RRP 08-243 – QUERI Project
Career Development Projects
Optimization of CHF Management in VA: Improve post discharge care plan
Prakash C. Deedwania MD
VA Central California Health Care System, Fresno, CA
February 2009 -
Several studies have shown that adherence to recommended self care improve quality and longevity of CHF patients. Heart Failure Registries (HFR), a database of patients with CHF can facilitate population based care management. In this study we developed a registry of CHF patients by utilizing EMR based clinical reminder tool to improve data accuracy and target patient education on self care.
Develop a Heart Failure Registry (HFR) to optimize CHF care management. Use clinical reminder tool to facilitate data enrichment. Evaluate self care knowledge gaps and promote targeted corrective education at point of care.
HFR is initiated by ICD-9 encounter data in Electronic Medical Record (EMR). EMR based clinical reminders made applicable to patient in the HFR. Two independent reminders (provider/nursing) were initiated. Use of these reminders were encouraged but not mandated. Provider reminder also served as a cleaning tool of the HFR as it allowed providers to mark patients who do not have CHF (coding error). Those patients were then excluded from the HFR and study cohort. Continuing reminder components collect and store data including medication use, NYHA class and LVEF from provider input and facilitated the access of quick orders for CHF related care. Data extracted periodically to update the HFR. Nursing reminder facilitated quick identification of patient's self care knowledge gaps by a series of short questions, and prompt needed education. Reminders were able to store data on self care knowledge assessments and provider inputs within the patient's own EMR as "health factors" that facilitated subsequent data extractions. In this study we report analysis of data from our HFR. Our study cohort comprised of patients whose diagnosis of CHF is confirmed by the primary provider (n=305).
Number of patients in HFR who had a clinic visit during 12 month study was 1577 and 629 (40%) had nursing and 679 (43%) had provider reminder completed. Providers have identified 374 patients in HFR as no CHF diagnosis and subsequently removed from the HFR and final study cohort. This may indicate a significant error rate in ICD-9 encounter data used to build our HFR. At the end of 12 months, 305 patients in HFR had CHF confirmed by the primary provider and 227 patients from this group also had nursing reminder completed. Beta blocker and ACE-I/ARB use were 80.3% and 84.3% respectively. Significant self-care knowledge gaps identified. Only 34.8% monitored daily weight and 16.3% never weighed them at home, 13.7% did not know they have CHF, 35% did not know the use of diuretics in symptom control. 15% who did not have a scale at home were provided a scale during visit. Appropriate education provided accordingly. All cause admission and ER visit rates were 30.2% and 53.1% respectively confirming the high rate of morbidity in this population.
Use of clinical reminders to enrich HFR and to facilitate targeted patient education is a valuable approach to population management of CHF. Such tools can have the ability to impact quality and/or outcomes in VA healthcare facilities.
None at this time.