Yancy et al. J Am Coll Cardiol. 2008;51:1675 84. Quality of Care of and Outcomes for African...

Yancy et al. J Am Coll Cardiol. 2008;51:167584.

Quality of Care of and Outcomes forAfrican Americans Hospitalized With Heart Failure: Findings From OPTIMIZE-HF (Organized Program To Initiate life-saving treatMent In hospitaliZEd patients with Heart Failure)

Clyde W. Yancy MD, FACC, William T. Abraham MD, FACC, Nancy M. Albert PhD, RN, Robert Clare, MS, Wendy Gattis Stough PharmD, Mihai Gheorghiade MD, FACC, Barry H. Greenberg MD, FACC, Christopher M. O'Connor MD, FACC, Jie Lena Sun MS, James B. Young MD, FACC and Gregg C. Fonarow MD, FACC for the OPTIMIZE-HF Investigators and Hospitals


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Disclosures

• Funding Support– GlaxoSmithKline funded the OPTIMIZE-HF registry

under the guidance of the OPTIMIZE-HF Steering Committee and funded data collection and management by Outcome Sciences, Inc (Cambridge, MA) and analysis of registry data at Duke Clinical Research Institute (Durham, NC)

• Individual author disclosures are listed in the manuscript


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Quality of Care of and Outcomes forAfrican American with HF

• Heart failure in African Americans is characterized by variations in natural history, lesser response to evidence based therapies, and disparate health care.

• We hypothesized that a performance improvement program will achieve similar adherence to quality measures in African Americans admitted with HF compared with non–African Americans.


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HF in African American Patients• African Americans have a greater prevalence of HF and a higher rate

of HF hospitalization and mortality than the general population1

• HF in African Americans presents at an earlier age, with more advanced LVSD and worse clinical class at the time of diagnosis2

• A-HeFT has suggested that among African American patients with HF and LVSD there is frequently a nonischemic etiology with a high prevalence of obesity and hypertension2,3

• African American patients may be less likely to receive guideline-recommended, evidence-based therapies due to less access to care4 or due to misconceptions from clinical trials5 that therapy is less effective in this population

1. American Heart Association. 2007 Heart and Stroke Disease Statistical Update. Dallas, Tex: American Heart Association; 2007. 2. Yancy C. Ethn Dis. 2002;12:S1S26. 3. Taylor AL, et al. N Engl J Med. 2004;351:20492057. 4. Yancy CW, Sica DA. J Clin Hypertens (Greenwich). 2004;6:5458. 5. Shekelle O. J Am Coll Cardiol. 2003;4141:1529-1538.


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Study Objective

• We sought to examine the characteristics, quality of care, and clinical outcomes for a large cohort of African-American patients hospitalized with heart failure (HF) in centers participating in a quality improvement initiative.


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OPTIMIZE-HF Program Objectives

• OPTIMIZE-HF is a national performance improvement initiative to improve guidelines adherence in patients hospitalized with HF

• Overall OPTIMIZE-HF program objectives: – Improve medical care and education of patients

hospitalized with HF – Accelerate initiation of HF evidence-based, guideline-

recommended therapies by starting these therapies before hospital discharge in appropriate patients without contraindications

– Increase understanding of barriers to use of ACEIs, -blockers, and other guideline-recommended therapies in eligible HF patients


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OPTIMIZE-HF Process-of-Care Intervention and Registry• “Process-of-care” intervention

– Enhanced inpatient HF care and education– Enhanced discharge planning– Care maps, pathways, and standardized order sets that

encouraged adoption of evidence-based therapies • ACEI and -blocker initiation before discharge• JCAHO performance indicators

– Educational programs to encourage adoption by providers

• Web-based registry – Tracks treatment rates and changes following

performance interventions– Captures JCAHO/ORYX Quality of Care indicators– Benchmarks comparisons between institutions– Enhances understanding of barriers to uptake


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OPTIMIZE-HF Performance Improvement Registry Protocol• Eligibility

– Adults hospitalized for episode of new or worsening HF as primary cause of admission, or with significant HF symptoms that develop during hospitalization when the initial reason for admission was not HF

– Includes patients with systolic dysfunction and/or isolated diastolic dysfunction (HF with preserved systolic function)

