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Enhancing Quality of Care in Heart Failure: Measure, Improve, Succeed

Explore the importance of performance measures in heart failure treatment and how they relate to quality of care. Learn about historical perspectives, process and outcome measures, and the impact on individual and population health. Discover the significance of structural, process, and outcome measures in improving healthcare practices.

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Enhancing Quality of Care in Heart Failure: Measure, Improve, Succeed

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  1. Performance measures in heart failure Dr. J.H. Kirkels Dr. A. Mosterd Drs. H. Hietbrink

  2. Quality of care is not equal to outcome • Tendencytofocuss on outcome (mortality, length of stay, re-hospitalisation) • Ranking based on outcomemeasures BUT: • Whatgoes in, comes out • Outcome is only a validmeasure in similarpopulations • Severalmeasurescanbemanipulated

  3. What is quality of care? ..”the degree to which health care systems, services, and supplies for individuals and populations increase the likelihood for desired health outcomes in a manner consistent with current professional knowledge” Fitzgerald et al, Ann N Y Acad Sci 2012

  4. Quality of medical care Safety Effectiveness Patient-centeredness 12.30 uur Lunch Timeliness Efficiency Equity 15.00 uur Toepassing 16.00 uur Kwaliteitsborging How to measure quality of medical care?

  5. Historical perspective of quality measurement • 1983: Medicare program to identify “outliers” • Philosophy that suboptimal care was rare and the responsibility of only a few individuals or institution • Appeared to endemic and resulted from systematic failures to deliver the best care • 1992: Medicare: quality of care myocardial infarction: Cooperatieve Cardiovascular Project • Evidence based processes of care: e.g. aspirin, beta blockers, thrombolysis • ‘92-’95: performance on quality indicators improved AND mortality declined

  6. Historical perspective of quality measurement • 1999: National Heart Failure Project • Focus on 4 inpatient processes of care: • Assessment of LVEF • Use of ACE-i in LV systolic dysfunction • Providing complete heart failure discharge instructions • Providing smoking cessation counseling • 2001: submit performance metrics for reimbursement and accreditation

  7. Heart failure and quality measurement • Prevalent • Impact on individual and population health • Most common cause of hospital admission in elderly • Highest readmission rates within 30 days • High risk for adverse events, death and poor QOL • High cost: 2015: $ 44 billion direct cost • Extensive evidence base; robust practice guidelines

  8. Measures (Donabedian 1966) What do I have toDOtoreachmy goal? Process Structure Whatexactly do I want toACHIEVE? Effective, timely, safe etc What do I NEED toachievemy goal? Organisation, logistics Outcome

  9. Structural measures • Health care environment • Personnel, facilities, training, certification, implementation of protocols • Presence of a nurse-lead heart failure “outpatient clinic”? • Case volume for procedures • Weak relationship with health outcomes • In heart failure rarely used

  10. Process measures • Characterize care that is delivered to patients • Medication, procedures, education • Patients with indication for therapy (in the absence of contraindication): denominator • Proportion that receives the therapy: numerator • Strong evidence is prerequisite • Interpretable, actionable, valid, reliable, feasible to calculate • For purpose of feedback, benchmarking, quality improvement (many) • For purpose of accountability: public reporting or pay-for –performance (few!)

  11. * Not for accountability

  12. Pro / Con process measures + Strong face validity + No risk adjusment required • Assess only small fraction of the processes of care and only those who qualify (retrospective contraindications) • Performance has reached high levels; fail to discriminate among institutions • Focus on eliminating underuse; issues of overuse and misuse are not adressed Relationship with patient outcome is controversial Only beta blocker and ACEi were associated with better outcome Adequate reflections of quality of care??

  13. Outcome measures • ACC/AHA standards for outcome measures: • Clearly defined patient sample • Clinically coherent variables for risk adjustment • High-quality and timely data • Reference time for collection of risk adjustment variables • Standardized period of assessment of outcome (not “in-hospital, but 30 day etc) • Analysis to account for clustering of patients within systems • Transparancy of the methods used • Difficult to apply on heart failure!

