IMPROVE HF Primary Results

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Improving Evidence-Based Care for Heart Failure
in Outpatient Cardiology Practices Primary
Results of the Registry to Improve Heart Failure
Therapies in the Outpatient Setting (IMPROVE HF)
Gregg C. Fonarow, Nancy M. Albert, Anne B.
Curtis, Wendy Gattis Stough, Mihai Gheorghiade,
J. Thomas Heywood, Mark L. McBride, Patches
Johnson Inge, Mandeep R. Mehra, Christopher M.
O'Connor, Dwight Reynolds Mary N. Walsh , Clyde
W. Yancy
Fonarow GC et al. Circulation. 2010122585-596
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Disclosures

• The IMPROVE HF registry is sponsored by
  Medtronic.
• The sponsor had no role or input into the
  selection of endpoints or quality measures used
  in the study.
• Outcome Sciences, Inc, a contract research
  organization, independently performed the
  practice site chart abstractions for IMPROVE HF,
  stored the data, and provided benchmarked quality
  of care reports to practice sites. Outcome
  Sciences received funding from Medtronic.
• Individually identifiable practice site data were
  not shared with either the steering committee or
  the sponsor.
• Individual author disclosures are provided in the
  manuscript.

Fonarow GC, et al. Circulation. 2010122585-596.
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Heart Failure Care in the Outpatient Cardiology
Practice Setting

• There are well documented gaps, variations, and
  disparities in the use of evidence-based,
  guideline recommended therapies for heart failure
  in inpatient and outpatient care settings.
• As a result many heart failure patients may have
  hospitalizations and fatal events that might have
  been prevented.
• Hospital-based performance improvement programs
  have improved the quality of care for heart
  failure patients.
• Similar programs in the outpatient setting have
  not been tested.

Fonarow GC, et al. Circulation. 2010122585-596.
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ACC/AHA 2005 HF Guidelines Implementation of
Guidelines
I IIa IIb III
Academic detailing or educational outreach visits
are useful to facilitate the implementation of
practice guidelines Chart audit and feedback
of results can be effective to facilitate
implementation of practice guidelines The use of
reminder systems can be effective to facilitate
implementation of practice guidelines The use
of performance measures based on practice
guidelines may be useful to improve quality of
care
I IIa IIb III
I IIa IIb III
Hunt SA, et al. ACC/AHA 2005 Practice Guidelines.
Available at http//www.acc.org.
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IMPROVE HF Study Overview

• Largest, most comprehensive performance
  improvement study for HF patients in the
  outpatient setting
• Designed to enhance quality of care of HF
  patients by facilitating adoption of
  evidence-based, guideline-recommended therapies
• Evaluate utilization rates of evidence-based,
  guideline-recommended HF therapies at baseline
  and over the course of the performance
  improvement intervention (chart audit and
  feedback use of performance measures)
• Multifaceted, practice-specific performance
  improvement toolkit including clinical decision
  support tools (reminder systems)
• Sites attended an educational workshop to set
  treatment goals and develop a customized clinical
  care pathway (educational outreach)

Fonarow GC et al. Am Heart J, 200715412-38.
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Methods Guideline-Recommended Quality Measures

• Seven quality measures with strong evidence
  prospectively selected
• Angiotensin-converting enzyme inhibitor (ACEI) or
  angiotensin II receptor blocker (ARB)
• ß-blocker
• Aldosterone antagonist
• Anticoagulation therapy for atrial
  fibrillation/flutter (AF)
• Cardiac resynchronization therapy with or without
  ICD (CRT)
• Implantable cardioverter defibrillator with or
  without CRT (ICD)
• Heart failure (HF) education
• Patients deemed eligible for individual quality
  measure based on meeting guideline criteria,
  without contraindications, intolerance, or other
  documented reasons for non-treatment.
• Steering committee selected quality measures
  based on potential to improve patient outcomes,
  definition precision, construct and content
  validity, feasibility.

