Download Dosage of enalapril for congestive heart failure in USA

Quality of care, part 2:
heart failure
Kim A Eagle MD
Albion Walter Hewlett Professor of Internal Medicine
Chief, Clinical Cardiology
Co-Director, Heart Care Program
University of Michigan
Ann Arbor, MI
William T Abraham MD, FACP, FACC
Professor of Medicine
Chief, Division of Cardiology
University of Kentucky College of Medicine
Lexington, KY
Heart failure
Hospitalization
Heart failure is the most rapidly growing form of
cardiovascular disease in the US and in developed
countries.
Hospitalization for heart failure has become a major
issue for the practitioner and for the healthcare
planner.
Heart failure (DRG 127) is now the most common
discharge diagnosis for those over 55 years.
Heart failure has recently become the fourth
leading cause of hospitalization for all US adults.
Heart failure
Measuring quality-of-care indicators
Primary goals of acute hospitalization for decompensated
heart failure are not routinely measured in clinical trials
or surveys of hospitalized patients for heart failure
• alleviation of symptoms
• achievement of a more compensated state
Measures that can be objectively assessed from the
medical record are used to assess quality of care
• use of appropriate medical therapy for the
treatment of heart failure where the index drug has
been an ACE inhibitor
• length of stay
• early (30–90 day) readmission rate
In-hospital treatment
Appropriate drug therapy
Many of the drugs used in the treatment of heart
failure (AIIAs for patients intolerant to ACE, beta
blockers and aldactone) are more appropriate in
outpatient settings.
An optimal drug regimen cannot be achieved
during a 5- or 6-day hospitalization for heart
failure.
Diuretics and ACE inhibitors are an appropriate
therapy for hospitalized patients.
Additional medications that take time to initiate
and titrate to target doses are more appropriate in
the outpatient environment.
Improving documentation
Ejection fraction
LVEF helps distinguish systolic heart failure from
heart failure associated with preserved LVF.
EF documentation should be included in the
medical record.
In a survey sponsored by the University Health
Systems Consortium evaluating more than 1450
hospitalized patients with heart failure, disease
severity as assessed by NYHC and LVEF was rarely
included in the medical record during index
hospitalization.
In-hospital treatment
Patient-specific benchmarks
The 2 most important benchmarks during
hospitalization for heart failure are EF and
whether the patient was placed on an ACE
inhibitor.
Ideally, more patient-oriented measures of
quality of care should be used
 disease-specific measures of quality of life
 patient satisfaction
 specific scales for assessing improvement
in symptoms
Outpatient care
Assessing quality
The simplest measure for assessing quality of care
for outpatients is appropriateness of drug therapy.
There is a growing list of effective pharmacologic
therapies for heart failure.
Nonpharmacologic treatments are as important as
drug therapy
 adequate patient education
 self-monitoring of daily weight by patients
 tracking patient compliance with
pharmacologic and nonpharmacologic
treatment
 understanding and complying with a lowsodium diet
Heart failure management
Practical strategies
Pharmacologic therapy
 diuretic therapy, particularly for patients
retaining fluid
 ACE inhibitors
 beta blockers
Process of care issues
 patient education
 low-sodium diet
 self-monitoring of daily weight
Improving quality
Do something
Develop a structured approach to heart failure care
that includes an advocate for the patient who can
help integrate their care.
There are many examples of heart failure care that
substantially reduce the incidence of hospitalization
or rehospitalization and improve care
 pharmacist-directed initiatives
 nurse-directed initiatives
 nurse-practitioner-directed initiatives
 primary-care-directed initiatives
 cardiologist-directed initiatives
Improving quality
Process-of-care improvements
Heart failure clinics providing specialized or focused
care for heart failure patients
Community-based case management for outpatients
with heart failure
Tele-management — improve patient satisfaction
and quality of life and reduce the need for
hospitalization
Hospital-sponsored cardiac rehabilitation
A multidisciplinary team approach to disease
management
Creating partnerships
Pooling resources
Advantages of partnering with local or community
hospitals to provide services
 better patient care
 benchmarks in heart failure care are more easily
achieved
 length of stay and early readmission rates are
reduced
 infrastructure necessary for heart failure
management can be established
The electronic age
Increased scrutiny
Physician performance will be increasingly
scrutinized as healthcare moves into the
electronic arena.
In the future, everything physicians do will be
tracked electronically in real time and immediate
feedback will be provided.
Continual feedback will lead to a better standard
of care.
Access to computer-based programs, protocols,
and algorithms for care will be patient-specific
rather than general.
The future of care
Changes in process
Tele-management or remote management of
patients will be more common.
New devices will allow monitoring of patients in
their homes either in an episodic or a moment-tomoment fashion.
New schemes for reimbursing remote management
and data management services will be required.
Process-of-care improvements will be rewarded.
In the long run, process-of-care improvements
may be a better (more economical) fit even to
community practices.
Evolution of care
Participation is key
Heart failure is going to continue to be a growing
problem and burden for the healthcare system.
Changes to the management of patients are
inevitable.
Process-of-care improvements should be put into
practice before they are mandated.
If physicians want to influence the system for
defining and measuring quality in the future,
participation in developing processes is essential.