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 results of this study show a statistically significant decrease in the number of admissions for congestive heart failure caused by systolic dysfunction during a specified period subsequent to the implementation of a clinical guideline for congestive heart failure. It is our belief that this decrease was a result of the more frequent and optimal inpatient and outpatient use of ACE inhibitor medications. It is important to note that our disease management guideline stressed principles of treatment that were identical for both inpatients and outpatients.

Although we would have preferred to collect our own data to prove increased ACE inhibitor therapy for outpatient treatment of systolic dysfunction, we were able to obtain supporting pharmacy data from health care insurers. The rate of inpatient use of ACE inhibitor therapy and the rate of hospital admissions, however, could be tracked easily by means of a hospital-based utilization review. Hospital admission rate was used as a measurement of quality and as a major outcomes indicator in the landmark SOLVD trial. It is our belief, therefore, that a reduction in the number of hospital admissions for congestive heart failure, the 100% appropriate usage of ACE inhibitors in three of the last four quarters, and a greater than 90% rate of left ventricular ejection fraction determination throughout the study were sound indicators of improved quality of care in the treatment of congestive heart failure. We met our study goal, and we found that a disease management guideline, when properly developed and applied, could lead to improved outcomes in a community-based medical group.

We were concerned that 8% of patients admitted for congestive heart failure admissions had no determination of systolic or diastolic dysfunction. Follow-up investigation with physicians, however, showed that these patients frequently had limited code status, and additional testing was not desired or consistent with the goals of therapy. Many of these patients were admitted for placement purposes and for comfort care only.

Patient education pertaining to diet and self-weighing was poorly documented. Based on discussions with the physicians, it is probable that patients were instructed regarding diet and weight often without documentation. To address this problem, a congestive heart failure treatment worksheet was subsequently developed and implemented to document each aspect of patient education. The education process begins when the patient is admitted to the hospital, and each item is checked off and initialed when completed. At the end of the hospitalization, the patient receives a copy as a discharge instruction sheet. It is signed by the patient, who then becomes an active participant in his or her own care.

In the opinion of these investigators, the success of this project depended on the following key elements:

  1. We selected a disease process that is commonly seen and treated by primary care physicians.

  2. We developed a meaningful and credible clinical practice guideline.

  3. The clinical study design was relatively simple and straightforward, and focused on a few key outcomes.

  4. The guideline and study design was endorsed by every physician involved in the study.

  5. The practice guideline was reinforced (1) by its availability on the hospital computer system and in every physician's office, (2) by the use of standardized congestive heart failure admission orders that followed every key decision point in the guideline, and (3) by reminders at the group's monthly quality improvement meetings and in our monthly newsletter.

  6. Quarterly updates of peer performance data were shared among all of the physicians.

  7. We used a risk pool with compensation methods based, in part, on clinical outcome data specific to each physician.

  8. The costs of both implementation and outcomes measurement were kept within the budget of our quality improvement committee.

Although sharing performance data among physicians was a sensitive issue, it was well received when done in a collaborative, educational manner. The group's experience and success with this study has resulted in enthusiasm for the development and implementation of similar projects for other disease states. In the future, progress will be facilitated by published guidelines that can be easily adapted for use within medical practices.

This study illustrates the value of implementing clinical guidelines as part of a complete continuous quality improvement program. Achieving high-quality primary care within a medical group and actually measuring it can be an expensive undertaking. We accomplished our study at a relatively low cost to the physicians, and we therefore believe that it would be easy to undertake similar studies in other primary care medical groups. Such efforts are no longer novel, but essential, as physician accountability has evolved into an everyday reality.[13,14]The community-based outcomes study can be used as a powerful tool to reduce the unnecessary variation that is the curse of clinical quality and efficiency. For physicians, favorable outcomes data will be requisite to contract for patients. For employers, they could result in lower costs, and most importantly, it will mean better care for patients.