1. Keeler 02/04 Changes in Care and Outcomes for Patients with Congestive Heart Failure: The Improving Chronic Illness Care Evaluation David W. Baker, MD, MPH Chief, Division of General Internal Medicine Feinberg School of Medicine, Northwestern University Chicago, Illinois June 6, 2004

2. A5162b-2 03/04 Keeler 02/04 Changes in Processes of Care: Methods for Chart Reviews 4 participant organizations (PART): N = 261 4 control organizations (CTRL): N = 228 Charts abstracted at baseline (7/98 to 5/99) & follow-up periods (9/99 to 8/00). –23 Quality Indicators: Dx, Rx, F/u, Counseling Determined changes in processes from baseline to follow-up period. –Compared differences b/n PART vs. CTRL.

3. A5162b-3 03/04 Keeler 02/04 Baseline Characteristics PARTCTRL Age, mean yrs6766 Male6864 New CHF Diagnosis15*8 LVEF < 40 %4748 Mean # of Chronic Dz5.96.1 Mean # of Visits/Year9.29.1 Hospitalized3536 * p = 0.01

4. A5162b-4 03/04 Keeler 02/04 Participants & Controls Had Similar Changes in Diagnostic Testing PART (abs % chg) CTRL (abs % chg) p LVEF measured 1613.49 Cr measured if on digoxin -30.65 BP measured at MD visit 68.15 LDL measured if CAD 4-9.09

5. A5162b-5 03/04 Keeler 02/04 Participants Increased Use of ACE Inhibitors and Lipid-Lowering Rx PART (abs % chg) CTRL (abs % chg) p ACEI for LVEF < 40 %13-5<.001 Beta blockade for LVEF < 40 % 57.49 Anticoagulation for atrial fibrillation -8-5.11 Lipid-lowering therapy for CAD 71<.001

6. A5162b-6 03/04 Keeler 02/04 Participants Increased Counseling PARTCTRLP Medication24<.0001 Diet33-4<.0001 Exercise24-2<.0001 Smoking-66.16 Weight loss30-2<.0001 Disease management414<.0001 Weight management243<.0001 Goal setting40<.0001

7. A5162b-7 03/04 Keeler 02/04 Conclusions from Chart Review Organizations that participated in the CHF Collaborative improved more than controls: –ACE Inhibitors for pts w/ LVEF  0.40 –Lipid lowering therapy for pts w/ CAD –All aspects of counseling x/ smoking No difference in change over time for: –LVEF measurement –Beta blocker use, anticoagulation –Other diagnostic tests, follow-up

8. A5162b-8 03/04 Keeler 02/04 Limitations of Results from Chart Review Brief period for participants to improve care. –Differences between PART and CTRL groups may have increased over time. Large improvements in care for pts in CTRL group, perhaps due to other QI forces. Improvement in patient counseling could be due to better documentation, gaming.

9. A5162b-9 03/04 Keeler 02/04 Differences in Communication, Education, and Health Status: Methods for Patient Surveys 6 participant organizations (PART): N = 387 6 control organizations (CTRL): N = 414 Telephone interviews conducted with patients approximately 10 months after collaborative. Survey developed for this study. Determined differences b/n PART vs. CTRL.

10. A5162b-10 03/04 Keeler 02/04 CHF Team  Satisfaction  Communication  Education  ACCESS  QUALITY  Knowledge  SELF- MANAGEMENT  Self-Efficacy Improved Health Outcomes Conceptual Model of How a CHF Team Acts to Improve Self-management, Access, Quality, and Health Outcomes.

11. A5162b-11 03/04 Keeler 02/04 Domains Included in Questionnaire Communication (4 item scale) Satisfaction (CAHPS) Education (15 items) Knowledge (15 items): sx, high salt foods, general knowledge and self-management. Behaviors: daily weights, low salt diet. Self-efficacy Generic (SF12) and CHF-specific health status (7 item scale)

12. A5162b-12 03/04 Keeler 02/04 Participant Characteristics PARTCTRL Age  65 (%) 6163 Female (%)5253 White7073 Less than High School4041 History of CAD, %6469 History of CABG, %2422 Hx of Revascularization %6661 Primary Care Physician30*39 *p = 0.02

13. A5162b-13 03/04 Keeler 02/04 Participants Had Better Provider-Patient Communication PART mean CTRL mean p Gave me choices and options about my treatment 3.93.70.03 Gave me confidence that I can make changes in my life to control my HF. 4.13.90.01 Were interested in my questions. 4.24.1<0.01 Regularly reviewed how I am doing in managing all aspects of my HF. 4.03.9<0.01

14. A5162b-14 03/04 Keeler 02/04 Participants Reported More Education About Lifestyle and Monitoring HF ADVISED TO:PARTCTRLp Not use salt when cooking and not to add salt to food. 91830.05 Avoid drinking large amounts of water/other fluids. 59380.01 Weigh self on a scale every morning and record weight. 8734< 0.01 Exercise regularly.9083<0.01

15. A5162b-15 03/04 Keeler 02/04 Participants Had Better HF Knowledge* *p < 0.001 for all comparisons PART (%) CTRL (%) A person with HF should not drink more fluids than normal. 7053 Someone with HF should check wt at least several times/week. 8444 Shortness of breath is a sx of HF. 6155 Swelling of the legs or ankles is a symptom of HF. 8070 Weight gain is a symptom of HF. 7661

16. A5162b-16 03/04 Keeler 02/04 Participants Had Better Weight Monitoring, but Similar Diet Compliance PARTCTRLp Has functioning scale at home (% yes). 93%81%<0.01 How frequently checks weight (1-5 scale, mean) 4.23.2<0.01 Took steps to eat low salt diet.88%85%0.35 Success at adhering to low salt diet (1-3 scale, mean) 2.1 0.48

17. A5162b-17 03/04 Keeler 02/04 Conclusions from Survey Organizations in the Collaborative had: –Better communication. –Higher self-reports of education received –Higher knowledge, including symptoms of heart failure and weight monitoring –Higher rates of monitoring weight No differences for self-efficacy, satisfaction, low salt diet compliance, and health status. Conclusions limited by lack of baseline data.

18. A5162b-18 03/04 Keeler 02/04 Final Conclusions from Evaluation Participation in the CHF Collaborative was associated with improvements in care, includ- ing prescribing of recommended therapies and patient self-management support. Chart review and patient survey support each other’s findings that there were large improve- ments in education and counseling. Viewed together, they mitigate the limitations in each.