HEART FAILURE PERFORMANCE MEASURES: NEW AND UPDATED. Connie White-Williams, PhD, RN, FAAN University of Alabama at Birmingham

Transcription

1 HEART FAILURE PERFORMANCE MEASURES: NEW AND UPDATED Connie White-Williams, PhD, RN, FAAN University of Alabama at Birmingham

2 DEVELOPMENT OF PERFORMANCE MEASURES American College of Cardiology Foundation (ACCF) American Heart Association (AHA) Physician Consortium for Performance Improvement (PCPI)

3 THE NATIONAL QUALITY FORUM (NQF) A nonprofit organization that operates under a three-part mission to improve the quality of American healthcare by: Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them Endorsing national consensus standards for measuring and publicly reporting on performance Promoting the attainment of national goals through education and outreach programs

4 NQF-ENDORSED MEASURES Congestive Heart Failure mortality rate Heart Failure 30-day mortality rate Congestive heart failure admission rate Heart failure 30-day risk standardized heart failure readmission rate Percentage of adult patients with primary diagnosis of heart failure who are readmitted for heart failure within 30 days of discharge Risk adjusted average length of inpatient hospital stay Overall inpatient hospital average length of stay (LOS) and average LOS by diagnosis related group category

5 CMS AND THE JOINT COMMISSION Center for Medicare and Medicaid Services mission is to provide access and quality health care The Joint Commission is dedicated to helping health care organizations prosper by improving quality of care and patient safety. Demonstrate role of the nurse in improving quality indicators

6 VALUE BASED PURCHASING Value Based Purchasing (VBP) is a new payment system incorporated into the existing Medicare Fee For Service (FFS) payment program that moves the Center for Medicaid and Medicare Services (CMS) from being a passive payer of services to becoming an active purchaser of high quality care. Links payments to quality and efficiency, not volume Evidence-based care, driven by process and outcomes Strongly patient-centered Provides transparency and patient access to information about quality, safety, and cost of care Uses clinical process, outcomes, and satisfaction measures to both penalize and reward

7 HF PERFORMANCE MEASURES Outcome Measures Addresses patient-centered outcomes Process Measures Addresses underuse of effective services (diagnostic and treatment strategies) Addresses underuse of patient-centered outcomes Addresses care coordination Paired/bundle Measures Addresses underuse of effective services (diagnostic and treatment strategies)

8 HF PERFORMANCE MEASURES Outcome Measures Measure 4: Symptom management

9 HF PERFORMANCE MEASURES Process Measures Measure 1: Left ventricular ejection fraction assessment (Outpatient) Measure 2: Left ventricular ejection fraction assessment (Inpatient) Measure 6: Beta-blocker therapy for left ventricular systolic dysfunction Measure 7: Angiotensin-converting enzyme inhibitor or Angiotensin-receptor blocker therapy for left ventricular systolic dysfunction

10 HF PERFORMANCE MEASURES Process Measures Measure 8: Counseling regarding implantable cardioverter-defibrillator implantation for patients with left ventricular systolic dysfunction on combination medical therapy Measure 3: Symptom and Activity assessment Measure 5: Patient Self Care Education Measure 9: Post-discharge appointment for heart failure patients

11 HF PERFORMANCE MEASURES Paired/Bundled Measures Measure 6: Beta-blocker therapy for left ventricular systolic dysfunction Measure 7: Angiotensin-converting enzyme inhibitor or Angiotensin-receptor blocker therapy for left ventricular systolic dysfunction

12 Outcome Measures MEASURE 4: SYMPTOM MANAGEMENT (OUTPATIENT) Evaluation and documentation of activity and clinical symptoms (improved, consistent, deteriorated) since last assessment Documented plan of care to include reevaluation of medical therapy, uptitration of doses, consideration of device therapy, lifestyle modifications, palliative care, referral for more advanced therapies or disease management program Addresses patient centered outcomes AHA update, 2010

13 PROGRESS NOTE Patient returns for follow-up of his multiple medical problems. He is still living alone in his own home. He doing fairly well, except his appetite is not very good. His medicines are the same since last seen. He does have some intermittent nausea, which is being helped by Tums. He has Class III dyspnea secondary to his heart failure, and rare chest pain that is relieved by nitroglycerin. He denies syncope or palpitations. He does sleep on 1-2 pillows. He denies any PND or swelling. His angina is early Class III.

