Target: Heart Failure Building on Success A national initiative of the American Heart Association that provides healthcare professionals with content-rich resources and materials designed to help advance heart failure awareness, prevention, and treatment. Building on Success GWTG-Heart Failure Mission: Lifeline OPTIMIZE-HF Joint Commission/AHA Heart Failure Advanced Certification Program The Guideline Advantage 4/13/2017 ©2010, American Heart Association

The Need 5.7 million Americans are currently living with heart failure, and 670,000 new cases are diagnosed each year- up significantly from 500,000 cases annually just a few years ago. As our population ages, this epidemic of heart failure will only continue to grow. The cost of providing heart failure ranks among the leading U.S. healthcare expenditures. Additionally, the toll of heart failure on life, both in quality and longevity, is sobering. 4/13/2017 ©2010, American Heart Association

What is Target: Heart Failure ? A national initiative of the American Heart Association that provides healthcare professionals with content-rich resources and materials designed to help advance heart failure awareness, prevention, and treatment. 4/13/2017 ©2010, American Heart Association

Target: Heart Failure Vision: To improve quality, care transitions, and outcomes for patients with heart failure with a targeted initiative and leveraging the American Heart Association’s premier quality improvement suite of resources including Get With The Guidelines-Heart Failure. 4/13/2017 ©2010, American Heart Association

Target: Heart Failure Mission: Increase 3 key patient-centered care domains with very well established or emerging evidence-base: Medication optimization Early follow-up and care coordination Enhanced patient education 4/13/2017 ©2010, American Heart Association

Target: HF Optimal Care Transitions and Patient Education: Discharge use of ACEI/ARB, evidence-based beta blocker, and aldosterone antagonist in all eligible heart failure patients with reduced LVEF, in absence of documented contraindications, intolerance, or patient/system reasons Early post-discharge follow-up with visit or contact within 48 hours of discharge scheduled Enhanced patient education as evidenced by referral to heart failure disease management program, provision of at least 60 minutes of heart failure education by a qualified heart failure educator, or provision of AHA heart failure interactive workbook 4/13/2017 ©2010, American Heart Association

Building on Success GWTG-Heart Failure Mission: Lifeline Joint Commission/AHA Heart Failure Advanced Certification OPTIMIZE-HF The Guideline Advantage 4/13/2017 ©2010, American Heart Association

Background on Heart Failure Population Group Prevalence Incidence Mortality Hospital Discharges Cost Total population 5,700,000 670,000 277,193 990,000 $39.2 billion Heart failure (HF) is a major public health problem resulting in substantial morbidity and mortality Despite recent advances a substantial number of patients are not receiving optimal care 2Jones DL et al. Heart Disease and Stroke Statistics 2011 Update. Report from the AHA . Circulation.2011. 9 9

Heart Failure Hospitalizations 1.0 Million Hospitalizations a Year and Rising 30-Day Rehospitalization Rates in HF 24.8% (Medicare) The majority of patients hospitalized with HF were previously hospitalized with HF 10 United States: 1979-2006 Source: NHDS/NCHS , NHLBI. Hospital Compare 2007-2010

30-Day Rehospitalization Rates in HF Vary Widely Between Hospitals X axis, hospital decile, 0-9 Y axis, mean hospital observed rates for 30-day rehospitalization from 0 to .40 11 Keenan PS et al. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.

All-Cause Mortality After Each Subsequent Hospitalization for HF 1.0 HF 1st admission (n = 14,374) 2nd admission (n = 3,358) 3rd admission (n = 1,123) 4th admission (n = 417) P<0.0001 0.8 0.6 Cumulative mortality 0.4 0.2 1st hospitalization: 30-day mortality = 12%; 1-year mortality = 34% 0.0 0.0 0.5 1.0 1.5 2.0 Time since admission Setoguchi S, et al. Am Heart J. 2007;154:260-266. 12

Estimated Direct and Indirect Costs of HF in US Total Cost $39.2 billion Hospitalization $20.9 53.3% Nursing Home $4.7 11.9% 6.4% 10.5% Physicians/Other Professionals $2.5 8.2% Lost Productivity/ Mortality* $4.1 9.7% Drugs/Other Medical Durables $3.2 Home Healthcare $3.8 13 Heart Disease and Stroke Statistics—2010 Update: A Report From the American Heart Association Circulation, Feb 2010; 121: e46 - e215. 13

Causes of Hospital Readmission for Heart Failure Over 2/3 of HF Hospitalizations Preventable Diet Noncompliance 24% Rx Noncompliance 24% 16% Inappropriate Rx 17% Other 19% Failure to Seek Care 14 Annals of Internal Medicine 122:415-21, 1995 14

