Best Practices in Managing Patients with Heart Failure Collaborative

Transcription

1 Best Practices in Managing Patients with Heart Failure Collaborative September 1, 2016 Add your company logo here

2 Todd O Connell Lean Six Sigma / Director of Process Improvement Quick update on data Reminder: Our approach Agenda Focus: Improving medical management and Rx choices Q&A 9/2/2016 2

3 Data Challenges Huge challenges to get hospital data: Wanted EF data in discrete format for all patients Coming from one hospital, still working on the other hospital 1 st Hospital: NO EF <45 for all patients studied! HF admits and re-admits Now have an imperfect version Plan now to file all outcomes data going back to the start of the Collaborative soon 3/29/2016 3

4 Reminder PriMed s Original Plan for HF 1. Better screening for patients at high/moderate risk of HF 2. Earlier identification of patients with HF Aggressive management; forestall decompensation 3. Effective management of Stage C patients to maximize cardiac and hemodynamic health, reduce need for diuretics when possible Fewer admits and re-admits 9/2/2016 4

5 Musingsponderingsandrants.me

6 PriMed/MediSync Earlier Work in HTN Three Causes of Treatment Failure Doctor Wrong Rx Wrong Dx Patient and Family or Patient Advocate Not taking medications Lifestyle Disease is Intractable Not engaged in care Can t afford treatment Etc.

7 Stages of HF STAGE A Actively screening patients at moderate or high risk of HF no HF diagnosis yet Actions: Manage BP Manage lipids Manage (pre) diabetes STAGE B Early identification of patients with asymptomatic HF Actions: Manage BP Manage lipids Manage (pre) diabetes Watch/manage heart /vascular function Vascular resistance Rate Stroke volume Cardiac index Etc. STAGE C Patients with diagnosed HF with symptoms and/or manifestations Actions: Lower BP <130/80 HR <70 (most cases) LDL <70 Avoid or manage fluid load Optimize Heart rate Stroke volume Cardiac index Hemodynamics (vascular)

8 Outcomes STAGE C Patients with diagnosed HF with symptoms and/or manifestations Actions: Lower BP <130/80 HR <70 (most cases) LDL <70 Avoid or manage fluid load Optimize Heart rate Stroke volume Cardiac index Hemodynamics (vascular) Patient well managed Successful engagement Well selected medications Patient not well managed due to medication choices Patient not well managed due to patient/family/socio-economic reasons

9 Our Theory From HTN The single biggest improvement we can make is to assure that the doctor writes the best therapies The second biggest improvement is to address the patient s educational, psychological, socioeconomic and other environmental (i.e. support system) factors For optimal outcomes, we need to do both

10 Degree of Difficulty On Med Choice Is Very High! The ability for a single physician or other provider to amass all the data and calculate the correct Tx/Rx is very, very difficult The error rate is necessarily high!

11 Status/Demographics Age <60 >60 Gender African American? Pregnancy a possibility Hemodynamic Status Vascular resistance Heart rate Stroke index Cardiac index Fluid load EF Hemodynamic/Vascular Drug Options Thiazides Aldosterone Antagonist Potassium Sparing Loop Diuretics ACEI ARB CCB Dihydropyridines CCB Non-Dihydropyridines β1 Blockers β1 + 2 Blockers α+β1+2 Blockers Vasodilating Vasodilators Central Alpha Agonist Peripheral α Blockers Co-Morbidities HTN Isolated systolic Resistant CAD Angina AFIB History MI History Stroke LVH 1 st Degree Heart block 2 nd Degree Heart block Diabetes Pre-diabetes BPH History of Gout Asthma/Reactive airway disease CKD GFR<30 GFR>30 Hepatic failure/cirrhosis Hypo / Hyperkalemia Hypercalcemia

12 Rx Selection Certain variables REMOVE some Rx options from consideration Example: History of Gout knocks out HCT Certain conditions INCREASE the value of a drug class Example: Obesity increases Aldosterone Antagonist as a choice All Rx choices are in steps

13 Example 1 Patient: Male, <60 Elevated BP NO HF High heart rate Co-morbidities: CAD, Diabetes STEP 1: STEP 2: STEP 3: STEP 4: STEP 5 B1 blocker CCB Non-dihydropyridines ACEi/ARB Thiazide Central Alpha Agonist 9/2/

14 Example 2 SAME PATIENT With HF Patient: Male, <60 Elevated BP WITH HF (EF 42; Thoracic Fluid Content: Elevated) High heart rate Co-morbidities: CAD, Prior Hx MI, Diabetes STEP 1: STEP 2: STEP 3: STEP 4 STEP 5 B1 Blocker ACEi/ARB Loop Diuretic Aldosterone Antagonist Thiazide 9/2/

15 Plan Forward Complete the HF grid ~60 days Test HF and HTN Build tool to grab data from EHR as required Test with docs Roll-out 9/2/