Keeler 02/04

Changes in Care and Outcomes for Patients with Congestive Heart Failure:

The Improving Chronic Illness Care Evaluation

David W. Baker, MD, MPHChief, Division of General Internal Medicine

Feinberg School of Medicine, Northwestern University

Chicago, Illinois

June 6, 2004

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Changes in Processes of Care: Methods for Chart Reviews

• 4 participant organizations (PART): N = 261

• 4 control organizations (CTRL): N = 228

• Charts abstracted at baseline (7/98 to 5/99) & follow-up periods (9/99 to 8/00).

– 23 Quality Indicators: Dx, Rx, F/u, Counseling

• Determined changes in processes from baseline to follow-up period.

– Compared differences b/n PART vs. CTRL.

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Baseline Characteristics

PART CTRL

Age, mean yrs 67 66

Male 68 64

New CHF Diagnosis 15* 8

LVEF < 40 % 47 48

Mean # of Chronic Dz 5.9 6.1

Mean # of Visits/Year 9.2 9.1

Hospitalized 35 36

* p = 0.01

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Participants & Controls Had Similar Changes in Diagnostic Testing

PART

(abs % chg)

CTRL

(abs % chg)

p

LVEF measured 16 13 .49

Cr measured if on digoxin -3 0 .65

BP measured at MD visit 6 8 .15

LDL measured if CAD 4 -9 .09

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Participants Increased Use of ACE Inhibitors and Lipid-Lowering Rx

PART

(abs % chg)

CTRL

(abs % chg)

p

ACEI for LVEF < 40 % 13 -5 <.001

Beta blockade for LVEF < 40 %

5 7 .49

Anticoagulation for atrial fibrillation

-8 -5 .11

Lipid-lowering therapy for CAD

7 1 <.001

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Participants Increased CounselingPART CTRL P

Medication 24 -1 <.0001

Diet 33 -4 <.0001

Exercise 24 -2 <.0001

Smoking -6 6 .16

Weight loss 30 -2 <.0001

Disease management 41 4 <.0001

Weight management 24 3 <.0001

Goal setting 4 0 <.0001

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Conclusions from Chart Review• Organizations that participated in the CHF

Collaborative improved more than controls:– ACE Inhibitors for pts w/ LVEF 0.40– Lipid lowering therapy for pts w/ CAD– All aspects of counseling x/ smoking

• No difference in change over time for:– LVEF measurement– Beta blocker use, anticoagulation– Other diagnostic tests, follow-up

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Limitations of Results from Chart Review

• Brief period for participants to improve care.– Differences between PART and CTRL

groups may have increased over time.

• Large improvements in care for pts in CTRL group, perhaps due to other QI forces.

• Improvement in patient counseling could be due to better documentation, gaming.

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Differences in Communication, Education, and Health Status: Methods for Patient Surveys

• 6 participant organizations (PART): N = 387

• 6 control organizations (CTRL): N = 414

• Telephone interviews conducted with patients approximately 10 months after collaborative.

• Survey developed for this study.

• Determined differences b/n PART vs. CTRL.

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CHF Team

Satisfaction

Communication

Education

ACCESS

QUALITY

Knowledge

SELF-MANAGEMENT Self-Efficacy

Improved Health Outcomes

Conceptual Model of How a CHF Team Acts to Improve Self-management, Access,

Quality, and Health Outcomes.

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Domains Included in Questionnaire• Communication (4 item scale)

• Satisfaction (CAHPS)

• Education (15 items)

• Knowledge (15 items): sx, high salt foods, general knowledge and self-management.

• Behaviors: daily weights, low salt diet.

• Self-efficacy

• Generic (SF12) and CHF-specific health status (7 item scale)

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Participant CharacteristicsPART CTRL

Age 65 (%) 61 63

Female (%) 52 53

White 70 73

Less than High School 40 41

History of CAD, % 64 69

History of CABG, % 24 22

Hx of Revascularization % 66 61

Primary Care Physician 30* 39*p = 0.02

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Participants Had Better Provider-Patient Communication

PARTmean

CTRLmean

p

Gave me choices and options about my treatment

3.9 3.7 0.03

Gave me confidence that I can make changes in my life to control my HF.

4.1 3.9 0.01

Were interested in my questions. 4.2 4.1 <0.01

Regularly reviewed how I am doing in managing all aspects of my HF.

4.0 3.9 <0.01

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Participants Reported More Education About Lifestyle and Monitoring HF

ADVISED TO: PART CTRL p

Not use salt when cooking and not to add salt to food.

91 83 0.05

Avoid drinking large amounts of water/other fluids.

59 38 0.01

Weigh self on a scale every morning and record weight.

87 34 < 0.01

Exercise regularly. 90 83 <0.01

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Participants Had Better HF Knowledge*

*p < 0.001 for all comparisons PART

(%)CTRL

(%)

A person with HF should not drink more fluids than normal.

70 53

Someone with HF should check wt at least several times/week.

84 44

Shortness of breath is a sx of HF. 61 55

Swelling of the legs or ankles is a symptom of HF.

80 70

Weight gain is a symptom of HF. 76 61

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Participants Had Better Weight Monitoring, but Similar Diet Compliance

PART CTRL p

Has functioning scale at home (% yes).

93% 81% <0.01

How frequently checks weight (1-5 scale, mean)

4.2 3.2 <0.01

Took steps to eat low salt diet. 88% 85% 0.35

Success at adhering to low salt diet (1-3 scale, mean)

2.1 2.1 0.48

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Conclusions from Survey• Organizations in the Collaborative had:– Better communication.– Higher self-reports of education received– Higher knowledge, including symptoms of

heart failure and weight monitoring– Higher rates of monitoring weight

• No differences for self-efficacy, satisfaction, low salt diet compliance, and health status.

• Conclusions limited by lack of baseline data.

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Final Conclusions from Evaluation

• Participation in the CHF Collaborative was associated with improvements in care, includ-ing prescribing of recommended therapies and patient self-management support.

• Chart review and patient survey support each other’s findings that there were large improve- ments in education and counseling. Viewed together, they mitigate the limitations in each.