Measuring quality of outpatient cardiovascular care

Technology-driven interactive care management identifies and resolves more clinical issues than a claims-based alerting system

Due to patient or physician factors, people with chronic diseases frequently do not receive evidence-based care. While a physician-directed claims-based alerting system targeting gaps in care was previously shown to increase resolution of specific clinical issues, many apparently relevant issues remained unresolved. The purpose of this research was to demonstrate that adding member interaction with a nurse to a physician alerting system can uncover additional care gaps beyond those identified by a claims, prescription, and lab results-based alerting system, and increase successful resolution of alerts by communicating care gaps to members. An opt-in nurse-managed pilot program focusing on identification and resolution of specific clinical issues was implemented for 205,463 members of self-insured health plans that had been utilizing the claims-based physician alerting system. Specific clinical issues identified by the claims-based system were communicated to both program enrollees and physicians, and new clinical issues were identified based on nurse-directed participant feedback. Participants were encouraged to discuss issues with their physicians. Issue resolution rates were tracked using subsequent claims, pharmacy, and lab data. At 1 year, we studied the rate of new clinical issue identification and compared the program's resolution rate of claims-identifiable issues to that of non-enrollees. While program participants accounted for 0.65% of total member-months in the pilot year, they triggered 4.82% (644) of the population's claims-based clinical alerts, and an additional 514 alerts from data based on participant-supplied data--80.8% more than claims/pharmacy/lab-generated alerts. Of the participants' claims-based alerts, 207 (32.1%) showed claims/lab evidence of successful resolution, compared with 3,380 of 12,714 (26.6%) for non-participants, a 20.9% increase in resolutions (chi2 = 9.8, p < 0.01). Care management technology complemented by a nurse-directed interactive program increased the rate of identification of clinical issues compared to claims alerts alone. Use of this program to communicate specific issues to both patients and physicians significantly increased the rate of issue resolution.

Factors influencing medical treatment of heart failure patients in Spanish internal medicine departments: a national survey

BACKGROUND

The medical management of heart failure (HF) in clinical practice varies considerably by country and by medical specialty.

AIM

To assess the treatment of HF patients admitted to Internal Medicine departments, and to evaluate out-patient management prior to admission, by specialty.

DESIGN

Prospective cross-sectional multi-centre survey.

METHODS

Of 55 randomly selected Spanish hospitals, 51 agreed to participate. All patients (n = 2145) consecutively admitted for decompensated HF to the Departments of Internal Medicine of these hospitals, over 5 months, were included. Twenty variables were analysed, including aspects relating to out-patient management prior to admission.

RESULTS

Mean +/- SD age was 77.2 +/- 10.5 years, 57.3% were female, 47% had systolic dysfunction. Prescriptions at discharge: loop diuretics 85.6%, spironolactone 29.8%, ACEIs 65.8%, beta-blockers 8.7%, cardiac glycosides 39%. At admission, 86% already had a diagnosis of HF. Of these, 53% (older patients and more women) were being treated on an out-patient basis by primary care physicians. Primary care physicians requested fewer echocardiograms than internists (38% vs. 69%, p<0.001) and prescribed fewer drugs (ACEIs 40% vs. 54%, p<0.001; spironolactone 15% vs. 23%, p<0.05; beta-blockers 6% vs. 13%, p<0.01). The internists treated more incapacitated patients than the cardiologists (p<0.001), prescribed more high-dose ACEIs (20% vs. 13%, p<0.01) and spironolactone (26% vs. 20%, p<0.05), and fewer anticoagulants (32% vs. 39%, p<0.05).

DISCUSSION

Patients admitted to medical departments with HF are different to those found in clinical trials. Their management is currently suboptimal. Differences in treatment between internists and cardiologists appear to be accounted for by differences in the patients they treat.