Included as ACC/AHA outpatient HF performance
measure, endorsed by National Quality Forum.
Fonarow GC, et al. Circulation. 2010122585-596.
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Methods Patient Selection, Practice Selection,
Data Collection and Management

• Patient Inclusion
• Clinical diagnosis of HF or prior MI with at
  least 2 prior clinic visits within 2 years
• LVEF 35 or moderate to severe left ventricular
  dysfunction
• Patient Exclusion
• Cardiac transplantation
• Estimated survival lt1 year from
  non-cardiovascular condition
• Average of 90 eligible patients per practice
  randomly selected for each of 3 study cohorts
• Practices Outpatient cardiology (single
  specialty or multi-specialty) practices from all
  regions of the country

• Data quality measures
• 34 trained, tested chart review specialists
• Training oversight by study steering committee
  members
• Monthly quality reports
• Automated data field range, format, unit checks
• Chart abstraction quality
• Interrater reliability averaged 0.82 (kappa
  statistic)
• Source documentation audit sample concordance
  rate range of 92.3 to 96.3
• Coordinating center Outcome Sciences, Inc.
  (Cambridge, MA)
• Individual practice data not shared with sponsor
  or steering committee

Fonarow GC, et al. Circulation. 2010122585-596.
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Methods Study Objectives
Practice Level Patient Level
Primary Analyses of Quality Measures
Changes for each of the 7 quality measures at 24 months X X
20 relative improvement in 2 or more quality measures at 24 months X Xa
Changes in 7 quality measures patients with both baseline and 24 month data X X
Other Analyses
Changes in 2 summary care measures at 24 months X X
Changes in 7 quality measures in single-time point cohorts compared with baseline X X
a Pre-specified primary objective
Practice level analysis proportion of eligible
patients receiving therapy for each
practice Patient level analysis proportion of
eligible patients receiving therapy for aggregate
of all practices
Fonarow GC, et al. Circulation. 2010122585-596.
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Methods Study Design and Patient Disposition
Baseline Chart Review 167 sites 15,177 patients
12 Month Chart Review 155 sites 9,386 patients
24 Month Chart Review 155 sites 7,605 patients
Longitudinal Cohort
Process Improvement Intervention (165 sites)
6 Month Chart Review 154 sites 9,992 patients
18 Month Chart Review 151 sites 9,641 patients
Two Single- Time-Point Cohorts

• Longitudinal cohort included the same patients
  reviewed at 3 time points.
• Single-time-point cohorts included separate
  patients from the same practices and unique from
  the longitudinal cohort, as well as from each
  other.

Total Sites 167
Patients Enrolled 34,810
Total Chart Reviews 63,143
Total of Site Visits 782
Fonarow GC, et al. Circulation. 2010122585-596.
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Methods Practice Specific Performance
Improvement Intervention
1-day workshop after baseline data collected Included study goals, guidelines, intervention tool kit, performance improvement methods, tips to promote practice change, effective use of collected data. Guideline-based, clinical decision tool kit Treatment algorithms, clinical pathways, standardized encounter forms, checklists, pocket cards, chart stickers, patient education materials. Tools available at www.ImproveHF.com. Web-based quality of care reports Practice specific reports from chart audit data with benchmarking capability. Bimonthly educational, collaborative Web based seminars
Use or participation was encouraged but not
mandatory. Practices could adopt or modify tools.

• Practice Survey
• 96 adopted one or more performance improvement
  strategies
• 85 used benchmarked quality reports
• 60 employed one or more IMPROVE HF tools

