A national initiative of the American Heart Association that provides healthcare professionals with content-rich resources and materials designed to help

A national initiative of the American Heart Association that provides healthcare professionals with content-rich resources and materials designed to help advance heart failure awareness, prevention, and treatment.

Target: Heart Failure

04/18/23 ©2010, American Heart Association 2

Building on Success• GWTG-Heart Failure• Mission: Lifeline• OPTIMIZE-HF• Joint Commission/AHA Heart Failure Advanced Certification Program• The Guideline Advantage

The Need


5.7 million Americans are currently living with heart failure, and 670,000 new cases are diagnosed each year- up significantly from 500,000 cases annually just a few years ago.

As our population ages, this epidemic of heart failure will only continue to grow. The cost of providing heart failure ranks among the leading U.S. healthcare expenditures.

Additionally, the toll of heart failure on life, both in quality and longevity, is sobering.

A national initiative of the American Heart Association that provides healthcare professionals with content-rich resources and materials designed to help advance heart failure awareness, prevention, and treatment.

What is Target: Heart Failure ?



Target: Heart Failure Vision:

To improve quality, care transitions, and outcomes for patients with heart failure with a targeted initiative and leveraging the American Heart Association’s premier quality improvement suite of resources including Get With The Guidelines-Heart Failure.


Target: Heart Failure Mission:

Increase 3 key patient-centered care domains with very well established or emerging evidence-base:

• Medication optimization• Early follow-up and care coordination• Enhanced patient education

Target: HF Optimal Care Transitions and Patient Education:


• Discharge use of ACEI/ARB, evidence-based beta blocker, and aldosterone antagonist in all eligible heart failure patients with reduced LVEF, in absence of documented contraindications, intolerance, or patient/system reasons

• Early post-discharge follow-up with visit or contact within 48 hours of discharge scheduled

• Enhanced patient education as evidenced by referral to heart failure disease management program, provision of at least 60 minutes of heart failure education by a qualified heart failure educator, or provision of AHA heart failure interactive workbook


Building on Success

• GWTG-Heart Failure

• Mission: Lifeline

• Joint Commission/AHA Heart Failure Advanced Certification

• OPTIMIZE-HF

• The Guideline Advantage

Background on Heart Failure

• Heart failure (HF) is a major public health problem resulting in substantial morbidity and mortality

• Despite recent advances a substantial number of patients are not receiving optimal care

2Jones DL et al. Heart Disease and Stroke Statistics 2011 Update. Report from the AHA . Circulation.2011.

Population Group Prevalence Incidence Mortality

Hospital Discharges Cost

Total population 5,700,000 670,000 277,193 990,000 $39.2

billion

9

Heart Failure Hospitalizations

0

100

200

300

400

500

600

700

79 80 85 90 95 00 06

Years

Dis

char

ges

in T

ho

usa

nd

s

Male Female

United States: 1979-2006 Source: NHDS/NCHS , NHLBI. Hospital Compare 2007-2010

The majority of patients hospitalized with HF were previously hospitalized with HF

1.0 Million Hospitalizations a Year and Rising

30-Day Rehospitalization

Rates in HF

24.8%(Medicare)

10

30-Day Rehospitalization Rates in HF Vary Widely Between Hospitals

Keenan PS et al. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.11

X axis, hospital decile, 0-9

Y axis, mean hospital observed rates for 30-day rehospitalization from 0 to .40

All-Cause Mortality After Each Subsequent Hospitalization for HF

Time since admission

0.0

0.2

Cum

ulati

ve m

orta

lity

0.8

1.0 HF1st admission (n = 14,374)2nd admission (n = 3,358)3rd admission (n = 1,123)4th admission (n = 417)

1st hospitalization: 30-day mortality = 12%; 1-year mortality = 34%

0.6

0.4

0.0 0.5 1.0 1.5 2.0

Setoguchi S, et al. Am Heart J. 2007;154:260-266.