Measuring and Improving the Quality of HF Care Heart failure remains a major public health problem resulting in substantial morbidity and mortality. A number of evidence-based, guideline-recommended therapies are available to treat patients with heart failure. However, study after study shows the large gaps, variations, and disparities in the use of these evidence based therapies in eligible patients.   15 15

ADHERE Quality of Care Conformity to The Joint Commission HF Performance Indicators Lagging Centers Leading Centers All P<0.0001 % Utilization Discharge Instructions LV Function Measurement ACEI use Smoking Cessation Length of Stay (median) Mortality 81 142 admissions between 6/2002 – 12/2003 at 223 hospitals Grouped by Leading (90th percentile) and Lagging (10th percentile) 16 Fonarow GC et al. Arch Intern Med 2005;165:1469-1477

Risk-Treatment Mismatch in HF: Canadian EFFECT Study At Hospital Discharge 90-Day Follow-Up 1-Year Follow-Up 90 80 70 60 Patients, % 50 40 30 20 10 ACEI ACEI or ARB -Blocker ACEI ACEI or ARB -Blocker 1-Year Mortality Rate Low Risk Average Risk High Risk Use rates in absence of contraindications. For all drug classes, P < .001 for trend. EFFECT, Enhanced Feedback for Effective Cardiac Treatment. Lee D. JAMA. 2005;294:1240-1247. 17

Evidence-Based Treatment for Heart Failure with Reduced LVEF Reduce Mortality Control Volume ACEI or ARB Aldosterone Antagonist Sodium Restriction* Diuretics* -Blocker Treat Residual Symptoms CRT  an ICD* ICD* Hyd/ISDN* Digoxin* Enhance Adherence Treat Comorbidities Education Disease Management Performance Improvement Systems Aspirin* Warfarin* Statin* 18 *For select indicated patients.

Established Benefits of Guideline-Recommended HF Therapies Guideline Recommended Therapy Relative Risk Reduction in Mortality Number Needed to Treat for Mortality NNT for Mortality (standardized to 36 months) Relative Risk Reduction in HF Hospitalizations ACEI/ARB 17% 22 over 42 months 26 31% Beta-blocker 34% 28 over 12 months 9 41% Aldosterone Antagonist 30% 9 over 24 months 6 35% Hydralazine/Nitrate 43% 25 over 10 months 7 33% CRT 36% 12 over 24 months 8 52% ICD 23% 14 over 60 months 23 NA Fonarow GC, et al. Am Heart J 2011;161:1024-1030. 19

Improved Adherence to ACC/AHA HF Guidelines Translates to Improved Clinical Outcomes in Real World HF Patients Each 10% improvement in ACC/AHA guideline- recommended composite care was associated with a 13% lower odds of 24-month mortality (adjusted OR 0.87; 95% CI, 0.84 to 0.90; P<0.0001). Fonarow GC, et al. Circulation. 2011;123:1601-1610.

Bridging the Gap Between Knowledge and Routine Clinical Practice ACC/AHA/HFSA Guidelines Systems Clinical Practice Clinical guidelines, implemented through critical pathways in the hospital and at discharge, help bridge any potential gaps and provide a smooth transition between acute care and long-term management. Implementing guideline-based critical pathways will: Optimize patient triage Ensure appropriate use of proven medications and treatments Facilitate communication between specialist physicians and PCPs during hospitalization and after discharge Enhance patient compliance and outcomes Reduce the potential for medical errors Reduce costs by limiting length of stay and unnecessary testing Improve compliance with national standards (such as the Joint Commission on Accreditation of Healthcare Organizations [JCAHO])   Cannon CP, O’Gara PT. Critical Pathways in Cardiology. Lippincott Williams & Wilkins; 2001. Implement evidence-based care Improve communications Ensure compliance Clinical trial evidence National guidelines Improve quality of care Improve outcomes Adapted from the American Heart Association. Get With The Guidelines; 2001. 20

ACC/AHA 2005 HF Guidelines: Implementation of Guidelines Academic detailing or educational outreach visits are useful to facilitate the implementation of practice guidelines Multidisciplinary disease-management programs for patients at high risk for hospital admission or clinical deterioration are recommended 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 A I IIa IIb III B Hunt SA, et al. ACC/AHA 2005 Practice Guidelines. Available at http://www.acc.org. 21

American Heart Association’s Get With the Guidelines–Heart Failure The AHA’s hospital based quality-improvement program aims at ensuring that every patient with HF receives the best possible care Continuity of data and hospital tools with OPTIMIZE-HF Launched January 2005; currently over 500 US hospitals participating, over 500,000 patient HF hospitalizations Opportunity for hospitals to achieve national recognition through participation Opportunity for advanced heart failure certification via The Joint Commission 22

