Innovative Strategies for Implementing New CHF Guideline Recommendations
Barry M. Massie MD
VA Medical Center San Francisco
San Francisco, CA
Funding Period: October 1999 - March 2003

BACKGROUND/RATIONALE:
Clinical practice guidelines are the primary approach by which evidence-based recommendations are translated into clinical practice. Chronic heart failure (HF) is a common condition associated with considerable mortality, morbidity, and cost. Clinical trials in HF patients have provided convincing evidence for several treatment recommendations. However, treatment practices have greatly lagged behind the evidence and guideline recommendations. Clinical trials involving over 14,000 patients have shown that beta-blockers reduce mortality in a wide spectrum of HF patients by approximately 35% and prevented hospitalizations to a similar degree, but their use continues to be low. Furthermore, physicians remain reluctant to use beta-blockers because of safety concerns, the time required and the perceived difficulty of initiating these agents. Because of the striking efficacy but low penetration of this therapy, this a high priority area in which to evaluate innovative implementation approaches.linical practice guidelines are an important avenue for improving health care quality and outcomes, but adherence is often suboptimal. CHF guidelines have recently been revised to incorporate the widespread use of beta-blockers, thus providing a unique opportunity to evaluate strategies for implementing this new recommendation.

OBJECTIVE(S):
The initial objective was to determine whether interventions using 1) individual patient-based Computer Reminders together with a Patient Letter ("talk to your provider about a new therapy") or 2) utilizing a Nurse Facilitator to assist the provider in initiating and uptitrating beta-blockers would be more effective in increasing beta-blocker use than 3) an intensive program of provider education. We hypothesized that neither intensive provider education nor computer reminders would be sufficient, and that an active intervention such as a nurse facilitator would be required. Our second objective was to determine the generalizability of the most successful strategy, by rolling it out to 2 additional VA facilities.To further develop a valid, responsive, case mix adjusted and inexpensive method to measure the quality of care.

METHODS:
The initial phase was conducted at a VA tertiary care teaching facility. All patients coded for HF and followed in the clinics with EF < 45% that were not receiving a beta-blocker or were on subtherapeutic doses without contraindications to these agents were identified. After a period of intensive education, with conferences, clinic meetings, and dissemination of specific beta-blocker protocols, 74 consenting primary care providers were assigned to one of the 3 groups using a stratified randomization procedure. The Control Group was only exposed to the education program. The second group of providers received Computerized Reminders (CR) during their next 2 visits with HF patients identified as potential beta-blocker candidates, and these patients also received the Patient Letter (PL). The third group of providers was assigned to work with a specially-trained nurse practitioner serving as a Nurse Facilitator (NF) supervised and supported by a cardiologist, who was given a list of appropriate HF patients and who, with their prior agreement, initiated and uptitrated beta-blocker therapy with carvedilol or metoprolol. The prespecified endpoints were the proportion of patients initiated or up-titrated and the proportion achieving target doses. Safety was assessed by chart review to detect serious adverse events, including hospitalizations and deaths. Subsequently, the more effective Nurse Facilitator strategy was evaluated in two additional facilities-a non-referral hospital and a primarily outpatient clinic facility, both of which have limited cardiology support.

FINDINGS/RESULTS:
During the 1 year period after initiation, 26% (14/51) patients followed by Control Group providers, 16% (10/64) of patients followed by CR/PL providers, and 67% (36/54, p<0.0001 vs other groups) patients treated by NF group providers were initiated or uptitrated on beta-blockers. 10%, 2%, and 43% of the patients in these groups, respectively, achieved full target doses (p<0.001 NF group vs other groups). No safety issues were identified. The estimated time expended per patient initiated by the NF was 192 minutes, making it likely that this intervention is cost-effective (full analysis is pending). In the second phase, the NF strategy was found to be similarly successful at the other two facilities. Initiation and target doses were achieved in 88% and 35% at Reno and 63% and 39% at the Sacramento VA Clinic.

IMPACT:
This project has clearly demonstrated that the use of a nurse facilitator can markedly enhance the implementation of beta-blocker therapy in patients with congestive heart failure. Since beta-blockers have been consistently found to reduce mortality by 35% and hospitalizations by 25-40% (for all cause and heart failure primary diagnosis, respectively), this intervention could have enormous impact on the outcomes and cost of heart failure management. Future work will address the cost-effectiveness and generalizability of this approach.

PUBLICATIONS:

Journal Articles

1. Massie BM. Heart failure trials: are they becoming impractical? Journal of Cardiac Failure. 2005; 11(3): 161-3.
2. Massie BM. Isosorbide dinitrate plus hydralazine was effective for advanced heart failure in black patients. ACP Journal Club. 2005; 142(2): 37.
3. Massie BM. The year in heart failure: 2004. Journal of Cardiac Failure. 2005; 11(1): 1-6.
4. Gottlieb SS, Abraham W, Butler J, Forman DE, Loh E, Massie BM, O'connor CM, Rich MW, Stevenson LW, Young J, Krumholz HM. The prognostic importance of different definitions of worsening renal function in congestive heart failure. Journal of Cardiac Failure. 2002; 8(3): 136-41.
5. Massie BM. Treating heart failure: it's time for new paradigms and novel approaches. Journal of Cardiac Failure. 2002; 8(3): 117-9.
6. Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA : The Journal of The American Medical Association. 2002; 287(12): 1541-7.
7. Massie BM. Neurohormonal blockade in chronic heart failure. How much is enough? Can there be too much? Journal of The American College of Cardiology. 2002; 39(1): 79-82.
8. Dauterman KW, Go AS, Rowell R, Gebretsadik T, Gettner S, Massie BM. Congestive heart failure with preserved systolic function in a statewide sample of community hospitals. Journal of Cardiac Failure. 2001; 7(3): 221-8.
9. Massie BM, Armstrong PW, Cleland JG, Horowitz JD, Packer M, Poole-Wilson PA, Rydén L. Toleration of high doses of angiotensin-converting enzyme inhibitors in patients with chronic heart failure: results from the ATLAS trial. The Assessment of Treatment with Lisinopril and Survival. Archives of Internal Medicine. 2001; 161(2): 165-71.
10. Frances CD, Noguchi H, Massie BM, Browner WS, McClellan M. Are we inhibited? Renal insufficiency should not preclude the use of ACE inhibitors for patients with myocardial infarction and depressed left ventricular function. Archives of Internal Medicine. 2000; 160(17): 2645-50.
11. Ashton CM, Bozkurt B, Colucci WB, Kiefe CI, Mann DL, Massie BM, Slawsky MT, Tierney WM, West JA, Whellan DJ, Wray NP. Veterans Affairs Quality Enhancement Research Initiative in chronic heart failure. Medical Care. 2000; 38(6 Suppl 1): I26-37.
12. Go AS, Rao RK, Dauterman KW, Massie BM. A systematic review of the effects of physician specialty on the treatment of coronary disease and heart failure in the United States. American Journal of Medicine. 2000; 108(3): 216-26.
13. Cuffe MS, Califf RM, Adams KF, Bourge RC, Colucci W, Massie B, O'Connor CM, Pina I, Quigg R, Silver M, Robinson LA, Leimberger JD, Gheorghiade M. Rationale and design of the OPTIME CHF trial: outcomes of a prospective trial of intravenous milrinone for exacerbations of chronic heart failure. American Heart Journal. 2000; 139(1 Pt 1): 15-22.

DRA: Chronic Diseases, Health Services and Systems
DRE: Communication and Decision Making, Quality of Care
Keywords: Chronic heart failure, Clinical practice guidelines, Nursing
MeSH Terms: none