P<0.0001

12

Estimated Direct and Indirect Costs of HF in US

10.5%

9.7%8.2%

6.4%

11.9%

53.3%

Hospitalization$20.9

Lost Productivity/Mortality*

$4.1Home Healthcare

$3.8

Drugs/Other Medical Durables

$3.2

Physicians/Other Professionals

$2.5

Nursing Home$4.7

Heart Disease and Stroke Statistics—2010 Update: A Report From the American Heart AssociationCirculation, Feb 2010; 121: e46 - e215.

Total Cost$39.2 billion

13

Causes of Hospital Readmission for Heart Failure

17%Other

19%Failure to Seek

Care

16%Inappropriate Rx

Rx Noncompliance 24%

Diet Noncompliance24%

Annals of Internal Medicine 122:415-21, 1995

Over 2/3 of HF Hospitalizations Preventable

14

Measuring and Improving the Quality of HF Care

• Heart failure remains a major public health problem resulting in substantial morbidity and mortality.

• A number of evidence-based, guideline-recommended therapies are available to treat patients with heart failure.

• However, study after study shows the large gaps, variations, and disparities in the use of these evidence based therapies in eligible patients.

15

ADHERE Quality of CareConformity to The Joint Commission HF Performance Indicators

Fonarow GC et al. Arch Intern Med 2005;165:1469-1477

1%

72%

58%

8%

70%

97%

88%85%

0%

20%

40%

60%

80%

100%

HF-1 HF-2 HF-3 HF-4

Lagging Centers Leading Centers

81 142 admissions between 6/2002 – 12/2003 at 223 hospitalsGrouped by Leading (90th percentile) and Lagging (10th percentile)

All P<0.0001

DischargeInstructions

LV FunctionMeasurement

ACEI use Smoking Cessation

% U

tiliz

ation

Length of Stay (median)

Mortality

16

Risk-Treatment Mismatch in HF: Canadian EFFECT Study

Use rates in absence of contraindications. For all drug classes, P < .001 for trend.

EFFECT, Enhanced Feedback for Effective Cardiac Treatment. Lee D. JAMA. 2005;294:1240-1247.

At Hospital Discharge 90-Day Follow-Up 1-Year Follow-Up

010

20

30

40

50

60

70

80

90

Low Risk Average Risk High Risk

ACEI ACEI or ARB

-Blocker

1-Year Mortality Rate

Pat

ien

ts, %

ACEI ACEI or ARB

-Blocker

17

Evidence-Based Treatment for Heart Failure with Reduced LVEF

Control VolumeReduce Mortality

Sodium Restriction*Diuretics*

Digoxin*

-BlockerACEIor ARB

AldosteroneAntagonist

Treat Residual SymptomsCRT an ICD*

Hyd/ISDN*

*For select indicated patients.

ICD*

Treat Comorbidities

Aspirin*Warfarin*

Statin*

Enhance Adherence

EducationDisease Management

Performance Improvement Systems18

Established Benefits of Guideline-Recommended HF Therapies

Fonarow GC, et al. Am Heart J 2011;161:1024-1030. 19

Guideline

Recommended

Therapy

Relative Risk

Reduction in

Mortality

Number Needed to

Treat for Mortality

NNT for Mortality

(standardized to 36

months)

Relative Risk

Reduction in HF

Hospitalizations

ACEI/ARB 17% 22 over 42 months 26 31%

Beta-blocker 34% 28 over 12 months 9 41%

Aldosterone Antagonist 30% 9 over 24 months 6 35%

Hydralazine/Nitrate 43% 25 over 10 months 7 33%

CRT 36% 12 over 24 months 8 52%

ICD 23% 14 over 60 months 23 NA

Improved Adherence to ACC/AHA HF Guidelines Translates to Improved Clinical Outcomes in Real World HF Patients

• Each 10% improvement in ACC/AHA guideline-recommended composite care was associated with a 13% lower odds of 24-month mortality (adjusted OR 0.87; 95% CI, 0.84 to 0.90; P<0.0001).