14 PLAN OF CARE Impression: Stable on current medications. No clinical signs and symptoms of worsening heart failure, but symptoms are baseline Class III. Angina persists, stable but severe Plan: Continue current medications. Refill medicines. Return to clinic to see us in 8 weeks for follow-up with Chem 7.

15 Process Measures MEASURE 1: LEFT VENTRICULAR EJECTION FRACTION ASSESSMENT (OUTPATIENT) MEASURE 2: LEFT VENTRICULAR EJECTION FRACTION ASSESSMENT (INPATIENT) Percentage of patients 18 years or older with a diagnosis of HF that have documented LVEF assessment within 12 months (outpatient) Prior to hospital arrival, during admission or documented in medical record that LVEF will take place after discharge Assess LVEF, left ventricular size, wall thickness, valve function (Class 1, Level of Evidence: C) Only 35.2% received evaluation of LVEF within 1 month (McGlynn, 2003)

16 RATIONALE FOR GUIDELINE ADHERE: Acute Decompensated Heart Failure National Registry 223 hospitals, July 2002 to December 2003 LV Function documented 84% of 69,069 admissions (Fonarow, Arch Intern Med, 2005) National average increased to 96.2% in (Joint Commission, 2009) Ongoing review of patients clinical status critical to appropriate treatment selection and monitoring

17 HEART FAILURE LVS FUNCTION

18 Process Measures Paired/ Bundled Measures MEASURE 6: BETA-BLOCKER THERAPY FOR LEFT VENTRICULAR SYSTOLIC DYSFUNCTION Percentage of patients with current or prior LVEF < 40% prescribed a beta-blocker within 12 months in the outpatient setting or at discharge Paired with Measure 7 Using 1 of 3 beta-blockers (bisoprolol, carvedilol, sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF unless contraindicated (Class 1, Level of Evidence A) (ACCF/AHA, 2009)

19 HFSA 2010 Practice Guideline Beta Blockers Recommendation 7.8 Beta blocker therapy is recommended for patients with a recent decompensation of HF after optimization of volume status and successful discontinuation of intravenous diuretics and vasoactive agents, including inotropic support. Whenever possible, beta blocker therapy should be initiated in the hospital setting at a low dose prior to discharge in stable patients. Strength of Evidence = B Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.

20 HFSA 2010 Practice Guideline Beta Blockers Summary of Recommendations General Initiate at low doses Up-titrate gradually, generally no sooner than at 2 week intervals Use target doses shown to be effective in clinical trials Aim to achieve target dose in 8-12 weeks Considerations if symptoms worsen or other side effects appear Considerations if uptitration continues to be difficult If an acute exacerbation of chronic HF occurs Maintain at maximum tolerated dose Adjust dose of diuretic or other concomitant vasoactive medication Continue titration to target dose after symptoms return to baseline Prolong titration interval Reduce target dose Consider referral to a HF specialist Maintain therapy if possible Reduce dosage if necessary Avoid abrupt discontinuation If discontinued or reduced, reinstate gradually before discharge Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.

21 Process Measures Paired/ Bundled Measures MEASURE 7: ACE INHIBITOR OR ARB THERAPY FOR LEFT VENTRICULAR SYSTOLIC DYSFUNCTION Percentage of patients with current or prior LVEF < 40% prescribed ACE inhibitor or ARB within 12 months in the outpatient setting or at discharge Paired with Measure 6 Treatment with ACEI are recommended for all patients with current or prior symptoms of heart failure (Class 1, Level of Evidence: A) (ACCF/AHA, 2009)

22 HFSA 2010 Practice Guideline (7.1, 7.7) Pharmacologic Therapy: ACE Inhibitors ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF 40%. Strength of Evidence = A ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF 40%. Post MI Strength of Evidence = B Non Post-MI Strength of Evidence = C Adapted from: Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.

