Advertisement

Heart failure outcomes in the community: clinical and policy implications for a vulnerable population

  • Marshall H Chin
    Correspondence
    Requests for reprints should be addressed to Marshall H. Chin, MD, MPH, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, Illinois 60637
    Affiliations
    Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA

    Iowa Foundation for Medical Care, West Des Moines, Iowa, USA
    Search for articles by this author
      Heart failure has emerged as a major clinical and public health challenge. As the population ages and survival with coronary artery disease and hypertension-related illnesses improves, more patients are developing, and subsequently dying from, heart failure (
      • Croft J.B.
      • Giles W.H.
      • Pollard R.A.
      • et al.
      National trends in the initial hospitalization for heart failure.
      ,
      Centers for Disease Control
      Changes in mortality from heart failure—United States, 1980–1995.
      ). Clinical trials have led to major therapeutic advances in the treatment of heart failure, but these studies generally contain highly selected volunteers who are not reflective of most patients with heart failure.
      Philbin and colleagues (
      • Philbin E.F.
      • Rocco T.A.
      • Lindenmuth N.W.
      • et al.
      Clinical outcomes in heart failure report from a community hospital-based registry.
      ) provide important information on the natural history of patients admitted with heart failure to 10 community hospitals in New York State in the mid 1990s. Their major finding is that the 6-month prognosis is poor for these patients. Within 6 months of the index hospitalization, 23% of the patients died and 43% of hospital survivors were readmitted to the hospital; thus, overall 55% of the patients either died or were readmitted. These sobering numbers indicate that a hospital admission for heart failure is a sentinel event for these predominantly elderly patients, who are at high risk for poor outcomes and thus are prime targets for clinical and policy attention. Despite clinical advances, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, cardiac transplantation, and multidisciplinary disease management programs, the absolute morbidity and mortality from heart failure remain high.
      What are the implications of the study by Philbin et al for those of us who care for patients with heart failure? I believe that these results help provide a roadmap for areas in which we will need to improve individual clinical skills, methods of enhancing system performance, and health services research.

      Individual clinical skills

      Recent physician education in heart failure has aimed to improve provision of basic processes of care such as assessment of left ventricular function and use of ACE inhibitors in target doses for patients with systolic dysfunction (
      American College of Cardiology/American Heart Association Task Force on Practice Guidelines
      Guidelines for the evaluation and management of heart failure.
      ). These diagnostic and therapeutic guidelines are important and will continue to evolve, such as with the incorporation of beta-blockers and possibly spironolactone into the treatment regimens of selected patients (
      • Packer M.
      • Cohn J.N.
      Consensus recommendations for the management of chronic heart failure.
      ). However, the findings by Philbin et al that the mean age of the patients was 76 years and that 1 in 4 died soon after hospitalization highlight the importance of developing skills in two areas traditionally not emphasized in training programs: geriatrics and end-of-life care (
      • Chin M.H.
      • Wang J.C.
      • Zhang J.X.
      • et al.
      Differences in the care of patients with heart failure among geriatricians, general internists, and cardiologists a cautionary tale of quality assessment.
      ). The geriatrics approach emphasizes maximizing functional status and health-related quality of life in patients, like those with heart failure, who often have multiple comorbid conditions and an underlying chronic disease that cannot be cured. Examples of geriatric issues common in patients with heart failure include choosing appropriate pharmacologic agents in patients who are at risk for falls, orthostatic hypotension, and changes in mental status; treating incontinence in patients requiring diuretics; working with patients who are cognitively impaired; discussing treatment plans with families and caregivers; and trying to devise an overall therapeutic approach that is sensible to the individual patient. These clinical challenges require awareness, technical competence, and comfort working with consultants and other team members.
      End-of-life care in the United States is frequently inadequate (
      • Meier D.E.
      • Morrison R.S.
      • Cassel C.K.
      Improving palliative care.
      ), and relatively little attention has been directed toward improving the palliative care of end-stage heart failure patients. Part of the problem is that it is often difficult to predict which patients with heart failure are likely to die within 6 months. Thus, we will need to think creatively about how to combine the best elements of traditional heart failure medical care and the hospice movement. Learning objectives for physicians include treating dyspnea and pain effectively, honing prognostic skills, improving communication skills with patients and families as the clinical course and goals of treatment for a patient evolve, helping patients decide whether to emphasize improved quality of life or survival—especially as some future therapies for heart failure may involve trade-offs (
      • Stevenson L.W.
      Inotropic therapy for heart failure.
      )—and creating links with palliative care resources.

