. Patients on a telemetry unit of a community hospital were randomly assigned to either an IR intervention or standard care. Charts were reviewed to determine LOS, patient characteristics, and indirect indices of quality of care.

INTERVENTION

Daily work rounds, in which resident physicians, nurses, and ancillary staff meet to discuss patients on the team.

RESULTS

84 patients were enrolled, 42 randomized to the intervention and 42 to standard care. There was no significant difference in LOS. Indirect measures of quality of care (dietician, pharmacist, or physical therapist visit) did not differ. In a multiple linear regression model, only abnormal laboratory data, the presence of dementia, and the presence of a home health aid significantly predicted LOS.

CONCLUSION

IRs did not decrease LOS in a telemetry ward. Whereas a potential benefit of IRs in other settings cannot be ruled out, this study emphasizes the importance of rigorous testing of strategies to enhance the quality or reduce the costs of inpatient care.

Do regulations limiting residents' work hours affect patient mortality?

OBJECTIVE

To conduct a statewide analysis of the effect of New York's regulations, limiting internal medicine and family practice residents' work hours, on patient mortality.

DESIGN

Retrospective study of inpatient discharge files for 1988 (before the regulations) and 1991 (after the regulations).

SETTING AND PATIENTS

Adult patients discharged from New York teaching hospitals (170214) and nonteaching hospitals (143,455) with a principal diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia, for the years 1988 and 1991 (periods before and after Code 405 regulations went into law). Patients from nonteaching hospitals served as controls.

MEASUREMENT

In-hospital mortality.

RESULTS

Combined unadjusted mortality for congestive heart failure, acute myocardial infarction, and pneumonia patients declined between 1988 and 1991 in both teaching (14.1% to 13.0%; P =.0001) and nonteaching hospitals (14.0% to 12.5%; P =.0001). Adjusted mortality also declined between 1988 and 1991 in both teaching (odds ratio [OR], death 1991/1988, 0.868; 95% confidence interval [CI], 0.843 to 0.894; P =.0001) and nonteaching hospitals (OR, death 1991/1988, 0.853; 95% CI, 0.826 to 0.881; P =.0001). This beneficial trend toward lower mortality over time was nearly identical between teaching and nonteaching hospitals (P =.4348).

CONCLUSION

New York's mandated limitations on residents' work hours do not appear to have positively or negatively affected in-hospital mortality from congestive heart failure, acute myocardial infarction, or pneumonia in teaching hospitals.

Differences in psychosocial and behavioral profiles between heart failure patients admitted to cardiology and geriatric wards

BACKGROUND

Heart failure represents a growing epidemic, primarily in the elderly. Development and implementation of management programs designed for use in daily clinical practice remains a major challenge.

AIMS

This study aimed at profiling a hospitalized heart failure population in view of medical, behavioral, educational, psychosocial and health resources utilization parameters stratified by admission to cardiology and geriatric wards.

METHODS AND RESULTS

Using a descriptive comparative design, 109 European heart failure patients admitted to cardiology (42%) and geriatric wards (58%) were included. Significant differences (all P<0.0001) were identified between the two groups. Patients admitted to cardiology had a mean age of 68.5, 33% were women, and the mean ejection fraction was 38%. Patients admitted to geriatrics had a mean age of 85, 68% were women, and the mean ejection fraction was 56%. Sixty-six percent were admitted for cardiac reasons. Medical, educational, behavioral, psychosocial and health resources utilization data were retrieved from medical files as well as by patient and family interviews. Results showed significant differences between groups. Patients admitted to geriatric wards received significantly less ACE inhibition and beta-blockers. Moreover, these patients were significantly less knowledgeable, showed poorer self-management, poorer hearing, more cognitive impairment, a higher degree of depressive symptomatology, more problems with ADL and IADL, and used significantly more home health care services compared to patients admitted to cardiology wards.

CONCLUSION

The characteristics of the heart failure population at large are quite different from those of populations included in large-scale therapeutic trials. Findings from this study provide options for tailored management strategies for both profiled subgroups.

