Heart Failure Care in the Outpatient Cardiology Practice Setting: Findings from IMPROVE HF

2. Heart Failure Care in the Outpatient Cardiology Practice Setting: Findings from IMPROVE HF Gregg C. Fonarow, Clyde W. Yancy, Nancy M. Albert, Anne B. Curtis, Wendy Gattis Stough, Mihai Gheorghiade, J. Thomas Heywood, Mark L. McBride, Mandeep R. Mehra, Christopher M. O'Connor, Dwight Reynolds and Mary N. Walsh Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

3. Disclosures • The IMPROVE HF registry is sponsored by Medtronic, Inc. • This manuscript was sponsored by Medtronic, Inc. • Individual author disclosures are provided in the manuscript Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

4. Heart Failure Care in the Outpatient Cardiology Practice Setting • Evidence-based, life-saving drug & device therapies continue to be underutilized despite overwhelming clinical-trial evidence, national guidelines, expert opinion, and a vast array of educational conferences. • Recommendations for medication and device therapies are rapidly evolving. Therapy is more complex and collaboration among physicians can be challenging. • For individuals hospitalized with HF, variations among hospitals between patient treatment and published evidence-based guidelines have been described. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

5. Heart Failure Care in the Outpatient Cardiology Practice Setting • Little is known about the contemporary rates of use of guideline-recommended heart failure therapies in the outpatient setting or their variability across practices. • Data regarding baseline care in the outpatient cardiology setting and, in particular, variations in care across practices, may provide important insights into the patterns of treatment of these patients and where quality improvement efforts should be focused. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

6. IMPROVE HF Study Overview • Largest, most comprehensive quality improvement study for HF patients in the outpatientsetting • Designed to enhance quality of care of HF patients by promoting adoption of evidence-based, guideline-recommended therapies: • Evaluates utilization rates of evidence-based, guideline-recommendedHF therapies • No procedures or assessments required • Sites attended an educational workshop to set treatment goals and develop a customized clinical care pathway • Sites are provided with HF disease state management tools to help improve the quality of care for patients Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

7. IMPROVE HF Study Goals Improve treatment rates for evidence-based, guideline- recommended HF therapies in the outpatient setting: • Track utilization (via chart reviews) for HF medications, devices, and patient education • Discover treatment gaps as compared to treatment guidelines and evidence from large clinical trials • Advance understanding of best approaches to identify appropriate HF patients for indicated medical and device therapies • Assist sites in closing treatment gaps by offering practical information and disease management tools and practice profile reports for sites to monitor their utilization of evidence-based, guideline-recommended therapies Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

8. 12 Month Chart Review (Cohort A) 24 Month Chart Review (Cohort A) 6 Month Chart Review (Cohort B) 18 Month Chart Review (Cohort C) IMPROVE HF Study Milestones • Longitudinal cohort allows investigators to evaluate changes in practice treatment patterns relative to baseline (historical control). • Single Time Point cohorts allow investigators to: • Characterize practice treatment patterns • Identify patients not receiving indicated therapies Baseline Chart Review (Cohort A) Longitudinal Cohort Process Improvement Intervention Single Time Points Fonarow GC et al. Improving the use of evidence-based heart failure therapies in the outpatient setting: the IMPROVE HF performance improvement registry. Am Heart J, 2007; 154:12-38.

9. IMPROVE HF Primary Objective To observe over the aggregate of IMPROVE HF practice sites a relative ≥20% improvement in at least 2 of the 7 performance measures at 24 months compared with baseline Fonarow GC et al. Improving the use of evidence-based heart failure therapies in the outpatient setting: the IMPROVE HF performance improvement registry. Am Heart J, 2007; 154:12-38.

10. Study Performance Measures • Use of ACE inhibitors and/or angiotensin II receptor blockers • Use of beta-blockers • Use of aldosterone receptor antagonists • Use of anticoagulation therapy in patients with atrial fibrillation • Use of implantable cardioverter-defibrillators (ICDs) • Use of cardiac resynchronization therapy (CRT) • Documentation that HF education was provided * in eligible patients without documented contraindications or intolerance Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

11. Study Objective • To characterize contemporary use of guideline-recommended heart failure therapies in the outpatient cardiology practice setting in eligible patients with systolic heart failure Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

12. Methods: Patient and Practice Enrollment Criteria • Patients diagnosed with HF or prior myocardial infarction (MI) and LVEF ≤ 35% • Patients with condition limiting one year survival and ESRD excluded • Practices: Outpatient cardiology (single specialty or multi-specialty) practices from all regions of the country • This baseline report included data from 167 cardiology practices and 15,381 patients entered into the registry. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