Fonarow GC, et al. Circulation. 2010122585-596.
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IMPROVE HF Practice Specific Education and
Implementation Tools
Evidence Based Algorithms and Pocket Cards
Clinical Trials and Current Guidelines
Clinical Assessment and Management Forms
www.improvehf.com
Patient Education Materials
Dissemination of best practices - Webcasts -
Online Education - Newsletters
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IMPROVE HF Performance InterventionBenchmarked
Practice Profile Report
Adherence to Guidelines
Practice or Single Physician
On-Demand Performance Measures across all
physicians within practice
Benchmarking Capability region, practice,
individual physician
Benchmarking
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Patient Characteristics
Longitudinal Cohort Longitudinal Cohort 18-Month Cohort N 9,641
Characteristic All Patients N 15,177 24-Month N 7,605 18-Month Cohort N 9,641
Age, median, years 70.0 71.0 70.0
Male, 71.1 71.3 70.7
Race White, black, unavailable, 42.4, 9.2, 46.7 42.6, 9.0, 46.5 55.9, 11.5, 31.0
Insured, not documented, uninsured, 92.2, 6.3, 1.2 95.2, 3.7, 1.0 90.6, 7.6, 1.8
Heart failure origin, ischemic, 65.4 67.0 65.9
Prior MI, 40.0 51.7 41.6
History of CABG, 31.2 34.1 31.2
History of PCI, 25.6 30.0 29.1
History of atrial fibrillation/flutter, 30.7 41.2 34.0
History of peripheral vascular disease, 11.5 16.0 12.3
History of diabetes, 34.1 37.8 35.6
History of hypertension, 62.2 75.1 69.7
History of COPD, 16.7 21.8 18.0
History of depression, 9.0 15.7 10.7
Fonarow GC, et al. Circulation. 2010122585-596.
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Patient Characteristics (Continued)
Longitudinal Cohort Longitudinal Cohort 18-Month Cohort N 9,641
Characteristic Baseline N 15,177 24-Month N 7,605 18-Month Cohort N 9,641
NYHA I, II, III, IV, unavailable, 34.7, 36.6, 20.7, 2.6, 5.5 38.0, 43.5, 16.4, 1.4, 0.7 32.0, 44.8, 21.1, 1.6, 0.5
LVEF, median, 25.0 30.0 25.0
Systolic blood pressure, median, mmHg 120 120 120
Diastolic blood pressure, median, mmHg 70 70 70
Resting heart rate, median, bpm 71 70 72
Sodium, median, mEq/L 139 139 139
Blood urea nitrogen, median, mg/dL 22 22 21
Creatinine, median, mg/dL 1.2 1.2 1.2
BNP, median, pg/mL 387 314 373
QRS duration, median, ms 124 (n 10,225) 132 (n 3,788) 122 (n 7,511)
Fonarow GC, et al. Circulation. 2010122585-596.
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IMPROVE HF Practice Characteristics
Characteristic Practice Sites (N 167)
Census region South, Northeast, Central, West, Missing, 38.9, 32.3, 15.6, 12.0, 1.2
Practice setting University, Non-university teaching, Non-university, non-teaching, (n157) 7.8, 21.6, 64.7
Multispecialty, 24.0
Hospital-based, 27.5
Transplant center, 9.6
Suburban or rural location, 71.3
HF clinic in practice, (n163) 41.3
HF nurse in practice, 34.7
Device clinic in practice, 78.4
No. of physicians in practice, 1-10, 11-20, gt20, 48.5, 27.5, 18.0
