Science + Technology

Initiative to Improve Heart Failure Care at Nation’s Hospitals Makes Major Gains, According to UCLA Study


A national initiative designed to improve heart-failurepatient care in hospitals proved effective at increasing hospital's adherenceto key quality-of-care performance measures and reducing the length of hospitalstays for patients.

It also resulted in favorable trends for in-hospital andpost-discharge mortality rates, according to a UCLA study published in the July23 edition of the journal Archives of Internal Medicine.

The initiative, called the Organized Program to InitiateLifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE–HF),is the largest of its kind undertaken for heart failure in the country, with259 hospitals participating, and is the only one designed to capture patientoutcomes data 60 to 90 days after discharge.

"Despite compelling scientific evidence and nationalguidelines for use of key life-prolonging agents and lifestyle changes, gapsexist in heart failure treatment," said principal investigator Dr. Gregg C.Fonarow, UCLA's Eliot Corday Chair in Cardiovascular Medicine and Science, directorof the Ahmanson-UCLA Cardiomyopathy Center and professor of medicine at theDavid Geffen School of Medicine at UCLA. "We hope more hospitals will adoptthis validated model for enhancing heart-failure patient care."

Heart failure affects 5 million Americans, and nearly 3.6million hospitalizations each year are attributed to the condition, whichoccurs when the heart's left ventricle can't pump enough blood to the body'sother organs. 

For the study, researchers utilized data from OPTIMIZE–HF'slarge heart-failure performance-improvement registry, which is designed to helphospitals increase adherence to standard hospital-based performance measuresdeveloped by the American College of Cardiology and the American HeartAssociation, as well as additional evidence-based measures.

Between March 2003 and December 2004, 48,612 eligible adultheart failure patients at academic and community hospitals nationwide wereenrolled in the registry. A subgroup of 5,791 patients was followed for 60 to90 days after hospital discharge to collect additional data on outcomes,including mortality and re-hospitalization rates.

Patients were registered through a unique Web-based program thatallowed hospitals to review data in real time and compare it to aggregate datafrom similar facilities. Information collected included data on admission,hospital, discharge care and outcomes.

Researchers found improvement in three of four standardperformance measures used by the Joint Commission on Accreditation of HealthcareOrganizations to gauge quality of heart failure care at hospitals:

       Giving complete medical instructions to patientsupon discharge increased from 46.8 percent of cases at the beginning of thestudy to 66.5 percent by the study's conclusion.

       Providing smoking cessation counseling topatients rose from 48.2 percent to 75.6 percent.

       Evaluating the heart's left ventricle systolicfunction started at a high rate of 89.3 percent and improved to 92.1 percent.

The fourth measure — prescribing an angiotensin-convertingenzyme or angiotensin II receptor blocker medication at discharge — remainedsteady during the study.

Adherence to other performance measures improved as well.The use of beta-blockers rose from 78 to 86 percent, the prescribing of aldosteroneantagonists increased from 11 to 20 percent and the use of statin medicationrose from 39 to 44 percent.

"We saw substantial and very rapid improvements in these keyperformance measures and in providing essential evidence-based medications forheart failure," Fonarow said.

With OPTIMIZE–HF, the length of hospital stays improvedsignificantly, dropping from 7.5 to 6.2 days, and there were favorable trendsfor post-discharge mortality, which dropped from 9.9 to 6.3 percent.

"If similarimprovements had occurred at hospitals nationwide, this would translate to40,000 less deaths and 1.4 million costly hospital days eliminated per year," Fonarowsaid.

OPTIMIZE–HF also provided tools to help hospitals improvethe reliability of heart failure care, including standardized admission orders,discharge checklists, pocket cards, medical chart stickers, best-practicealgorithms and critical pathways. Researchers found that use of these toolsimpacted outcomes. In-hospital mortality dropped from 4.1 to 2.5 percent forcases in which hospital staff utilized standard admission orders to help directtreatment. Post-discharge death and re-hospitalization rates decreased from38.2 to 34.8 percent when tools were utilized during care.

Fonarow said that the American Heart Association has adoptedOPTIMIZE–HF for use in its Get With the Guidelines–Heart Failure qualityimprovement program, in which more than 400 hospitals nationwide are nowparticipating.

GlaxoSmithKline sponsored the OPTIMIZE–HF registry andfunded the study. Fonarow has received research grants and honoraria fromGlaxoSmithKline and has served as a consultant to the company.

Additional author financial disclosures are available in thepaper published in the Archives of Internal Medicine

Other study authors include: Dr. William T. Abraham of Ohio State University; Nancy M.Albert and Dr. James B. Young of the Cleveland Clinic Foundation; Wendy GattisStough, Pharm.D., and Dr. Christopher M. O'Connor of Duke University Medical Center;Dr. Mihai Gheorghiade of Northwestern University's Feinberg School of Medicine;Dr. Barry H. Greenberg of the University of California, San Diego MedicalCenter–Hillcrest; Karen Pieper and Jie Lena Sun of the Duke Clinical ResearchInstitute; and Dr. Clyde Yancy of the Baylor Heart and Vascular Institute atBaylor University Medical Center.



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