Advertisement

The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure

      Abstract

      PURPOSE: Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.
      PATIENTS AND METHODS: This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a “usual care” control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.
      RESULTS: Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of −1.1 days (95% confidence interval [CI]: −2.9 to 0.7 days, P = 0.18) and in hospital charges of −$817 (95% CI: −$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.
      CONCLUSIONS: The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • O’Connell J.B
        • Bristow M.R
        Economic impact of heart failure in the United States.
        J Heart Lung Transplant. 1994; 13: S107-S112
      1. Domanski MJ, Garg R, Yusuf S. Prognosis in congestive heart failure. In: Hosenpud JD, Greenberg BH, eds. Congestive Heart Failure: Pathophysiology, Diagnosis and Comprehensive Approach to Management. New York: Springer-Verlag; 1994:622–627.

        • Edep M.E
        • Shah N.B
        • Tateo I.M
        • Massie B.M
        Differences between primary care physicians and cardiologists in management of congestive heart failure.
        J Am Coll Cardiol. 1997; 30: 518-526
        • Philbin E.F
        Factors determining angiotensin-converting enzyme inhibitor use in heart failure in the community setting.
        Clin Cardiol. 1998; 21: 103-108
        • Philbin E.F
        • Andreou C
        • Rocco T.A
        • et al.
        Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in 2 community hospitals.
        Am J Cardiol. 1996; 77: 832-838
        • Fonarow G.C
        • Stevenson L.W
        • Walden J.A
        • et al.
        Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure.
        J Am Coll Cardiol. 1997; 30: 725-732
        • Hanumanthu S
        • Butler J
        • Chomsky D
        • et al.
        Effect of a heart failure program on hospitalization frequency and exercise tolerance.
        Circulation. 1997; 96: 2842-2848
        • Kornowski R
        • Zeeli D
        • Averbuch M
        • et al.
        Intensive home-care surveillance prevents hospitalization and improves morbidity among elderly patients with severe congestive heart failure.
        Am Heart J. 1995; 129: 762-766
        • Rich M.W
        • Beckman V
        • Wittenberg C
        • et al.
        A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.
        N Engl J Med. 1995; 333: 1190-1195
        • Shah N.B
        • Ruggerio C
        • et al.
        • Der E
        Prevention of hospitalizations for heart failure with an interactive home monitoring program.
        Am Heart J. 1998; 135: 373-378
        • West J.A
        • Miller N.H
        • Parker K.M
        • et al.
        A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization.
        Am J Cardiol. 1997; 79: 58-63
        • Philbin E.F
        • Lynch L.J
        • Rocco T.A
        • et al.
        Does quality improvement work? The Management to Improve Survival in Congestive Heart Failure (MISCHF) study.
        Joint Comm J Qual Improv. 1996; 22: 721-733
        • Pearson S.D
        • Goulart-Fisher D
        • Lee T.H
        Critical pathways as a strategy for improving care.
        Ann Intern Med. 1995; 123: 941-948
      2. Konstam MA, Dracup K, Bottoroff MB, et al. Quick Reference Guide for Clinicians No. 11. Heart Failure: Management of Patients with Left Ventricular Systolic Dysfunction. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, AHCPR Publication No. 94–0613; 1994.

