CHF study finds gaps in diagnosis, treatment

Discharge instructions fall short as well

A study of CHF patients recently completed by the Missouri Patient Care Review Foundation (MPCRF) in Jefferson City indicates that physicians don’t always provide the best diagnoses and don’t always adequately treat the disease.

The foundation’s Regional CHF Cooperative Project looked at whether patients were receiving left ventricular function assessments and whether they were put on angiotensin-converting enzyme (ACE) inhibitors to improve left ventricular diastolic disfunction, according to Carl Bynum, DO, MPH, principal clinical coordinator. MPCRF contracts with the federal Health Care Financing Administration (HCFA) to monitor quality of care for Medicare beneficiaries.

Looking beyond the symptoms

The study revealed that the assessment is "not routinely done," Bynum says. "Lots of times physicians are evaluating and making a diagnosis based on symptoms. To accurately diagnose [left ventricular diastolic dysfunction] you have to evaluate the function of the heart. It’s important because it determines what medication the patient should be placed on."

The assessment of cardiac function was performed in 72% of the cases studied, Bynum says, and most of the patients deemed ideal to be put on ACE inhibitors were given that treatment. That means the study did not consider patients who were allergic to ACE inhibitors or had some other reason for not taking the medication, he adds.

"Of ideal patients, 80% were put on ACE inhibitors," Bynum notes. "That’s not too bad, but there are still another 20% that had the potential of being on the medication."

The foundation is working with the hospitals involved in the study to implement plans to educate their physicians and to change their processes, he says. "This is an important aspect of the overall treatment of these patients, and we need to make sure there are processes in place to evaluate that."

Prepare patients thoroughly for discharge

Another aspect of the study looked at discharge planning for the patients, Bynum says. It found that 46% received instructions on medication, 27% received instructions on diet, and only 10% were instructed on weight monitoring. "We looked at what was written in the chart, and for our purposes, if it wasn’t written in the chart, it didn’t happen," he adds.

Post-discharge monitoring is an important part of preventing complications from CHF, Bynum points out. "For patients to recognize that they might be retaining fluid, that they need to call the physician or make some changes" is crucial, he says.

Hospitals that fell short in this area might want to develop a preprinted form or take some other action to alert nurses and physicians to the importance of discharge planning, he suggests.

MPCRF continues to analyze data from the study, which was initiated by the Kansas City regional office of HCFA with final outcomes due in December. The study involved eight states, but the percentages cited apply only to the Missouri patients.