Number of electrophysiologists in practice, median 1.0
Interventionalist in practice, 87.4
Annual number of patients managed by practice, median 1837.5
Two sites did not provide any survey data. N165
for these characteristics unless otherwise noted.
Fonarow GC, et al. Circulation. 2010122585-596.
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Results Improvement in Quality Measures at 24
Months (Practice Level Analysis)
Longitudinal Cohort 123 of 155 practices (79)
with 20 relative improvement in 2 or more care
measures
Quality Measure Baseline (95 CI) N 167 24 Months (95 CI) N 155 Absolute Improvement (95 CI) Relative Improvement (95 CI) P-value
ACEI/ARB 78.3 (76.5 80.2) 85.1 (83.4 86.8) 6.8 (4.8 8.8) 19.4 (-1.1 39.8) 0.063
ß-blocker 86.0 (84.3 87.7) 92.2 (90.6 93.8) 6.2 (4.8 7.6) 7.6 (5.1 10.2) lt0.001
Aldosterone antagonist 34.5 (31.5 37.4) 60.3 (56.1 64.4) 25.1 (20.7 29.6) 86.5 (67.1 105.9) lt0.001
Anticoagulation for AF 68.0 (65.5 70.5) 67.8 (65.0 70.7) - 0.1 (-3.0 2.8) 1.0 (-3.6 5.5) 0.673
CRT-P/CRT-D 37.2 (32.2 42.2) 66.3 (61.6 71.1) 29.9 (23.6 36.2) 124.5 (85.5 163.5) lt0.001
ICD/CRT-D 50.1 (47.3 52.8) 77.5 (74.8 80.1) 27.4 (24.6 30.2) 70.9 (61.0 80.8) lt0.001
HF education 59.5 (55.7 63.2) 72.1 (68.3 75.9) 12.6 (8.2 17.0) 50.6 (27.1 74.2) lt0.001
Fonarow GC, et al. Circulation. 2010122585-596.
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Results Improvement in Quality Measures at 24
Months (Patient Level Analysis)
Longitudinal Cohort Prespecified primary
objective met Relative improvement 20 in 3
quality measures
Quality Measure Baseline (95 CI) N 15,177 24 Months (95 CI) N 7,605 Absolute Improvement (95 CI) Relative Improvement (95 CI) P-value
ACEI/ARB 79.8 (79.2 80.5) 86.5 (85.6 87.3) 6.7 (5.6 7.8) 8.4 (7.0 9.7) lt0.001
ß-blocker 86.2 (85.6 86.8) 93.6 (93.0 94.2) 7.4 (6.6 8.2) 8.6 (7.7 9.6) lt0.001
Aldosterone antagonist 34.4 (32.7 36.1) 61.8 (59.2 64.5) 27.4 (24.3 30.6) 79.7 (70.5 89.0) lt0.001
Anticoagulation for AF 68.6 (67.2 70.0) 69.3 (67.5 71.0) 0.7 (-1.5 2.9) 1.0 (-2.2 4.2) 0.546
CRT-P/CRT-D 37.7 (35.2 40.1) 68.5 (65.8 71.3) 30.9 (27.2 34.5) 81.9 (72.2 91.7) lt0.001
ICD/CRT-D 48.8 (47.8 49.8) 79.1 (78.0 80.2) 30.3 (28.8 31.8) 62.1 (59.1 65.1) lt0.001
HF education 61.8 (61.0 62.5) 70.8 (69.8 71.9) 9.1 (7.8 10.4) 14.7 (12.6 16.8) lt0.001
Fonarow GC, et al. Circulation. 2010122585-596.
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Results Improvement in Quality Measures at 24
Months (Patient Level Analysis)
Significant Improvement in 6 of 7 Quality
Measures at 12 and 24 Months Pre-specified
Primary Objective Met Relative Improvement 20
in 3 Quality Measures
Eligible Patients Treated
Plt0.001 vs. baseline
P-values are for relative change
Fonarow GC, et al. Circulation. 2010122585-596.
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Longitudinal Cohort with Complete Follow-up at 24
Months Modified Intention to Treat Analyses
Patient Level Analysis Improvement in 6 of 7
