achieving coordinated identification, systems detection ...€¦ · detection and treatment of...

Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD

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Larry AllenHeart Failure Summit

April 12, 2017, Bethesda

Creating Systems of Care to Diagnose and Track

Patients with Heart Failure

Keep your eye on the ball…


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DisclosuresGrant funding: AHA, PCORI, NIH

Consultant: Novartis, Janssen

Employer: University of Colorado


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Health systems do not consistently delivery high-value care

Smith M, et al. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine. 2012

Americans only receive ~half of guideline-indicated care.


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Of eligible HFrEF patients:• only receive spironolactone or eplerenone only 25% of the time


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Of eligible HFrEF patients:

• only receive sacubritil/valsartan only 2.5% of the time

• only receive spironolactone or eplerenone only 25% of the time


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Triple Aim

Administrative support

Clinician leaders

System changesEMR

Standing ordersCritical pathways

Integrated care

BenchmarkingData

=

Quality Infrastructure

Therapeutic Innovation Payment and Policies


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The course of Stage C HF

Symptomatic HFOnset of Symptoms

Transition to Stage D

(…Death)

MAJORITY of patients with HF and associated burdens and costs


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The course of Stage C HFand opportunities along the way

Timely Diagnosis

Symptomatic HF


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Timely Diagnosis

Symptomatic HF

Case: 67yo F with progressive shortness of breath and cough. After a week, sees PCP, prescribed Z-pack. Persists, after 3 weeks, sees PCP again, prescribed levofloxacin. A week later taken to ED in florid pulmonary edema.


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Timely Diagnosis

Symptomatic HF

Case: 35yo M with fatigue, RUQ abdominal pain. Gall bladder “sludge” on ultrasound. Taking to the OR for lap chole, when he becomes extremely hypotensive with induction of anesthesia. Stat echo shows LVEF 10%.

Case: 67yo F with progressive shortness of breath and cough. After a week, sees PCP, prescribed Z-pack. Persists, after 3 weeks, sees PCP again, prescribed levofloxacin. A week later taken to ED in florid pulmonary edema.


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Timely Diagnosis

Link Care to LVEF

Symptomatic HF


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The almighty ejection fraction

LVEF


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How hard can it be?


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KPNCPDFNLP

KPCOFree textManual

KPNWEcho autoNuclear

MGHUnable Utah

Solution A DukeSolution B

UCHSolution C

LVEFField Coded


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Timely Diagnosis

Link Care to LVEF

AutomaticIdentification

Symptomatic HF


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Deployed at all VA cath labs (N=78)

Point of care data collection

Standardized ACC NCDR definitions

Real-time capture and feedback

Maddox TM, et al. Integrating Quality Improvement into the Clinical Workflow of Cardiac Catheterization Laboratories: The VA Clinical Assessment, Reporting, and Tracking (CART) Program. Am J Cardiol. 2014 Dec 1;114(11):1750-7

Presenter

Presentation Notes

The VA CART – which stands for Clinical Assessment, Reporting and Tracking – program is a national clinical quality program for all VA cath labs CART collects data on every diagnostic angiogram and percutaneous coronary intervention performed in all of these labs It then uses that data to optimize quality and safety In addition, it stores the data in a comprehensive repository that is linked to a variety of VA and CMS databases to facilitate research


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Intelligent re-design

Ho PM, et al. Hybrid Effectiveness Study to Improve Clopidogrel Adherence. VA HSR&D SDP 12-179.

When a DES is implanted….

… automatic link to pharmacy; If patient does

not pick up clopidogrel, patient contacted

IVR during follow-up: adherence &

refill reminders, detect problems with meds

Presenter

Presentation Notes

Stent (DES) implanted Alert to pharm Ensures that patient leaves cath lab and hospital with clopidogrel Also follows that patient over time Calls patient with IVR to encourage adherence, remind about refills, detect problems Monitors for failure to pick up clopidogrel refills


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Who in your hospital has HF?

~$10,000/episode (70% HF $)

Mean LOS 5 days

Opportunities

• Education

• Rx optimization

Coding retrospective

• Admitting Dx nonspecific

• Requires active approaches


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Timely Diagnosis

Link Care to LVEF

Integrated Risk Stratification

Automatic Identification

Symptomatic HF


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Automated risk score display


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Trigger high-intensity interventions


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Timely Diagnosis

Link Care to LVEF

Integrated Risk Stratification

Early In-hospital Identification Follow Patients Home

Symptomatic HF (Stage C)


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Integrating home-based data

.


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Question #1: How can we improve the diagnosis of symptomatic heart failure so that it is more timely and maps more specifically to the underlying cause?

Question #2: How can we improve the identification and tracking of patients with heart failure in order to targetthe appropriate interventions?

Medical InnovationSystems Redesign

Payment and Policy Reform

achieving coordinated identification, systems detection ...€¦ · detection and treatment of...

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