  14. Outcome measures for heart failure • Mortality 60-90 day • 30-day readmission rate • Combined mortality and rehospitalizations rates • Quality of life • Decreasing symptoms of HF • Mean number of treatment hours • % of patients with troughput time below 12 weeks • % of patients with increase on Quality of Life Questionannaire • % of patients with increase on the Shuttle Walk Test • Length of stay • EOC (all hospital days for an HF admission and any subsequent admissions within 30 days)

  15. Pro / con outcome measures + Patient centered and meaningful to patient and society as a whole + Do not require restrictions to patients who qualify for a specific therapy + Reflect the overall performance of health systems • Risk adjustment techniques must be fair to account for casemix • Decisions about when to measure the outcome of interest are arbitrary • Sometimes difficult to measure in large populations (e.g. health status) • Quality of life: also greatly improved by “dummy ICD or CRT” • Sometimes relatively rare, limiting power • Attributing the outcome to the condition of interest can be complicated by coexisting conditions • Competingoutcomes: 1993-2006 • Decline in length of hospitalstay, in-hospitalmortality, 30-d mortality • Discharge tonursingfacilitiesincreasedproportionally • Readmission increased

  16. GWTG mortality prediction (in hospital)

  17. Expected mortality: Get with the guidelines

  18. How to measure? • Integrity of data • Commitment, planning, resources • Administrative sources (claims data) • No clinical detail; discordant with clinical reality • Not timely • Clinical chart abstraction • Clinical detail; relies on available documentation • Labor intensive • Clinical registries • Observational databases of a clinical condition, procedure, therapy: most effective approach to measuring quality • AHA Get With The Guidelines Heart Failure • Voluntary; limited by selection bias • Privacy regulations; funding? • Electronic Health Records: potential for automatic data collection

  19. How to use measurements? • Local level: • Feedback to physicians, benchmarking to improve processes of care • National level: online data on: • Processes of heart failure care • 30-d RISK ADJUSTED mortality after HF admission • 30-d RISK ADJUSTED readmission after HF admission • Value-based purchasing program: • Higher quality care through financial incentives

  20. Findings concerning process measures HF

  21. Findings concerning outcome measures HF

  22. Findings concerning outcome measures HF

  23. Bron: Bonow RO et al. ACC/AHA Heart Failure Clinical Performance Measures. Journal of the American College of Cardiology Volume 46, Issue 6, 20 September 2005, Pages 1144–1178

  24. Discharge instructions Heart failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: • Activity level • Diet • Discharge medications • Follow-up appointment • Weight monitoring • What to do if symptoms worsen

  25. GWTG Best practices

  26. ACCF/AHA/AMA-PCPI 2011 Performance measures for adults with heart failure JACC 2012

  27. CBO consensus hartfalen 2010

  28. CBO consensus hartfalen 2010

  29. CBO consensus hartfalen 2010

  30. CBO consensus hartfalen 2010

  31. CBO consensus hartfalen 2010

  32. The future of quality of heart failure care • So far mainly focussed on underuse • Ignored cost of care and safety • Unsustainable health care cost • New interest in overuse and value of therapies • Outcomes of healthcare as a function of the cost • ICD’s in heart failure: underuse and overuse! • Aldosterone antagonists: • Reduce risk of death and hospitalization • Increase risk due to hyperkalemia (misuse)

  33. What do we need? • IT to improve data sources; real-time feedback on quality • Process meaures with stronger relationship to health outcome • Patient-centered outcomes (physical function, symptoms) as metrics of quality • Adequate system for comorbidities (risk adjustment) • Focusing on subgroups underrepresented in trials (elderly) • Expanding measurement into palliative / end-of-life care, which is often relevant in heart failure • Preventing patient selection for better outcomes

  34. Correlation between Elsevier and AD hospital ranking

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