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  1. 1. Improving the Management of Patients with Heart Failure Joseph J. Benich III, MD Trident/MUSC Family Medicine Residency Program
  2. 2. Heart Failure (HF) <ul><li>Common problem in primary care: </li></ul><ul><ul><li>Prevalence - 4.9 million people in US </li></ul></ul><ul><ul><li>Incidence - 550,000 people each year in US </li></ul></ul><ul><li>Guidelines established: </li></ul><ul><ul><li>American College of Cardiology and the American Heart Association </li></ul></ul><ul><li>Many clinic patients are not receiving optimized treatment regimens in accordance with these guidelines </li></ul>
  3. 3. I3 Collaborative <ul><li>A Practice Innovations Collaborative for Family Medicine Educators in North and South Carolina </li></ul><ul><ul><li>Trident/MUSC FM Program participating </li></ul></ul><ul><li>Purpose: </li></ul><ul><ul><li>To monitor and improve the care being provided by FM Residencies in NC and SC, especially focusing on the care being provided to patients with diabetes and HF </li></ul></ul>
  4. 4. Trident/MUSC Family Medicine <ul><li>Purpose: </li></ul><ul><ul><li>Are the chronic care model and quality improvement initiatives effective approaches to managing patients with HF in the Trident/MUSC FM Residency Practice? </li></ul></ul>
  5. 5. Measures <ul><li>Process measures: </li></ul><ul><ul><li>Percentage of patients with ejection fraction (EF) measured </li></ul></ul><ul><ul><li>EF <40% on ACE-inhibitor or angiotensin receptor blocker (ACEI/ARB) </li></ul></ul><ul><ul><li>EF <40% on beta blocker (BB) </li></ul></ul><ul><li>Outcome measures: </li></ul><ul><ul><li>Hospital admission and readmission rates </li></ul></ul>
  6. 6. Methods <ul><li>Patient registry: </li></ul><ul><ul><li>Adults with HF based on ICD-9 codes and either outpatient or inpatient contact </li></ul></ul><ul><ul><li>Baseline chart review to evaluate process and outcome measures </li></ul></ul><ul><ul><li>Updated quarterly with patients seen in the past 6 months </li></ul></ul><ul><li>Approved as exempt research by the MUSC IRB </li></ul>
  7. 7. Methods <ul><li>Interventions: </li></ul><ul><ul><li>Delivery system redesign - case management </li></ul></ul><ul><ul><ul><li>Additional clinic appointments scheduled at least once in every 3 month block to allow for desired changes to be made to current treatment regimens </li></ul></ul></ul><ul><ul><li>Collaboration with I3 programs </li></ul></ul><ul><ul><ul><li>Monthly conference calls to share data and senior leader reports </li></ul></ul></ul>
  8. 8. Results: Demographics Quarter # of Patients EF Documented % HF Systolic Baseline 32 87% 33 1 st 42 94% 28 2 nd 36 98% 33 3 rd 37 100% 38
  9. 9. Results: Process measures <ul><li>Percentage of patients on ACE/ARB, BB therapy with EF < 40% </li></ul><ul><li>Best Practice = EF measured on ACE/ARB + BB </li></ul>Quarter ACEI/ARB BB Best Practice Goal 80% 60% 60% Baseline 62% 69% 46% 1 st 44% 89% 44% 2 nd 79% 86% 64% 3 rd 79% 86% 64%
  10. 10. Results: Outcome Measures Quarter Admissions (%) Re-admissions (%) Baseline 51 21 1 st 53 22 2 nd 50 24 3 rd 24 8
  11. 11. Discussion <ul><li>Goals are being met for the percentages of patients who have EF measured and who are taking ACEI/ARB and BB </li></ul><ul><li>Hospitalization and re-hospitalization rates are decreasing </li></ul>
  12. 12. Future Direction <ul><li>Decision support </li></ul><ul><ul><li>Redesigning electronic health record templates to embed point of care reminders from HF guidelines </li></ul></ul><ul><li>Self management plans need to be created and implemented </li></ul><ul><ul><li>Monitoring weights at home is the next step, once electronic health record revised </li></ul></ul>
  13. 13. Conclusion <ul><li>HF is a serious condition with high morbidity and mortality commonly managed in primary care </li></ul><ul><li>Applying the principles of the chronic care model and quality improvement are effective approaches to the management of patients with HF </li></ul><ul><li>I3 collaborative is an effective organization for optimizing the care of patients </li></ul>