Most Quality Improvement is Unsuccessful: The Heart Failure Example
Make Your Medicare Advantage Program More Successful
Most larger hospital systems and medical groups have quality improvement programs, and they believe that they are doing the work. Most of them don’t improve health or reduce cost because significant improvement requires a comprehensive solution combining new science, new systems, and a new payment model. A recent article on congestive heart failure (CHF) quality improvement in the Journal of the American Medical Association (JAMA) on July 27, 2021 is a good example of the reason these programs are not successful.
Improved CHF management is a critical issue for all Americans. Because of an aging population and failure to apply proven treatments consistently, the incidence and prevalence of CHF are increasing. This condition already consumes a third of Medicare spending. CHF is one of the highest risk, highest cost conditions in all of medicine, and taxpayer dollars pay for most of it. We all have a stake in this. The main interventions that have been tried to improve care are educational outreach to providers around guideline recommendation and providing feedback to them on their performance in following guidelines. These efforts have been uniformly unsuccessful.
The JAMA research mentioned above involved patients with heart failure and a low pumping function at 151 American hospitals. It was led by the Duke Clinical Research Unit—one of the best in the country. The intervention combined education delivered by external experts and tracking performance on providing guideline-directed medical therapy. They compared that intervention with usual care. In other words, the investigators in this large trial, kept doing what had failed before, and it should surprise no one that this trial also failed to show improvement. Education, exhortation, and measurement alone do not improve performance in cardiovascular and related conditions. There is established evidence of what does work and what we must do. (This link is worth your time) The one thing that works in cardiovascular quality improvement is an advanced medical home team of nurses and pharmacists using a protocol that are authorized to make changes in treatment in real time without the approval of the team doctor. This evidence on changing systems of care is just as important as the evidence about the medical interventions themselves.
Our failure to follow this important evidence about team structure has grave consequences. Patients with this type of heart failure should be on an ACE inhibitor like lisinopril or an ARB like losartan. They should be on a beta blocker like carvedilol or metoprolol, and they should be on an MRA like spironolactone or eplerenone. The doses of each should be titrated upward until adequate doses are achieved. At baseline, in this current study, only 73% of patients were on a beta blocker, 59% on an ACE inhibitor or an ARB, and just 22% on an MRA. The number of patients who achieve adequate doses of these medications is much worse—13% for ACE inhibitors or ARBs, 20% for beta blockers, and 25% for MRAs. Fewer than 1% of patients were simultaneously treated with adequate doses of all three classes of medicines over a 1-year period. These are lifesaving and disease modifying treatments. The MRA alone reduces death and hospitalization by this type of heart failure by a third. Cost is no barrier. ACE inhibitors, beta blockers and MRA antagonists only cost $4 a month each. The stakes are even higher now because medications like Jardiance also reduce heart failure hospitalization and death by a third, but like the other medications translation of evidence to practice is low. An editorial in the same JAMA edition says these problems are pervasive in cardiovascular and related conditions. It is time to do something different.
We have great tools to treat cardiovascular and related diseases now. We could have better health at lower cost now, but we have not consistently translated the evidence. Failure to develop advanced medical home teams where nurses and pharmacists using protocols to make real time decisions is a huge barrier to progress. The fee for service payment system is the biggest barrier and the move to full risk systems like Medicare Advantage should be accelerated. High blood pressure and heart attack are among the most common conditions leading to CHF. Hypertension management is as bad as heart failure management, and it is worsening. Only 44% of Americans with hypertension have their blood pressure controlled to goal. An advanced medical home team achieves 90% control to goal in high blood pressure. Taking a statin properly after a heart attack reduces the risk of a second attack by 50%. Despite this benefit, 25% of patients in usual care do not fill their first prescription and 25% did not fill their second. Only 6% took the statin adequately- 80% of the time. An advanced medical home team produced consistent statin use in 91% of their patients which was an important element of a protocol leading to a 90% mortality reduction and $21,900 per patient per year savings. Another team in Europe dramatically reduced cardiovascular events at 13 years of follow-up of patients with high-risk diabetes. Patients treated with protocol-driven intervention delivered by nurses had one fourth as many heart attacks, one fifth as many strokes, and one sixth as many went on dialysis compared with usual care. Advanced primary care medical home teams focused on cardiometabolic conditions represent the only model proven to dramatically change clinical and financial outcomes in cardiovascular and related conditions. These successes all used optimal medical treatment[WB1] for cardiovascular and related conditions compared with usual care—the care most of us receive.
We cannot keep doing the same thing and expect a different result. You cannot push someone to do the right thing. Fortunately, the Medicare Advantage (MA) model can pull providers to better performance. Medicare Advantage payment pays medical systems and provider groups more for better health at lower cost. Heart failure is a third of all Medicare spending, if you are running a Medicare Advantage program, getting heart failure treatment right is critical for you. The new American guidelines for stable heart artery disease now call for optimal medical therapy first. Twenty five percent of Medicare beneficiaries have stable heart artery disease. Addressing high risk patients with cardiovascular and related conditions is the low hanging fruit for increased Medicare Advantage success.
As a patient, I prefer original Medicare and a supplement for the flexibility it affords me in choosing physicians and when I travel. However, patients with serious chronic illness do need a team approach. I support payment for outcome rather than fee for service. Why can't we have that for patients who do not choose Medicare Advantage?
The root of this unresolved problem is lacking an accurate diagnostic tool to identify the culprit in the causes of heart failure. This case example highlights this void in everyday clinical practice:
https://youtu.be/zc-848s4_rE
This story tells us that even with all the "gold standards interventions and standard medical treatments, "the best in-kind of care" is simply not enough! We must do a better job on the early detection and optimize lifestyle combined with medical intervention to improve overall care and reduce unnecesary hospital admissions and inpatient care.