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RRP 09-170 – HSR&D Study

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RRP 09-170
Developing a Hub and Satellite Heart Failure Providers Network
Henry H Ooi MD
Tennessee Valley Healthcare System Nashville Campus, Nashville, TN
Nashville, TN
Funding Period: March 2010 - June 2011

BACKGROUND/RATIONALE:
Congestive heart failure (HF) is a major public health problem. There is a pressing need to improve treatment of HF, but lifesaving therapies remain underused in clinical practice. We proposed a novel, potentially cost-effective model of community-based, multidisciplinary, collaborative HF care - the "Hub and Satellite" Heart Failure Providers Network. Primary care providers trained in HF management would provide improved care to their clinic patients with HF in "satellite" clinics, supported by the Regional HF Center "hub".

OBJECTIVE(S):
1)To establish and demonstrate the feasibility of the "Hub and Satellite" Heart Failure Providers Network

2)To obtain data examining clinical effectiveness and barriers

METHODS:
Volunteer community-based primary care providers underwent 3 days of HF management training at the regional HF center (Nashville), consisting of 21 hours of lectures, briefings, teaching sessions and case presentations. Multiple choice testing and a survey interview were completed at the beginning and end of training. Exclusive access was given to the services of a clinical pharmacist to titrate HF medications to clinical guideline-recommended doses.
Providers received updates on advances in HF management. A confidential feedback report on their performance was given to HF providers. Formative evaluation was performed through pre-educational and 4 subsequent telephone interviews with HF providers.
DSS data was used to identify patients with systolic HF (ejection fraction<40%) cared for by the HF providers; systolic HF patients in the same clinics cared for by non-HF trained providers were randomly selected as controls. Data on the care received over the one year period of follow-up was collected from DSS data and the computerized patient record system (CPRS).

FINDINGS/RESULTS:
8 volunteer providers (6 MDs, 2 nurse practitioners) attended training as HF providers. The 2 nurse practitioners were excluded from the study as they did not have their own patient panels. The mean knowledge test score was 21.1/35 at the beginning of the training and increased to 25.2/35 at the conclusion of training.
129 patients with systolic HF were identified in each group. There was no significant difference in baseline demographics between the two groups. Median ejection fraction was 30% in each group. There was a median of 2 Primary Care clinic visits in each group (IQR 1-3 and 1-2 in the HF providers and Control groups respectively). 17% and 14% of patients were not seen in clinic during the follow-up period. 84% and 90% of patients were also followed in Cardiology Clinics. 9 performance measures were studied:
% patients with weight checked
% patients with assessment of activity level
% patients with assessment of clinical signs of volume overload
% patients prescribed ACEI or ARB therapy
% target dose achieved
% patients prescribed beta-blocker therapy
% patients receiving evidence-based beta-blockers
% target dose achieved
% patients with atrial fibrillation prescribed coumadin

No statistically significant improvement in any of the measures was observed in the HF providers group during follow-up when compared with the control group. Of note, 5 of the 9 measures had compliance rates of greater than 79% at baseline, making an improvement in performance difficult to demonstrate. 30 patients (23%) in the HF providers group were referred to the clinical pharmacist for medication titration.
Formative evaluation provided the following findings:
-Satisfaction with the program and belief in its impact on care was immediate, very high (generally 8 or above on a 10 point scale where 10 is highly satisfied) and, in the opinion of the senior formative evaluator, unusually sustained for an educational intervention after a year.
-Satisfaction was linked to the excellence of teaching, program timing (dedicated time outside clinic hours), emphasis on skill development in clinical management (particularly physical examination), improved patient communication, improved provider comfort and efficiency in dealing with HF patients, error prevention and access to experts.
-Barriers to overall outcomes improvement: providers indicated that the time to manage complex patients with multiple drugs and chronic illnesses including HF was still insufficient though training had made them more efficient. No barriers of the program itself were identified.
-Utilization of the rapid access expert consultation system was low; some participants noted that their patients were already "plugged in" so they did not want or need consultation with the specialist.

IMPACT:
This project potentially provides a novel, simple and collaborative model at a grassroots level to improve care for patients with HF, a major national health problem. The feasibility of establishing a "Hub and Satellite" HF Providers network was demonstrated in the work performed. However, despite very high and unusually sustained provider satisfaction with the program including increased confidence in their ability to manage patients with HF, no significant improvements in performance measures was achieved. This could be related to one or more factors:
-A ceiling effect with high baseline performance scores, making it difficult to achieve further improvements
-High percentage of patients being concurrently followed in Cardiology clinics, reducing opportunities and motivation to make positive changes
-Limited number of opportunities to make a positive change, with a median of only 2 visits per patient during the follow-up period; 17% and 14% of the HF providers' and control patients were not seen at all during the one year of follow-up
-Providers' perception of lack of time during a standard clinic visit to adequately deal with multiple co-morbidities including HF

The data from this pilot project does not at this time support wider scale implementation of this novel concept of HF care despite high levels of provider satisfaction with the training and increased confidence in their ability to manage HF. However, due to the limitations described and the short duration of follow-up, a positive impact of the program may still be demonstrable in a different region and with longer follow-up duration.

PUBLICATIONS:
None at this time.


DRA: Health Systems, Cardiovascular Disease
DRE: Treatment - Comparative Effectiveness
Keywords: Cardiovasc’r disease, Care Management, Practice patterns
MeSH Terms: none

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