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


The goal of this study was to evaluate whether implementing a congestive heart failure clinical guideline within the continuous quality improvement process would lead to more frequent and optimal use of ACE inhibitors in the treatment of systolic congestive heart failure and therefore decrease the number of hospital admissions for this diagnosis.

Preferred Primary Care Physicians, located in Pittsburgh, is an independent, 20-physician primary care medical group made up of 10 family physicians and 10 internists, of whom 13 are share holders. The group has a 7-physician board of directors, a centralized business office, an executive director, a medical director, a 4-physician quality improvement committee, and 2 full-time employees (1 registered nurse and 1 clinical assistant) dedicated to clinical projects and outcomes measurement.

This prospective study, conducted for a period of 21 months from 1 November 1995 to 31 July 1997, included all patients admitted to the group's primary community-based hospital. Patients were selected for inclusion in the study if on a medical record review they had a confirmed discharge diagnosis of congestive heart failure (International Classification of Diseases, code 428).[11] The attending physician determined the primary discharge diagnosis, defined as the single disease process most responsible for the patient's admission. Hospital-based case management nurses performed baseline and quarterly medical record reviews.

The designated physicians in the group developed a guideline for congestive heart failure based on a literature review and several preexisting guidelines from hospital systems and health plans. The guideline was presented to the group at a formal continuing medical education session at the outset of the study. Discussion of the most recent literature in the treatment of congestive heart failure took place to affirm the scientific credibility of the guideline. All physicians were given ample time to comment on the guideline and study design. After appropriate modifications, approved by group consensus, each physician verbally endorsed the plan.

The final product was a comprehensive, disease state management program applicable to both the inpatient and outpatient settings. This guideline was addressed at the group's monthly quality improvement meetings, was available to the physicians for reference in the hospital computer system located at all clinical sites within the facility, and was in a ring binder in every physician office within the group. Although the guideline was comprehensive, the following three primary objectives were emphasized at each monthly quality improvement meeting:

  1. All patients with congestive heart failure require an assessment of left ventricular function to determine appropriate treatment.

  2. Patients found to have systolic congestive heart failure should have an ACE inhibitor medication prescribed that is titrated to a targeted optimal dosage, as tolerated, provided there are no contraindications.

  3. All patients with congestive heart failure should be instructed to weigh themselves daily on the same scale and to telephone their physician's office if they experience a predetermined amount of short-term weight gain.

Standardized inpatient admission orders were developed to parallel the congestive heart failure guideline and prompt the physicians to address every decision point. The physicians were apprised of their performance data at the quarterly quality improvement meetings. The group decided at the outset to share the individual and aggregate clinicians' data openly with all physicians in the group.

The following data were obtained from baseline and quarterly inpatient medical record audits:

  1. Left ventricular function measurement by echocardiogram or multigated angiogram within 1 year of admission or sooner if there had been an intercurrent cardiac event

  2. ACE inhibitor treatment for congestive heart failure for patients with confirmed systolic dysfunction, defined as a left ventricular ejection fraction of 0.40 or less

  3. Appropriate adjustment to achieve optimal ACE inhibitor therapy, as tolerated, according to the following target doses: (1) enalapril---10 mg twice a day, (2) captopril---50 mg three times a day, (3) lisinopril---20 mg every day, and (4) quinapril---20 mg twice a day. Maximal doses were considered in patients depending upon their clinical responses to ACE-inhibitor therapy

  4. Documentation of one or more of the following contraindications to prescribing ACE inhibitors for congestive heart failure for patients with systolic dysfunction who were not treated with ACE inhibitor: (1) history of intolerance to ACE inhibitors, (2) serum potassium > 5.5 mEq/L, (3) serum creatinine > 3.0 mg/dL, (4) systolic blood pressure < 90 mm Hg, (5) severe ACE inhibitor-related cough, (6) bilateral renal artery stenosis, or (7) pregnancy

  5. Confirmation that patients received instructions by physicians to weigh themselves daily and telephone their physicians if they gained more than 2 pounds in 1 day or more than 3 pounds in 1 week

  6. Documentation of dietary instructions

  7. The number of patients admitted with congestive heart failure

  8. The number of patients readmitted with congestive heart failure within 30 days of discharge