– Any admission satisfying JCAHO HF core measure criteria

• Prespecified subgroup (10%) with 60–90-day follow-up data– Survival, readmissions, and medical regimen– Informed consent required for follow-up

• The registry coordinating center was Outcome Sciences, Inc


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OPTIMIZE-HF Hospital CharacteristicsTotal Hospitals(N=259), n (%)

Follow-Up Hospitals(N=91), n (%)

Bed size: 0 to 99 31 (12) 9 (10)

100 to 249 58 (22) 21 (23)

250 to 499 103 (40) 40 (44)

500 to 749 38 (15) 13 (14)

750 13 (5) 4 (4)

Unknown 16 (6) 4 (4)

Academic* 118 (48) 48 (55)

Transplant program* 34 (14) 9 (10)

Interventional† (CABG/PCI) 163 (67) 62 (70)

Region‡: Midwest 68 (27) 27 (30)

Northeast 44 (17) 14 (16)

South 87 (34) 34 (38)

West 56 (22) 15 (17)

* N=246, n=88; † N=245, n=88; ‡ N=255, n=90.

CABG/PCI = coronary artery bypass graft/percutaneous coronary intervention.


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OPTIMIZE-HF Patient CharacteristicsHospital Cohort

(N=48,612)Follow-Up Cohort

(N=5,791)

Age, mean (years) 73.1 72.0

Male (%) 48 51

Caucasian (%) 74 78

Ischemic etiology (%) 46 42

LVEF, mean (%) 39.0 36.9

LVSD (% of those assessed) 48.8 53.2

Insulin-treated diabetes (%) 17 17

Non–insulin-treated diabetes (%) 25 26

Hypertension (%) 71 72

Rales (%) 64 62

Mean SBP (mmHg) 143 140

Mean heart rate (bpm) 87 86

Mean sodium (mEq/L) 136.7 136.8

Mean serum creatinine (mg/dL) 1.8 1.7

Mean hemoglobin (g/dL) 12.1 12.2


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HF Etiology by Race

African American Patients

31.3

29.5

39.2

Non–African American Patients

19.3

49.4

31.3

Hypertensive Etiology Other* Ischemic Etiology

*Other etiologies include postpartum, valvular, familial, alcohol/other drug, other, chemotherapy, unknown/idiopathic, and viral. P.0001 between both groups for each etiology.


Patient Characteristics by Race

Characteristic

African American (n=8,608)

Non-African American (n=38,581) P Value

Mean Age, years (SD) 63.6 (15.4) 75.3 (12.7) 0.0001

Female (%) 52.7 51.4 0.0287

Hypertensive Etiology (%) 39.2 19.3 0.0001

Ischemic Etiology (%) 29.5 49.4 0.0001

Mean LVEF % (SD) 35.4 (17.8) 39.7 (17.5) 0.0001

LVSD (LVEF <40% or moderate/severe LVD; %)

56.9 47.1 0.0001

Hyperlipidemia (%) 24.7 33.8 0.0001

Cigarette Smoker Within Past Year %

27.3 14.2 0.0001


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Patient Lab and Exam Findings by Race

CharacteristicAfrican

American (n=8,608)

Non–African American (n=38,581) P Value

Mean admission weight, kg (SD) 90.7 (30.0) 80.8 (25.0) .0001

Mean weight change, kg (SD) 2.59 (5.33) 2.53 (4.67) .4332

Mean admission SBP, mmHg (SD) 153.06 (35.98) 140.34 (31.73) .0001

Mean admission HR, bpm (SD) 90.27 (20.85) 85.76 (21.48) .0001

JVD (%) 36.9 31.6 .0001

Rales (%) 63.7 64.0 .5493

Mean serum creatinine (mg/dL) 1.8 (1.3) 1.6 (1.0) .0001

Mean hemoglobin (g/dL) 12.0 (2.1) 12.1 (2.0) .0001


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Diagnostic Studies and Procedures by Race

CharacteristicAfrican

American (n=8,608)

Non–African American (n=38,581)

P Value

Patients with BNP measured (%) 4,349 (50.5) 26,086 (67.6) .0001

Median BNP, pg/mL (IQR) 965 (450, 2130) 785 (403, 1,600) .0001

Median troponin I, ng/mL (IQR) 0.2 (0.1, 0.5) 0.1 (0.0, 0.3) .0001

Left heart catheterization (%) 10.1 8.5 .0001

Coronary artery bypass graft (%) 0.4 1.0 .0001

Dialysis (%) 9.0 4.2 .0001


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47.3

87.880.6

57.764.6

73.7

55.4

86.2

0

10

20

30

40

50

60

70

80

90

100

Pat

ien

ts (

%)