13. Methods • Baseline data abstracted from eligible patient charts included: • Practice characteristics (by survey) • Patient demographics, laboratory testing, and diagnostic studies • Contraindications, medical/patient reasons for not implanting • Use of guideline recommended therapies in eligible patients • Variability across practices in use of guideline recommended therapies Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

14. Baseline Practice Characteristics *Two sites did not provide any survey data. †N=157  N=163. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

15. Baseline Patient Characteristics Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

16. Baseline Patient Characteristics Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

17. Patient Characteristics: NYHA Functional Class and QRS Duration • Documentation of the New York Heart Association (NYHA) functional class is a prerequisite for ICD, CRT, and aldosterone antagonist care metric eligibility • NYHA Class documented in 67.0% of patients* • Distribution in patients with NYHA documentation: • Class I 30.4% • Class II 39.5% • Class III 26.4% • Class IV 3.7% • QRS duration: documented in 67.7% of patients • QRS duration mean: 129.0 msec • 52% of patients with QRS duration 120 ms or above * Includes both quantitative and qualitative documentation of NYHA functional class Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

18. Quality of Outpatient HF Care Conformity with Performance Measures at Baseline 51 Patients (%) 39 7 33 32 18 (N = 11,271 / 14,167) (N = 12,039 / 14,058) (N = 3630 / 7169) (N = 9459 / 15,381) (N = 905 / 2505) (N = 528 / 1361) (N = 2450 / 3533) Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

19. Variation in HF Quality of Care The frequency distribution of conformity rates by practice Box plots represent median, 10th and 90th percentiles, and minimum and maximum values across practices. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

20. Variation in Outpatient HF Care Median, 79.5 Mean, 78.1 Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

21. Variation in Outpatient HF Care Median, 87.6 Mean, 85.3 Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

22. Variation in Outpatient HF Care Median, 33.3 Mean, 35.0 Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

23. Variation in Outpatient HF Care Median, 33.3 Mean, 37.3 Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

24. Variation in Outpatient HF Care Median, 49.1 Mean, 50.7 Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

25. Variation in Outpatient HF Care Median, 70.0 Mean, 67.8 Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

26. Variation in Outpatient HF Care Median, 60.7 Mean, 59.8 Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

27. Quality of Outpatient HF Care • The use of ACEI/ARB and beta blockers among eligible patients in the outpatient cardiology practice setting is higher than previously reported in the general outpatient practice setting • Baseline use of evidence-based therapy in the outpatient cardiology practice setting is still below optimal, particularly for: • Aldosterone antagonist therapy • ICD and CRT device therapy • HF education • Consistent documentation of NYHA class may represent a quality initiative and an opportunity to improve care. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

28. Variation in Outpatient HF Care • Significant variation exists across cardiology practices in the use of evidence-based, guideline-recommended therapies in eligible patients. • Variations in care were particularly large for: • Aldosterone antagonist therapy • ICD and CRT device therapy • HF education • Certain practices were able to provide and document substantial use of guideline-recommended therapies. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

29. Documentation of NYHA / Activity • Documentation of NYHA functional class and/or limitation to physical activity in the outpatient cardiology practice setting is not optimal. • Lack of documentation may prevent a portion of potentially eligible patients from being appropriately considered for recommended therapies. • Practice-specific performance improvement strategies are needed to enhance documentation of NYHA functional class and current symptom status. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

30. Limitations of Study • Data is dependent on medical record documentation and thus may not accurately reflect practice in all sites • Rationale for decisions regarding therapy utilization may not be captured • QRS duration and NYHA Class missing in a proportion of patients • These findings may not apply to practices that differ in patient characteristics or care patterns from IMPROVE HF cardiology practices Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

31. Conclusions • These data are among the first to assess treatment in the outpatient setting since the release of the latest national HF guidelines • They demonstrate substantial treatment gaps and variation among cardiology practices in the documented therapies provided to HF patients. • Certain practices participating were able to provide higher rates of therapies as judged by the IMPROVE HF care metrics. • Opportunities exist to improve documentation and/or care for many HF patients in the outpatient setting. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

32. Implications • There is an urgent need to identify best practice methodologies in the outpatient cardiology practice setting. • The ongoing IMPROVE HF Performance Improvement Program is testing whether practice based intervention will improve the quality of outpatient care for heart failure. Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

33. IMPROVE HF Additional Information IMPROVE HF Study Website: • Study Overview & Design • Manuscripts & Abstracts • News & Events • Steering Committee Overview Study Rationale & Design Manuscript: • Published: July 2007, American Heart Journal www.IMPROVEHF.com Baseline Manuscript: • Published: 2008, Circulation: Heart Failure