Heart Failure
Conditions
Keywords
Heart Failure, Outcome Assessment, Congestive Heart Failure
Brief summary
The aim of this study is to serve as a pilot showing the feasibility of a Hub and Satellite Heart Failure (HF) Provider's Network which will aim to provide improved, evidence-based care to Veterans with HF. Primary Care Providers in the VA Community Based Outpatient Clinics (CBOCs) will undergo a brief period of intensive training in HF management and then practice in a network of primary care providers supported by the Regional HF Center.
Detailed description
Background: Congestive heart failure (HF) is a major public health problem. There is a pressing need to improve treatment of HF, but lifesaving therapies remain underused in clinical practice. The investigators proposed a novel, potentially cost-effective model of community-based, multidisciplinary, collaborative HF care - the Hub and Satellite Heart Failure Providers Network. Primary care providers trained in HF management would provide improved care to their clinic patients with HF in satellite clinics, supported by the Regional HF Center hub. Objectives: 1. To establish and demonstrate the feasibility of the Hub and Satellite Heart Failure Providers Network 2. To obtain data examining clinical effectiveness and barriers Methods: Volunteer community-based primary care providers underwent 3 days of HF management training at the regional HF center (Nashville), consisting of 21 hours of lectures, briefings, teaching sessions and case presentations. Multiple choice testing and a survey interview were completed at the beginning and end of training. Exclusive access was given to the services of a clinical pharmacist to titrate HF medications to clinical guideline-recommended doses. Providers received updates on advances in HF management. A confidential feedback report on their performance was given to HF providers. Formative evaluation was performed through pre-educational and 4 subsequent telephone interviews with HF providers. Decision Support System (DSS) data was used to identify patients with systolic HF (ejection fraction\<40%) cared for by the HF providers; systolic HF patients in the same clinics cared for by non-HF trained providers were randomly selected as controls. Data on the care received over the one year period of follow-up was collected from DSS data and the computerized patient record system (CPRS). Status: One year of study follow-up has been completed. Primary data analysis is continuing. Work done to date has successfully demonstrated the feasibility of implementing a Hub and Satellite HF Providers network, including high provider satisfaction.
Interventions
OTHERHF training
These are CBOC Providers who received HF Training as the active intervention. HF training includes didactic lectures, case discussions and interactive symposia, course materials including teaching material, textbooks, copies of HF clinical guidelines and patient education material for distribution, participation in HF Clinics and Inpatient Heart Failure Rounds. Providers were given access to clinical pharmacist services Including medication and disease teaching, adjustment and uptitration. There was quarterly analysis of patient compliance including individualized confidential, non-punitive feedback to providers from a set of prespecified core HF performance measures.
OTHERNo HF training
These are control providers drawn from the same CBOCs who have not received HF training, access to clinical pharmacist medication titration services or performance feedback
Sponsors
VA Office of Research and Development
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
20 Years to 70 Years
Healthy volunteers
Yes
Inclusion criteria
Healthcare providers (physicians, nurse practitioners, physician's assistants) who practice in a Community Based Outpatient Clinic (CBOC) in the Tennessee Valley Healthcare System, and are willing to undergo Heart Failure Training
Exclusion criteria
Community Based Outpatient Clinic (CBOC) Providers who are unable to attend the 3 day Heart Failure Training at the Regional Heart Failure Center.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of Superior Heart Failure Performance Outcome Quality Measures | 12 months | This was a pilot, qualitative study to assess the feasibility and preliminary outcomes of a program to train primary care providers in specialty care. 9 Heart Failure Performance Outcome Quality Measures were studied: Patient weight measured at clinic visit; level of activity assessed; volume status assessed; Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker (ACEI/ARB) prescribed; ACEI/ARB at target dose; beta-blocker prescribed; beta-blocker at target dose; evidence-based beta-blocker used; coumadin prescribed in atrial fibrillation. Healthcare provider performance with each of the Performance Outcome Quality Measures was assessed at each study visit. Superior performance was defined as a higher score for each Measure on the follow-up visit compared to the baseline visit. The primary outcome of the study was considered to have been reached if 6 of the 9 outcome measures were superior to the baseline visit. |
Countries
United States
Participant flow
Recruitment details
Primary care providers practicing were recruited from Primary Care Clinics in the local VA healthcare system. Providers volunteered to be trained as Heart Failure providers and underwent specialized training in May 2010.
