Physician, Teach Thyself: IMPROVE-HF Initiative Boosts Use of Evidence-Based Outpatient Care

September 24, 2009

September 23, 2009 (Boston, Massachusetts) — Clearly there's room for improvement in the outpatient care of heart failure, with some evidence-based, guidelines-recommended therapies unused in many patients who qualify for them. Less evident and seldom studied is how best to get physicians who treat heart-failure patients to apply those therapies more consistently.

The IMPROVE-HF initiative, a prospective observational study of the out-of-hospital care of 35 000 heart-failure patients spanning dozens of US practices [1], has demonstrated at least one way that it can work: educate the physicians, provide the guidelines, perform chart reviews, give feedback, and include a system of reminders, and physicians--at least the kind who participated in the study--will respond with significantly better application of evidence-based care.

According to Dr Clyde W Yancy (Baylor University Medical Center, Dallas, TX), who presented the IMPROVE-HF primary results here at the Heart Failure Society of America 2009 Scientific Meeting, the teaching materials and processes aren't very complicated. The hard part, he told heartwire , "is creating the algorithm that facilitates doing all those things so that it's an active process."

It worked, at least over the IMPROVE-HF study's two-year follow-up time.

Baseline chart reviews were conducted at the study's 167 sites for 34 954 outpatients with systolic heart failure or post-MI left ventricular dysfunction. Additional chart reviews, in all totaling 63 362, were conducted at months 12 and 24.

As Yancy reported, after two years, significantly more patients with indications for ACE inhibitors or angiotensin-receptor blockers, beta blockers, aldosterone-receptor antagonists, implantable cardioverter-defibrillators (ICDs), or cardiac resynchronization therapy (CRT) were actually getting those therapies, and significantly more patients were receiving appropriate heart-failure education.

The biggest jumps in application were in the three least-used quality measures at baseline: aldosterone antagonists, ICDs, and CRT, all initially received by less than half of patients with indications for them.

Anticoagulation therapy in the setting of atrial fibrillation (AF) was the only quality measure in IMPROVE-HF whose usage didn't change.

Changes in Appropriate Application (% of Patients)A of Seven Quality Measures Over Two Years in IMPROVE-HF

Quality measure Baseline (%) 24 mo (%) Relative improvement (%)
ACE inhibitors or ARBs 79.7 84.4 8.3
Beta blockers 86.0 93.6 8.7
Aldosterone-receptor antagonists 34.7 59.9 72.9
Anticoagulation in patients with AF 68.4 68.6 0.3b
ICDs 38.7 67.6 74.7
CRT 50.0 78.0 55.8
Provision of heart-failure education 61.9 69.7 12.6
a. Treatment-eligible heart-failure patients without documented exceptions, including contraindications, intolerance, or other medical or patient-related reasons for not providing therapy.

b. Nonsignificant change. All other differences p<0.001

A caveat: no outcomes data were collected, so there's no evidence that greater use of evidence-based care meant fewer deaths or hospitalizations. The quality measures in IMPROVE-HF had already passed muster in randomized controlled trials, Yancy observed for heartwire , so there's plenty of confidence that the quality-improvement initiative also improved outcomes.

Regarding another possible limitation of the study, Yancy observed that about 80% of heart-failure outpatients in actual practice are treated in a primary-care setting. Participating IMPROVE-HF physicians, however, tended to be in cardiology groups, and 40% of them had dedicated heart-failure clinics. "We don't know if one can scale these results to the other 80% of the patient population and to the other cohort, a larger cohort, in fact, of practitioners who take care of those patients."

The challenge of proving the system's viability across the broad range of heart-failure outpatients remains, agreed Dr Marc A Pfeffer (Brigham and Women's Hospital, Boston, MA), who wasn't involved in IMPROVE-HF. "The study proved a principle, that with reminders, prods, and educational materials, performance measures can be improved. How you extrapolate that to [physician] groups that are facing so many other problems, including immunizations and other prophylaxis, not just for heart failure, remains to be shown. I empathize with the primary-care doctor who is bombarded with our guidelines, other groups' guidelines--it can just be overwhelming. So the more we [heart-failure physicians] get our act together, the more we can see what works and what doesn't work. That's how I look at IMPROVE-HF."

IMPROVE-HF is sponsored by Medtronic. Yancy had no disclosures. Pfeffer discloses that he has received research grants from Amgen, Baxter, Bristol-Myer Squibb, Celladon, Novartis, and Sanofi-Aventis and has been a consultant or served on an advisory board for Novartis, AstraZeneca, Biogen, Boston Scientific, Bristol-Myers Squibb, CVRx, Cytokinetics, Genentech, Medtronic Vascular, Merck, Roche, Sanofi-Aventis, and Via.

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