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RRP 08-236 – QUERI Project

RRP 08-236
Disparities in VA Heart Failure Care
Paul A. Heidenreich, MD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: January 2009 - September 2009
High quality care comprises both a high average level of quality across the health care system and a minimum level of quality that no patient group drops below. While the VA's performance on the Mission Critical heart failure measures is high, it is unclear if certain racial or other groups are all receiving high levels of care.

1)To determine race-specific performance gaps for VA heart failure care for the following mission critical and emerging quality indicators:
a.Mission critical VA measures (Joint Commission measures)
b.Hydralazine/nitrate use (specifically recommended for blacks with heart failure by the Food and Drug Administration)
c.Beta-blocker use
d.Early follow-up following discharge from a heart failure hospitalization
e.Composite quality measure derived from existing mission critical measure and emerging measures
2)To determine disparities in quality of care based on the presence or absence of mental illness including alcohol dependence.
3)To determine disparities in quality of care based on facility location: urban vs. rural
4)To determine if the above disparities are associated with differences in hospitalization for heart failure or mortality
5)To determine if the presence of certain characteristics of heart failure programs are associated with smaller or greater disparities.

We have already obtained data on heart failure quality measures from the External Peer Review Program (EPRP), pharmacy data from the Decision Support System and early follow-up data from outpatient and inpatient administrative datasets (Austin Automation Center). The EPRP program identifies patients with heart failure through chart confirmation of those with ICD9 diagnoses of heart failure. The external peer review program has data on use of Mission critical performance measures that are based on inpatient care: documentation of left ventricular ejection fraction (LVEF), use of angiotensin converting enzyme (ACE) inhibitors if the LVEF is < 40%, discharge instructions, smoking cessation counseling. In addition, EPRP data also includes information on other quality indicators based on VA -DOD guidelines for the management of heart failure. These include outpatient quality indicators for treatments known to prolong survival: beta-blockers if the LVEF is < 40% and aldosterone antagonists if the LVEF is <40% and the patient is highly symptomatic. Use of hydralazine/nitrate combination will be obtained from pharmacy data of DSS and will be linked to EPRP. Early follow-up following hospital discharge will be determined by identifying admissions with a principal discharge diagnosis of heart failure, and linking to outpatient encounter data.

We found many differences in treatment and outcome in sub-groups of patients based on age, gender, race and history of psychosis. These patient groups differed in many clinical characteristics. In general the very elderly and women were less likely to receive guideline recommended care. Racial differences in quality of care were minimal and outcome differences were divergent (e.g. better mortality but more rehospitalizations for black veterans). Those with psychosis had small differences in quality of care, but less readmission and higher mortality. This work suggests several areas for improving care including a focus on follow-up of veterans with psychosis, and a better understanding of the reasons for repeat admission among black veterans. The interventions designed to improve patient self-care may need to be different for different groups. Finally, long-term outcomes should be examined to determine if any of the differences in process of care measures have a delayed impact.

This project identified gaps in VA heart failure care for specific groups of veterans. Additional work of CHF QUERI can be aimed at these groups to improve their heart failure care.

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