Chronic Heart Failure (CHF) Quality Enhancement Research Initiative

Mission

The mission of our CHF QUERI (Chronic Heart Failure Quality Enhancement Research Initiative) center is to improve survival and quality of life for all VA patients with heart failure and those at risk for heart failure through collaboration with other VA organizations to implement best practices.

We believe the best way to achieve this mission is through improved recognition of heart failure and increased use of care known to prolong survival. Thus, we will focus our activities on identification and treatment of patients with left ventricular systolic dysfunction since these are the patients for which life prolonging therapies are indicated. The medical treatment of heart failure and preserved systolic function (diastolic dysfunction) will not be a focus of our QUERI due to the lack of relevant clinical practice guidelines.

Goals

We have rank ordered heart failure related issues and display those we feel are of the highest priority. They are practices that improve survival, apply to a large proportion of the population, and for which the VA is known to be below optimal use receive highest priority. We recognize that clinical issues that have never been tested or known not to prolong survival may have substantial value but we give them lower priority. We expect this ranking to change over time as the VA improves care and more clinical trial data are published and guidelines are revised.

Rank Order of Clinical Issues

1) Life-prolonging treatments

1a) Beta-blockers: large population will benefit, not at target usage

1b) Devices (ICDs, Bi-Ventricular Pacemakers): expensive, not available at each VA center, not at target usage

1c) Spironolactone: smaller population for benefit but not at target usage

1d) ACE inhibitors: already at a high level although dosage can be improved

1e) Hydralazine/Nitrates, at low level including among African-Americans

2) Readmission rates: Disease management and home based monitoring and education not widely used

3) Prevention and Identification of those with unrecognized heart failure

4) Emerging and other therapies: Limited guideline recommendations

4a) Digoxin: no mortality benefit

4b) Diuretics: not studied in large randomized trials

5) End of life care: No specific guideline recommendations

Based on the above ranking we have identified three clinical goals that span all time horizons: increasing the use of life prolonging treatment, preventing and identifying unrecognized heart failure and reducing hospitalizations through patient centered care coordination. In working toward each goal we aim to make contributions to implementation science.

Goal 1: Increase the Use of Life-Prolonging Treatment

The first goal of our QUERI center will be to increase compliance with evidence based treatment guidelines for patients with heart failure. Results from randomized trials indicate that survival, hospitalizations and quality of life improve with appropriate use of medications (first priority: beta-blockers) and ICDs. We have chosen beta-blockers as the first target because of their high impact on survival, the large number of eligible patients and the sub-optimal use.

A clinical focus of the CHF- QUERI will be the use of intracardiac defibrillators (ICDs) in patients with heart failure. The appropriate use of ICDs is a growing challenge for the VA that will benefit from work by CHF-QUERI. ICDs are expensive ($20-30,000 per device) but have also been shown to improve survival for a large portion of the population of patients with reduced left ventricular dysfunction. The VA has lagged behind the rest of the United States in use of appropriate procedures for ischemic heart disease (percutaneous interventions, bypass surgery) while leading in medical treatment (aspirin, beta-blockers). Partly in response to these findings, the VA is installing and refurbishing cardiac catheterization laboratories in order to improve access to cardiac procedures. It is likely that a similar limitation in infrastructure exists for ICD placement. CHF QUERI will take advantage of the VA ICD Surveillance Center located at VA San Francisco Health Care System to determine clinical effectiveness and cost-effectiveness of these devices as currently implanted.

Goal 2. Reduce Admission Rates

We have chosen reduction in readmission as our second goal because it is a major economic burden for the VA due to the high cost of care ($1000 per day, for a typical 5-6 day stay). Success with this goal will be highly correlated with success with our first goal given that most medical treatments (e.g. ACE inhibitors, beta-blockers, spironolactone) also reduce admission rates. However, there are specific interventions that can be employed to reach this goal. These include optimal use of disease management including home based monitoring and education.

Goal 3: Prevention and Identification of Unrecognized Heart Failure

We believe important targets for improvement of VA heart failure care include the identification of Stage B (asymptomatic) patients with ischemic heart disease, and unrecognized Stage C patients with symptoms of heart failure (dyspnea).