Transcript ACEI/ARB - American Stroke Association

Target: Heart Failure
A national initiative of the American Heart Association that
provides healthcare professionals with content-rich
resources and materials designed to help advance heart
failure awareness, prevention, and treatment.
Building on Success
• GWTG-Heart Failure
• Mission: Lifeline
• OPTIMIZE-HF
• Joint Commission/AHA Heart Failure Advanced Certification Program
• The Guideline Advantage
3/29/2016
©2010, American Heart Association
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The Need
5.7 million Americans are currently living with heart
failure, and 670,000 new cases are diagnosed each yearup significantly from 500,000 cases annually just a few
years ago.
As our population ages, this epidemic of heart failure will
only continue to grow. The cost of providing heart failure
ranks among the leading U.S. healthcare expenditures.
Additionally, the toll of heart failure on life, both in quality
and longevity, is sobering.
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©2010, American Heart Association
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What is Target: Heart Failure ?
A national initiative of the American Heart Association that
provides healthcare professionals with content-rich
resources and materials designed to help advance heart
failure awareness, prevention, and treatment.
3/29/2016
©2010, American Heart Association
4
Target: Heart Failure Vision:
To improve quality, care transitions, and outcomes for patients
with heart failure with a targeted initiative and leveraging the
American Heart Association’s premier quality improvement
suite of resources including Get With The Guidelines-Heart
Failure.
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©2010, American Heart Association
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Target: Heart Failure Mission:
Increase 3 key patient-centered care domains with very well
established or emerging evidence-base:
• Medication optimization
• Early follow-up and care coordination
• Enhanced patient education
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©2010, American Heart Association
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Target: HF Optimal Care Transitions and
Patient Education:
• Discharge use of ACEI/ARB, evidence-based beta blocker, and
aldosterone antagonist in all eligible heart failure patients with
reduced LVEF, in absence of documented contraindications,
intolerance, or patient/system reasons
• Early post-discharge follow-up with visit or contact within 48
hours of discharge scheduled
• Enhanced patient education as evidenced by referral to heart
failure disease management program, provision of at least 60
minutes of heart failure education by a qualified heart failure
educator, or provision of AHA heart failure interactive workbook
3/29/2016
©2010, American Heart Association
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Building on Success
• GWTG-Heart Failure
• Mission: Lifeline
• Joint Commission/AHA Heart Failure Advanced Certification
• OPTIMIZE-HF
• The Guideline Advantage
3/29/2016
©2010, American Heart Association
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Background on Heart Failure
Population
Group
Total
population
Prevalence
Incidence
Mortality
Hospital
Discharges
5,700,000
670,000
277,193
990,000
Cost
$39.2
billion
• Heart failure (HF) is a major public health problem resulting in
substantial morbidity and mortality
• Despite recent advances a substantial number of patients are not
receiving optimal care
2Jones
DL et al. Heart Disease and Stroke Statistics 2011 Update. Report from the
AHA . Circulation.2011.
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Heart Failure Hospitalizations
1.0 Million Hospitalizations a Year and Rising
Discharges in Thousands
700
600
30-Day
Rehospitalization
Rates in HF
500
400
300
200
24.8%
(Medicare)
100
0
79
80
85
90
95
00
06
Years
Male
Female
The majority of patients hospitalized with HF were
previously hospitalized with HF
United States: 1979-2006 Source: NHDS/NCHS , NHLBI. Hospital Compare 2007-2010
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30-Day Rehospitalization Rates in HF Vary
Widely Between Hospitals
X axis, hospital
decile, 0-9
Y axis, mean
hospital observed
rates for 30-day
rehospitalization
from 0 to .40
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Keenan PS et al. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.
All-Cause Mortality After Each Subsequent
Hospitalization for HF
1.0
HF
1st admission (n = 14,374)
2nd admission (n = 3,358)
3rd admission (n = 1,123)
4th admission (n = 417)
Cumulative mortality
0.8
P<0.0001
0.6
0.4
0.2
1st hospitalization: 30-day mortality = 12%; 1-year mortality = 34%
0.0
0.0
0.5
1.0
Time since admission
Setoguchi S, et al. Am Heart J. 2007;154:260-266.
