Wide Variation in Outpatient HF Quality of Care, Even on Some Basics, Analysis Finds

September 18, 2007

September 18, 2007 (Washington, DC) - The application of evidence-based guidelines for managing chronic heart failure varied widely at cardiology practices participating in a national performance-improvement initiative, with shortfalls showing up in some surprisingly fundamental areas, according to reports presented here at the Heart Failure Society of America 2007 Scientific Meeting.

It's not just that many eligible patients were missing out on some recommended drug therapies and that others who qualified for cardiac resynchronization therapy (CRT) or implantable cardioverter-defibrillators (ICDs) weren't receiving them, as suggested by baseline data from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE-HF).

Other findings from the registry suggest that incomplete documentation of guidelines-stipulated patient information could potentially be behind some of the observed gaps between treatment eligibility and treatment application. For example, the records of about two-thirds of the >14 000 patients in IMPROVE-HF make no mention of NYHA functional class, basic information that heart-failure management guidelines use to help define the appropriateness of important drug and device therapies [1].

"Shocking. These are cardiology practices from across the country participating in a quality-improvement program, so you'd imagine that if anything, documentation would be even better than usual," the registry's steering committee cochair, Dr Gregg C Fonarow (University of California, Los Angeles Medical Center), told heart wire .

"And yet we see huge numbers of patients without sufficient documentation of their functional status despite guidelines recommending this assessment on each visit," Fonarow said. The rate of collecting NYHA class information varied from about 6% to about 64% across the registry's 157 participating practices.

The treatments probably most affected by the missing information, Fonarow observed, are aldosterone antagonists, CRT, and ICDs; in the guidelines, their use is guided by functional status.

Other baseline analyses from IMPROVE-HF showed "phenomenal differences" across practices in the application of seven care processes that the initiative will track prospectively, according to Fonarow [ 2]. "We saw some practices [with performance-measure application] at 100% and others down at zero."

Room for improvement at the starting block

The registry entered 14 640 patients with heart failure and an LVEF <35% or post-MI LV dysfunction. Its prospectively defined goal is to achieve >20% mean improvement in at least two of seven performance measures within two years [3].

Most of the participating centers, 69% of them, aren't teaching hospitals or affiliated with a medical school; only 8.3% are academic medical centers. About 42% feature a heart-failure clinic.

The centers' average baseline rates of adherence to the seven performance measures, among patients eligible for each treatment, were 79.5% for use of ACE inhibitors or angiotensin-receptor blockers (ARBs), 85% for use of beta blockers, and 35.1% for use of aldosterone antagonists; 67.7% for anticoagulation in patients with atrial fibrillation; and 36.9% and 51.5% for use of CRT devices (regardless of whether there is ICD capability) and ICDs (whether or not there is also biventricular pacing), respectively. The performance measures also included documentation of education on salt restriction, daily weight monitoring, recognition of worsening heart failure, and recommended activity levels; such records were kept in 58.9% of cases overall.

But there was profound variation in the appropriate application of some performance measures. The average rate of adherence to CRT guidelines was about 80% for centers in the top adherence decile, but it was close to nil for among centers in the lowest decile. Meeting the educational goals similarly varied from a high exceeding 90% to less than 30% for centers in the lowest adherence decile. The high exceeded 60% and the low was less than 10% for aldosterone antagonists. Guidelines adherence for ACE inhibitors/ARBs and for beta blockers was more common and consistent.

As simple a thing as documentation

Documentation of NYHA status was present for only 32% of the registry's patients. The rate rose to 58% when patients whose records contained data sufficient to infer functional class were included.

The odds ratio for having NYHA class explicitly documented was significantly increased for patients getting combination CRT/ICD devices, those with ischemic heart disease, and those with an LVEF less than the registry mean of 25% (p<0.0001 for each). It was significantly decreased for patients getting percutaneous interventions (p<0.0001) and those with atrial fibrillation (p<0.021) or chronic obstructive pulmonary disease (p<0.003).

NYHA class was more likely to be documented at centers that perform cardiac transplantation (p<0.0001) or use electronic medical records as compared with paper records (p=0.0002).

"When we talk about treatment gaps," Fonarow said, "we're working with known eligibility rates." But when documentation is incomplete, "we can't even begin to see who may be eligible for some treatments.

"There's a huge opportunity to improve the quality of care for outpatients in cardiology practices," according to Fonarow. "These are the first data regarding conformity to the most current [heart-failure] guidelines, involving not just medications but also devices, education, and anticoagulation." It shows variation across practices, he said, with some practices reliably delivering guidelines-based care and others with more room for improvement.

IMPROVE HF is supported by Medtronic. Fonarow reports receiving research grants from Amgen, Biosite, Bristol-Myers Squibb/Sanofi, Boston Scientific/Guidant, GlaxoSmithKline, Medtronic, Merck, Pfizer, Scios, and St Jude Medical; being on the speakers' bureaus for or receiving honoraria from AstraZeneca, Biosite, Boston Scientific/Guidant, Bristol-Myers Squibb/Sanofi, GlaxoSmithKline, Medtronic, Merck, NitroMed, Pfizer, Schering-Plough, Scios, St Jude Medical, Takeda, and Wyeth; and consulting for Biosite, Bristol-Myers Squibb/Sanofi, Boston Scientific/Guidant, GlaxoSmithKline, Medtronic, Merck, NitroMed, Pfizer, Schering-Plough, Scios, and Wyeth.

  1. Yancy CW, Fonarow GC, Albert NM, et al. Outpatient documentation of NYHA functional class and/or activity level in HF patients: A report from IMPROVE HF. J Cardiac Failure 2007;13(Suppl 2):S177. Abstract 356.

  2. Fonarow GC, Yancy CW, Albert NM, et al. Variation in HF quality of care among US outpatient practices: Analysis of 131 cardiology practices in IMPROVE HF. J Cardiac Failure 2007;13(Suppl 2):S156. Abstract 283.

  3. Fonarow GC, Yancy CW, Albert NM, et al. Improving the use of evidence-based heart failure therapies in the outpatient setting: The IMPROVE HF performance improvement registry. Am Heart J 2007 Jul;154:12-38. Abstract

The complete contents of Heartwire , a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.


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