Initiative to improve heart failure care at nation's hospitals makes major gains

Jul 24 2007

A national initiative designed to improve heart-failure patient care in hospitals proved effective at increasing hospital adherence to key quality-of-care performance measures and reducing the length of hospital stays for patients.

It also resulted in favorable trends for in-hospital and post-discharge mortality rates, according to a UCLA study published in the July 23 edition of the journal Archives of Internal Medicine.

The initiative, called the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE–HF), is the largest of its kind undertaken for heart failure in the country, with 259 hospitals participating, and is the only one designed to capture patient outcomes data 60 to 90 days after discharge.

“Despite compelling scientific evidence and national guidelines for use of key life-prolonging agents and lifestyle changes, gaps exist in heart failure treatment,” said principal investigator Dr. Gregg C. Fonarow, UCLA's Eliot Corday Chair in Cardiovascular Medicine and Science, director of the Ahmanson-UCLA Cardiomyopathy Center and professor of medicine at the David Geffen School of Medicine at UCLA. “We hope more hospitals will adopt this validated model for enhancing heart-failure patient care.”

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

For the study, researchers utilized data from OPTIMIZE–HF's large heart-failure performance-improvement registry, which is designed to help hospitals increase adherence to standard hospital-based performance measures developed by the American College of Cardiology and the American Heart Association, as well as additional evidence-based measures.

Between March 2003 and December 2004, 48,612 eligible adult heart failure patients at academic and community hospitals nationwide were enrolled in the registry. A subgroup of 5,791 patients was followed for 60 to 90 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 that allowed hospitals to review data in real time and compare it to aggregate data from similar facilities. Information collected included data on admission, hospital, discharge care and outcomes.

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

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

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

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

The fourth measure — prescribing an angiotensin-converting enzyme or angiotensin II receptor blocker medication at discharge — remained steady 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 aldosterone antagonists increased from 11 to 20 percent and the use of statin medication rose from 39 to 44 percent.

“We saw substantial and very rapid improvements in these key performance measures and in providing essential evidence-based medications for heart failure,” Fonarow said.

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

“If similar improvements had occurred at hospitals nationwide, this would translate to 40,000 less deaths and 1.4 million costly hospital days eliminated per year,” Fonarow said.

OPTIMIZE–HF also provided tools to help hospitals improve the reliability of heart failure care, including standardized admission orders, discharge checklists, pocket cards, medical chart stickers, best-practice algorithms and critical pathways. Researchers found that use of these tools impacted outcomes. In-hospital mortality dropped from 4.1 to 2.5 percent for cases in which hospital staff utilized standard admission orders to help direct treatment. Post-discharge death and re-hospitalization rates decreased from 38.2 to 34.8 percent when tools were utilized during care.

Fonarow said that the American Heart Association has adopted OPTIMIZE–HF for use in its Get With the Guidelines–Heart Failure quality improvement program, in which more than 400 hospitals nationwide are now participating. GlaxoSmithKline sponsored the OPTIMIZE–HF registry and funded the study. Fonarow has received research grants and honoraria from GlaxoSmithKline and has served as a consultant to the company.

Additional author financial disclosures are available in the paper 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 Gattis Stough, 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 Medical Center–Hillcrest; Karen Pieper and Jie Lena Sun of the Duke Clinical Research Institute; and Dr. Clyde Yancy of the Baylor Heart and Vascular Institute at Baylor University Medical Center.