Congestive Heart Failure Clinical Outcomes Study in a Private Community Medical Group

Louis A. Civitarese, DO, and Nicholas DeGregorio, MD,


J Am Board Fam Med. 1999;12(6) 

In This Article

Abstract and Introduction

Background: Although angiotensin-converting enzyme (ACE) inhibitor therapy has been shown to improve clinical outcomes of patients with systolic dysfunction, it has been underused or prescribed in inadequate dosages by physicians in the treatment of congestive heart failure. Our goal was to evaluate whether integration of a clinical guideline within a continuous quality improvement program would improve care for patients with congestive heart failure caused by systolic dysfunction.
Methods: All patients of a private community medical group who were admitted to the hospital with congestive heart failure were studied prospectively for 21 months. An internally developed congestive heart failure practice guideline was presented to the group's physicians. The guidelines were available in the hospital computer system and were reinforced at monthly quality improvement meetings. Performance data were reviewed quarterly with the physicians.
Results: Rates of classifying systolic vs diastolic dysfunction remained unchanged during the study. Use of ACE inhibitor therapy at the time of discharge improved substantially for patients with systolic dysfunction. Quarterly admissions of patients with systolic dysfunction declined 49% throughout the study period. No improvement was noted in the documentation of specific discharge instructions.
Conclusions: Use of a disease management guideline, ongoing physician education, and feedback of peer performance data to physicians significantly improved the quality and efficiency of care provided to patients with congestive heart failure in an independent, primary care medical group.

In the book Making Integrated Health Care Work[1] the authors stated, "We are not aware of any situations in which physicians in solo or small, single-specialty groups have been involved in meaningful efforts to develop and implement clinical guidelines." The care that physicians provide for their patients, however, is now being measured more intensely than ever before, and techniques to improve the quality and efficiency of patient care are becoming valuable tools for today's physicians. As a result, continuous quality improvement processes are being incorporated into the private practice of medicine. The incorporation of an effective clinical guideline within the continuous quality improvement process can reduce unnecessary variation in clinical practice and can ultimately lead to improved patient care.[2,3] This report is an account of a clinical outcomes project undertaken by an independent 20-physician primary care medical group.