Much attention has been paid to heart failure centers in partnership with hospitals, particularly since the Centers for Medicare and Medicaid Services adopted the demonstration project for patients with congestive heart failure, in which reimbursement to hospitals was tied to performance on five core measures.

Since that time, many hospitals have feverishly sought to improve their compliance with these metrics all the while aiming to convince CMS that HF programs are good for patients, good for payers and good for providers.

Despite these efforts, however, it has been difficult to show that true improvement in HF care can be had by simply documenting many of the parameters for patients hospitalized for CHF.

In fact, a paper by Fonarow based on the Optimize-HF data set called to question whether these core measures have any ability to affect 30-day mortality and re-admission.

Physician involvement key

Certainly all of the five core measures are laudable health goals, particularly for those with HF. However, most would have little impact on 30-day mortality. Determination of left ventricular systolic function is extremely important to discern systolic from diastolic HF so that appropriate therapy can be instituted. However, this metric primarily would impact individuals who had impaired systolic function and needed to be on an ACE inhibitor. Yet the major ACE inhibitor studies have failed to show a difference between the control group and the treatment group until approximately 90 days after starting drug therapy.

Similarly, smoking cessation is clearly a public health initiative that merits advancement but halting cigarette smoking would likely have very little effect on 30-day admission for HF and/or 30-day mortality.

The use of discharge instructions may have the highest chance of success because poor compliance with medication is a major factor contributing to cardiovascular morbidity and mortality in HF. The difficulty is that much of medication reconciliation has been misdirected to noncardiac medications and therefore has little impact.

In aggregate, these core measures are clearly important for our patients’ well-being, but HF clinics and initiatives must not stop there. The HF practice involves much more than a brief encounter with an individual at the end of the hospital stay. It involves physician-directed comprehensive management of both the HF state and other co-morbid illnesses that may be present in this elderly and complex patient population. Physician involvement continues to be key because without physician involvement there is now substantive data from the COACH (Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure) trial suggesting nonphysician-based interventions may well not offer the same long-term beneficial effects to our patients.

COACH results

By placing improper emphasis on these inappropriate measures, care-givers and patients lose sight of the truly valid metrics. It is common for patients to be discharged with a list of medications and no way to pay for them. Similarly many individuals are asked to monitor their salt intake but have no idea what to do or who to call if they again feel short of breath.

COACH was a trial performed in 17 centers in the Netherlands and followed more than 1,000 patients for 18 months. The patients were divided into three groups: usual care, basic education and intensive education. Despite a six-fold increase in the follow-up in the basic group and a 16-fold increase in the intensive education group, there was no difference noted in the end point of HF hospitalization or death.

Upon closer examination, COACH echoes the sentiment that most HF specialists continue to promote. That is, the only way the true HF initiative is capable of affecting patient outcome is when it is a partnership between physicians and nursing in cooperation with hospitals and payers. COACH, as well as the experience gained with CMS core measures, demonstrates that simple education without the intervention required to normalize the patient’s volume status and to advance their therapy will fail to prevent frequent re-admissions.

The HF clinic is the mainstay of treatment for these individuals who constantly impact the medical system. Physician-directed programs can and do make a difference. The future challenge will be whether they can survive under the pressure of declining reimbursement and little attention by CMS to the real core measures.

References
  * Frank W. Smart, MD, is Chair of Cardiology at The Gagnon Heart Hospital at Atlantic Health, Morristown, N.J., and a member of the Cardiology Today Editorial Board.
  * Fonarow GC; Abraham WT; Albert NM et al. Hospitalized with heart failure. JAMA. 2007;297:61-70.
  * The coordinating study evaluating outcomes of advising and counseling in heart failure (COACH-study) results: A head-to-head comparison of two non-pharmacological interventions. Special topic 415. Presented at: American College of Cardiology 56th Annual Scientific Sessions; March 24-27, 2007; New Orleans.

by Frank W. Smart, MD
Cardiology Today