P=.0003P<.0001

P<.0001

P.0001

Complete Discharge

Instructions

LVEF Assessed Discharge ACEI Smoking Cessation

Advice

HF Measures at Hospital Discharge by Race

African AmericanNonAfrican American


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Use of Evidence-Based HF Therapy at Discharge by Race

86.883.8

36.7

24.4

4.5

24.1

2.67.0

21.9

50.0

16.9

39.7

81.2 82.9

52.4

4.0

0

20

40

60

80

100

Tre

ated

Pat

ien

ts (

%)

P=.1178

P<.0001 P=.2250

P<.0001

P=.6744P<.0001

P<.0001

ACEI/ARB

-Blocker Statin Aldosterone Antagonist

Warfarin Hydralazine Nitrate

ACEI/ARB, β-blocker, aldosterone antagonist, hydralazine, and nitrate use in eligible patients with LVSD; statin in coronary artery disease, cerebrovascular accident/transient ischemimc attack, diabetes, hyperlipidemia, and/or peripheral vascular disease; and warfarin use in patients with atrial fibrillation .

Hydralazine/Isosorbide

Dinitrate

P=.0001



Independent Association of African American Race and Quality of Care

Performance Measure Odds Ratio95% Confidence

Interval P Value

HF-1 Delivery of HF discharge instructions

1.02 0.94-1.10 0.701

HF-2 Left ventricular function assessment

1.19 1.05-1.34 0.007

HF-3 ACEI at discharge 1.18 1.01-1.39 0.039

HF-4 Smoking cessation counseling

0.87 0.75-1.02 0.093

ACEI or ARB at discharge 1.16 0.97-1.39 0.104

-Blocker 0.89 0.71-1.11 0.292


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5.69

2.20

4.40

6.01

0

1

2

3

4

5

6

7

8

9

10

In-Hospital and Follow-Up Outcomes in HF Patients With LVSD by Race

P=.0025

P<.0001

Length of Stay (days)

In-Hospital Mortality (%)

93/4,212

670/15,365

60- to 90-DayRehospitalization

60- to 90-DayMortality

P=.0164

P=.0549

Pat

ien

ts (

%)

191/560

616/2,133

35/553

183/2,060



19

1.5

5.8

3.1

5.7

0

1

2

3

4

5

6

7

8

9

10

In-Hospital and Follow-Up Outcomes in HF Patients Without LVSD by Race

P=.2532

P<.0001

Length of Stay (days)

In-Hospital Mortality (%)

60- to 90-DayRehospitalization

60- to 90-DayMortality

P=.1166

P=.2918 Pat

ien

ts (

%)

49/3,187

539/17,283

93/360

603/2,015

23/353

159/1,947



Multivariable Mortality Analyses by Race

In-Hospital MortalityOdds Ratio

95% Odds Ratio Confidence Limits P Value

Race (African American) 0.71 0.57 0.87 <0.001

Follow-Up MortalityHazardRatio

95% Odds Ratio Confidence Limits P Value

Race (African American) 1.12 0.80 1.58 0.508


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Limitations

• The present observations include only hospitalized patients with HF, a population known to be at increased risk of adverse outcomes

• Race was not a self-reported variable but rather was determined as that documented in the medical record, thus errors in racial determination could have occurred.

• Follow-up data were collected only from a pre-specified subset of patients and extended only 60 to 90 days

• Despite extensive covariate and propensity adjustment, residual confounding cannot be excluded, thus may only be demonstrating associations, rather than cause-and-effect relationships


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Conclusions

• African-American HF patients, when exposed to a process-of-care improvement initiative, had better-than-previously observed treatment with evidence-based therapies.

• African-American HF patients when treated according to guidelines had similar or better outcomes compared with non–African-American patients.

• The OPTIMIZE-HF program suggests that an in-hospital process-of-care improvement program might help to achieve similar conformity with quality measures for African Americans with HF.

Yancy et al. J Am Coll Cardiol. 2008;51:1675 84. Quality of Care of and Outcomes for African...

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