GWTG-HF Performance Measures All p<0.0001 May 2011 Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from 1/1/05-12/31/10 23

GWTG-HF Performance Measures All p<0.0001 Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from 1/1/05-12/31/10 May 2011 24

GWTG-HF Performance Measures All p<0.0001 Data from 458 GWTG-HF hospitals and 481,098 HF hospitalizations collected from 1/1/05-12/31/10 May 2011 25

GWTG-HF Participation and Quality of Care for Heart Failure Measure GWTG Hospitals (n=355) Non-GWTG Hospitals (n=3909) P-Value LVEF documented 92.8% 83.0% <0.0001 ACEI/ARB in LVSD 85.6% 81.4% 0.001 Discharge Instructions 67.7% 55.3% <0.001 Smoking Cessation Counseling 85.7% 81.3% 0.04 Heidenreich PA et al Am Heart J 2009;158:546-53

Impact of Evidence-Based HF Therapy Use at Hospital Discharge on Treatment Rates During Follow-Up 60- to 90-Day Postdischarge Follow-Up OR 30.6 (95% CI, 22.53-41.57) P.0001 OR 10.22 (95% CI 7.79-13.41) P.0001 -Blocker at Discharge YES -Blocker at Discharge NO ACEI/ARB at Discharge YES ACEI/ARB at Discharge NO (1,579/1,697) (94/309) (1,329/1,861) (75/382) 26 Fonarow GC et al. J Card Fail 2007;13:722-31

Days After Hospital Discharge Impact of Discharge Use of Beta Blocker on Early Clinical Outcomes in Heart Failure 30 day Survival P<0.01 1.00 P=0.0003 0.95 0.90 Survival Probability 0.85 0.80 0.75 Beta-Blocker No Beta-Blocker 0.70 10 20 30 40 50 60 70 80 90 100 110 120 130 Days After Hospital Discharge Patients at Risk Beta-blocker 1,946 1,855 1,649 333 68 No Beta-blocker 362 337 304 60 7 *Only subset of patients with 60- to 90-day follow-up are included. Patients with beta-blocker contraindications are excluded. Fonarow et al. J Am Coll Cardiol. 2008;52:190-199. 27

In-Hospital and Follow-Up Outcomes Improve When Process of Care Tools are Used: OPTIMIZE-HF 60- to 90-Day Mortality and Rehospitalization In-Hospital Mortality P<.02 P.001 Patients (%) PrCI Tool Use No PrCI Tool Use PrCI Tool Use No PrCI Tool Use Process of care tool use (admission order set or discharge checklist) was reported during hospitalization in 45.3% of patients (n=22,017/48,612) Fonarow GC, et al. Arch Intern Med. 2007;167:14931502. 28

4/13/2017 ©2010, American Heart Association

GWTG-HF Results in Equitable Care With few exceptions, individual HF core measures were similar for Black, Hispanic, and White patients. When there were differences in core measures, they predominantly favored nonwhite subgroups Unadjusted Thomas K et al. Am Heart J. 2011;161:746-54 30

GWTG-HF Resulted in Equitable Improvement by Race/ Ethnicity in HF Quality Trends in “All-or-None HF Care Measure* by Race/Ethnicity Unadjusted Odds Ratio Adjusted** White (Year 1 vs. Baseline) 1.60 1.55 White (Year 2 vs. Baseline) 2.34 2.29 White (Year 3 vs. Baseline) 3.07 3.04 Black (Year 1 vs. Baseline) 1.70 1.74 Black (Year 2 vs. Baseline) 2.32 2.40 Black (Year 3 vs. Baseline) 3.18 3.28 Hispanic (Year 1 vs. Baseline) 1.43 1.39 Hispanic (Year 2 vs. Baseline) 2.00 Hispanic (Year 3 vs. Baseline) 2.48 2.46 *”All-or-None HF Care Measure” = 100% adherence to al 4 HF care measures plus B-Blocker use in patients with LV systolic dysfunction **Adjusted variables include age, gender, body mass index, insurance, medical history, systolic blood pressure and hospital characteristics Thomas K et al. Am Heart J. 2011;161:746-54 31

Hospital Variation in Early Follow-up After Heart Failure Hospitalization Median Follow-up Visit within 7 days = 37.5% 225 Hospitals Hernandez et al. JAMA 2010;303:1716-1722. 32

Hospital Variation in Early Follow-up After HF Hospitalization: Follow-up by Physician Type Hernandez et al. JAMA 2010;303:1716-1722.