Quality Measures
Quality Measure Baseline (95 CI) N 7,605 24 Months (95 CI) N 7,605 Absolute Improvement (95 CI) Relative Improvement (95 CI) P-value
ACEI/ARB 83.0 (82.1 83.8) 86.5 (85.6 87.3) 3.5 (2.3 4.8) 4.3 (2.8 5.7) lt0.001
ß-blocker 88.5 (87.7 89.2) 93.6 (93.0 94.2) 5.1 (4. 6.1) 5.8 (4.7 6.9) lt0.001
Aldosterone antagonist 35.4 (32.8 38.1) 61.8 (59.2 64.5) 26.4 (22.6 30.1) 74.4 (63.9 84.9) lt0.001
Anticoagulation for AF 72.2 (70.3 74.1) 69.3 (67.5-71.0) - 2.9 (-5.5 -0.3) - 4.1 -7.7 -0.5) 0.026
CRT-P/CRT-D 41.2 (37.4 44.9) 68.5 (65.8 71.3) 27.4 (22.7 32.0) 66.5 (55.2 77.7) lt0.001
ICD/CRT-D 54.4 (53.0 55.8) 79.1 (78.0 80.2) 24.7 (23.0 26.5) 45.4 (42.4 48.6) lt0.001
HF education 59.7 (58.6 60.8) 70.8 (69.8 71.9) 11.2 (9.7 12.7) 18.7 (16.2 21.2) lt0.001
Fonarow GC, et al. Circulation. 2010122585-596.
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Newly Documented Contraindications/Intolerance
and Newly Treated patients at 24 monthsPaired
Longitudinal Cohort
Quality Measure Newly documented contraindication/ Intolerance at 24 mo. in patients initially eligible at baseline (N7,605), Newly treated at 24 mo. in patients initially eligible at baseline (N7,605), Newly treated at 24 mo. in patients not initially eligible at baseline, but eligible at 24 mo.
ACEI/ARB 9.8 (699/7138) 7.6 (546/7138) 67.1 (49/73)
ß-blocker 5.5 (381/6905) 6.3 (434/6905) 83.9 (208/248)
Aldosterone antagonist 16.4 (210/1278) 10.3 (132/1278) 54.2 (396/730)
Anticoagulation for AF 8.8 (181/2061) 6.9 (143/2061) 58.1 (493/848)
CRT-P/CRT-D 1.8 (12/673) 23.5 (158/673) 59.3 (377/636)
ICD/CRT-D 3.9 (198/5028) 15.3 (769/5028) 71.1 (857/1205)
HF education 0.0 (0/7605) 26.3 (2003/7605) 0.0 (0/0)
Fonarow GC, et al. Circulation. 2010122585-596.
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Results Summary Measures Significantly Improved
at the Patient Level
Fonarow GC, et al. Circulation. 2010122585-596.
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Single Time Point Cohorts Improvement at 18
Months
Directionally similar, smaller magnitude
improvements than longitudinal cohort
Quality Measure Baseline (95 CI) N 15,177 18 Months (95 CI) N 7,605 Absolute Improvement (95 CI) Relative Improvement (95 CI) P-value
ACEI/ARB 79.8 (79.2 80.5) 81.3 (80.5 82.1) 1.5 (0.4 2.5) 1.9 (0.5 3.2) 0.006
ß-blocker 86.2 (85.6 86.8) 91.9 (91.3 92.5) 5.7 (4.9 6.6) 6.7 (5.7 7.6) lt0.001
Aldosterone antagonist 34.4 (32.7 36.1) 38.0 (35.8 40.3) 3.6 (0.8 6.5) 10.6 (2.3 18.8) 0.012
Anticoagulation for AF 68.6 (67.2 70.0) 69.9 (68.2 71.5) 1.3 (-0.9 3.5) 1.9 (-1.3 5.1) 0.237
CRT-P/CRT-D 37.7 (35.2 40.1) 44.1 (41.1 47.1) 6.4 (2.6 10.3) 17.1 (6.8 27.4) 0.001
ICD/CRT-D 48.8 (47.8 49.8) 55.9 (54.7 57.0) 7.0 (5.5 8.6) 14.4 (11.3 17.6) lt0.001
HF education 61.8 (61.0 62.5) 75.8 (75.0 76.7) 14.1 (12.9 15.2) 22.8 (20.9 24.7) lt0.001
Patient level analysis
Fonarow GC, et al. Circulation. 2010122585-596.
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Study Limitations