Fonarow GC, et al. Circulation. 2011;123:1601-1610.

Adapted from the American Heart Association. Get With The Guidelines; 2001.

• Implement evidence-based care

• Improve communications• Ensure compliance

Systems Clinical Practice

ACC/AHA/HFSA Guidelines

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

• Improve quality of care

• Improve outcomes

• Clinical trial evidence

• National guidelines

Bridging the Gap Between Knowledge and Routine Clinical Practice

20

ACC/AHA 2005 HF Guidelines: Implementation of Guidelines

• Academic detailing or educational outreach visits are useful to facilitate the implementation of practice guidelines

• Multidisciplinary disease-management programs for patients at high risk for hospital admission or clinical deterioration are recommended

• Chart audit and feedback of results can be effective to facilitate implementation of practice guidelines

• The use of reminder systems can be effective to facilitate implementation of practice guidelines

• The use of performance measures based on practice guidelines may be useful to improve quality of care


Hunt SA, et al. ACC/AHA 2005 Practice Guidelines. Available at http://www.acc.org.



21

American Heart Association’s Get With the Guidelines–Heart Failure

• The AHA’s hospital based quality-improvement program aims at ensuring that every patient with HF receives the best possible care

• Continuity of data and hospital tools with OPTIMIZE-HF

• Launched January 2005; currently over 500 US hospitals participating, over 500,000 patient HF hospitalizations

• Opportunity for hospitals to achieve national recognition through participation

• Opportunity for advanced heart failure certification via The Joint Commission

22

May 2011

69.6%

89.8%

81.3%78.1%

93.5%

85.4%82.0%

95.5%

89.1%86.5%

96.4%91.5%90.3%

98.0%92.9%93.3%

98.0%94.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Discharge Instructions Measure LV Function ACEI/ARB for LVSD at D/C

2005 2006 2007 2008 2009 2010

GWTG-HF Performance Measures

Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from 1/1/05-12/31/10

All p<0.0001

23

May 2011

77.5%

87.3%91.0% 90.0%

94.9%90.4%

97.2%92.6%

97.7%92.5%

99.3%94.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Smoking Cessation Beta Blocker for LVSD at D/C

2005 2006 2007 2008 2009 2010

GWTG-HF Performance Measures


All p<0.0001

24

May 2011

79.9%

60.1%

86.2%

71.3%

89.1%

76.4%

91.6%

81.6%

94.0%

85.9%

95.1%

89.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Composite Performance Measure 100% Compliance Measure

2005 2006 2007 2008 2009 2010


GWTG-HF Performance Measures All p<0.0001

25

GWTG-HF Participation and Quality of Care for Heart Failure

Heidenreich PA et al Am Heart J 2009;158:546-53

Measure GWTG Hospitals(n=355)

Non-GWTG Hospitals(n=3909)

P-Value

LVEF documented 92.8% 83.0% <0.0001

ACEI/ARB in LVSD 85.6% 81.4% 0.001

Discharge Instructions

67.7% 55.3% <0.001

Smoking Cessation Counseling

85.7% 81.3% 0.04

Impact of Evidence-Based HF Therapy Use at Hospital Discharge on Treatment Rates During Follow-Up

0

20

40

60

80

100 93.1

30.4

71.4

19.6

Eli

gib

le P

atie

nts

T

reat

ed a

t Fo

llo

w-

Up

(%)

-Blocker at Discharge

YES

-Blocker at Discharge

NO

ACEI/ARB at Discharge

YES

ACEI/ARB at Discharge

NO

(1,579/1,697) (94/309) (1,329/1,861) (75/382)

60- to 90-Day Postdischarge Follow-Up

OR 30.6(95% CI, 22.53-41.57)

P.0001

OR 10.22(95% CI 7.79-13.41)

P.0001

Fonarow GC et al. J Card Fail 2007;13:722-31 26

Impact of Discharge Use of Beta Blocker on Early Clinical Outcomes in Heart Failure

*Only subset of patients with 60- to 90-day follow-up are included. Patients with beta-blocker contraindications are excluded.