Relationship Between Early Physician Follow-up and 30-day Outcomes for Medicare Beneficiaries 30-Day Mortality p= 0.44 30-Day Readmission p <0.01 Hernandez et al. JAMA 2010;303:1716-1722.

Relationship Between Early Physician Follow-up and 30-day Readmission Among Medicare Beneficiaries Hospitalized for HF Early Follow-up Unadjusted HR 95% CI P Value Adjusted HR Quartile 1 1.0 (REF) Quartile 2 0.86 0.78-0.94 <.01 0.85 0.78-0.93 <01 Quartile 3 0.76-0.94 0.87 0.78-0.96 Quartile 4 0.79-0.95 0.91 0.83-1.0 .05 Hospitals in the lowest quartile of early physician follow-up had higher rates of rehospitalization within 30-days, than those in the other 3 quartiles, independent of other factors 33 Hernandez et al. JAMA 2010;303:1716-1722.

Rehospitalizations in Heart Failure Nearly one in four patients hospitalized with HF is rehospitalized within 30 days of discharge Opportunity to Improve 30-day rates of rehospitalizations in HF have risen over the past 2 decades and vary widely by hospital, even after adjusting for case mix and other factors Many HF hospitalizations are preventable, but effective strategies to prevent rehospitalizations are underutilized 34

Get With The Guidelines® Heart Failure Clinical Tools Library Over 60 heart failure tools, including: Discharge Orders/Instructions Order Sets Pathways/Algorithms Patient Education Materials Other Tools All posted submissions were reviewed/evaluated by AHA volunteer workgroup. AHA does not endorse any tools. Submissions are intended solely as examples that hospitals may want to consider using/modifying. Heart failure clinical tools library: heart.org/hfclinicaltools. Stroke clinical tools library: heart.org/strokeclinicaltools. Submit tools you would like us to consider to penelope.solis@heart.org. 37

AHA Interactive Workbook to help educate patients and help them manage Heart Failure. Created for after the patients hospital stay, the interactive workbook focuses on preventing recurring events.  The workbook helps improve patient health and track recovery.  These workbook are designed to help the patient better understand their condition, how to maximize their recovery and provide the skills to the patient and their caregivers need to better manage heart failure. 

Challenges to Implement a HF Performance Improvement System This will not work in a community practice or hospital. The cardiologists will not agree to this. We can not get a consensus. The managed care organization will not pay for it. Patients do not want to be on a lot of medications. There is not enough time. It will cost too much. It may not be safe to start Beta Blocker medications in heart failure patients. This will benefit the competition. The administration will not pay for it. What about the liability? It will take too much time. All my patients are too complex for this. The patients should all be followed by someone else. It is too hard to get things through the practice committee. The physicians at my office do not like cookbook medicine. We do not have anyone to do this. 38

Key Elements to Quality Improvement: Why Do Some Programs Succeed? Access to current and accurate data on treatment and outcomes Have stated goals Administrative support Support among clinicians Use of care maps and pathways Use of data to provide feedback Bradley. JAMA. 2001;285:2604-2611. 39

Potential Impact of Optimal Implementation of Evidence-Based HF Therapies on Mortality Guideline Recommended Therapy HF Patient Population Eligible for Treatment, n* Current HF Population Eligible and Untreated, n (%) Potential Lives Saved per Year (Sensitivity Range*) ACEI/ARB 2,459,644 501,767 (20.4) 6516 (3336-11,260) Beta-blocker 2,512,560 361,809 (14.4) 12,922 (6616-22,329) Aldosterone Antagonist 603,014 385,326 (63.9) 21,407 (10,960-36,991) Hydralazine/Nitrate 150,754 139,749 (92.7) 6655 (3407-11,500) CRT 326,151 199,604 (61.2) 8317 (4258-14,372) ICD 1,725,732 852,512 (49.4) 12,179 (6236-21,045) Total - 67,996 (34,813-117,497) Fonarow GC, et al. Am Heart J 2011;161:1024-1030.

Target: Heart Failure Honor Roll Recognition Requirements: Documentation of all three care components for 50% or more of eligible patients with heart failure discharged to home. Hospitals must be GWTG-HF performance achievement award hospitals. 4/13/2017 ©2010, American Heart Association

Target: Heart Failure Resources Get With The Guidelines-Heart Failure Patient Management Tool™ Get With The Guidelines Heart Failure Tool Kit AHA patient education resources Heart Failure Best Practices Center Heart Failure Interactive Patient Education Workbook Heart Failure guidelines, publications, and resources Heart 360 4/13/2017 ©2010, American Heart Association 41

For more information and to register for Target: Heart Failure, go to www.heart.org/targethf. 4/13/2017 ©2010, American Heart Association