• Patient eligibility and utilization rates
  determined by accuracy and completeness of
  medical records and their abstraction
• Reasons for preventing treatment may not have
  been documented
• Potential for ascertainment bias
• Self-selected cardiology practices, primary care
  setting not included
• Not randomizedsecular trends may have influenced
  results
• Follow-up not available for all patients
• Practices dropped out, patients died or were lost
  to follow-up
• Paired analyses revealed similar improvements
• Clinical outcomes could not be evaluated with the
  design
• Unable to measure use of therapies outside of
  guidelines
• Relative efficaciousness of intervention
  components could not be determined

Fonarow GC, et al. Circulation. 2010122585-596.
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Conclusions

• IMPROVE HF is the largest outpatient cardiology
  heart failure practice performance improvement
  program.
• Implementation of a defined and scalable
  performance improvement intervention may improve
  the use of evidence-based, guideline-recommended
  heart failure therapies in real-world cardiology
  practices.
• Study findings may serve as a model for existing
  and future performance improvement programs.

Fonarow GC, et al. Circulation. 2010122585-596.
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Clinical Implications
Implementation of a defined and scalable
practice specific performance improvement
intervention enhances use of evidence-based,
guideline-recommended HF therapies demonstrated
to improve outcomes In all care settings where
HF patients are managed, programs to provide
practitioners with useful reminders based on the
guidelines and to continuously assess the success
achieved in providing these recommended therapies
to the patients who can benefit from them should
be implemented
Fonarow GC, et al. Circulation. 2010122585-596.
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Back-up Slides
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Practice-Level Use of Guideline-Recommended
Therapies in the Longitudinal Cohort with
Complete Follow-up at 24 Months
N155 practices
Quality Measure Baseline (95 CI) 24 Months (95 CI) Absolute Improvement (95 CI) Relative Improvement (95 CI) P-value
ACEI/ARB 80.7 (78.5 82.8) 85.9 (84.3 87.5) 5.3 (3.0 7.5) 5.7 (3.6 7.7) lt0.001
ß-blocker 87.9 (86.1 89.8) 92.8 (91.3 94.3) 4.8 (3.5 6.2) 6.6 (4.5 8.6) lt0.001
Aldosterone antagonist 34.5 (30.6 38.6) 61.8 (57.6 66.0) 25.1 (20.6 29.6) 88.5 (65.2 111.7) lt0.001
Anticoagulation for AF 69.5 (66.4 72.6) 68.4 (65.5 71.4) 1.1 (-4.1 1.8) 0.3 (-5.2 5.9) 0.903
CRT-P/CRT-D 36.8 (30.7 43.0) 67.2 (62.5 72.0) 30.4 (23.5 37.3) 66.1 (39.1 93.0) lt0.001
ICD/CRT-D 54.1 (51.0 57.1) 77.7 (75.0 80.4) 24.1 (22.1 26.2) 55.5 (48.8 62.2) lt0.001
HF education 58.9 (55.0 60.8) 72.5 (68.7 76.3) 13.5 (9.1 11.9) 53.7 (30.1 77.2) lt0.001
All-or-none care 25.5 (23.4 27.7) 44.1 (41.0 47.2) 18.6 (15.4 21.7) 125.1 (86.8 163.4) lt0.001
Composite care 69.1 (67.6 70.6) 79.6 (78.1 71.1) 10.5 (9.1 11.9) 16.7 (14.0 19.4) lt0.001
Fonarow GC, et al. Circulation. 2010122585-596.
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Odds Ratios for the Use of Guideline-Recommended
Therapies in the Longitudinal Cohort with
Complete Follow-up at 24 months Relative to
Baseline in GEE Models 
Quality Measure Unadjusted Odds Ratio (95 CI) P-value Adjusted Odds Ratio (95 CI) P-value
ACEI/ARB 1.079 (0.993 1.772) 0.0715 1.108 (0.985 1.247) 0.0889
ß-blocker 1.680 (1.513 1.865) lt0.0001 1.678 (1.474 1.910) lt0.0001
