|
BACKGROUND/RATIONALE:
Heart failure has been diagnosed in 5% of veterans eligible for VA health benefits, and it has an annual mortality of 13% [1]. For patients with advanced disease, access to multi-disciplinary programs offering advanced therapies results in improvements in the quality of life and reductions in morbidity, mortality and the cost of medical care [2]. For several years, such a program has been in place at the VA Salt Lake City Health Care System, a nationally-designated VA heart transplant center and the VISN 19-designated center for advanced anti-arrhythmic therapies.
Geography has been shown to reduce access to advanced medical care [3-5]. VISN 19 covers an especially broad geographic area, and outlying VA Health Care Facilities (Fort Harrison, MT; Sheridan, WY; Cheyenne, WY; and Grand Junction, CO) provide a large proportion of the medical care to veterans in this VISN [6] (figure 1). Advanced heart failure is likely to be as prevalent among patients at these centers as in patients seen at the VA Salt Lake City HCS. This raises the question of whether outcomes can be improved through an increase in the access of veterans at outlying facilities to an advanced heart failure program.
OBJECTIVE(S):
1. To implement outreach activities at outlying VA Health Care Facilities in VISN
19 that will include educational sessions, consultations and the
establishment of direct referral lines to the VA Salt Lake City Advanced Heart
Failure Program.
2. To quantify the consequent increase in referrals to the VA Salt Lake City
Advanced Heart Failure Program.
3. To quantify changes in the application of evidence-based therapies for heart
failure, including initiation and/or up-titration of therapies of proven value
and discontinuation of unhelpful and potentially harmful therapies, in referred
patients.
4. To quantify the predicted impact of these changes on survival.
METHODS:
1. To implement outreach activities at outlying VA Health Care Facilities in VISN 19 that will include educational sessions, consultations and the establishment of direct referral lines to the VA Salt Lake City Advanced Heart Failure Program: A cardiologist and a nurse practitioner from the VA Salt Lake City Advanced Heart Failure Program will visit two of the four outlying VA Health Care Facilities - Grand Junction, CO and Fort Harrison, MT - twice during the six-month period. No visits will be made to the Sheridan, WY and Cheyenne, WY facilities, which will serve as a control group. Visits will include didactic sessions, case-oriented discussions and distribution of teaching materials for providers and patients. Contact information for direct interaction with the Advanced Heart Failure Program team will be provided.
2. To quantify the consequent increase in referrals to the VA Salt Lake City Advanced Heart Failure Program: Upon completion of outreach efforts, the number of referrals to the Advanced Heart Failure Program from each outlying health care facility - including actual patient visits and 'virtual' referrals by telephone and email consultation - will be compared to the number of referrals in the corresponding six-month period in the prior year. Changes in referral rates from the facilities visited and from the 'control facilities will be compared..
3. To quantify changes in the application of evidence-based therapies for heart failure, including initiation and/or up-titration of therapies of proven value and discontinuation of unhelpful and potentially harmful therapies, in referred patients: Specific changes to be quantified include initiation or up-titration of -adrenergic receptor antagonists, angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, aldosterone receptor antagonists, hydralazine and nitrates. We will also quantify discontinuation of non-steroidal anti-inflammatory agents, first-generation calcium channel blockers and other antihypertensive agents whose use in heart failure is not supported by published evidence.
4. To quantify the predicted impact of these changes on survival: The impact of changes in therapy in patients will be analyzed using the Seattle Heart Failure Model, through which predicted survival benefits of newly implemented therapies can be quantified [7]. (This model can be applied only to newly implemented therapies and not to up-titration of existing therapies.)
Personnel and resources
The Advanced Heart Failure Program at the VA Salt Lake City Health Care System is comprised of Drs Josef Stehlik and Matthew Movsesian, the co-principal investigators on this proposal, and NP's Mary Hagan and Robin Waxman. These providers will visit the outlying health care facilities and carry out educational activities and consultations. Ms Hagan and Ms Waxman will coordinate referrals, see patients in clinic with Drs Stehlik and Movsesian and carry out the data-collection aspects of the proposal. The creation of a new staff support position for the Advanced Heart Failure Program has made it possible for Ms Hagan and Ms Waxman to take on these additional responsibilities, which have been given a high priority by the VA Salt Lake City Health Care System administration.
FINDINGS/RESULTS:
Start-up activities are under way. At this point, there are no results to be presented.
IMPACT:
This pilot study will help us to assess the likelihood that outreach efforts by providers from an advanced heart failure program can improve outcomes in veterans at remote VA health care facilities, where geography limits access to tertiary care. The information obtained may help shape longer-term prospective studies examining the duration of benefit and cost-effectiveness as a precursor to implementation of outreach programs on a larger scale. Finally, an increase in the number of veterans referred to advanced heart failure programs should lead to an increase in the number of patients who can participate in clinical trials and other research programs.
References
1.Yu W, Ravelo A, Wagner TH, Phibbs CS, Bhandari A, Chen S, Barnett PG (2003) Prevalence and costs of chronic conditions in the VA health care system. Med Care Res Rev 60:146S-167S.
2.McAlister FA, Stewart S, Ferrua S, McMurray JJ (2004) Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol 44:810-9.
3.Groeneveld PW, Heidenreich PA, Garber AM (2005) Trends in implantable cardioverter-defibrillator racial disparity: the importance of geography. J Am Coll Cardiol 45:72-8.
4.Mooney C, Zwanziger J, Phibbs CS, Schmitt S (2000) Is travel distance a barrier to veterans' use of VA hospitals for medical surgical care? Soc Sci Med 50:1743-55.
5.Probst JC, Laditka SB, Wang JY, Johnson AO (2007) Effects of Residence and Race on Burden of Travel for Care: Cross Sectional Analysis of the 2001 US National Household Travel Survey. BMC Health Serv Res 7:40.
6.(2007) Directory of VA and DoD Health Care Facilities. Federal Practitioner
7.Levy WC, Mozaffarian D, Linker DT, Sutradhar SC, Anker SD, Cropp AB, Anand I, Maggioni A, Burton P, Sullivan MD, Pitt B, Poole-Wilson PA, Mann DL, Packer M (2006) The Seattle Heart Failure Model: prediction of survival in heart failure. Circulation 113:1424-33.
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases
DRE:
Quality of Care, Treatment
Keywords:
Cardiovasc’r disease, Education (provider), Practice patterns
MeSH Terms:
none
|
