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Original Articles

Heart Failure Care in the Outpatient Cardiology Practice Setting

Findings From IMPROVE HF

Gregg C. Fonarow, MD; Clyde W. Yancy, MD; Nancy M. Albert, PhD, RN; Anne B. Curtis, MD; Wendy Gattis Stough, PharmD; Mihai Gheorghiade, MD; J. Thomas Heywood, MD; Mark L. McBride, PhD; Mandeep R. Mehra, MD; Christopher M. O'Connor, MD; Dwight Reynolds, MD and Mary Norine Walsh, MD

From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University School of Pharmacy, Research Triangle Park, NC, Department of Medicine (W.G.S.), Duke University Medical Center, Durham, NC, Division of Cardiology (M.G.), Northwestern University, Feinberg School of Medicine, Chicago, Ill, Division of Cardiology (J.T.H.), Scripps Clinic, La Jolla, Calif, Outcome Sciences, Inc. (M.L.M.), Cambridge, Mass, Division of Cardiology (M.R.M.), University of Maryland, Baltimore, Md, Division of Cardiology (C.M.O.), Duke University Medical Center, Durham, NC, Cardiovascular Section (D.R.), University of Oklahoma Health Sciences Center, Oklahoma City, Okla, The Care Group (M.N.W.), LLC, Indianapolis, Ind.

Correspondence to Gregg C. Fonarow, MD, Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, 10833 LeConte Avenue, Room 47-123 CHS, Los Angeles, CA 90095-1679. E-mail gfonarow{at}mednet.ucla.edu

Received February 12, 2007; accepted May 5, 2008.

Background— Few data exist regarding contemporary care patterns for heart failure (HF) in the outpatient setting. IMPROVE HF is a prospective cohort study designed to characterize current management of patients with chronic HF and ejection fraction 35% in a national registry of 167 US outpatient cardiology practices.

Methods and Results— Baseline patient characteristics and data on care of 15381 patients with diagnosed HF or prior myocardial infarction and left ventricular dysfunction were collected by chart abstraction. To quantify use of therapies, 7 individual metrics (use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, β-blocker, aldosterone antagonist, anticoagulation, implantable cardioverter defibrillator, cardiac resynchronization therapy, and HF education) and composite metrics were assessed. Care metrics include only patients documented to be eligible and without contraindications or intolerance. Among practices, 69% were nonteaching. Patients were 71% male, with a median age of 70 years, and a median ejection fraction of 25%. Use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (80%) and β-blocker (86%) was relatively high in eligible patients in the outpatient cardiology setting; other metrics, such as aldosterone antagonist (36%), device therapy (implantable cardioverter defibrillator/cardiac resynchronization therapy with defibrillator, 51%; cardiac resynchronization therapy, 39%), and education (61%), showed lower rates of use. A median 27% of patients received all HF therapies for which they were potentially eligible on the basis of chart documentation. Use of guideline-recommended therapies by practices varied widely.

Conclusions— These data are among the first to assess treatment in the outpatient setting since the release of the latest national HF guidelines and to demonstrate substantial variation among cardiology practices in the documented therapies provided to HF patients.

Key Words: heart failure • outpatient • quality of care

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