How Health-System Pharmacists Can Ensure Quality Measures for HF Patients

The quality of care health care professionals provide heart failure patients depends more on how well they follow guideline recommendations than it does on the number of patients they treat, according to Dharam Kumbhani, MD, SM, an assistant professor of medicine and a cardiologist at UT Southwestern Medical Center.

His recent study assessed more than 125,000 older heart failure patients who were treated at 342 hospitals participating in a voluntary program that promotes use of the American Heart Association’s evidence-based treatment guidelines. The findings showed that providers at hospitals with a higher volume of patients were more likely to perform appropriate testing, administer needed drugs, and conduct smoking cessation counseling. However, there was no difference in mortality and readmission rates between large- and small-volume hospitals where providers followed guidelines of care.

Dr. Kumbhani took a few minutes to talk about why heart failure patients who go to high-volume hospitals for treatment aren’t guaranteed to have the best outcomes and how health-system pharmacists can help to ensure quality measures are met at facilities of all sizes.

What led you investigate the association between volume and outcomes in heart failure patients?

We’ve disproved that hospitals performing more procedures always have better outcomes, but saw a similar mindset setting in for the treatment of acute medical conditions such as heart failure. My primary interest is assessing quality outcomes in outcomes-based care and volume is one of the metrics that’s frequently discussed. The assumption is that if a hospital treats more patients with heart failure, it has better outcomes. We’ve always noticed a volume-outcomes association, but there’s a bigger association between volume and processes and quality-of-care measures. From a policy standpoint, focusing on that relationship is a better way to improve patient care.

What did your study’s findings indicate?

Quality measures were more important than volume—how well a hospital adheres to quality measures had a higher correlation to outcomes. It’s an obvious paradigm—hospitals that are interested in improving patient care should measure quality measures, not volume. Higher volume hospitals certainly do better for certain quality metrics such as how well they prescribe ace inhibitors and beta blockers. Our study suggests that understanding why they do better is much more important than increasing admissions of heart failure patients in lower volume hospitals to improve their quality of care.

What are the best ways to ensure heart failure patients receive optimal care and the medications they need?

More research is needed to understand how higher volume hospitals deliver better care but, from my perspective at a very busy tertiary care hospital, having order sets in place for heart failure patients that incorporates as many quality measures as possible is effective and that provide hard stops if providers fail to explain why they don’t prescribe ace inhibitors at the time of admission and discharge. It's also important to ensure heart failure patients are seen by a cardiologist instead of a hospitalist. Other studies that measured quality of care indicated the prescribing of medications was better when cardiologists cared for patients.

What role can health-system pharmacists play in those efforts? 

Pharmacists should certainly be involved in inpatient care, from admission to discharge, to flag patients who are missing quality metrics. There’s a very large drop off in medication compliance among patients after discharge. We have powerful drugs that are proven to work at our disposal, but the biggest issue is patient compliance with prescribed therapies. Being able to partner with pharmacists in a longitudinal fashion to help improve compliance would go a long way. 

In your experience, how can pharmacists ensure heart failure patients receive the medications they need?

At our hospital, clinical pharmacists are embedded in our heart failure team and are an invaluable resource. They’re actively involved in patient care and constantly discussing treatment options with physicians. The structure and economics of that staffing scenario might not work in smaller, community hospitals, but health systems should figure out ways to empower pharmacists to be active participants in patient care and help ensure quality metrics are met in a collegial way.

—Dan Cook