1.5
2.0
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Estimated Direct and Indirect Costs of HF in US
Total Cost
$39.2 billion
Hospitalization
$20.9
53.3%
11.9%
6.4%
10.5%
Lost Productivity/
Mortality*
$4.1
Nursing Home
$4.7
9.7%
Home Healthcare
$3.8
Physicians/Other
Professionals
$2.5
Drugs/Other
Medical Durables
$3.2
8.2%
Heart Disease and Stroke Statistics—2010 Update: A Report From the American Heart Association
Circulation, Feb 2010; 121: e46 - e215.
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Causes of Hospital Readmission for Heart Failure
Over 2/3 of HF Hospitalizations Preventable
Rx Noncompliance
24%
Diet Noncompliance
24%
16%
Inappropriate Rx
17%
Other
19%
Failure to Seek
Care
Annals of Internal Medicine 122:415-21, 1995
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Measuring and Improving the Quality of HF Care
• Heart failure remains a major public health problem
resulting in substantial morbidity and mortality.
• A number of evidence-based, guideline-recommended
therapies are available to treat patients with heart failure.
• However, study after study shows the large gaps,
variations, and disparities in the use of these evidence
based therapies in eligible patients.
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ADHERE Quality of Care
Conformity to The Joint Commission HF Performance Indicators
Lagging Centers
Leading Centers
97%
100%
88%
80%
% Utilization
70%
85%
All P<0.0001
72%
58%
60%
40%
20%
8%
1%
0%
Discharge
HF-1
Instructions
LV Function
HF-2
Measurement
ACEIHF-3
use
81 142 admissions between 6/2002 – 12/2003 at 223 hospitals
Grouped by Leading (90th percentile) and Lagging (10th percentile)
Fonarow GC et al. Arch Intern Med 2005;165:1469-1477
Smoking
HF-4
Cessation
Length of Stay
(median)
Mortality
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Risk-Treatment Mismatch in HF: Canadian EFFECT Study
Patients, %
At Hospital Discharge
90
80
70
60
50
40
30
20
10
0
ACEI
ACEI or
ARB
90-Day Follow-Up
Blocker
Low Risk
ACEI
ACEI or
ARB
Average Risk
Blocker
1-Year Follow-Up
1-Year
Mortality Rate
High Risk
Use rates in absence of contraindications. For all drug classes, P < .001 for trend.
EFFECT, Enhanced Feedback for Effective Cardiac Treatment. Lee D. JAMA. 2005;294:1240-1247.
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Evidence-Based Treatment for Heart Failure with Reduced
LVEF
Reduce Mortality
ACEI
or ARB
ICD*
-Blocker
CRT 
an ICD*
Control Volume
Aldosterone
Antagonist
Treat Residual Symptoms
Hyd/ISDN*
Enhance Adherence
Education
Disease Management
Performance Improvement Systems
*For select indicated patients.
Sodium Restriction*
Diuretics*
Digoxin*
Treat Comorbidities
Aspirin*
Warfarin*
Statin*
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Established Benefits of Guideline-Recommended
HF Therapies
Guideline
Relative Risk
Number Needed to
NNT for Mortality
Relative Risk
Recommended
Reduction in
Treat for Mortality
(standardized to 36
Reduction in HF
months)
Hospitalizations
Therapy
Mortality
ACEI/ARB
17%
22 over 42 months
26
31%
Beta-blocker
34%
28 over 12 months
9
41%
Aldosterone
Antagonist
30%
9 over 24 months
6
35%
Hydralazine/Nitrate
43%
25 over 10 months
7
33%
CRT
36%
12 over 24 months
8
52%
ICD
23%
14 over 60 months
23
NA
Fonarow GC, et al. Am Heart J 2011;161:1024-1030.
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Improved Adherence to ACC/AHA HF Guidelines
Translates to Improved Clinical Outcomes in Real
World HF Patients
• Each 10% improvement in ACC/AHA guidelinerecommended composite care was associated
with a 13% lower odds of 24-month mortality
(adjusted OR 0.87; 95% CI, 0.84 to 0.90;
P<0.0001).
Fonarow GC, et al. Circulation. 2011;123:1601-1610.
