How to Reduce Unwarranted Care Variation for Patients with Heart Failure – Part 2

October 27, 2022

Article Summary

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. 

Heart Failure

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. 

Why HF Care Standardization Matters 

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:  

  • Reduce morbidity, mortality, and total cost of care   
  • Improve management of comorbid conditions   
  • Delay disease progression and exacerbation  
  • Increase quality of life 
  • Achieve value-based care performance goals 

How to Build Standardized Care Processes 

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. 

  1. Systematized HF population health to address risk factors, including diseases (hypertension, diabetes, etc.) and lifestyle choices (smoking, diet, activity, etc.).
  2. Activation of patients in their care plan.
  3. GDMT-based outpatient care management focused on optimal dosing across four HF medication classes.
  4. Acute decompensation management treatment protocols aligned with the American College of Cardiology and the American Heart Association Joint Committee’s Clinical Practice Guidelines (e.g., GDMT).
  5. Smooth and effective transitions of care across settings and providers.

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. 

Systematized Population Health 

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: 

  • If the data demonstrate a high prevalence of patients with a blood pressure >140/90, an in-home BP monitoring and management protocol should be the first priority. 
  • If population demographics reveal a strong prevalence of unmanaged diabetes, an evidence-based diabetes clinic will drive long-term risk reduction. 
  • If obesity, unhealthy diets, and inactivity are the prevailing findings, a broader campaign may be in order to deliver community-based education, weight loss program enrollment, cognitive behavioral therapy opportunities, mobile food markets in food deserts, etc. 

Patient Activation 

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: 

  • Visit reminders and scheduling: Send reminders about the need for annual wellness visits if they are not already scheduled. Include links to scheduling systems to optimize follow-through. Likewise, reminders about upcoming visits and lab tests reduce no-shows and support timely treatment decisions. 
  • Screening and assessments: Annual screening (or more often if warranted) can help care teams identify evolving social determinants of health (SDOH) and automatically alert staff when changes may impact care decisions. These assessments may also identify risk factors that can trigger corollary pathways to encourage and coach patients in modifying lifestyle choices. Patient-reported outcome measures (PROMs) may also be collected at regular intervals. 
  • Care plan compliance: Communication pathways support care plan compliance for HF, as well as comorbid conditions such as diabetes, sleep apnea, hypertension, etc. Messages can educate and guide patients over time through short, simply phrased content. This improves understanding, provides motivation, and celebrates milestone achievements to encourage ongoing improvement. 
  • Medication adherence: Medication titration and management are particularly important in HF. Communication pathways can gather home monitoring data (weight, blood pressure, oxygen saturation) and patient-reported symptoms. This supports timely adjustment and addition of medication to achieve therapeutic doses of all four HF drug classes: renin-angiotensin-aldosterone system inhibitors (RAASIs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2Is).  

Outpatient Care Protocols 

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: 

  • Beta blockers, RAASI, and MRA medications are discontinued in the inpatient setting due to aggressive diuresis, mild drop in BP, or renal deterioration despite research findings that recommend continuation. 
  • Medications are often not resumed prior to discharge. 
  • Medication titration should take place every 1–2 weeks post-discharge but is rarely done. 
  • BP treatment goal should be <130/80 mmHg, though many providers are content with BPs <140/90 or greater. 
  • Medication titration attempts are often aborted for non-symptomatic changes in BP. 
  • Patients should be closely managed until they are on all four classes of medications, but often are not. 

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: 

  • Ongoing staff education 
  • Annual protocol updates, consistent with evidence-based guideline changes 
  • Pre-built post-discharge follow-up order sets and protocols 
  • Nurse navigator support 
  • Medication titration protocols to achieve target doses, inclusive of: 
  • Remote patient monitoring (RPM) utilization 
  • Patient engagement to gather symptoms and PROMs 
  • Ongoing routine heart health evaluations 
  • Monthly metrics monitoring of provider performance/compliance 
  • Community engagement programs 
  • Patient support groups 

Acute Decompensation Management 

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: 

  • GDMT should not routinely be discontinued for mild decrease of renal function or asymptomatic reduction of blood pressure. 
  • If discontinuation of GDMT is necessary during hospitalization, it should be reinitiated and further optimized as soon as possible. 

Streamlined Care Transitions 

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: 

  • Providing detailed discharge instructions and arranging a follow-up phone call within three days and an outpatient provider appointment within seven days 
  • Completing discharge summary in less than 24 hours and sending it to an outpatient provider 
  • Creating a plan for resuming medications held in the hospital and initiating new medications 
  • Addressing limitations in psychosocial support 
  • Providing a referral to palliative care specialists and/or enrollment in hospice in selected patients 

Case in Point: New Initiative Supports Cardiac Patients on a Better Path to Health

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: 

  • Written evidence-based guidelines 
  • Order sets 
  • Patient pathways 
  • Patient education materials 
  • Staff education support materials 
  • Process and clinical metrics to gauge success 
  • Implementation plans 
  • Communication plans 

Through the efforts of this dedicated team, MultiCare has seen the following outcome improvements in HF patients:  

  • 24 percent relative reduction in HF readmission rates 
  • 18 percent relative reduction in mortality rate 
  • 8.7 percent relative increase in LOS 

The organization’s ongoing improvement work has led to additional data-driven HF optimization work including: 

  • Implementation of a patient navigator program to make sure patients understand their respective care pathways, receive and understand any needed education, make and get their follow up appointments, take their medications appropriately, and inform the care team of changes in their condition. 
  • Development of an artificial intelligence model to improve the accuracy of HF readmission risk prediction, and thereby inform the medical treatment plan, discharge plan, and after hospital follow-up care to decrease the likelihood of avoidable readmission. 

“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. 

Additional Reading

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