Aldosterone antagonist 1.836 (1.538 2.192) lt0.0001 2.102 (1.610 2.744) lt0.0001
Anticoagulation for AF 1.040 (0.952 1.135) 0.3873 1.053 (0.949 1.168) 0.3302
CRT-P/CRT-D 4.092 (3.167 5.286) lt0.0001 6.500 (4.386 9.633) lt0.0001
ICD/CRT-D 2.401 (2.243 2.571) lt0.0001 2.523 (2.229 2.854) lt0.0001
HF education 1.642 (1.540 1.750) lt0.0001 1.725 (1.582 1.887) lt0.0001
All-or-none care 2.182 (2.049 2.324) lt0.0001 2.360 (2.152 2.587) lt0.0001
Model controlled for within-patient and
within-practice correlations. The multivariate
model included all patient and practice
characteristics that were significant at the P lt
0.10 level in univariate analysis.
Fonarow GC, et al. Circulation. 2010122585-596.
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Use of Guideline-Recommended Therapies in the
Longitudinal Cohort at Baseline for the Entire
Cohort, and by Patient status at 24 Months
Quality Measure Total cohort (N15,177) Alive and with 24-month follow-up (N7,605) Subsequently lost to follow-up (N5,003) Subsequently died (N2,569) Subsequently lost or died (N7,572)
ACEI/ARB 79.8 (11,165/13,987) 83.0 (5,921/7138) 79.0 (3,624/4,588) 71.6 (1,620/2,261) 76.6 (5,244/6,849)
ß-blocker 86.2 (11,868/13,772) 88.5 (6,109/6,905) 85.3 (3,870/4,537) 81.1 (1,889/2,330) 83.9 (5,759/6,867)
Aldosterone antagonist 34.4 (987/2,870) 35.4 (453/1,278) 32.1 (313/976) 35.9 (221/616) 33.5 (534/1,592)
Anticoagulation for AF 68.6 (2,910/4,244) 72.2 (1,488/2,061) 65.3 (835/1,278) 64.9 (587/905) 65.1 (1,422/2,183)
CRT-P/CRT-D 37.7 (580/1,540) 41.2 (277/673) 36.1 (174/482) 33.5 (129/385) 34.9 (303/867)
ICD/CRT-D 48.8 (4,799/9,830) 54.4 (2,736/5,028) 41.4 (1,262/3,048) 45.7 (801/1,754) 43.0 (2,063/4,802)
HF education 61.8 (9,373/15,177) 59.7 (4,539/7,605) 65.1 (3,259/5,003) 61.3 (1,575/2,569) 63.8 (4,834/7,572)
Fonarow GC, et al. Circulation. 2010122585-596.
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Odds Ratios for the Use of Guideline-Recommended
Therapies in the 18-Month Single-Point-in-Time
Cohort Relative to the Longitudinal Baseline
Cohort in GEE Models 
Quality Measure Unadjusted Odds Ratio (95 CI) P-value Adjusted Odds Ratio (95 CI) P-value
ACEI/ARB 1.079 (1.008 1.556) 0.0284 1.036 (0.941 1.140) 0.04745
ß-blocker 1.736 (1.580 1.907) lt0.0001 1.685 (1.474 1.927) lt0.0001
Aldosterone antagonist 1.107 (0.975 1.257) 0.1166 1.018 (0.875 1.183) 0.8194
Anticoagulation for AF 1.063 (0.958 1.180) 0.2489 1.025 (0.894 1.174) 0.7243
CRT-P/CRT-D 1.334 (1.132 1.573) 0.0006 1.361 (1.136 1.629) lt0.0001
ICD/CRT-D 1.310 (1.231 1.395) lt0.0001 1.269 (1.138 1.8415) lt0.0001
HF education 2.024 (1.910 2.146) lt0.0001 2.072 (1.894 2.267) lt0.0001
All-or-none care 1.552 (1.464 1.645) 0.0001 1.684 (1. 568 1. 810) lt0.0001
Model controlled for within-practice
correlations. The multivariate model included all
patient and practice characteristics that were
significant at the P lt 0.10 level in univariate
analysis.
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Eligible Patients for Each Quality Measure by
Cohort
Longitudinal Longitudinal Longitudinal Single Time Point Single Time Point
Baseline 12 Months 24 Months 6 Months 18 Months
Total patients 15,177 9,386 7,605 9,992 9,641
ACEI/ARB 13,987 7,968 6,183 9,130 8,685
ß-blocker 13,772 8,274 6,608 8,930 8,519
Aldosterone antagonist 2,870 1,656 1,291 1,862 1,804
Anticoagulation for AF 4,244 3,219 2,719 2,967 2,951
CRT-P/CRT-D 1,540 1,173 1,096 1,052 1,034
ICD/CRT-D 9,830 6,575 5,331 6,907 6,859
HF education 15,177 9,386 7,605 9,992 9,641
Fonarow GC, et al. Circulation. 2010122585-596.
33
Results Summary of Baseline Patient
Characteristics