Bridging the Gap Between Knowledge and Routine
Clinical Practice
ACC/AHA/HFSA
Guidelines
Systems
Clinical
Practice
I IIa IIb III
• Clinical trial evidence
• National guidelines
• Implement evidence-based
care
• Improve communications
• Ensure compliance
Adapted from the American Heart Association. Get With The Guidelines; 2001.
• Improve quality of care
• Improve outcomes
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ACC/AHA 2005 HF Guidelines: Implementation of
Guidelines
I IIa IIb III
• Academic detailing or educational outreach visits are useful
to facilitate the implementation of practice guidelines
• Multidisciplinary disease-management programs for patients
at high risk for hospital admission or clinical deterioration are
recommended
I IIa IIb III
• Chart audit and feedback of results can be effective to
facilitate implementation of practice guidelines
I IIa IIb III
• The use of reminder systems can be effective to facilitate
implementation of practice guidelines
• The use of performance measures based on practice
guidelines may be useful to improve quality of care
Hunt SA, et al. ACC/AHA 2005 Practice Guidelines. Available at http://www.acc.org.
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American Heart Association’s Get With the
Guidelines–Heart Failure
• The AHA’s hospital based quality-improvement program
aims at ensuring that every patient with HF receives the
best possible care
• Continuity of data and hospital tools with OPTIMIZE-HF
• Launched January 2005; currently over 500 US hospitals
participating, over 500,000 patient HF hospitalizations
• Opportunity for hospitals to achieve national recognition
through participation
• Opportunity for advanced heart failure certification via
The Joint Commission
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GWTG-HF Performance Measures
100.0%
90.3%
90.0%
93.5%
93.3%
95.5% 96.4%
98.0% 98.0%
89.8%
86.5%
89.1%
70.0%
91.5% 92.9%
94.2%
85.4%
82.0%
81.3%
78.1%
80.0%
All p<0.0001
69.6%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Discharge Instructions
Measure LV Function
2005
2006
2007
2008
2009
ACEI/ARB for LVSD at D/C
2010
Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from
1/1/05-12/31/10
May 2011
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GWTG-HF Performance Measures
100.0%
94.9%
97.2%
97.7%
99.3%
91.0%
87.3%
90.0%
80.0%
All p<0.0001
90.0%
90.4%
92.6%
92.5%
94.8%
77.5%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Smoking Cessation
Beta Blocker for LVSD at D/C
2005
2006
2007
2008
2009
2010
Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from
1/1/05-12/31/10
May 2011
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GWTG-HF Performance Measures
100.0%
90.0%
80.0%
86.2%
89.1%
91.6%
94.0%
All p<0.0001
95.1%
89.4%
85.9%
81.6%
79.9%
76.4%
71.3%
70.0%
60.1%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Composite Performance Measure
2005
100% Compliance Measure
2006
2007
2008
2009
2010
Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from
1/1/05-12/31/10
May 2011
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GWTG-HF Participation and Quality of Care for
Heart Failure
Measure
GWTG
Hospitals
(n=355)
Non-GWTG
Hospitals
(n=3909)
P-Value
LVEF documented
92.8%
83.0%
<0.0001
ACEI/ARB in LVSD
85.6%
81.4%
0.001
Discharge
Instructions
67.7%
55.3%
<0.001
Smoking Cessation
Counseling
85.7%
81.3%
0.04
Heidenreich PA et al Am Heart J 2009;158:546-53
Impact of Evidence-Based HF Therapy Use at Hospital
Discharge on Treatment Rates During Follow-Up
Eligible Patients
Treated at FollowUp (%)
60- to 90-Day Postdischarge Follow-Up
100
OR 30.6
(95% CI, 22.53-41.57)
93.1
P.0001
80
OR 10.22
(95% CI 7.79-13.41)
P.0001
71.4
60
40
30.4
19.6
20
0
-Blocker at
Discharge
YES
(1,579/1,697)
-Blocker at
Discharge
NO
ACEI/ARB at
Discharge
YES
ACEI/ARB at
Discharge
NO
(94/309)
(1,329/1,861)
(75/382)
Fonarow GC et al. J Card Fail 2007;13:722-31
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Impact of Discharge Use of Beta Blocker on Early Clinical Outcomes in
Heart Failure
30 day Survival
P<0.01
Survival Probability
1.00
P=0.0003
0.95
0.90
0.85
0.80
0.75
Beta-Blocker
No Beta-Blocker
0.70
0
10
20
30
40
50
60
70
80
90
100 110 120 130
Days After Hospital Discharge
Patients at Risk
Beta-blocker
No Beta-blocker
1,946
1,855
1,649
333
68
362
337
304
60
7
*Only subset of patients with 60- to 90-day follow-up are included. Patients with beta-blocker contraindications are excluded.
