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Effective Interventions & Processes. Leading to High Performance in the Heart Failure Measures Eric Streicher, MD Judy Frisch, RN, MBA, CPHQ July 25, 2007. Overview. Demographics HF measures Guideline issues Interventions Outcomes Summary. HF Demographics. Affects 4.9 million people

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Effective interventions processes

Effective Interventions & Processes

Leading to High Performance in the Heart Failure Measures

Eric Streicher, MD

Judy Frisch, RN, MBA, CPHQ

July 25, 2007


Overview
Overview

  • Demographics

  • HF measures

  • Guideline issues

  • Interventions

  • Outcomes

  • Summary


Hf demographics
HF Demographics

  • Affects 4.9 million people

  • 550,000 new cases each year

  • Primarily a disease of the elderly

  • 12-15 million office visits

  • 6.5 million hospital days each year

  • Most common Medicare DRG

  • Total direct and indirect cost $27 billion in 2005


Hf 1 discharge instructions
HF 1-Discharge Instructions

  • Educational intervention – 35% decrease in risk of hospitalization and death

  • Disease management program – improved functional capacity decreased hospitalizations


Hf 2 lvf assessment
HF 2-LVF Assessment

  • Necessary for determination of eligibility for ACE inhibitor/ARB

  • Associated with increased use of ACE inhibitors and subsequent improved outcomes


Hf 3 acei or arb for lvsd
HF 3-ACEI or ARB for LVSD

  • ACEI decrease morbidity and mortality

  • ARBs are acceptable if ACEI intolerant

  • Included in guidelines

  • Underutilized


Effect of enalapril
Effect of Enalapril

  • Mortality reduction of 40% at 6 months, 31% at one year

  • Mortality effect in patients with progressive heart failure

  • No decrease in sudden cardiac death

  • Decrease in heart size, decrease in need for other medications

  • Improvement in functional status

    NEJM 1991; 325:293-302


Effect of candesartan
Effect of Candesartan

  • Chronic HF

  • Decreased cardiac deaths

  • Decreased hospitalization

    The Lancet 2003; 362:759-766.


Hf 4 adult smoking cessation advice counseling
HF 4-Adult Smoking Cessation Advice/Counseling

  • No trials to specifically assess this in HF patients

  • Guideline derived from expert opinion

  • Validated in patients after MI



Cabana et al
Cabana et al

  • Knowledge

  • Attitudes

  • Behavior

    JAMA. 1999; 282:1458-1465


Knowledge
Knowledge

  • Lack of familiarity

  • Lack of awareness

    JAMA. 1999; 282:1458-1465


Attitudes
Attitudes

  • Lack of agreement with specific guidelines

  • Lack of agreement with guidelines in general

  • Lack of outcome expectancy

  • Lack of self-efficacy

  • Lack of motivation/inertia of previous practice

    JAMA. 1999; 282:1458-1465


External barriers
External Barriers

  • Patient factors

  • Guideline factors

  • Environmental factors

    JAMA. 1999; 282:1458-1465



Presentation objectives
Presentation Objectives

  • Identify gaps in the care process for heart failure patients

  • Describe effective interventions and processes to remove or decrease those gaps

  • Summarize commonalities across the success stories


Sources
Sources

  • The National Committee for Quality Assurance: www.ncqa.org

  • American Heart Association Heart Disease and Stroke Statistics-2003 Update. Dallas, Tex. American Heart Association 2002

  • www.premierhealthcare.com

  • www.hfsa.org


Hf 1 discharge instructions common gaps
HF 1-Discharge InstructionsCommon Gaps

  • Consistent education for patients with HF

  • Instructions for intensive monitoring of symptoms

  • Secondary diagnosis confusion

  • Patient compliance


Hf 1 discharge instructions effective interventions processes
HF 1-Discharge InstructionsEffective Interventions/Processes

  • For consistent heart failure education

    • Specified units for admission placement

    • Nursing knowledge of secondary diagnoses

    • EMR capabilities to track and support HF management

    • Grouping similar diagnoses

    • Discharge units

    • Order set, care maps and care pathways


Hf 1 discharge instructions effective interventions processes1
HF 1-Discharge InstructionsEffective Interventions/Processes