• Mean and median age 68.7 and 70.0 years
• Sex 71.1 male
• Mean LVEF 25.4
• Ischemic etiology 65.4
• Comorbidities
• Hypertension 62.2
• Diabetes 34.1
• AF 30.7
• Chronic obstructive pulmonary disease 16.7
• Median blood pressure 120/70 mm Hg
• Median Creatinine 1.2 mg/dL
• NYHA functional class 34.7 Class I, 36.6 Class
  II, 20.7 Class III, 2.6 Class IV, 5.5
  undocumented

Fonarow GC, et al. Circulation. 2010122585-596.
34
IMPROVE HF Primary Objective

• To observe over the aggregate of IMPROVE HF
  practice sites a relative 20 improvement in at
  least 2 of the 7 performance measures at 24
  months compared with baseline

Fonarow GC et al. Improving the use of
evidence-based heart failure therapies in the
outpatient setting the IMPROVE HF performance
improvement registry. Am Heart J, 2007 15412-38.
35
Results Baseline Practice Characteristics
APN, advanced practice nurse. n163
Fonarow GC, et al. Circulation. 2010122585-596.
36
Results Improvement in Quality Measures at 24
Months (Practice Level Analysis)
Improvement in 5 of 7 Quality Measures 123 of 155
practices (79) with 20 Relative Improvement
in 2 or more Quality Measures
Eligible Patients Treated
Plt0.001 vs. baseline (P-values for 12 months
vs. baseline not reported)
N 167 practices at baseline and 155 practices
at 12 and 24 months
P-values are for relative change
Fonarow GC, et al. Circulation. 2010122585-596.
37
Longitudinal Cohort with Complete Follow-up at 24
Months
Improvement in 6 of 7 quality measures
Eligible Patients Treated
Plt0.001 vs. baseline P0.026 vs. baseline
P-values are for relative change
Patient level analyses
Fonarow GC, et al. Circulation. 2010122585-596.
38
Single Time Point Cohorts Quality Measures at 18
Months
Directionally similar, smaller magnitude
improvements than longitudinal cohort
Eligible Patients Treated
P 0.001 vs. baseline P 0.006 vs.
baseline P 0.012 vs. baseline
Patient level analyses
P-values are for relative change
Fonarow GC, et al. Circulation. 2010122585-596.
39
Results Summary Measures at Practice Level
Fonarow GC, et al. Circulation. 2010122585-596.
40
Baseline Quality of Outpatient HF Care
Conformity with Quality Measures at Baseline
41
Methods Study Design and Patient Disposition
34,810 patients enrolled 167 total sites
63,143 chart reviews
Baseline Chart Review 167 sites 15,177 patients
12 Month Chart Review 155 sites 9,386 patients
24 Month Chart Review 155 sites 7,605 patients
Longitudinal Cohort
Process Improvement Intervention (165 sites)
6 Month Chart Review 154 sites 9,992 patients
18 Month Chart Review 151 sites 9,641 patients
Two Single- Time-Point Cohorts
Longitudinal Cohort Patient Disposition

• Longitudinal cohort included the same patients
  reviewed at 3 time points.
• Single-time-point cohorts included separate
  patients from the same practices and unique from
  the longitudinal cohort, as well as from each
  other.

Longitudinal cohort baseline 15,177
Died - 2,569
Did not complete 24 mo FU - 1,446
From practices without 24 mo FU - 1,049
Status unknown - 2,508
Alive with 24 mo FU 7,605
FU, Follow Up
Fonarow GC, et al. Circulation. 2010122585-596.
42
IMPROVE HF Performance Improvement Tools

• As part of an enhanced treatment plan, IMPROVE HF
  provided evidence-based best-practices
  algorithms, clinical pathways, standardized
  encounter forms, checklists, pocket cards, chart
  stickers, and patient education and other
  materials to facilitate improved management of
  outpatients with HF.
• The materials can be downloaded from
  www.improvehf.com
• The materials are also included in the
  Circulation online-only Data Supplement

Fonarow GC, et al. Circulation. 2010122585-596.