Future challenges in quality improvement in heart failure

This is the final installment in a series reporting on the Centers for Medicare & Medicaid Services (CMS) initiatives to improve care for Medicare beneficiaries with heart failure through its Quality Improvement Organization (QIO) contractors during the 1999-2002 contract cycle. Previous columns have reported on a nation-wide hospital-based effort, the National Heart Failure project, and a more limited outpatient-based effort, the Heart Failure Practice Improvement Effort. After 3 years of experience with the National Heart Failure project, it is appropriate to highlight the issues pertinent to future quality improvement initiatives in heart failure care.     

Baseline quality indicator rates from the National Heart Failure Project: a HCFA initiative to improve the care of medicare beneficiaries with heart failure

This column is the third in a series reporting on Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The first paper outlined the history of HCFA quality improvement projects and current initiatives to improve care in six priority areas: heart failure, acute myocardial infarction, stroke, pneumonia, diabetes, and breast cancer. The second reported in more detail the structure of the national inpatient fee-for-service heart failure initiative, known as the National Heart Failure project. It described the development of the quality indicators, the sampling strategy for selecting charts to be reviewed, and the types of local efforts spurred by the project through the activities of each state's HCFA contractor peer review organization. This article discusses baseline quality indicator rates from the National Heart Failure project. (c)2001 by CHF, Inc.     

Improving heart failure care: CMS' initiative. Improving heart failure care in outpatient practices

This column is the eighth in a series reporting on the efforts of the Centers for Medicare & Medicaid Services ([CMS], formerly known as the Health Care Financing Administration), to improve care for Medicare beneficiaries with heart failure. Previous columns have focused on the hospital-based National Heart Failure project. An outpatient practice-based project, the Heart Failure Practice Improvement Effort (HF PIE), was described in the fourth and sixth columns. This column reports experience from the HF PIE project at the practice level in three states.     

The National Heart Failure Project: a health care financing administration initiative to improve the care of Medicare beneficiaries with heart failure

This is the second in a series describing Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The first article outlined the history of HCFA quality-improvement projects and current initiatives to improve care in six priority areas: heart failure, acute myocardial infarction, stroke, pneumonia, diabetes, and breast cancer. This article details the objectives and design of the Medicare National Heart Failure Quality Improvement Project (NHF), which has as its goal the improvement of inpatient heart failure care. (c)2000 by CHF, Inc.     

Improving heart failure care in the office setting

This column is the sixth in a series describing Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The fourth column addressed the Heart Failure Practice Improvement Effort, HCFA's pilot project to test the feasibility of assessing and improving heart failure care in the outpatient setting through the activities of HCFA-contracted peer review organizations in eight states. This column is dedicated to illustrating the progress of the Heart Failure Practice Improvement Effort project at an individual state and practice level, focusing on the quality improvement activities in outpatient heart failure care conducted by the Colorado peer review organization. (c)2001 CHF, Inc.     

Medicare initiatives to improve heart failure care: an introduction

Purchasers of health care, patients, physicians, and other health care professionals are increasingly seeking to evaluate quality of health care. Scattered reports have suggested that there is currently marked variation in evaluation and treatment of heart failure and substantial gaps between guideline recommendations and care delivered to heart failure patients. Heart failure is the most common discharge diagnosis for Medicare beneficiaries and yet, until recently, relatively little national information was available to describe the quality of care and to identify opportunities to improve practice. To address the need to evaluate care of patients with heart failure and support national, state, and local efforts to improve care and outcomes, the Health Care Financing Administration has initiated three programs that stretch across much of the continuum of care: the National Heart Failure Quality Improvement Project, focusing on inpatient care; the Heart Failure Practice Improvement Effort (HF PIE), a pilot outpatient effort in 11 states; and the 2001 requirement for Medicare+Choice Organizations to initiate quality improvement efforts for their heart failure patients. This paper is the first in a series that will provide information about these programs. We hope that this series will stimulate discussion on how clinicians can join these national efforts to improve the care and outcomes of patients with heart failure. (c)2000 by CHF, Inc.     

Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology

Heart failure is a serious condition and equivalent to malignant disease in terms of symptom burden and mortality. At this moment only a comparatively small number of heart failure patients receive specialist palliative care. Heart failure patients may have generic palliative care needs, such as refractory multifaceted symptoms, communication and decision making issues and the requirement for family support. The Advanced Heart Failure Study Group of the Heart Failure Association of the European Society of Cardiology organized a workshop to address the issue of palliative care in heart failure to increase awareness of the need for palliative care. Additional objectives included improving the accessibility and quality of palliative care for heart failure patients and promoting the development of heart failure‐orientated palliative care services across Europe. This document represents a synthesis of the presentations and discussion during the workshop and describes recommendations in the area of delivery of quality care to patients and families, education, treatment coordination, research and policy.     

