|
BACKGROUND/RATIONALE:
There are data emerging in the HF literature concerning the negative effects of diuretic use. Among the arguments for controlling diuretic use are the increase in the renin-angiotensin-aldosterone system (RAAS) as a result of diuresis. Although a therapeutic goal is to achieve euvolemia, the ADHERE(acute HF) Registry has pointed to a higher mortality associated with higher diuretic use. Whether the association is truly causal is uncertain at this time. The use of ACEI/ARB for reduction in the RAAS cascade has been well documented in the literature and serves as a performance measure which is linked to a favorable outcome and quality care.
OBJECTIVE(S):
To improve heart failure (HF) practice quality by decreasing diuretics and increasing neurohormonal inhibition in outpatients at the VA Cuyahoga County facilities with a diagnosis of HF secondary to systolic dysfunction. Angiotensin converting enzyme inhibition(ACEI) and/or angiotensin II receptor blocker (ARB)administration is part of the evidenced-based HF Guidelines and a performance measure for HF. Aims: 1. To decrease loop diuretic to the lowest necessary level in the Cleveland VAMC, Brecksville and McCafferty and institute a flexible diuretic regimen as recommended in the HF Guidelines. To maximize ACEI/ ARB use to tolerability.
METHODS:
NHeFT(National Heart Failure Training Program) of CASE consists of a unique, multi-site, nation-wide HF training CME program that has been in existence for > 7 years. The mission of NHeFT is to disseminate best practices in HF care for physicians and other health care practitioners to change practice patterns. The Core Curriculum for this implementation project will be focused on Primary Care. The typical program includes day of didactics followed by a personal hands-on preceptorship with the instructors at the attendees own site seeing HF patients and discussing the clinical care in each. The program stresses the implementation and appropriate use of Guideline-driven therapy with emphasis on RAAS inhibition and an additional emphasis on lowering diuretics to optimally needed doses with a flexible diuretic regimen. Protocols and other tools are provided. NHeFT process and structure tend to encourage participants to think about, struggle to clarify and continue to re-clarify their individual improvement priorities thus meeting the physician learner need for self-efficacy. Primary Care physicians and other health care providers will be enrolled in the NHeFT programs at all 3 facilities after the baseline data collection.
Baseline and 6 month data to be collected: Using the SMA HF clinic at the Wade Park VA as the benchmark group, matched to age, and disease burden, we will collect demographics, echocardiographic parameters of remodeling, vital signs, current medications and 1 year hospitalizations at baseline and at 6 months in HF patients at the Cuyahoga county facilities. The Kansas City Cardiomyopathy questionnaire (KCCQ) health status instrument to be administered to patients being assessed in the clinic both at baseline and at 4 month follow-up. Outcomes will be: Change in RAAS inhibition use and dosing; Drop in diuretic dose. Additional outcomes will include subsequent hospitalizations, and unscheduled clinic visits, as well as urgent care visits.
FINDINGS/RESULTS:
No results at this time. The teaching has been nearly completed.
IMPACT:
The project has the potential of impacting on rehospitalization rates and ultimately 30 day mortality as an outcome. The benchmark is the Heart Failure Shared MEdical Appointment Clinic at the Cleveland VA.
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases
DRE:
Quality of Care
Keywords:
Cardiovasc’r disease, Implementation
MeSH Terms:
none
|
