The Doctor Weighs In

by Pat Salber, MD

In the early days of the clinical practice guidelines movement, doctors used to complain that it was “cookbook medicine.” As a pretty good cook, who still uses cookbooks, I say, great – when you follow the directions of experts, instead of “winging it,” you increase the odds of getting a good outcome.

So it should be not a surprise that a new study, in the July 23 issue of Archives of Internal Medicine, found that outcomes of hospitalized heart-failure patients are improved when hospital personnel follow clinical guidelines.

OPTIMIZE-HF (“Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure”) is a heart failure guidelines/quality improvement program adopted by the American Heart Association (and sponsored by drug maker GlaxoSmithKline). The program provides hospitals with tools to help improve the reliability of care, including standardized admission orders, discharge checklists, pocket cards, medical chart stickers, best-practice algorithms and critical pathways. It is currently being used by 259 hospitals across the US.

The study, led by Gregg Fonarow, MD from UCLA’s Department of Medicine, looked at data entered into an online OPTIMIZE-HF performance improvement registry. Admission, hospital, discharge care, and outcomes (death and hospital readmission rates) data on 48,612 heart failure patients were entered into the registry between March 2003 and December 2004. A subgroup of 5,791 patients were followed for an additional 60-90 days after they were discharged from the hospital.

The researchers found statistically significant improvements in three of four of the Joint Commission on Accreditation of Healthcare Organization's performance measures used to gauge the quality of heart failure care in hospitals. They included:

· Better patient discharge instructions. The rate of giving complete medical instructions to patients increased from 46.8 percent at the beginning of the study to 66.5 percent by the study's end.

· Smoking cessation counseling. Hospitals provided smoking cessation counseling to 75.6 percent of the patients at the end of the study, compared with 48.2 percent in the beginning.

· Left ventricular function assessment. Evaluating the heart's left ventricle systolic function rose from 89.3 percent to 92.1 percent.

A fourth measure, the rate of angiotensin-converting enzyme inhibitors (ACEIs) prescribed to eligible patients at discharge was 75.8% at baseline. This rate did not improve during the 2-year study.

There was a statistically significant reduction in the mean length of stay for these patients, going from 7.5 days at baseline to 6.2 days at the end of the study. In addition, were trends for reduction of in-hospital mortality, postdischarge death, and combined postdischarge death and rehospitalization, but they did not reach statistical significance.

So patients did better and hospital days were reduced (and so were costs presumably). What’s not to like? According to the lead author, Dr. Fonarow, as quoted in the Washington Post:

"If similar improvements had occurred at hospitals nationwide, this would translate to 40,000 less deaths and 1.4 million costly hospital days eliminated per year. Despite compelling scientific evidence and national guidelines for use of key life-prolonging agents and lifestyle changes, gaps exist in heart failure treatment. We hope more hospitals will adopt this validated model for enhancing heart-failure patient care."

Amen.