Heart failure practice improvement effort in the outpatient setting: a health care financing administration initiative to improve the care of medicare beneficiaries with heart failure

This column is the fourth in a series describing Health Care Financing Administration initiatives to improve care for Medicare beneficiaries with heart failure. The first three papers addressed the background, design, and baseline results of the Health Care Financing Administration national initiative to improve quality of inpatient care for heart failure through the activities of each state's Health Care Financing Administration contractor Peer Review Organization. This paper describes a smaller-scale but equally important endeavor: the Heart Failure Practice Improvement Effort, a pilot project to test the feasibility of assessing and improving heart failure care in the outpatient setting. (c)2001 by CHF, Inc.     

Accuracy of a heart failure diagnosis in administrative registers

BACKGROUND: The incidence of heart failure is frequently reported using hospital discharge diagnoses. The specificity of a diagnosis has been shown to be high but the sensitivity of a reported diagnosis is unknown. PURPOSE: To study the accuracy of a heart failure diagnosis reported to the Danish National Patient Registers during routine clinical work. METHODS: The patient population consisted of 3644 consecutive patients admitted to all departments in one hospital. Diagnoses reported to the National Patient Register were recorded. A study team evaluated each patient independently of routine care, performed an echocardiogram and evaluated whether clinical symptoms of heart failure were present. Heart failure was defined in accordance with current ESC guidelines as symptoms of heart failure and evidence of cardiac dysfunction. RESULTS: A registered diagnosis of heart failure (n=126) carried a specificity of 99% and a sensitivity of 29% for all patients. The positive predictive value was 81%, the negative predictive value 90%. CONCLUSION: The diagnosis of Heart Failure in the Danish National Registers is underreported, but very specific.     

Advanced Heart Failure and Transplant Cardiology: A Subspecialty is Born

Recently, the American Board of Medical Specialties approved a proposal from the American Board of Internal Medicine for establishing the secondary subspecialty of Advanced Heart Failure and Transplant Cardiology. This step represents culmination of a process that began 4 years ago, through advocacy by the Heart Failure Society of America. It represents an essential step to ensure quality of care by specialists in a field that has grown up de facto amid rapid expansion both of the population of patients with heart failure and of diagnostic and therapeutic options for their management. The vast majority of care for most patients with heart failure will continue to be provided by general internists and cardiologists. Certification in Advanced Heart Failure and Transplant Cardiology will require a high degree of competency in all aspects of heart failure care, including technical proficiencies required to manage patients undergoing heart transplant and device implants. These specialists will play a key role in delivering the highest quality of complex care in the most cost-effective manner. In the years to come, the specialty must adapt to the ongoing rapid expansion of evidence-based knowledge in this field to continue to provide the highest level of care and the best outcomes to patients with heart failure.     

Quality of care and outcomes in acute decompensated heart failure: The ADHERE registry

Despite 1 million or more annual hospitalizations, the management of acute decompensated heart failure remains largely empiric. Data are lacking regarding patient characteristics, usual comorbidities, commonly used treatment strategies, clinical outcomes, and adherence to recently published quality indicators. The Acute Decompensated Heart Failure National Registry (ADHERE(R)) has been established to capture data regarding the presentation, management, and expected outcomes of acute decompensated heart failure. The size of the registry and its web-based platform allow for evaluation of compliance with quality indicators, assessment of mortality risk, and correlation of parenteral treatment strategies with clinical outcomes. More than 100,000 patient episodes have been recorded in the registry. These patient data have been reviewed and reveal important findings regarding acute decompensated heart failure and potential opportunities to improve the quality of care.     

2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure: Executive Summary

BackgroundThe 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America (AHA/ACC/HFSA) Guideline for the Management of Heart Failure replaces the 2013 ACCF/AHA Guideline for the Management of Heart Failure and the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose and manage patients with heart failure.MethodsA comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews and other evidence conducted in human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies published through September 2021 were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.Results and ConclusionsHeart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients’ interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments that have high-quality published economic analyses.     

Stroke epidemiology and outcomes in the modern era of left ventricular assist devices

Heart Failure Reviews - The care for the patients with end-stage heart failure has been revolutionized by the introduction of durable left ventricular assist devices, providing a substantial...     

Facteurs associés à l'inclusion des patients dans le programme PRADO - Insuffisance Cardiaque : étude cas-témoin au Centre Hospitalier de Troyes en 2017–2018

