A main goal of our Chronic Heart Failure Quality Enhancement Research Initiative (CHF-QUERI) is to increase use of care known to prolong survival while maintaining or improving quality of life. Studies have indicated that these treatments are not used as frequently as they should be both within and outside the VA system. The reasons for non-optimal use are not clear but may be due to organizational and provider factors. VA centers likely vary in their use of disease management, cardiology heart failure clinics, and use of clinical reminder systems among other structural characteristics.
The immediate objectives are to determine the variation in organizational characteristics for VA cardiology sections that treat heart failure patients. We also plan to determine if this variation explains variation in guideline compliant care for heart failure.
We surveyed the Chiefs of the Cardiology (or Medical Service if no Cardiology) at 146 VA centers. Each VA was asked if they used 1) a HF clinic, 2) home monitoring, 3) reminders for angiotensin converting enzyme inhibitors (ACEi), and 4) reminders for beta-blockers (BB). To determine the association with quality we linked data from the survey to chart review data from the External Peer Review Program (EPRP) from 2003 to 2005 for use of ACEi, use of BB, contraindications to ACEi or BB (defined as any provider documentation), and left ventricular ejection fraction (<40% yes/no). Candidates for ACEi or BB were HF patients with an EF < 40% with no contraindication.
There were 104 responses to the center survey (71%). An HF clinic was used by 48%, home monitoring by 65%, reminders for ACEi by 65% and reminders for BB use by 58%. ACEi use was 88% (1867/2121) for centers with a HF clinic compared to 89% (1250/1402) for those without (p=0.3). Overall BB use was not associated with having a HF clinic [86% (1753/2047) clinic vs. 84% (1166/1389) no clinic, p=0.17], however a HF clinic was associated with use of recommended BBs (59% vs. 51%, P<0.0001). ACEi reminders were not associated with more ACEi use (88% clinic vs. 89% no clinic) but BB reminders had a borderline association with use (86% clinic vs. 84 no clinic p=0.05). There was no association between home monitoring and ACEi or BB use (all p>0.2).
Additional studies are needed to confirm that heart failure programs improve the quality and outcome of heart failure care.
- Sahay A, Massie B, Heidenreich PA. Heart Failure Program and Barriers for Improving Quality of Care. [Abstract]. Journal of cardiac failure. 2007 Aug 1; 13(6):S163-S163.
- Sahay A, Heidenreich PA. Heart Failure Program and Barriers for Improving Quality of Care. Presented at: Heart Failure Society of America Annual Scientific Meeting; 2007 Sep 16; Washington, DC.