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IHI 02-062 – QUERI Project

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IHI 02-062
Collaborative Cardiac Care Project (C3P)
Stephan D. Fihn MD MPH
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: January 2004 - December 2007

BACKGROUND/RATIONALE:
Data from VA-funded studies and the broader literature indicate that chronic stable angina (CSA) is prevalent, under recognized, under treated and associated with reduced quality of life. There are substantial opportunities for improving care of patients with this debilitating and potentially fatal problem. Because primary care providers manage most patients with CSA, efforts to improve care must necessarily involve the primary care delivery system. C3P is composed of a set of interventions employing a Collaborative Care Team model, which has been shown to be effective in managing other chronic illnesses in the primary care setting.

OBJECTIVE(S):
Objectives of the project are to: 1) ascertain whether a collaborative approach to managing CSA in primary care results in better symptom control and quality of life than routine care; 2) assess whether the practice of providers assigned to the intervention group is more consistent with national clinical practice guidelines than that of control providers; 3) assess satisfaction of both patients and providers with this approach to management; and 4) assess marginal cost-effectiveness.

METHODS:
This provider-randomized study includes General Internal Medicine Clinics in four VA Health Care Systems: Eastern Colorado, Palo Alto, Portland and Puget Sound. Patients with a diagnosis of IHD who made at least two visits in the past year were identified using Austin databases. Of these, patients assigned to a consented study provider were mailed a screening survey to identify respondents who report having angina more than two times per week on the Seattle Angina Questionnaire (SAQ). These highly symptomatic patients are the focus of the intervention and were approached for consent. At each site, a Collaborative Care Team, consisting of a cardiologist, an internist, a research assistant and nurse specialist meet weekly to develop diagnostic and treatment plans in accordance with VA Clinical Practice Guidelines and to conduct progress evaluations for intervention patients. Treatment recommendations are being made to primary care providers using CPRS notes and unsigned orders. The team facilitates access to cardiology consultation, performs standardized follow-up, provides local leadership, distributes educational materials, and conducts group sessions for patients. The primary outcome is patient-reported changes in scores on the angina frequency, physical limitation and quality of life scales of the SAQ, a reliable, valid and responsive measure, widely used in clinical trials.

FINDINGS/RESULTS:
Twenty-five thousand IHD patients were identified using Austin databases. Seventeen thousand of these are assigned to a consented, participating provider and have been screened for eligibility. To date, 280 providers and 562 patients have been enrolled. Losses have been minimal; 13 providers were withdrawn because they left the VA or moved to a non-participating clinic, and one provider was withdrawn because she joined the Collaborative Care Team. Of the 562 patients consented, 501 remain active. Losses include 19 deaths (not study related), 15 patients who moved or could not be contacted, one patient with an adverse event , one patient who had a conflict with another study, and 11 patients who withdrew from the study. Fifty-seven control and 51 treatment providers currently have two or more active, consented patients; power calculations for this provider randomized trial are based on 46 treatment and 46 control providers with two or more patients each. Five hundred and eight Collaborative Cardiac Care Team reviews have been conducted, and 415 treatment recommendations have been made. Of 314 recommendations entered into CPRS as unsigned orders/notes, providers have accepted and implemented 85%. Patient compliance with orders (medications, tests, etc.) has also been high (92%). The method of entering recommendations as unsigned orders and consults in CPRS to be reviewed and signed by the patient's primary care provider has been very well received by clinicians, and it is hoped that conveying recommendations using this "actionable" method will have an impact.

IMPACT:
This proposed project is closely integrated with activities of the IHD-QuERI and directly addresses one of the three main strategic goals of the IHD-QuERI: improved recognition and treatment of angina in patients with IHD. If this intervention is found to be effective, there is the potential to dramatically improve the care of VA outpatients with IHD, and the results would be generalizable to the management of other serious chronic medical conditions.

PUBLICATIONS:

Journal Articles

  1. Wang L, Porter B, Maynard C, Bryson C, Sun H, Lowy E, McDonell M, Frisbee K, Nielson C, Fihn SD. Predicting risk of hospitalization or death among patients with heart failure in the veterans health administration. The American journal of cardiology. 2012 Nov 1; 110(9):1342-9.
  2. Fihn SD, Bucher JB, McDonell M, Diehr P, Rumsfeld JS, Doak M, Dougherty C, Gerrity M, Heidenreich P, Larsen G, Lee PI, Lucas L, McBryde C, Nelson K, Plomondon ME, Stadius M, Bryson C. Collaborative care intervention for stable ischemic heart disease. Archives of internal medicine. 2011 Sep 12; 171(16):1471-9.
  3. Fan VS, Bridevaux PO, McDonell MB, Fihn SD, Besser LM, Au DH. Regional variation in health status among chronic obstructive pulmonary disease patients. Respiration; International Review of Thoracic Diseases. 2011 Jan 1; 81(1):9-17.
Conference Presentations

  1. Trivedi RB, Gerrity M, Doak M, Lucas L, Spertus J, Rumsfeld J, Sun H, McDonell M, Fihn SD. Depressive symptoms and angina burden in ischemic heart disease (IHD) patients: The Collaborative Cardiac Care Project. Presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2012 Apr 14; New Orleans, LA.
  2. Liu C, Chapko MK, Burgess J, Bryson CL, Perkins M, Fortney J, Manning W, Sharp ND. Use of Outpatient Care in VA and Medicare among CBOC and VAMC Patients. Presented at: International Health Economics Association Biennial World Congress on Health Economics; 2009 Jul 14; Beijing, China.
  3. Fan VS, Udris EM, Au DH. Factors Associated with Efficacy in COPD. Poster session presented at: American Thoracic Society Annual International Conference; 2009 May 17; San Diego, CA.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Ischemic Heart Disease, Primary care, Quality assessment
MeSH Terms: Quality

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