Improving guideline adherence: a randomized trial evaluating strategies to increase beta-blocker use in heart failure

BACKGROUND

The dissemination of clinical practice guidelines often has not been accompanied by desired improvements in guideline adherence. This study evaluated interventions for implementing a new practice guideline advocating the use of beta-blockers for heart failure patients.

METHODS AND RESULTS

This was a randomized controlled trial involving heart failure patients (n=169) with an ejection fraction < or =45% and no contraindications to beta-blockers. Patients' primary providers were randomized in a stratified design to 1 of 3 interventions: (1) control: provider education; (2) provider and patient notification: computerized provider reminders and patient letters advocating beta-blockers; and (3) nurse facilitator: supervised nurse to initiate and titrate beta-blockers. The primary outcome, the proportion of patients who were initiated or uptitrated and maintained on beta-blockers, analyzed by intention to treat, was achieved in 67% (36 of 54) of patients in the nurse facilitator group compared with 16% (10 of 64) in the provider/patient notification and 27% (14 of 51) in the control groups (P<0.001 for the comparisons between the nurse facilitator group and both other groups). The proportion of patients on target beta-blocker doses at the study end (median follow-up, 12 months) was also highest in the nurse facilitator group (43%) compared with the control (10%) and provider/patient notification groups (2%) (P<0.001). There were no differences in adverse events among groups.

CONCLUSIONS

The use of a nurse facilitator was a successful approach for implementing a beta-blocker guideline in heart failure patients. The use of provider education, clinical reminders, and patient education was of limited value in this setting.

Status of practice guidelines in the United States: CDC guidelines as an example

BACKGROUND

Clinical practice guidelines have proliferated in the past several decades, starting with only a handful in the 1980s to over 1000 approved through The National Guideline Clearinghouse in 2002.

METHODS

The purposes of this article to review research related to guideline adoption and impact and to make recommendations for assessing the outcomes of guidelines, using the CDC guideline process as an example.

RESULTS

Despite the national movement toward standardization of evidence-based practice, few studies have been conducted to assess the costs of guideline development and implementation, and some practice guidelines have been implemented without concomitant assessment on patient outcomes and costs and benefits of changes in care.

CONCLUSIONS

An immediate mandate is to ensure that when guidelines are promulgated, they include an evaluation plan, developed by the implementer of the guideline, which takes advantage of existing qualitative and quantitative data and programs (e.g., patient-centered care, quality assurance, risk management) not limited to expensive and sophisticated clinical trials.

Quality of care of patients hospitalized with congestive heart failure

BACKGROUND

Congestive heart failure (CHF) is an increasingly prevalent poor-prognosis condition for which effective interventions are available. It is -therefore important to determine the extent to which patients with CHF receive appropriate care in Australian hospitals and identify ways for improving suboptimal care, if it exists.

AIM

To evaluate the quality of in-hospital acute care of patients with CHF using explicit quality indicators based on published guidelines.

METHODS

A retrospective case note review was -performed, involving 216 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between October 2000 and April 2001. Outcome measures were process-of-care quality -indicators calculated as proportions of all, or strongly -eligible (ideal), patients who received -specific interventions.

RESULTS

Assessment of underlying causes and acute precipitating factors was undertaken in 86% and 76% of patients, respectively, and objective evaluation of left ventricular function was performed in 62% of patients. Prophylaxis for deep venous thrombosis (DVT) was used in only 29% of ideal patients. Proportions of ideal patients receiving pharmacological treatments at discharge were: (i) angiotensin--converting enzyme inhibitors (ACEi) (82%), (ii) target doses of ACEi (61%), (iii) alternative vasodilators in patients ineligible for ACEi (20%), (iv) beta-blockers (40%) and (v) warfarin (46%).

CONCLUSIONS

Opportunities exist for improving quality of in-hospital care of patients with CHF, -particularly for optimal prescribing of: (i) DVT prophylaxis, (ii) ACEi, (iii) second-line vasodilators, (iv) beta-blockers and (v) warfarin. More research is needed to identify methods for improving quality of in-hospital care.