In order to reduce unwarranted care variation for patients with heart failure, healthcare providers should consider five critical elements of care standardization including systematized population health, patient activation, outpatient care protocols, acute decompensation management, and streamlined care transitions.
When unwarranted care variation is eliminated, organizations will see a higher rate of evidence-based care that helps reduce morbidity, mortality, and total cost of care.
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Part 1 of this article explored the technical foundation of a comprehensive approach to eliminating unwarranted care variation in heart failure (HF) treatment—that which cannot be explained by personal preference, illness, medical need, or the dictates of evidence-based medicine. Part 2 examines the importance of data-informed clinical care practices.
Guideline-directed medical therapy (GDMT) improves outcomes. However, less than 25% of patients who have HF with reduced left ventricular ejection fraction (HFrEF) are on the appropriate medical regimen titrated to the target doses. When unwarranted care variation is eliminated, organizations will see a higher rate of evidence-based care that helps:
What does standardized care look like for patients with HF, and how can those best practices be applied across facilities, providers, and care teams? Five critical elements of care standardization can be adopted with the help of strong clinical leadership, direct physician involvement, and continuous program oversight through analytics monitoring.
Each of these standardization elements demands time and resources to ensure long-lasting change. Organizations are wise to approach these activities in a stepwise fashion that prioritizes high-value outcomes—clinical, financial, or operational—based on their unique situation. For example, some health systems experience reimbursement penalties and a high cost of care related to inpatient length of stay, readmissions, and mortality. Those entities should prioritize improvement work for acute decompensation management and care transition processes. Other organizations have committed to value-based care contracts. They would benefit from a greater focus on programs designed to mitigate risk factors and identify and manage patients within each of the four clinical classifications of HF.
Risk factor mitigation activities are most effective when they are targeted and personalized. Marketing and communications-driven outreach should also focus on key data findings about the patient population. As referenced in Part 1 of this article, technology is a powerful tool to automate outreach to specific patients and populations and ensure a standardized outreach approach. For example:
Patient-physician relationships help determine how active a role patients play in their health or healthcare. levels of patient activation of interpersonal exchange with physicians, greater fairness in the treatment process, and more out-of-office contact with physicians. However, a study commissioned by the American Health Information Management Association Foundation (AHIMA) found that a majority of Americans report they aren’t fully grasping the information discussed with their healthcare provider, leaving many confused and unsure of how to proceed.
Automated outreach is helping providers bridge the patient relationship gap. First organizations must identify the technologies to help them reach and engage more than 75% of their patient population. Then they can use standardized communication protocols and pathways to help patients become active participants in their lifetime health journey.
Each cohort merits unique content pathways designed to help patients self-manage illness, reduce health declines, be involved in treatment and diagnostic choices, collaborate with providers, and navigate the health system. A wide variety of communication pathways support a holistic approach to HF and may be automatically triggered by data within the EHR:
The lack of compliance with HF treatment guidelines has been documented in several studies. Per the 2022 AHA/ACC Clinical Practice Guidelines:
“…Based on information obtained from claims data, roughly 42% of patients are not prescribed any GDMT within 30 days post index hospitalization, and 45% are prescribed either no oral GDMT or monotherapy within 1-year post-hospitalization. In the management of patients with HF with reduced ejection fraction (HFrEF) in the community, very few receive target doses of oral GDMT. Moreover, most patients with HFrEF have no changes made to oral GDMT over 12 months, despite being discharged on suboptimal doses or no GDMT. It cannot be assumed that oral GDMT will be initiated or optimized after hospitalization for HFrEF.”
Flaws in each step of the care process lead to deviations from GDMT, including the following:
A variety of tactics may be used to standardize HF management in the ambulatory setting to improve mortality, morbidity, quality of life, and hospital admission and readmission rates. Organizations with a large population of patients with HF may benefit from a formalized heart and vascular clinic. Others should steer patients to specific providers that consistently demonstrate best-practice care. Tactics include:
The right technology can simplify the activation of standardized admission order sets and protocols. These include initial triage assessment, EF measurement, medication reconciliation, and risk stratification to determine the inpatient plan of care. GDMT based on HF stage is important to address the proper cardiovascular support. This starts with medication titration and regular patient monitoring of symptoms and physiologic status. Alerts and notifications can be set for immediate awareness of deviation from standard protocols or changes in a patient’s condition.
The growing and evolving knowledge about GDMT commands a formal process for updating order sets, protocols, and processes. Fundamental practice patterns may be hard for staff to modify, dictating the need for education, performance monitoring, and feedback to ensure lasting change. Examples of protocol changes in the 2022 AHA/ACA Clinical Practice Guidelines that are difficult to convert include the following:
Leverage technology to activate standardized discharge order sets and protocols, including checklists, reminders, and notifications for incomplete tasks. Prescription fulfillment—whether in-house or automated prescription transmission to the pharmacy—can improve workflows for medication reconciliation and patient support.
As with acute decompensation management, guidelines for care transitions also continue to evolve and require regular modification to incorporate the latest knowledge. Below are some recent changes to recommendations:
MultiCare regards continuous quality improvement as an essential value, which led to the formation of the HF Collaborative. It has spent several years increasing quality and standardizing care for HF and acute myocardial infarction (AMI) patients.
MultiCare’s HF Collaborative credits ready access to data as the fundamental driver for successfully implementing evidence-based practice. The ability to engage physicians with data and results that were readily available, reliable, and relevant—and then show them the impact on outcomes of their improvement efforts—proved very effective in driving adoption. They standardized the following, system-wide:
Through the efforts of this dedicated team, MultiCare has seen the following outcome improvements in HF patients:
The organization’s ongoing improvement work has led to additional data-driven HF optimization work including:
“We can no longer afford to think in a ‘bricks and mortar’ mentality that what happens in the hospital stays in the hospital and that everything that happens outside of it is invisible. That’s just not the practical reality of how we all experience healthcare,” said the President of MultiCare Accountable Care Organization.
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