Fonarow et al. J Am Coll Cardiol. 2008;52:190-199.
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In-Hospital and Follow-Up Outcomes Improve When
Process of Care Tools are Used: OPTIMIZE-HF
10
9
50
In-Hospital Mortality
40
7
6
P.001
5
4.1
4
3
Patients (%)
Patients (%)
8
60- to 90-Day Mortality and
Rehospitalization
P<.02
38.2
34.8
30
20
2.5
2
10
1
0
0
PrCI
Tool Use
No PrCI
Tool Use
PrCI
Tool Use
No PrCI
Tool Use
Process of care tool use (admission order set or discharge checklist) was reported during
hospitalization in 45.3% of patients (n=22,017/48,612)
Fonarow GC, et al. Arch Intern Med. 2007;167:14931502.
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©2010, American Heart Association
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GWTG-HF Results in Equitable Care
• With few exceptions, individual HF core measures were similar for Black,
Hispanic, and White patients. When there were differences in core measures,
they predominantly favored nonwhite subgroups
Unadjusted
Thomas K et al. Am Heart J. 2011;161:746-54
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GWTG-HF Resulted in Equitable Improvement by Race/
Ethnicity in HF Quality
Trends in “All-or-None HF Care Measure* by
Race/Ethnicity
Unadjusted
Odds Ratio
Adjusted**
Odds Ratio
White (Year 1 vs. Baseline)
1.60
1.55
White (Year 2 vs. Baseline)
2.34
2.29
White (Year 3 vs. Baseline)
3.07
3.04
Black (Year 1 vs. Baseline)
1.70
1.74
Black (Year 2 vs. Baseline)
2.32
2.40
Black (Year 3 vs. Baseline)
3.18
3.28
Hispanic (Year 1 vs. Baseline)
1.43
1.39
Hispanic (Year 2 vs. Baseline)
2.00
2.00
Hispanic (Year 3 vs. Baseline)
2.48
2.46
*”All-or-None HF Care Measure” = 100% adherence to al 4 HF care measures plus B-Blocker use in patients with LV systolic dysfunction
**Adjusted variables include age, gender, body mass index, insurance, medical history, systolic blood pressure and hospital characteristics
Thomas K et al. Am Heart J. 2011;161:746-54
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Hospital Variation in Early Follow-up After
Heart Failure Hospitalization
Median
Follow-up
Visit within
7 days =
37.5%
225 Hospitals
Hernandez et al. JAMA 2010;303:1716-1722.
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Hospital Median Follow-up %
Hospital Variation in Early Follow-up After HF
Hospitalization: Follow-up by Physician Type
Any Physician
100
90
80
70
60
50
40
30
20
10
0
Cardiologist
81.3
75.9
63.9
37.6
7.3
7
15.9
14
21
Days
Hernandez et al. JAMA 2010;303:1716-1722.
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30.8
28
Relationship Between Early Physician Follow-up
and 30-day Outcomes for Medicare Beneficiaries
30-Day Mortality p= 0.44
30-Day Readmission p <0.01
Hernandez et al. JAMA 2010;303:1716-1722.
Relationship Between Early Physician Follow-up
and 30-day Readmission Among Medicare
Beneficiaries Hospitalized for HF
Early Follow-up
Unadjusted
HR
95% CI
P
Value
Quartile 1
1.0 (REF)
Quartile 2
0.86
0.78-0.94
<.01
Quartile 3
0.85
0.76-0.94
Quartile 4
0.87
0.79-0.95
Adjusted
HR
95% CI
P
Value
0.85
0.78-0.93
<01
<.01
0.87
0.78-0.96
<01
<.01
0.91
0.83-1.0
.05
1.0 (REF)
Hospitals in the lowest quartile of early physician follow-up had higher
rates of rehospitalization within 30-days, than those in the other 3 quartiles,
independent of other factors
Hernandez et al. JAMA 2010;303:1716-1722.
