Fewer heart failure patients die when hospitals make efforts to improve care

11/10/05

Mortality and hospital readmission rates drop when doctors, nurses and patients team up to ensure quality care

DALLAS -- Heart failure patients are less likely to die after they go home from the hospital if the hospital has participated in an organized quality improvement program, compared with patients treated at hospitals where such efforts aren't undertaken, a new study finds. They're also less likely to need another hospital stay.

Today at the Scientific Sessions meeting of the American Heart Association, University of Michigan Cardiovascular Center heart failure expert Todd Koelling, M.D., will present data from a two-year study involving more than 2,500 heart failure patients treated at 14 community hospitals in and around Flint, Mich.

Significantly lower death rates in the month after hospitalization were seen among those patients treated at eight hospitals that cooperated to find ways to deliver proven care and educate patients about their treatment, compared with six hospitals that didn't take part in the cooperative effort. Rehospitalization rates also dropped, by 22 percent, when doctors and nurses used a "toolkit" of heart failure specific standard admission orders, in-patient clinical pathways, and discharge checklists to make sure that patients didn't miss out on treatments or counseling.

All patients in the study had heart failure, a chronic and disabling condition that affects 5 million Americans, mainly heart attack survivors and longtime high blood pressure patients. Heart failure is the most common heart-related cause of hospitalization in America, responsible for about 1 million hospital stays each year.

The new data echo the significant drops in mortality and complications that were achieved in a similar project in heart attack patients, a project also co-led by U-M heart specialists. Both projects are sponsored by the American College of Cardiology as part of its Guidelines Applied in Practice or GAP project, which seeks to ensure that all hospitalized heart patients receive proven treatments, counseling for lifestyle changes and education that can help them care for themselves after they go home.

U-M doctors have helped lead both projects, with help from MPRO, Michigan's healthcare quality improvement organization. The heart failure project, which grew out of the heart attack project, was spearheaded by the Greater Flint Health Coalition.

"To our knowledge, this is the first report that a community hospital quality-improvement program has resulted in meaningful improvement in heart failure mortality," says Koelling, associate professor of cardiovascular medicine. "The hospitals and health coalition should be commended because this was a cooperative fact-sharing, lesson sharing project among institutions that normally compete with one another. The winners from this cooperation are the patients."

Today at the Scientific Sessions meeting, Koelling will present the results on behalf of the hospitals and project manager Cecelia Montoye, MSN, a consultant to the ACC for both GAP projects. The data are from an analysis of medical records from the eight participating hospitals and six other hospitals in the Flint area that did not take part in the heart failure project, but had taken part in the heart attack project. Even though those hospitals were working to improve their heart failure care, their patients still had no changes in their 30-day mortality and rehospitalization rates.

In all, 30-day re-hospitalization rates for patients treated at the participating hospitals fell from 26.1 percent at the start of the project to 21.7 percent by the end, compared with a slight increase among patients treated at the non-participating hospitals. The 30-day mortality rates fell from 9.4 percent at the beginning to 7 percent at the end at participating hospitals, compared with a jump from 8.5 percent to 10.7 percent in non-participating hospitals.

The project began in 2003 when lead physicians and nurses from each of the eight hospitals came together in a series of learning sessions to develop tools that could

be used in each hospital to ensure the heart failure patients received optimal care. They based the tools on ACC/AHA guidelines, which recommend treatments based on medical evidence from research studies. Some of the tools and tactics were patterned after those already in use for heart failure treatment at the U-M Health System, considered a leader in heart failure care.

For instance, they wrote standard orders for drugs called beta blockers, diuretics, ACE inhibitors and aldosterone antagonists -- all of which have been shown to help reduce problems in heart failure patients. A standard order means that a doctor is automatically prompted to prescribe certain drugs to all heart failure patients, except to those with underlying reasons not to take the drugs.

Standards also included in-hospital counseling heart failure patients on stopping smoking, exercising, limiting their salt intake to prevent fluid retention, and other lifestyle steps that have been shown to keep heart failure from worsening or slow its progression.

Another key element was the discharge contract, which patients, doctors and nurses all had to read, understand and sign before the patient could go home from the hospital. Heart failure patients can do a lot at home to help their health and prevent another crisis that will send them back to the hospital -- but it can be difficult to keep up with all the medications and lifestyle actions.

The discharge contract, which explains the individual at-home plan for each patient, makes doctors and nurses stop to make sure that all prescriptions have been written and educational sessions have been conducted before the patient goes home. But it also helps patients get a sense of responsibility for what they must do at home to stay out of the hospital for as long as possible.

After developing the toolkit cooperatively, the lead physicians and nurse liaisons from each hospital met several more times to share successes and problems, and learn from one another. The goal, Koelling says, was to have as many of the tools used in the treatment of as many patients at each hospital as was possible. Today at the AHA meeting, he will show that while no hospital was able to ensure that every patient's care was governed by all the tools, the percentages rose significantly from the start of the project to the end.

Koelling and his colleagues will soon make the toolkit elements available on the Web at www.acc.org. Meanwhile, the heart attack toolkit and framework for implementing it are now available online at content.onlinejacc.org/content/vol46/10_Suppl_B/. The research project was funded by unrestricted grants from AstraZeneca Pharmaceuticals; Pfizer, Inc.; GlaxoSmithKline and the Blue Cross Blue Shield of Michigan Foundation. The data were drawn from Medicare and Medicaid records analyzed by an independent firm, DynKePRO, from the period before and after the toolkit was implemented.

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