  • For intensive monitoring of symptoms

    • Interactive activities with high risk HF patients (referral for telemonitoring after discharge)

    • ICU/Telemetry Nurse telephonic follow-up

    • Case management

    • Dedicated hospital heart failure educator


Hf 1 discharge instructions effective interventions processes2
HF 1-Discharge InstructionsEffective Interventions/Processes

  • For patient compliance

    • Hospital nurse call back systems

    • Telemonitoring capabilities

    • Involvement of family and/or significant other


Hf 2 lvf assessment common gaps
HF 2-LVF AssessmentCommon Gaps

  • Readily available LVF assessment results

  • Timely feedback regarding physician outlier data

  • Documentation by physician of the LVF test results


Hf 2 lvf assessment effective interventions processes
HF 2-LVF Assessment Effective Interventions/Processes

  • Nursing orders for LVF assessment

  • EMR capabilities for rapid recovery of test results

  • Collaboration with the clinics

  • Physician education related to the clinical practice guidelines

  • Order sets, care maps and care pathways

  • Hospitalist programs


Hf 3 acei or arb for lvsd common gaps
HF 3-ACEI or ARB for LVSDCommon Gaps

  • Under utilization of ACE Inhibitors or ARBs due to provider concerns about

    • Hypotension

    • Renal impairment

  • Mismatch of heart failure medications from admission to discharge

  • Lack of documentation of LVF test results


Hf 3 acei or arb for lvsd effective interventions processes
HF 3-ACEI or ARB for LVSDEffective Interventions/Processes

  • Interventions and process steps to use ACEI or ARB for heart failure patients are

    • Power of medication reconciliation

      • Pharmacist programs

    • Order sets, care maps and care pathways

    • Incorporation of heart failure CPOE into EMR system

    • Standardization of the placement of discharge medication lists in the chart


Hf 4 adult smoking cessation advice counseling common gap
HF 4-Adult Smoking Cessation Advice/Counseling – Common Gap

  • Assessment completed, yet often the counseling is not done or documented

  • Lack of consistent process for smoking cessation education


Hf 4 adult smoking cessation advice counseling1
HF 4-Adult Smoking Cessation Advice/Counseling Gap

  • Dedicated health promotion specialist

    • Counsels and offers smoking cessation tips

    • Enrolls in outpatient services

  • Pharmacy programs

  • Initiation of a physician and staff champions

  • Nursing admission assessment contains question and counseling


Commonalities across success stories
Commonalities Across Success Stories Gap

  • Key elements of successful strategies

    • Developing the right culture for quality to flourish

    • Attracting and retaining the right people to promote quality

    • Devising and updating the right processes for quality improvement

    • Giving staff the right tools

    • Implemented performance incentives for contracted and for organization employees for job well done

    • Data sharing at many different places


Commonalities across success stories1
Commonalities Across Success Stories Gap

  • Multiple effective interventions and adjustments in response to data

  • Data profiling

  • Understanding of current process

  • Identification of the gaps for resolution

  • Hospitalist practice linked with core measures

  • Order sets required


Commonalities across success stories2
Commonalities Across Success Stories Gap

  • Computer-based physician reminder systems

  • Facilitated relay of data from outpatient to inpatient data



Measures vs outcomes
Measures vs. Outcomes Gap

  • 5,900 patients hospitalized with HF

  • 60-90 day follow-up after discharge

  • Process-outcome relationship for performance measures

    Fonarow, et al, JAMA. 2007;297:61-70


Measures vs outcomes1
Measures vs. Outcomes Gap

  • Discharge instructions – no

  • Evaluation of LVS function – no

  • ACEI/ARB for LVS dysfunction – yes

  • Smoking cessation counseling – no

  • Warfarin for atrial fibrillation – no

  • Beta-blocker at discharge – yes

    Fonarow, et al, JAMA. 2007;297:61-70


Contact information

Contact Information: Gap

MetaStar, Inc.

2909 Landmark Place

Madison, WI 53713

(608) 274-1940 or (800) 362-2320

www.metastar.com

[email protected]

[email protected]

This material was prepared by MetaStar under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-WI-INP-07-103


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