Sur

viva

l Pro

bab

ility

1.00

0.95

0.90

0.85

0.80

0.75

0.700 10 20 30 40 50 60 70 80 90 100 110 120 130

Patients at Risk

Beta-blocker 1,946 1,855 1,649 333 68

No Beta-blocker 362 337 304 60 7

Days After Hospital Discharge

Beta-Blocker No Beta-Blocker

P=0.0003

Fonarow et al. J Am Coll Cardiol. 2008;52:190-199.

30 day Survival P<0.01

27

2.5

4.1

0

1

2

3

4

5

6

7

8

9

10

Pat

ien

ts (

%)

In-Hospital and Follow-Up Outcomes Improve When Process of Care Tools are Used: OPTIMIZE-HF

P.001

PrCI Tool Use

No PrCI Tool Use

PrCI Tool Use

No PrCI Tool Use

P<.02

Pat

ien

ts (

%)

Process of care tool use (admission order set or discharge checklist) was reported during hospitalization in 45.3% of patients (n=22,017/48,612)

Fonarow GC, et al. Arch Intern Med. 2007;167:14931502.

In-Hospital Mortality60- to 90-Day Mortality and Rehospitalization

28


• With few exceptions, individual HF core measures were similar for Black, Hispanic, and White patients. When there were differences in core measures, they predominantly favored nonwhite subgroups

GWTG-HF Results in Equitable Care

Unadjusted

Thomas K et al. Am Heart J. 2011;161:746-54 30

GWTG-HF Resulted in Equitable Improvement by Race/Ethnicity in HF Quality

Trends in “All-or-None HF Care Measure* by Race/Ethnicity

Unadjusted Odds Ratio

Adjusted** Odds Ratio

White (Year 1 vs. Baseline) 1.60 1.55



Black (Year 1 vs. Baseline) 1.70 1.74



Hispanic (Year 1 vs. Baseline) 1.43 1.39



*”All-or-None HF Care Measure” = 100% adherence to al 4 HF care measures plus B-Blocker use in patients with LV systolic dysfunction

**Adjusted variables include age, gender, body mass index, insurance, medical history, systolic blood pressure and hospital characteristics

Thomas K et al. Am Heart J. 2011;161:746-54 31

Hospital Variation in Early Follow-up AfterHeart Failure Hospitalization

Median Follow-upVisit within7 days = 37.5%

225 Hospitals

Hernandez et al. JAMA 2010;303:1716-1722. 32

37.6

63.975.9 81.3

7.315.9

25 30.8

0102030405060708090

100

7 14 21 28

Hos

pita

l Med

ian

Follo

w-up

%

Days

Any Physician Cardiologist

Hospital Variation in Early Follow-up After HFHospitalization: Follow-up by Physician Type

Hernandez et al. JAMA 2010;303:1716-1722.

30-Day Mortality p= 0.4430-Day Readmission p <0.01

Hernandez et al. JAMA 2010;303:1716-1722.

Relationship Between Early Physician Follow-up and 30-day Outcomes for Medicare Beneficiaries

Relationship Between Early Physician Follow-up and 30-day Readmission Among Medicare Beneficiaries Hospitalized for HFEarly Follow-up Unadjusted

HR95% CI P

ValueAdjusted

HR95% CI P

Value

Quartile 1 1.0 (REF) 1.0 (REF)

Quartile 2 0.86 0.78-0.94 <.01 0.85 0.78-0.93 <01

Quartile 3 0.85 0.76-0.94 <.01 0.87 0.78-0.96 <01

Quartile 4 0.87 0.79-0.95 <.01 0.91 0.83-1.0 .05

Hernandez et al. JAMA 2010;303:1716-1722.33

Hospitals in the lowest quartile of early physician follow-up had higher rates of rehospitalization within 30-days, than those in the other 3 quartiles,

independent of other factors

Rehospitalizations in Heart Failure

34

•Over 60 heart failure tools, including: Discharge Orders/Instructions Order Sets Pathways/Algorithms Patient Education Materials Other Tools

•All posted submissions were reviewed/evaluated by AHA volunteer workgroup.

