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RRP 07-299 – QUERI Project

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RRP 07-299
QI in Heart Failure for VA Cleveland Facilities: An Implementation Plan
Ileana L. Piña MD
Louis Stokes VA Medical Center, Cleveland, OH
Cleveland, OH
Funding Period: April 2008 - September 2008

BACKGROUND/RATIONALE:
The prevalence of heart failure (HF) continues to increase. Although advances have been made in medical therapy, there exists a gap between evidenced based care and actual practice. Hospitalizations have increased to over 600,000/year. HF constitutes the # 1 discharge diagnosis in the US for Medicare accounting for >700,000 admissions/year. Parallel to this increase in hospitalizations over the past 10 yrs, there has been a wealth of new information about pharmacologic therapy that decreases hospitalizations and improves survival. While the beneficial effects of ACE inhibitors (ACEI) and beta blockers(BB) have been known for over a decade, studies suggest that they still are underutilized and underdosed.

OBJECTIVE(S):
The purpose of the study was to determine if a program combining 2 modalities of education, i.e., didactic + preceptorship, could change provider behavior as measured by process indicators of evidenced based medical therapy for HF. The aims of the project were to: 1) Determine if a HF educational program which combines 2 strategies of education via the National Heart Failure Training Program (NHeFT) could change provider behavior as measured by changes in process measures with increases in ACEI or ARB and a concomitant decrease in diuretic comparing pre-training to post training doses in the same HF patients (pts) seen in the PCP Clinics at the Cleveland VA, Brecksville and McCafferty facilities. 2)To determine if the training program increased evidenced -based HF therapy de novo HF pts identified after training.

METHODS:
The project was a randomized, controlled, unblinded study of training with the NHeFT program vs. the dissemination alone of Guidelines /Performance Measures for HF. Brecksville providers underwent the reverse preceptorship and Firm Clinic A and 1 provider of McCafferty were trained by direct preceptorship at the Cleveland VA HF clinic. Controls were given Guidelines and Performance Measures for HF. Education stressed the importance of Evidence Based care for HF and concentrated on increase in ACEI/AII receptor blockers(ARB) and diuretic decrease. CPRS records were de-identified and reviewed by echocardiography to establish ventricular function. Pts with ejection fractions <40% were selected. Tests comparing proportion or associations across independent groups were performed, (significance level of p<0.05).

FINDINGS/RESULTS:
Training had a significant effect on patients being placed on ACEI/ARB or BB de novo, p=0.0002. In addition, training had a significant effect on patients meeting the endpoint of "optimal" treatment, p=0.0089. An increase in ACE/ARB adjusted for provider training was strongly associated with a decrease in loop diuretic (p=0.0003). Therefore, training with a didactic + preceptorship modality significantly changed provider behavior in this pilot study of a VA PCP setting.

IMPACT:
If an educational program that targets improvement in evidenced-based care can change behavior, then potentially outcomes related to HF, e.g., repeat hospitalizations, should also be improved. Dissemination of this program could ultimately improve resource utilization and decrease costs due to hospitalizations.

PUBLICATIONS:
None at this time.


DRA: none
DRE: none
Keywords: Cardiovasc’r disease, Implementation
MeSH Terms: none