Background

Heart failure is a common chronic disease marked by frequent exacerbations often resulting in hospitalization and death. At age 40 the life time risk of developing heart failure is one in five. It has been the number one reason for admission among Medicare patients and those in the Veterans' Health Care System. Readmission for heart failure occurs in 20% within 30 days of discharge in those over age 65 in the Medicare health care system. The high rate of hospitalization is a major contributor to the estimated $37.2 billion in cost of heart failure care in the United States for 2009.

Mission

The mission of our CHF QUERI 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 increased use of care known to prolong survival and other interventions that reduce hospitalization rates. An additional objective is to contribute to implementation science while we work toward the above goals. We have designed our implementation projects accordingly using formative evaluations and randomized trials of different implementation strategies. Once the use rates of life-prolonging treatments are at a high level and readmission rates are low, we plan to focus on identification and treatment of patients with unsuspected reduced left ventricular ejection fraction (LVEF) in order to prevent subsequent heart failure. The medical treatment of heart failure and preserved systolic function (diastolic dysfunction) is also not a current focus of our QUERI due to the lack of relevant clinical practice guidelines. However, this may change if specific treatment guidelines for patients with diastolic heart failure (Step two) become available.

Goals

Rank Order of Clinical Issues

Goal 1: Decrease Hospitalization Rates

We have chosen reduction in hospitalization rates as our primary 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 second goal given that the life-prolonging medical treatments (ACE inhibitors, beta-blockers, aldosterone antagonists) also reduce admission rates. However, there are specific interventions that can be employed to reach this goal, such as greater attention to the transition from inpatient to outpatient care, optimal use of disease management including home based monitoring and patient education. Many of the life-prolonging treatments are promoted as part of the Hospital to Home Initiative (H2H) of the Institute for Healthcare Improvement (IHI) and American College of Cardiology that the VA has joined. Reducing VA admission rates may take several years given that there has been no recent improvement in readmission rates despite improvement in process of care for inpatients ( Mission Critical measures), and improved survival.

Goal 2: Increase the Use of Life-Prolonging Treatment

In the past, the first goal of our QUERI Center was to increase compliance with treatments known to prolong survival 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). We chose beta-blockers as the first target because of their high impact on survival, the large number of eligible patients and the sub-optimal use in the VA system. Given the high use rates now achieved by the VA we consider further increases a secondary goal.

A related goal of our center has been to improve care for patients who historically have been undertreated. Specifically, we will examine disparities in heart failure care based on race, gender, age, rural vs. urban location, mental illness, alcohol dependence and renal insufficiency. Although there are many potential candidates for ICDs within the VA system, increasing their use will not be a top priority. Instead we have focused on understanding the cost and benefit of these devices on different groups of VA patients based on certain clinical characteristics.

Goal 3: Increasing Care that Improves Quality of Life

This is a new goal for CHF QUERI that was started due to a change in CMS performance measures, and to an increase in capacity of CHF QUERI. CMS recently expanded their performance measures to include use of anti-coagulation for patients with atrial fibrillation at significant risk of stroke. Future projects will examine treatment variation for atrial fibrillation and heart failure in the VA with the goal of creating interventions for improved anti-coagulation.

Goal 4: Empowering Patient and Caregiver for Self-Management

While improved patient self-management is an intermediate goal that ultimately helps us reach goals 1-3 we list it as a new goal since interventions are often specific to self-management. Encouraging the patient to become an active partner in their care is important to the success of our mission of improving survival and quality of life.

Goal 5: Improving Appropriateness of Heart Failure Treatments and Tests

This is a new goal of CHF QUERI based on the recommendations from QUERI leadership and Patient Care Services. In particular, cardiac imaging is of concern as its use has grown exponentially in the United States without a clear benefit for patients. Much of this imaging is for documentation of the left ventricular ejection fraction (LVEF). While an occasional measurement is consistent with good care, routine testing without a change in health status has been labeled as inappropriate care. CHF QUERI will begin by addressing the current use of testing and, if high, develop interventions to reduce inappropriate testing. We expect progress toward this goal will be achieved in 3 years.

Minor Goals

We now list three minor goals that will be addressed in the future depending on our success with the major goals. These include identifying unrecognized heart failure, treating advanced (end-stage) heart failure, and preventing heart failure. While preventing heart failure is highly desirable, there are already many efforts within the VA that will have the impact of decreasing heart failure incidence.