•AHA does not endorse any tools. Submissions are intended solely as examples that hospitals may want to consider using/modifying.

•Heart failure clinical tools library: heart.org/hfclinicaltools.•Stroke clinical tools library: heart.org/strokeclinicaltools. •Submit tools you would like us to consider to [email protected].

Get With The Guidelines® Heart Failure Clinical Tools Library

37

http://www.heart.org/hfclinicaltools

http://www.heart.org/strokeclinicaltools

mailto:[email protected]

AHA Interactive Workbook to help educate patientsand help them manage Heart Failure.

Created for after the patients hospital stay, the interactive workbook focuses on preventing recurring events. The workbook helps improve patient health and track recovery.

These workbook are designed to help the patient better understand their condition, how to maximize their recovery and provide the skills to the patient and their caregivers need to better manage heart failure.

Challenges to Implement a HF Performance Improvement System

• This will not work in a community practice or hospital.• The cardiologists will not agree to this.• We can not get a consensus.• The managed care organization will not pay for it.• Patients do not want to be on a lot of medications.• There is not enough time.• It will cost too much.• It may not be safe to start Beta Blocker medications in heart failure patients.• This will benefit the competition.• The administration will not pay for it.• What about the liability?• It will take too much time.• All my patients are too complex for this.• The patients should all be followed by someone else.• It is too hard to get things through the practice committee.• The physicians at my office do not like cookbook medicine.• We do not have anyone to do this.

38

Bradley. JAMA. 2001;285:2604-2611.

Key Elements to Quality Improvement:Why Do Some Programs Succeed?

• Access to current and accurate data on treatment and outcomes

• Have stated goals

• Administrative support

• Support among clinicians

• Use of care maps and pathways

• Use of data to provide feedback

39

Potential Impact of Optimal Implementation of Evidence-Based HF Therapies on Mortality

Fonarow GC, et al. Am Heart J 2011;161:1024-1030.

Guideline Recommended

Therapy

HF Patient

Population Eligible

for Treatment, n*

Current HF

Population

Eligible and

Untreated, n (%)

Potential Lives

Saved per Year

Potential Lives Saved

per Year

(Sensitivity Range*)

ACEI/ARB 2,459,644 501,767 (20.4) 6516 (3336-11,260)

Beta-blocker 2,512,560 361,809 (14.4) 12,922 (6616-22,329)

Aldosterone Antagonist 603,014 385,326 (63.9) 21,407 (10,960-36,991)

Hydralazine/Nitrate 150,754 139,749 (92.7) 6655 (3407-11,500)

CRT 326,151 199,604 (61.2) 8317 (4258-14,372)

ICD 1,725,732 852,512 (49.4) 12,179 (6236-21,045)

Total - - 67,996 (34,813-117,497)

Target: Heart Failure Honor Roll Recognition


Requirements: Documentation of all three care components for 50% or more of eligible patients with heart failure discharged to home. Hospitals must be GWTG-HF performance achievement award hospitals.

Target: Heart Failure Resources

04/18/23 ©2010, American Heart Association

• Get With The Guidelines-Heart Failure • Patient Management Tool™• Get With The Guidelines Heart Failure Tool Kit

• AHA patient education resources• Heart Failure Best Practices Center• Heart Failure Interactive Patient Education Workbook• Heart Failure guidelines, publications, and resources• Heart 360

41

For more information and to register for Target: Heart Failure, go to

www.heart.org/targethf.


Documents

A national initiative of the American Heart Association that provides healthcare professionals with content-rich resources and materials designed to help