Implementation of a Heart Failure Template into the Workflow of a Rural Cardiology Clinic

Background: Despite improvements in medical therapy in the past two decades, readmission rates following a heart failure hospitalization remain high, with over 50% of patients being readmitted to the hospital within six months of discharge (Desai & Stevenson, 2012). Due to reduced reimbursement for health care institutions, there are national research and hospital-driven efforts to help predict which patients with heart failure are at highest risk for readmission, and the proposal of interventions to prevent readmissions (Desai & Stevenson, 2012). Furthermore, despite guidelines and quality improvement efforts, many patients with heart failure with reduced ejection fraction (HFrEF) are not prescribed guideline directed medical therapy (GDMT), which increases the risk of readmission (Allar, 2018). Among those patients who are prescribed the recommended medications, fewer than one-fourth receive optimal doses (Allar, 2018). The reasons for non-use and under-dosing of these evidence-based therapies are frequently not apparent from detailed chart review, and only rarely related to documented medication intolerance or contraindication (Smith et al., 2018). Purpose: The purpose of this project was to increase provider compliance with prescribing guideline-directed heart-failure therapy through the use of a heart-failure clinic template. Population: This project was conducted at a rural Cardiology clinic in Western Kansas. There were seven participating cardiology providers: four board-certified cardiologists and three cardiology nurse practitioners. The project focused on the outpatient records of adult patients over the age of 21 with a diagnosis of HFrEF with an ejection fraction (EF) less than or equal to 40%. Intervention: The intervention for this project was the implementation of a GDMT template into the current workflow of the rural cardiology clinic. The goal was to have providers utilize the template at every heart failure clinic visit. Two retrospective chart reviews were completed. The first chart review was completed on 30 heart failure charts of patients who were been seen in the clinic between June 1, 2019 and August 1, 2019. The second review was completed on 30 heart failure charts of patients who were seen in the clinic between September 1, 2019 and November 1, 2019. Evaluation: The chart review evaluated the use of an ACE inhibitor or ARB, beta-blocker, and aldosterone antagonist, as these medications have been shown to improve mortality and prevent hospital readmission in this population. In addition, the review also assessed whether documentation of heart failure education regarding lifestyle modifications and medication non-compliance are addressed, as education and compliance have also been shown to decrease readmission. Although the post-test ratio for beta-blockers was greater than the pre-test ratio, the difference was not statistically significant. Evaluation of results indicated a drastic increase in documentation of education or reason for medication non-use. There was sufficient evidence (95% confidence level) to suggest the post-test ratio for documentation of education or reason for non-use was greater than the pre-test ratio. Keywords: heart failure treatment, heart failure with reduced ejection fraction (HFrEF), guideline directed medical therapy (GDMT