ObjectivesIn 2013, the French National Health Insurance set up a programme to help patients with heart failure to return home and stay there (PRADO). During a hospitalization for cardiac decompensation, the medical team decides on the inclusion of the patient in the programme based on eligibility criteria defined. The objective of this study was to identify the factors most associated with the inclusion of heart failure patients in the PRADO program.Materials and MethodsThis was a monocentric retrospective analytical stratified case-control study. It focused on the analysis of patient records hospitalized for cardiac decompensation between 01/01/2017 and 31/12/2018 in the cardiology department of the Centre Hospitalier de Troyes. For each patient included in the PRADO Heart Failure programme, one or two controls, not included in the PRADO Heart Failure programme were matched. The matching was exact without discounting. It was performed on the following criteria: age in 10-year increments, sex, main diagnosis of the stay, major category of diagnosis of the stay and its type (medical or surgical), the severity score of the Homogeneous Group of Patients of the stay and the Charlson score.ResultsA total of 40 patients included in PRADO Heart Failure were matched to 56 controls not included in PRADO Heart Failure. Patients with respiratory disease (3.77 [1.07 – 13.29]), as well as patients on renin-angiotensin system inhibitors (2.24 [1.61 – 5.31]) were more often included in the PRADO Heart Failure programme. The most frequent criteria for non-eligibility were the need to transfer the patient to a specialised institution and significant impairment of higher functions.ConclusionRespiratory comorbidity and renin-angiotensin system blocker treatment are the factors most associated with the inclusion of heart failure patients in the PRADO Heart Failure programme.     

Etiologies and predictors of readmission among obese and morbidly obese patients admitted with heart failure

Heart Failure Reviews - The relationship between severity of obesity and outcomes in heart failure (HF) has long been under debate. We studied index HF admissions from the 2013–14 National...     

Hospital Management of Acute Decompensated Heart Failure

Heart failure (HF) is one of the leading causes of hospitalizations for elderly adults in the United States. One in 5 Americans will be >65 years of age by 2050. Because of the high prevalence of HF in this group, the number of Americans requiring hospitalization for this disorder is expected to rise significantly. We reviewed the most recent and ongoing studies and recommendations for the management of patients hospitalized due to decompensated HF. The Acute Decompensated Heart Failure National Registry, together with the 2013 American College of Cardiology Foundation and American Heart Association heart failure guidelines, earlier retrospective and prospective studies including the Diuretic Optimization Strategies Evaluation (DOSE), the Trial of Intensified vs Standard Medical Therapy in the Elderly Patients With Congestive Heart Failure (TIME-CHF), the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE–HF), the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) and the Comparison of Medical, Pacing and Defibrillation Therapies in Heart Failure (COMPANION) trial were reviewed for current practices pertaining to these patients. Gaps in our knowledge of optimal use of patient-specific information (biomarkers and comorbid conditions) still exist.     

Management of heart failure patients with COVID‐19: a joint position paper of the Chinese Heart Failure Association & National Heart Failure Committee and the Heart Failure Association of the European Society of Cardiology

The coronavirus disease 2019 (COVID‐19) pandemic of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is causing considerable morbidity and mortality worldwide. Multiple reports have suggested that patients with heart failure (HF) are at a higher risk of severe disease and mortality with COVID‐19. Moreover, evaluating and treating HF patients with comorbid COVID‐19 represents a formidable clinical challenge as symptoms of both conditions may overlap and they may potentiate each other. Limited data exist regarding comprehensive management of HF patients with concomitant COVID‐19. Since these issues pose serious new challenges for clinicians worldwide, HF specialists must develop a structured approach to the care of patients with COVID‐19 and be included early in the care of these patients. Therefore, the Heart Failure Association of the European Society of Cardiology and the Chinese Heart Failure Association & National Heart Failure Committee conducted web‐based meetings to discuss these unique clinical challenges and reach a consensus opinion to help providers worldwide deliver better patient care. The main objective of this position paper is to outline the management of HF patients with concomitant COVID‐19 based on the available data and personal experiences of physicians from Asia, Europe and the United States.     

Managing acute renal failure in patients with acute decompensated heart failure: The cardiorenal syndrome

In patients with acute decompensated heart failure, worsening renal function during conventional decongestive therapy (cardiorenal syndrome) affects prognosis and the initiation of therapies with known benefit in chronic heart failure. Potential strategies for decongestion in patients who develop cardiorenal syndrome include invasive hemodynamic monitoring to guide therapy, use of continuous diuretic infusions, ultrafiltration, or novel therapy with adenosine or vasopressin receptor antagonists. Clinical trials by the National Heart, Lung, and Blood Institute’s Heart Failure Network are currently underway to validate such therapies in patients with acute decompensated heart failure with worsening renal function and to establish novel biomarkers for the early identification of patients who develop cardiorenal syndrome.     

Improving Provider Adherence to Guideline Recommendations in Heart Failure

Purpose of Review

Heart failure clinical practice guidelines are fundamental and serve as framework for providers to deliver evidence-based care that correlates with enhanced patient outcomes. However, adherence, particularly to guideline-directed medical therapy, remains suboptimal for a multitude of reasons.

Recent Findings

Despite robust clinical trials, updated guidelines and an expert consensus statement from American Heart Association, American College of Cardiology, and Heart Failure Society of America registry data signal that heart failure patients do not receive appropriate pharmacotherapy and may receive an intracardiac device without prior initiation or optimization of medical therapy.

Summary

Strategies to improve provider adherence to heart failure guidelines include multidisciplinary models and appropriate referral and care standardization. These approaches can improve morbidity, mortality, and quality of life in HF patients.