      Health systems performance

      Similar to investigators in other settings, Philbin et al found that many patients received care that did not adhere to evidence-based guidelines (
      American College of Cardiology/American Heart Association Task Force on Practice Guidelines
      Guidelines for the evaluation and management of heart failure.
      ). Three quarters of patients had an assessment of left ventricular function, 79% of ideal candidates were prescribed ACE inhibitors, and only 31% of patients on ACE inhibitors were prescribed target doses. Implementation of guidelines and changing provider behavior remain key challenges. Although only 22% of the patients in their study were in multidisciplinary team treatment or disease management programs, these interventions have become increasingly popular in recent years. These programs generally include nurse case management under the supervision of a physician, telephone medicine, dietary counseling and education, and clinical pathways spanning the inpatient, outpatient, and home settings (
      • Philbin E.F.
      Comprehensive multidisciplinary programs for management of patients with congestive heart failure.
      ). Many of the principles of this model, including the creation of an educated, motivated patient and close follow-up of high-risk patients, are likely to be fundamental components of most successful programs. However, the generalizability of these programs remains uncertain. For example, providers in rural settings and those in federally funded health centers serving the poor may not have adequate numbers of patients or resources to support a comprehensive multidisciplinary team. Generalist physicians who are not part of integrated delivery systems might also need a different approach.
      Thus, it is likely that a variety of systems approaches will be needed to improve care (
      • Bero L.A.
      • Grilli R.
      • Grimshaw J.M.
      • et al.
      Closing the gap between research and practice an overview of systematic reviews of interventions to promote the implementation of research findings.
      ). Most providers want to deliver the best care possible for their patients, and educational programs and guidelines are necessary components of quality improvement efforts. National organizations can help facilitate and expedite improvement in the quality of care through collaborative efforts and incentives. Diabetes is the chronic disease that has perhaps most successfully brought key national organizations together. In the Diabetes Quality Improvement Program, representatives of the American Diabetes Association, the Foundation for Accountability, the Health Care Financing Administration, the National Committee on Quality Assurance, the American Academy of Family Physicians, the American College of Physicians, and the Veterans Administration developed a set of seven feasible, evidence-based performance measures (

      Diabetes Quality Improvement Project Initial Measure Set (final version). Alexandria, VA: American Diabetes Association; 1998.

      ). These measures are being incorporated into the Health Plan Employer Data and Information Set (HEDIS) that evaluates managed care plans, and the Health Care Financing Administration’s national measure set used by the Peer Review Organizations to assess the quality of care for Medicare beneficiaries. Since these measures will be used to evaluate health plans in the private and public marketplaces, incentives are created for medical systems and providers to improve their care in ways that are suitable for their local situations. Similar ongoing efforts to create collaborative networks of national private and public organizations in heart failure will be critical to jump-starting and supporting quality improvement.

      Community-based health services research

      While many important clinical trials have been performed, relatively little research has focused on the care of patients with heart failure in the community. The work by Philbin et al is a useful example of health services research that can guide policy. Several pressing basic and applied research questions remain unanswered. For example, heart failure has been labeled the prototype of the “ambulatory care-sensitive condition” for which good outpatient care should prevent hospital admissions. To what extent are admissions truly preventable (
      • Chin M.H.
      • Goldman L.
      Factors contributing to the hospitalization of patients with congestive heart failure.
      )? How can we facilitate patients’ adherence to diet and medications? What are patients’ health beliefs toward their illness and symptoms, and how can we encourage patients to seek care before they require a visit to the emergency department? What are the roles of family and friends in the decision-making and health-seeking behavior of patients? Do patients’ attitudes vary by race, culture, or socioeconomic status? What are the key elements of disease management programs that are necessary for improved patient outcomes? What are the best ways to increase providers’ adherence to evidence-based guidelines? What types of organizational structures and incentives are most likely to lead to quality improvement in different types of health plans and provider groups? How can we improve care for the most vulnerable poor patients who have difficulty accessing the health care system? What creative programs can we develop for financially strapped health centers and hospitals that care for the indigent? What are the key attitudinal, provider, and systems barriers facing medically underserved minority patients with heart failure?
      Despite the discouraging findings of Philbin et al, I have been telling my patients with heart failure that this is a good time to have the condition because of therapeutic advances and improvements in our understanding of how to deliver care. To realize the potential that we have to improve care for these patients, we will need to broaden our treatment paradigms and improve our skills in geriatrics, end-of-life care, doctor-patient communication, local systems redesign, and advocacy for quality improvement within national organizations.

      References

        • Croft J.B.
        • Giles W.H.
        • Pollard R.A.
        • et al.
        National trends in the initial hospitalization for heart failure.
        J Am Geriatr Soc. 1997; 45: 270-275
        • Centers for Disease Control
        Changes in mortality from heart failure—United States, 1980–1995.
        MMWR. 1998; 47: 633-637
        • Philbin E.F.
        • Rocco T.A.
        • Lindenmuth N.W.
        • et al.
        Clinical outcomes in heart failure.
        Am J Med. 1999; 107: 549-555
        • American College of Cardiology/American Heart Association Task Force on Practice Guidelines
        Guidelines for the evaluation and management of heart failure.
        J Am Coll Cardiol. 1995; 26: 1376-1398
        • Packer M.
        • Cohn J.N.
        Consensus recommendations for the management of chronic heart failure.
        Am J Cardiol. 1999; 83: 1A-38A
        • Chin M.H.
        • Wang J.C.
        • Zhang J.X.
        • et al.
        Differences in the care of patients with heart failure among geriatricians, general internists, and cardiologists.
        J Am Geriatr Soc. 1998; 46: 1349-1354
        • Meier D.E.
        • Morrison R.S.
        • Cassel C.K.
        Improving palliative care.
        Ann Intern Med. 1997; 127: 225-230
        • Stevenson L.W.
        Inotropic therapy for heart failure.
        NEJM. 1998; 339: 1848-1850
        • Philbin E.F.
        Comprehensive multidisciplinary programs for management of patients with congestive heart failure.
        J Gen Intern Med. 1999; 14: 130-135
        • Bero L.A.
        • Grilli R.
        • Grimshaw J.M.
        • et al.
        Closing the gap between research and practice.
        BMJ. 1998; 317: 465-468
      1. Diabetes Quality Improvement Project Initial Measure Set (final version). Alexandria, VA: American Diabetes Association; 1998.

        • Chin M.H.
        • Goldman L.
        Factors contributing to the hospitalization of patients with congestive heart failure.
        Am J Pub Health. 1997; 87: 643-648