Correspondence *Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 East Medical Center Dr, CVC Room 2167, SPC 5853, Ann Arbor, MI 48109, USA

Email tkoellin@umich.edu

Original article

Fonarow GC et al. for the OPTIMIZE-HF Investigators and Hospitals (2007) Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Arch Intern Med 167: 1493–1502   PubMed

Synopsis

Background

Despite the publication of international guidelines for the treatment of heart failure (HF), adherence to evidence-based therapies is poor.

Objectives

To assess the quality of care given to patients hospitalized with HF and to improve adherence to evidence-based treatment recommendations.

Design

OPTIMIZE-HF is a large hospital-based scheme comprising an internet registry of patients with HF. Enrollment took place between 1 March 2003 and 31 December 2004. Patients were eligible for inclusion if they were admitted to one of 259 participating hospitals in the US with new onset or worsening HF, or if symptoms of HF developed during hospital admission for another condition. Data on adherence to four core JCAHO (Joint Commission on Accreditation of Healthcare Organizations) quality of care measures were included in the database. Participating hospitals were provided with a process of care intervention (PrCI) 'toolkit' that included discharge checklists and best-practice algorithms.

Outcome measures

The primary outcomes were changes in the rates of adherence to four JCAHO quality of care measures (issuing of discharge instructions, assessment of left ventricular [LV] function, prescription of angiotensin-converting-enzyme [ACE] inhibitors at hospital discharge for patients with LV systolic dysfunction, and provision of smoking-cessation counseling) and in the use of ACE inhibitors, angiotensin receptor blockers, and -blockers at hospital discharge. The impacts of PrCI tools on duration of hospital stay, in-hospital mortality, total mortality, and rehospitalization were also assessed.

Results

A total of 48,612 patients were enrolled in the study, 5,791 of whom were followed-up for clinical outcomes at 60–90 days after hospital discharge. The majority of participants were white (74.1%) and female (51.6%). The mean age at enrollment was 73.1 years. The mean LV ejection fraction of the cohort was 39.0%. LV systolic dysfunction was present in 48.8% of patients, and ischemic HF in 45.7%. Adherence to three of the four JCAHO quality of care measures increased significantly over the study period. The proportion of patients for whom appropriate discharge instructions were issued rose from 46.8% to 66.5% during the study (P <0.001). The proportion of patients receiving smoking-cessation counseling also rose over this period (from 48.2% to 75.6%), as did the rate of LV function assessment (from 89.3% to 92.1%; P <0.001 for both). There was, however, no significant change in the proportion of patients prescribed ACE inhibitors at hospital discharge (P = 0.18). From the first quarter of 2003 to the last quarter of 2004 there were significant increases in the percentages of patients prescribed -blockers (from 76.3% to 86.4%), aldosterone inhibitors (from 11.3% to 20.3%), and statins (from 39.0% to 44.0%; P <0.001 for all). Trends towards reduced in-hospital mortality (from 3.5% to 3.4%; P = 0.06) and reduced rates of the combined end point of 60–90 day death or rehospitalization (38.0% to 30.2%; P = 0.18) did not reach statistical significance.

Conclusion

The rates of adherence to evidence-based therapies for HF increased in hospitals that took part in OPTIMIZE-HF, and the use of PrCI tools was associated with improved patient outcomes at 60–90 days after discharge.

Commentary

Randomized controlled trials performed over the past 25 years have contributed greatly to the body of evidence upon which treatment decisions for patients with HF are based. These studies led to the evolution of HF treatment from an empirically-based approach to an approach guided by the literature.¹ In the past decade, numerous efforts have been made to improve the quality of hospital-based care for patients with HF, including the introduction of national programs instigated by organizations such as the JCAHO and the Centers for Medicare and Medicaid Services (CMS). Trends in the US demonstrate that this attention to quality has led to substantial improvements in care over time, as measured by quality indicators. From 2002 to 2004, JCAHO performance measurement data showed increases in the use of appropriate discharge instructions, LV functional assessment, the use of ACE inhibitors for LV systolic dysfunction, and smoking-cessation counseling.²

The OPTIMIZE-HF Investigators now report the results of a prospective, multihospital, web-based registry and quality improvement intervention that provided real-time feedback on performance measures. Over the 21-month study period, there were increases in the frequency of LV functional assessment, use of appropriate discharge instructions, and smoking-cessation counseling. No significant change was seen in ACE inhibitor usage during the study, but significant increases in the use of -blockers, statins, and aldosterone antagonists were observed.

Although OPTIMIZE-HF demonstrated trends towards reduced in-hospital mortality and combined 60–90 day postdischarge mortality or rehospitalization, no significant associations between the quality improvement initiative and clinical outcomes were seen. The use of the PrCI toolkit was, however, associated with significantly reduced in-hospital mortality (P <0.001) and 60–90-day death or rehospitalization rates (P = 0.02). In our opinion, the 60–90-day follow-up was insufficient to evaluate the influence of specific performance measures on clinical outcomes, as the effects of smoking cessation, warfarin use, and even -blockade would be expected to manifest over a longer period of time. Remarkably, the length of hospital stay dropped from 7.5 to 6.2 days (P <0.001) during the study, although it is unclear which aspect of the quality improvement program was responsible for this dramatic change.

In the absence of concurrent data from a control group of hospitals, the true effect of the OPTIMIZE-HF initiative is unclear. Without question, the OPTIMIZE-HF hospitals were under pressure from the JCAHO, CMS, and other organizations, such as the Blue Cross Blue Shield Association, the AHA, and the ACC, to maximize the quality of care for HF during the study period. Improvements documented during OPTIMIZE-HF mirror those seen in the JCAHO experience, but whether national efforts by the JCAHO and CMS also resulted in changes in length of stay or use of non-performance-measure therapies, such as -blockers and aldosterone antagonists, is not known. Additional studies are necessary to help us understand whether prospective, web-based reminder tools can improve the current practices for HF care.

What is becoming clear is that support strategies, whether based on paper checklists or more sophisticated online systems, strongly influence the over-all quality of care delivered to patients.^{3, 4} The sustainability of quality improvements depends on the extent to which the process can be systematized and become part of the very fabric of clinical care. Further assessments of the cost-effectiveness of quality improvement initiatives are needed to determine which systems deserve investment.

Acknowledgments

The synopsis was written by Alexandra King, Associate Editor, Nature Clinical Practice.

References

1. Hunt SA (2005) ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 46: e1–e82 | Article | PubMed |
2. Williams SC et al. (2005) Quality of care in US hospitals as reflected by standardized measures, 2002–2004. N Engl J Med 353: 255–264 | Article | PubMed | ChemPort |
3. Mehta RH et al. for the GAP Steering Committee of the American College of Cardiology (2002) Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) initiative. JAMA 287: 1269–1276 | Article | PubMed | ISI |
4. Eagle KA et al. (2005) Guideline-based standardized care is associated with substantially lower mortality in Medicare patients with acute myocardial infarction: The American College of Cardiology's Guidelines Applied in Practice (GAP) projects in Michigan. J Am Coll Cardiol 46: 1242–1248 | Article | PubMed | ISI |

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Subject areas under which this article appears: Cardiomyopathy and heart failure