23 ACE INHIBITORS USED IN CLINICAL TRIALS Generic Name Trade Name Initial Daily Dose Target Dose Mean Dose in Clinical Trials Captopril Capoten 6.25 mg tid 50 mg tid mg/day Enalapril Vasotec 2.5 mg bid 10 mg bid 16.6 mg/day Fosinopril Monopril 5-10 mg qd 80 mg qd N/A Lisinopril Zestril, Prinivil mg qd 20 mg qd 4.5 mg/day, 33.2 mg/day* Quinapril Accupril 5 mg bid 80 mg qd N/A Ramipril Altace mg 10 mg qd N/A qd Trandolapril Mavik 1 mg qd 4 mg qd N/A Lindenfield et al, 2010 HFSA Comprehensive Heart Failure Guidelines, J Cardiac Failure, 2010

24 ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative 100 Val-HeFT 50 CHARM-Alternative Survival % Placebo Valsartan CV Death or HF Hosp % Placebo Candesartan p = HR 0.77, p = Months Months Maggioni AP et al. JACC 2002;40: Granger CB et al. Lancet 2003;362:772-6

25 ARBS USED IN CLINICAL TRIALS Generic Name Trade Name Initial Daily Dose Target Dose Mean Dose in Clinical Trials Candesartan Atacand 4 8 mg qd 32 mg qd 24 mg/day Losartan Cozaar mg qd 150 mg qd 129 mg/day Valsartan Diovan 40 mg bid 160 mg qd 254 mg/day Lindenfield et al, 2010 HFSA Comprehensive Heart Failure Guidelines, J Cardiac Failure, 2010

26 HEART FAILURE ACEI OR ARB Top Hospitals 100%

27 Process Measures MEASURE 8: COUNSELING REGARDING ICD IMPLANTATION FOR PATIENTS WITH LV SYSTOLIC DYSFUNCTION ON COMBINATION MEDICAL THERAPY Percentage of HF patients with current LVEF 35% despite 3 months on ACEI or ARB and beta-blocker therapy who were counseled on ICD implantation for prophylaxsis against sudden death 51% of eligible patients were prescribed ICD or cardiac resynchronization therapy (Fonarow, Arch Intern Med, 2005) Less than 40% of eligible hospitalized patients received ICD therapy, disparities exist (Lloyd-Jones et al., Circulation 2010)

28 Process Measures MEASURE 3: SYMPTOM AND ACTIVITY ASSESSMENT Evaluation of current level of activity and clinical symptoms documented New York Heart Association functional classification Initial and each subsequent assessment: ability to perform activities of daily living (ACCF/AHA, 2009) Type, severity and duration of symptoms Evaluation to identify etiology, symptom nature, functional impairment, prognosis of established heart failure (HFSA, 2010) Document ability to perform ADLs and grade by NYHA class or 6 minute walk (HFSA, 2010)

29 Process Measures MEASURE 5: PATIENT SELF CARE EDUCATION Percentage of patients provided self care education (3 or more elements) during 1 or more visits in 12 months Self care education includes: definition and cause of HF, recognition and plan of response of worsening symptoms, medication, risk factor modification, diet, alcohol, activity and exercise, adherence, weight monitoring

30 EVIDENCE BASED DISCHARGE TEACHING Paul, CCN, 2008

31 ACTIVITY AND EXERCISE Consult with the patient s physician before recommending exercise program Teach patient to keep an exercise diary include time, duration and any symptoms experienced during exercise Patients with severe, symptomatic left ventricular dysfunction can benefit from an individually tailored exercise program based on the results of formal exercise testing (Fletcher et al., 2001). Patients with uncontrolled edema and persistent crackles should not be encouraged to exercise until their HF is stabilized Paul S. Hospital Discharge Education for Patients with Heart Failure: What Really Works and What is the Evidence? Critical Care Nurse. 2008; 28(2):

32 DIET Encourage a heart-healthy diet that includes: > 5 servings of fruits and vegetables and > 6 servings of grain products per day. Fat-free and low-fat milk products, fish, legumes (beans), skinless poultry and lean meats. <3 grams of salt (sodium chloride) per day (2,400 milligrams of sodium). Teach patient Limit fats and cholesterol Avoid foods high in sodium to help avoid fluid overload AHA: Eating Plan for Healthy Americans, Oct 2010

33 SMOKING Smoking damages blood vessels, reduces the amount of oxygen in the blood and increases the HR Nicotine disrupts lipid metabolism by LDL and HDL Carbon monoxide interferes with oxygen transport and increases myocardial workload Smokers are not considered for heart transplants Smoking Education Resources: American Lung Association 800-LUNG-USA, American Heart Association,

34 SYMPTOMS New onset SOB or awakening with SOB New onset inability to sleep flat Weight gain of 2-3 pounds or more in one day or 5 pounds or more in one week New or increased edema of ankles or legs New onset or increased dizziness and/or syncope New or increased cough Pulse <60 or >100 Albert N, Trochelman K, Li J, Lin S. Signs and Symptoms of Heart Failure: Are you asking the Right Questions? American Journal of Critical Care. 2010; 19(5):

