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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…
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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DisclosuresGrant funding: AHA, PCORI, NIH
Consultant: Novartis, Janssen
Employer: University of Colorado
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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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.
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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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.
Of eligible HFrEF patients:• only receive spironolactone or eplerenone only 25% of the time
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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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.
Of eligible HFrEF patients:
• only receive sacubritil/valsartan only 2.5% of the time
• only receive spironolactone or eplerenone only 25% of the time
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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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
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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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
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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The course of Stage C HFand opportunities along the way
Timely Diagnosis
Symptomatic HF
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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The course of Stage C HFand opportunities along the way
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.
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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The course of Stage C HFand opportunities along the way
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.
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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The course of Stage C HFand opportunities along the way
Timely Diagnosis
Link Care to LVEF
Symptomatic HF
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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The almighty ejection fraction
LVEF
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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How hard can it be?
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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KPNCPDFNLP
KPCOFree textManual
KPNWEcho autoNuclear
MGHUnable Utah
Solution A DukeSolution B
UCHSolution C
LVEFField Coded
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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The course of Stage C HFand opportunities along the way
Timely Diagnosis
Link Care to LVEF
AutomaticIdentification
Symptomatic HF
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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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
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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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
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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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
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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The course of Stage C HFand opportunities along the way
Timely Diagnosis
Link Care to LVEF
Integrated Risk Stratification
Automatic Identification
Symptomatic HF
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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Automated risk score display
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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Trigger high-intensity interventions
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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The course of Stage C HFand opportunities along the way
Timely Diagnosis
Link Care to LVEF
Integrated Risk Stratification
Early In-hospital Identification Follow Patients Home
Symptomatic HF (Stage C)
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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Integrating home-based data
.
Achieving Coordinated Identification,Detection and Treatment of Heart Failure SummitApril 12th, Hyatt Regency Bethesda, MD
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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
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