        • Hadorn D.C
        • Baker D.W
        • Kamberg C.J
        • Brook R.H
        Phase II of the AHCPR-sponsored heart failure guideline.
        Joint Comm J Qual Improv. 1996; 22: 265-276
        • Williams J.F
        • Bristow M.R
        • Fowler M.B
        • et al.
        Guidelines for the evaluation and management of heart failure. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure).
        Circulation. 1995; 92: 2764-2784
        • Johnstone D.E
        • Abdulla A
        • Arnold J.M.O
        • et al.
        Diagnosis and management of heart failure.
        Can J Cardiol. 1994; 10: 613-631
        • Brophy J.M
        • DesLauriers G
        • Boucher B
        • Rouleau J.L
        The hospital course and short term prognosis of patients presenting to the emergency room with decompensated congestive heart failure.
        Can J Cardiol. 1993; 9: 219-224
        • Mohan P
        • Hii J.T
        • Wuttke R.D
        • et al.
        Acute heart failure.
        Int J Cardiol. 1991; 32: 365-376
        • Cohn J.N
        • Johnson G.R
        • Shabetai R
        • et al.
        Ejection fraction, peak exercise oxygen consumption, cardiothoracic ratio, ventricular arrhythmias and plasma norepinephrine as determinants of prognosis in heart failure.
        Circulation. 1993; 87: 5-16
        • Gradman A.H
        • Deedwania P.C
        Predictors of mortality in patients with heart failure.
        Card Clin. 1994; 12: 25-35
        • Charlson M.E
        • Pompei P
        • Ales K.L
        • MacKenzie C.R
        A new method of classifying prognostic comorbidity in longitudinal studies.
        J Chron Dis. 1987; 40: 373-383
        • Girman C.J
        • Kolman C
        • Liss C.L
        • et al.
        Effects of finasteride on health-related quality of life in men with symptomatic benign prostatic hypertrophy.
        Prostate. 1996; 29: 83-90
        • Philbin E.F
        • DiSalvo T.G
        The influence of race and gender on process of care, resource utilization, and hospital-based outcomes in congestive heart failure.
        Am J Cardiol. 1998; 82: 76-81
        • Weingarten S
        • Agocs L
        • Tankel N
        • et al.
        Reducing lengths of stay for patients hospitalized for chest pain using medical practice guidelines and opinion leaders.
        Am J Cardiol. 1993; 71: 259-262
        • Pozen M.W
        • D’Agostino R.B
        • Selker H.P
        • et al.
        A predictive instrument to reduce coronary-care-unit admissions in acute ischemic heart disease. A prospective multicenter clinical trial.
        N Engl J Med. 1984; 310: 1273-1278
        • Velasco F.T
        • Ko W
        • Rosengart T
        • et al.
        Cost containment in cardiac surgery.
        Best Pract Benchmark. 1996; 1: 21-28
        • Turley K
        • Tyndall M
        • Woo D
        • Mohr T
        Radical outcome method. A new approach to critical pathways in congenital heart disease.
        Circulation. 1995; 92: 245-249
        • Davis D.A
        • Thomson M.A
        • Oxman A.D
        • Haynes R.B
        Changing physician performance. A systematic review of the effect of continuing medical education strategies.
        JAMA. 1995; 274: 700-705
        • Eagle K.A
        • Lee T.H
        • Brennan T.A
        • et al.
        Practice guidelines and the quality of care. Task Force 2.
        J Am Coll Cardiol. 1997; 29: 1141-1148
        • Philbin E.F
        • Roerden J.B
        Longer hospital length of stay is not related to better clinical outcomes in congestive heart failure.
        Am J Manag Care. 1997; 3: 1285-1291
        • Philbin E.F
        • Rogers V.A
        • Sheesley K.A
        • et al.
        The relationship between hospital length of stay and rate of death in heart failure.
        Heart Lung. 1997; 26: 177-186
        • Philbin E.F
        • DiSalvo T.G
        Prediction of hospital readmission for heart failure.
        J Am Coll Cardiol. 1999; 33: 1560-1566
        • Vinson J.M
        • Rich M.W
        • Sperry J.C
        • et al.
        Early readmission of elderly patients with congestive heart failure.
        J Am Geriatr Soc. 1990; 38: 1290-1295
        • Krumholz H.M
        • Parent E.M
        • Tu N
        • et al.
        Readmission after hospitalization for congestive heart failure among Medicare beneficiaries.
        Arch Intern Med. 1997; 157: 99-104
        • Stearns S.C
        Hospital discharge decisions, health outcomes, and the use of unobserved information on case-mix severity.
        Health Serv Res. 1991; 26: 27-51
        • Ashton C.M
        • Kuykendall D.H
        • Johnson M.L
        • et al.
        The association between the quality of inpatient care and early readmission.
        Ann Intern Med. 1995; 122: 415-421
        • Philbin E.F
        Comprehensive multidisciplinary programs for management of patients with congestive heart failure.
        J Gen Intern Med. 1999; 14: 130-135