35 SELF CARE TEACHING o o o o o o o o o o o o o Maintain current immunizations Develop system for taking all medications as prescribed Monitor for unexpected decline in body weight + signs/symptoms of worsening HF Restrict dietary sodium Restrict alcohol intake Avoid other recreational toxins, especially cocaine Cease tobacco use and avoid exposure to second-hand smoke Identify + seek treatment early for emotional distress, e.g., depression / anxiety Tell your provider about sleep disturbances Achieve and maintain physical fitness Visit your provider at regular intervals Talk to pharmacist or other provider about herbal medicines If diabetic, achieve diabetes mellitus treatment goals Riegel B. et al. State of the Science. Promoting self care in persons with heart failure. Circulation. 2009;120:

36 CMS MANDATES THAT ALL HEART FAILURE PATIENTS RECEIVE PRINTED INSTRUCTIONS AT DISCHARGE The six areas to be addressed are: Activity level Diet Follow-up Medications Symptoms of worsening heart failure Weight monitoring

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38 Process Measures MEASURE 9: POST-DISCHARGE APPOINTMENT FOR HEART FAILURE PATIENTS Percentage of patients discharged with a documented follow up appointment

39 HFSA 2010 Practice Guideline (12.25, Table 12.7) Discharge Criteria for Hospitalized ADHF Patients Recommended prior to discharge for all patients with HF: Exacerbating factors addressed Near optimum fluid status and pharmacologic therapy achieved Transition from IV to oral diuretic completed Patient education completed with clear discharge instructions Follow-up clinic visit scheduled, usually 7-10 days Should be considered prior to discharge for patients with advanced HF or a history of recurrent admissions: Oral regimen stable for 24 hours No IV inotrope or vasodilator for 24 hours Ambulation before discharge to assess functional capacity Plans for post-discharge management Referral for disease management, if available Strength of Evidence =C Adapted from: Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.

40 2005 Measure 2011 Measure Change Rationale Evaluation of LVS function (1 and 2) LVEF Assessment Inpatient and Outpatient Added qualitative description of LVEF Provides important information required to direct evidence based treatment Beta blocker therapy (6) Beta blocker therapy for LVSD (outpatient and inpatient) Added inpatient setting Added specific beta blockers 2009 ACCF/AHA guideline recommend specific evidence based BB be prescribed, Class I BB at discharge ACEI or ARB therapy for LVSD (7) ACEI or ARB therapy for LVSD Inpatient and Outpatient Combines inpatient and outpatient Added definition of prescribed Simplified exclusions Recent national registry data indicated use is still suboptimal especially in outpatient setting

41 2005 Measure 2011 Measure Change Rationale No measure in 2005 (8) Counseling about ICD implantation for patients with LVSD combination therapy New, to be used as quality metric ICD highly effective in preventing sudden death Recent registry data suggest 50% of eligible patient do not undergo implantation of ICD or cardiac resynchronization therapy Bonow et al., ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults with Heart Failure. JACC, 2012

42 2005 Measure 2011 Measure Change Rationale No measure in 2005 Assessment of activity Assessment of clinical symptoms of volume overload No measure in 2005 Patient education (9) Postdischarge appointment for HF patients (3) Symptom and activity assessment (4) Symptom Management (5) Patient self care education New Combination of the two original measures New, to be used as a quality metric The measure has changed to a quality metric. Developed with the intent to have an impact on readmission and mortality Provides a more comprehensive assessment of patient s status Decreasing symptoms and improving function are the 2 main goals of HF treatment Based on expert opinion Focus on Quality of education, not just compliance

43 SO HOW DO WE MEASURE UP? GET WITH THE GUIDELINES Get With The Guideline s Program Participat ion, Process of Care, and Outcome for Medicare Patients Hospitaliz ed With Heart Failure. Heidenrei ch, Paul; MD, MS; Hernande z, Adrian; MD, MHS; Yancy, Clyde; Liang, Li; Peterson, Eric; MD, MPH; Fonarow, Gregg Circulatio n: Cardiovas cular Quality & Outcomes. 5(1):37 43, January 2012.

44 HOW DO YOU MEASURE UP? WHAT IS YOUR HOSPITAL DOING TO IMPROVE CARE?