Participants by arm
| Arm | Count |
|---|---|
| Arm 1: Received HF Training CBOC Providers who have received HF Training
3 days of training in HF management: HF training includes didactic lectures, case discussions and interactive symposia, course materials including teaching material, textbooks, copies of HF clinical guidelines and patient education material for distribution, participation in HF Clinics and Inpatient Heart Failure Rounds.
Access to clinical pharmacist services: Including medication and disease teaching, adjustment and uptitration
Quarterly analysis of physician compliance: Individualized confidential, non-punitive feedback to providers from a set of prespecified core HF performance measures. | 129 |
| Arm 2: No HF Training CBOC Providers in the same CBOC who have not received HF Training | 129 |
| Total | 258 |
Baseline characteristics
| Characteristic | Arm 1: Received HF Training | Arm 2: No HF Training | Total |
|---|---|---|---|
| Age, Continuous | 65 years | 65 years | 65 years |
| Coronary Artery Disease Coronary artery disease not present | 28 participants | 32 participants | 60 participants |
| Coronary Artery Disease Coronary Artery Disease present | 101 participants | 97 participants | 198 participants |
| Diabetes Diabetes not present | 57 participants | 64 participants | 121 participants |
| Diabetes Diabetes present | 72 participants | 65 participants | 137 participants |
| Followed by Advanced Heart Failure Clinic Followed by Heart failure Clinic | 26 participants | 37 participants | 63 participants |
| Followed by Advanced Heart Failure Clinic Not followed by Heart Failure Clinic | 103 participants | 92 participants | 195 participants |
| Followed by Cardiology Number followed by Cardiology | 116 participants | 108 participants | 224 participants |
| Followed by Cardiology Number not followed by Cardiology | 13 participants | 21 participants | 34 participants |
| HF Hospitalization past year No. with a HF hospitalization in the past year | 26 participants | 15 participants | 41 participants |
| HF Hospitalization past year No. without a HF hospitalization in the past year | 103 participants | 114 participants | 217 participants |
| Hypertension Hypertension not present | 10 participants | 10 participants | 20 participants |
| Hypertension Hypertension present | 119 participants | 119 participants | 238 participants |
| Median ejection fraction | 30 % left ventricular end-diastolic volume | 30 % left ventricular end-diastolic volume | 30 % left ventricular end-diastolic volume |
| Sex: Female, Male Female | 4 Participants | 1 Participants | 5 Participants |
| Sex: Female, Male Male | 125 Participants | 128 Participants | 253 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 0 | 0 / 0 |
| serious Total, serious adverse events | 0 / 0 | 0 / 0 |
Outcome results
Primary
Number of Superior Heart Failure Performance Outcome Quality Measures
This was a pilot, qualitative study to assess the feasibility and preliminary outcomes of a program to train primary care providers in specialty care. 9 Heart Failure Performance Outcome Quality Measures were studied: Patient weight measured at clinic visit; level of activity assessed; volume status assessed; Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker (ACEI/ARB) prescribed; ACEI/ARB at target dose; beta-blocker prescribed; beta-blocker at target dose; evidence-based beta-blocker used; coumadin prescribed in atrial fibrillation. Healthcare provider performance with each of the Performance Outcome Quality Measures was assessed at each study visit. Superior performance was defined as a higher score for each Measure on the follow-up visit compared to the baseline visit. The primary outcome of the study was considered to have been reached if 6 of the 9 outcome measures were superior to the baseline visit.
Time frame: 12 months
Population: 129 patients cared for by HF trained primary care providers in Intervention Arm. 129 patients in the Control group, cared for by non-HF trained primary care providers.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Arm 1: Received HF Training | Number of Superior Heart Failure Performance Outcome Quality Measures | 5 number of outcome measures superior |
| Arm 2: No HF Training | Number of Superior Heart Failure Performance Outcome Quality Measures | 4 number of outcome measures superior |