Has the heart failure clinic outlived its usefulness?

Much attention has been paid to heart failure centers in partnership with hospitals, particularly since the Centers for Medicare and Medicaid Services adopted the demonstration project for patients with congestive heart failure, in which reimbursement to hospitals was tied to performance on five core measures.

Since that time, many hospitals have feverishly sought to improve their compliance with these metrics all the while aiming to convince CMS that HF programs are good for patients, good for payers and good for providers.

Despite these efforts, however, it has been difficult to show that true improvement in HF care can be had by simply documenting many of the parameters for patients hospitalized for CHF.

In fact, a paper by Fonarow based on the Optimize-HF data set called to question whether these core measures have any ability to affect 30-day mortality and re-admission.

Physician involvement key

Certainly all of the five core measures are laudable health goals, particularly for those with HF. However, most would have little impact on 30-day mortality. Determination of left ventricular systolic function is extremely important to discern systolic from diastolic HF so that appropriate therapy can be instituted. However, this metric primarily would impact individuals who had impaired systolic function and needed to be on an ACE inhibitor. Yet the major ACE inhibitor studies have failed to show a difference between the control group and the treatment group until approximately 90 days after starting drug therapy.

Similarly, smoking cessation is clearly a public health initiative that merits advancement but halting cigarette smoking would likely have very little effect on 30-day admission for HF and/or 30-day mortality.

The use of discharge instructions may have the highest chance of success because poor compliance with medication is a major factor contributing to cardiovascular morbidity and mortality in HF. The difficulty is that much of medication reconciliation has been misdirected to noncardiac medications and therefore has little impact.

In aggregate, these core measures are clearly important for our patients’ well-being, but HF clinics and initiatives must not stop there. The HF practice involves much more than a brief encounter with an individual at the end of the hospital stay. It involves physician-directed comprehensive management of both the HF state and other co-morbid illnesses that may be present in this elderly and complex patient population. Physician involvement continues to be key because without physician involvement there is now substantive data from the COACH (Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure) trial suggesting nonphysician-based interventions may well not offer the same long-term beneficial effects to our patients.

COACH results