QI project improves patient outcomes

Results include increased use of ACE inhibitors

A quality improvement project at the Cleveland Clinic Health System has improved the use of ACE inhibitors, drugs proven in studies to slow the progression of heart failure. Leaders say one of the keys to success was allowing different institutions to do what works best for them.

In 1998, physician leaders at the Cleveland Clinic Health System hospitals identified congestive heart failure as the No. 1 high-volume, high-cost health issue. Using a team approach, the system began making physicians more aware that prescribing ACE inhibitors could improve mortality and morbidity as well as reduce the hospital readmission rates of patients with severe systolic dysfunction. ACE inhibitors work by widening blood vessels to increase blood flow.

All Cleveland Clinic Health System hospitals increased the use of ACE inhibitors with high-risk congestive heart failure patients. The change was statistically significant, increasing from 61% to 66% the first year. The rate climbed again — from 66% to 68% — from 1999 to 2000. And patients have been included in the effort through an education book that explains how to manage their heart failure, including the benefits of ACE inhibitors.

Deborah Nadzam, director of the Quality Institute for the Cleveland Clinic Health System, says the ACE inhibitor initiative was led by physicians and constructed in a way that encouraged them to cooperate.

A medical operations council was formed in 1997, with representatives from 13 affiliated health centers in the Cleveland area. Chaired by Robert Kay, MD, chief of staff for the Cleveland Clinic Foundation, the council’s goal was to share information that might help improve patient care. The council was created with no line reporting or rank, he says. The goal was for the physicians to gather as a group of colleagues and discuss information freely.

"Engaging physician leadership across the health system was key to the project. Our physicians identified an opportunity to improve outcomes across the system for a highly prevalent and serious disease: congestive heart failure," Kay says. "Physician leadership of multidisciplinary teams at each hospital promoted and strengthened the positive effect of this quality improvement activity."

In 1998, the council identified congestive heart failure as one of several problems, Nadzam says, and that problem was an attractive target for quality improvement efforts because the Cleveland Clinic system has a very high volume of such patients throughout the entire system. The council called on cardiologists from each of the facilities to help define quality and determine what information was needed.

"We gathered some baseline data and found some interesting things," Nadzam says. "Our community population of heart failure patients was different from the typical clinical trial population, which told us that some findings from formal research initiatives may not be totally generalizable to the general community. The second thing we found was that the rate of ACE inhibitor use was not optimized."

CME program educates physicians

The medical council didn’t like the rate of ACE inhibitor use either at individual facilities or as an aggregate for the health system. To increase the use of the drugs, the council implemented a continuing medical education (CME) program for physicians in the system, educating them about quality improvement for heart failure and specifically the indications for ACE inhibitors. Then the council encouraged each facility in the Cleveland Clinic system to implement initiatives to increase the use of the drugs.

"Each hospital implemented its own activities that it thought would work," Nadzam says. "Some included pharmacists on discharge rounds to see what the patient was going out the door with. Some used laminated cards for physicians that laid out the guidelines for treating heart failure and using ACE inhibitors."

At each hospital, physician leaders conducted grand rounds on ACE inhibitors at least once, reinforcing the information provided in the CME program. Meanwhile, Nadzam and her colleagues continued to collect data. Soon, they saw significant increases in the use of the drugs.

The system rate for the first six months of 1998 was 61%, meaning that 61% of the patients for whom ACE inhibitors might be clinically appropriate actually received the drugs. The annual rate for 1999 was 66%, a statistically significant increase, and then it rose to 68% in 2000. The rate for 2001 reached 80%, where it now stands. Nadzam says 80% was the target rate because some patients who initially seem eligible for ACE inhibitors turn out to have contraindications.

James B. Young, MD, a cardiologist at the Cleveland Clinic, calls the numbers "a very significant improvement. "We can translate the degree of improvement into the number of lives that could be saved per year of follow-up," he says.

"We know that having a patient on specific drugs — ACE inhibitors in this case — can reduce mortality by 20% or 30%, depending on the patient group," Young says. "The fact is that by increasing the proportion of patients discharged from the hospital who are eligible for these drugs, by increasing that number significantly, we obviously reduce the number of deaths in the community."

Nadzam says the ACE inhibitor initiative led to several insights that could be put to use in any quality improvements. She offers these examples:

Keep people informed at a system level, but let the physicians formulate the changes in practice. The initiative ultimately came down to trying to change the behavior of physicians, so it was important that physicians actually determine how to do that, she says. But on a system level, Nadzam and her colleagues kept the project in front of influential leaders who could offer support and resources.

Allow individual health care units to do what works best for them. As long as everyone understands the goal and is working toward the same result, some flexibility in the execution can be very effective. Circumstances and needs will differ from one facility to the next, and allowing providers to do what works best for them will encourage their participation.

Put respected leaders on the council, but promote a collegial atmosphere. The Cleveland Clinic carefully selected leaders for the project who were experts in treating heart failure, but they encouraged a collegial atmosphere in which physicians could make suggestions and ask questions.

"Get some leaders who know the material but who also know how to run a team," Nadzam says. "That was really important. They got together as colleagues and said, ACE inhibitors are the right thing to do, and we’re all in this together. Let’s go back to our hospitals and make this happen.’ We provided information, guidance, and support, rather than mandates and centralized control."

Administrative sources can be used to collect medication data. The quality team found that some Medicare paperwork was useful when collecting data about ACE inhibitor use. They first gathered data only from chart reviews, but then they found that additional useful information was available in Form CMS-1450 (UB-92), which is used by institutional and other selected providers to complete a Medicare Part A claim.

"When we combined the UB-92 data with data collected by going in and looking at chart and medication records, we found more patients getting ACE inhibitors," Nadzam says. "The lesson is that when you use more than one source of information, you can get a more complete picture. And that’s important when every [full-time equivalent] counts and you want to minimize data collection from charts because it’s so labor-intensive."

Quarterly reports can spur improvements.

As part of the effort to keep everyone aware of the ACE inhibitor campaign, Nadzam sent quarterly reports to each facility in the Cleveland Clinic system. The reports showed everyone’s rate of ACE inhibitor use, and hospital leaders quickly started comparing their rates. "A very constructive, competitive spirit now exists," she says. "No one wants to be the lowest."

[For more information, contact:

  • Deborah Nadzam, Director, Quality Institute, Cleveland Clinic Health System, 9500 Euclid Ave., Cleveland, OH 44195. Telephone: (216) 444-2200.
  • Robert Kay, MD, Chief of Staff, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195. Telephone: (216) 444-2200.
  • James B. Young, MD, Cardiologist, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195. Telephone: (216) 444-2200.]