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

1. Decrease Unnecessary Hospitalizations, Tests and Treatments for Heart Failure

2. Increase Use of Life-Prolonging Therapy

3. Increase Use of Therapy that Improves Quality of Life

Goal 1. Decrease Unnecessary Hospitalizations, Tests and Treatments for Heart Failure
The overall aim of this goal is to increase the efficiency of VA heart failure care. A reduction in avoidable care is our primary goal because it is a major economic burden for the VA due to the high cost of inpatient care and concern over excessive use of cardiac imaging.

Preventable readmissions and 30-day all-cause readmission rates. During the last three years, a primary goal has been reducing 30-day all-cause readmissions. While reducing the 30-day all-cause readmission rate remains an interest due to it being publically reported on HospitalCompare.gov, ongoing HSR&D and QUERI funded studies suggest that preventable readmissions are much less common than previously thought and potentially preventable readmissions are difficult to predict. For this reason we feel our efforts best spent on additional areas of potential overuse including overall admissions for heart failure (not just readmissions). We are also evaluating alternatives to the 30-day readmission rate that capture resource use following discharge and are more patient centered. An example is the number of days alive out of the hospital during the year following admission.

In order to achieve this goal we have defined five specific objectives. Fortunately, treatments that improve mortality (goal 2), and quality of life (goal 3) also reduce admission rates. Thus many of our strategies to achieve one goal will help achieve all three goals (e.g. increased use of aldosterone antagonists). The first objective is to identify and predict preventable admissions for heart failure. The second is to improve transition of care following hospital discharge. This practice should improve overall care, even if such improvement is not reflected in a reduction in the 30-day readmission rate. The third objective is to enhance coordination of primary care (PACT) and specialty care (heart failure). The fourth and fifth objectives aim at reducing inappropriate care in the VA and duplicate care for those receiving VA and Non-VA care.

Goal 2. Increase Use of Life-Prolonging Therapy
While there are multiple treatments known to prolong survival in patients with heart failure and depressed ejection fraction, many are already at a high level of use (angtiotensin converting enzyme inhibitors, beta-blockers). Devices such as implantable cardioverter defibrillators and cardiac resynchronization therapy are expensive, and while reasonably cost-effective by most estimates, they are not as high value (benefit per cost) as medication use. The one medication still used in a minority of candidates is aldosterone antagonists and for this reason is a primary objective of Goal 2.

Goal 3. Increase Use of Therapy that Improves Quality of Life
Progress on goals 1 and 2 will also lead to an improvement in quality of life because the treatments that improve readmission and survival also usually improve symptoms. However, there are select areas not directly related to survival that we will target for the ability to improve symptoms. The first objective is to address a common comorbidity of heart failure: atrial fibrillation. A second objective is to increase the abilities of patients and their caregivers to improve self-care care for heart failure. The third objective is to improve palliative care at the end-of-life.