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Rehospitalizations in Heart Failure
•
Nearly one in four patients hospitalized with HF is rehospitalized
within 30 days of discharge
Opportunity to Improve
•
30-day rates of rehospitalizations in HF have risen over the past 2
decades and vary widely by hospital, even after adjusting for case
mix and other factors
Opportunity to Improve
•
Many HF hospitalizations are preventable, but effective strategies
to prevent rehospitalizations are underutilized
Opportunity to Improve
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Get With The Guidelines® Heart Failure Clinical Tools Library
•Over 60 heart failure tools, including:
Discharge Orders/Instructions
Order Sets
Pathways/Algorithms
Patient Education Materials
Other Tools
•All posted submissions were reviewed/evaluated by AHA volunteer workgroup.
•AHA does not endorse any tools. Submissions are intended solely as examples that
hospitals may want to consider using/modifying.
•Heart failure clinical tools library: heart.org/hfclinicaltools.
•Stroke clinical tools library: heart.org/strokeclinicaltools.
•Submit tools you would like us to consider to [email protected].
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AHA Interactive Workbook to help educate patients
and help them manage Heart Failure.
Created for after the patients hospital stay,
the interactive workbook focuses on
preventing recurring events. The
workbook helps improve patient health and
track recovery.
These workbook are designed to help the
patient better understand their condition,
how to maximize their recovery and
provide the skills to the patient and their
caregivers need to better manage heart
failure.
Challenges to Implement a HF Performance
Improvement System
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
This will not work in a community practice or hospital.
The cardiologists will not agree to this.
We can not get a consensus.
The managed care organization will not pay for it.
Patients do not want to be on a lot of medications.
There is not enough time.
It will cost too much.
It may not be safe to start Beta Blocker medications in heart failure patients.
This will benefit the competition.
The administration will not pay for it.
What about the liability?
It will take too much time.
All my patients are too complex for this.
The patients should all be followed by someone else.
It is too hard to get things through the practice committee.
The physicians at my office do not like cookbook medicine.
We do not have anyone to do this.
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Key Elements to Quality Improvement:
Why Do Some Programs Succeed?
• Access to current and accurate data on treatment and outcomes
• Have stated goals
• Administrative support
• Support among clinicians
• Use of care maps and pathways
• Use of data to provide feedback
Bradley. JAMA. 2001;285:2604-2611.
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Potential Impact of Optimal Implementation of
Evidence-Based HF Therapies on Mortality
Guideline Recommended
Therapy
HF Patient
Current HF
Potential Lives
Potential Lives Saved
Population Eligible
Population
Saved per Year
per Year
for Treatment, n*
Eligible and
(Sensitivity Range*)
Untreated, n (%)
ACEI/ARB
2,459,644
501,767 (20.4)
6516
(3336-11,260)
Beta-blocker
2,512,560
361,809 (14.4)
12,922
(6616-22,329)
Aldosterone Antagonist
603,014
385,326 (63.9)
21,407
(10,960-36,991)
Hydralazine/Nitrate
150,754
139,749 (92.7)
6655
(3407-11,500)
CRT
326,151
199,604 (61.2)
8317
(4258-14,372)
ICD
1,725,732
852,512 (49.4)
12,179
(6236-21,045)
-
67,996
(34,813-117,497)
Total
Fonarow GC, et al. Am Heart J 2011;161:1024-1030.
Target: Heart Failure Honor Roll Recognition
Requirements: Documentation of all three care
components for 50% or more of eligible patients with
heart failure discharged to home. Hospitals must be
GWTG-HF performance achievement award hospitals.
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©2010, American Heart Association
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Target: Heart Failure Resources
• Get With The Guidelines-Heart Failure
• Patient Management Tool™
• Get With The Guidelines Heart Failure Tool Kit
• AHA patient education resources
• Heart Failure Best Practices Center
• Heart Failure Interactive Patient Education Workbook
• Heart Failure guidelines, publications, and resources
• Heart 360
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©2010, American Heart Association
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For more information and to register for
Target: Heart Failure, go to
www.heart.org/targethf.
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©2010, American Heart Association
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