# Presentation: 139327

## 2007 Heart Disease and Stroke Prevention Training

- Amy Carte, RN MS
- September 18, 2007

## Accessing the Health Care System in West Virginia

**Opportunity for Improvement:**
**Acute Myocardial Infarction,**
**Heart Failure, and Stroke**

**Notes:**
Improving Health Care Quality through the Health Care system is certainly an uphill climb.  Today, we’ll take a hike through the health care system and try to make things better.

## Choosing your path

- Don’t we already know the basics for treatment of AMI, CHF, and STROKE?
- How well are we applying guidelines in treatment of AMI, CHF and STROKE?
- What are the obstructions to further improvement in care of AMI, CHF and STROKE?
- How can we achieve “Top 10%” status throughout the state?  nation?

**Notes:**
The hike began with asking ourselves these questions which helped us select the path we would follow.

## Identifying the Opportunity

- Heart disease is the #1 killer of Americans.
- 1 in 4 males and females has some form of CVD.
- Stroke is the #3 killer of Americans in most states.
- About 700,00 Americans will have a stroke this year.
- Heart Failure accounts for approximately 1,000,000 hospital admissions each year in US.
- Heart failure leading cause of hospitalization in persons over 65
- Average US hospital ***loses ***$1,288 per HF patient admitted
- Sources: *American Heart Assn 2005 Update; CMS National 2001 discharge database; MEDPAR, DRG 427;Cardinal Health Clinical Services and Consulting (CHCSC);Heart Disease and Stroke Statistics - 2005 Update; Rich MW, Epidemiology, Pathophysiology and Etiology of Congestive Heart Failure in Older Adults; O'Connell JB, The Economic Burden of Heart Failure*

**Notes:**
Include discussion of HF facts selected

## West Virginia Coalition for Quality Health Care

- a grant funded, physician-directed organization dedicated to exploring clinical variation,and improving health care in West Virginia for more than 7 years
- The Coalition has been funded by the WV Cardiovascular Health Program and the WV Health Care Authority

**www.wvheart.org**

**Identify Your Partners**

**Notes:**
The WV Coalition for Quality Health Care began in 1997 as a 3 yr demonstration project with funding from RWJF, Benedum and the HCA. 
Because of our success we have been able to secure  grant funding to continue the work of the Coalition from the HCA, and the BPH Cardiovascular Health Program 

The entire project, including myself, is funded through grants

## Identify Your Partners

**Identify Your Partners**

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**Identify Your Partners**

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**Identify Your Partners**

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**Identify Your Partners**

## Identify Your Partners

**Identify Your Partners**

## Identify Your Partners

**Identify Your Partners**

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**Identify Your Partners**

## Identify Your Partners

**Identify Your Partners**

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**Identify Your Partners**

## Identify the Process

- Study Groups formed by physician interest
- Physicians and nurses study care with areas of high variation
- Emphasis is placed on identifying what drives variation
- Strategies devised to decrease variation and IMPROVE CARE

## Study Group Timeline

- Formative meeting
- Planning retreat
- Quarterly Video Conference Meetings
- Roll-out (recruiting) meetings
- Develop Tool (Resource) Kit
- Learning sessions
- Site Visits
- Ongoing Technical Assistance

## AMI Project: “GAP in the Mountains” 

- Modeled after the successful American College of Cardiology/American Heart Assn GAP Project in Michigan
- 31 Hospitals participated on a voluntary basis (59%)
- Each participating hospital had a Physician Champion and                   a Project Leader (RN or QI coordinator)

**Notes:**
AMI stands for Acute Myocardial Infarction, also commonly known as a heart attack

The AMI Project had 2 arms
	- a hospital based project called “GAP in the 	Mountains” designed to help physicians and hospitals 	work together to improve AMI/ACS care
and
	-a patient education component via commercial 	messages on the “ABC’s of Heart Health” with web 	based support for these messages. Geared to get pts to 	access the health care system earlier, and to partner w/ 	their caregivers by understanding their condition/meds 	for better outcomes

## GAP TEAM MEMBERS(For AMI, CHF, and STROKE)

| Administrators | Cardiac / Medical Rehabilitation |
| --- | --- |
| Physicians | Health Educators |
| Nurses | Social Services |
| Quality Improvement Staff | Physical Therapy
 |
| Pharmacy | Respiratory Therapy |
| Utilization Review Staff | Occupational Therapy |

## ABC’s of Heart Health

- A- Aspirin and ACE Inhibitors
- B- Beta Blockers
- C- Cholesterol screening and medications

**Notes:**
The Coalition has created and sponsored a series of 3x 30 second commercial messages around this theme 

Each message should serve as a “call to action”  to get the public more involved and personally invested in their/family’s own care for better outcomes

Aired statewide on NBC and CBS affiliates, and PBS.

Messages direct individuals to the Coalition’s website where we have placed more information on these ABC’s of heart health as well as links to other helpful websites for additional information

## Heart Failure Project

- Fashioned after our successful AMI *GAP in the Mountains* Project
- Three arms to this project
**Inpatient care**
**Physician involvement**
**Public Education campaign**

## HEART FAILURE QUALITY MEASURES

- Discharge instructions
- LVF assessment
- ACEI for LVSD
- Adult Smoking Cessation Counseling

## GAP STROKE PROJECT	

- Began 2005 in West Virginia
- No publicly reported data
- Need to develop indicators
- Will apply GAP AMI and HF Process to Stroke

## Who can remember all that?

- Clinical guidelines
- Quality measures
- ER orders
- Admission orders
- Nursing clinical pathways
- Discharge contracts/instructions

## STRIKE WHILE THE IRON IS HOT

## CMS Hospital ComparePhysician Specific Data

## Slide 26

## CMS Hospital Compare Data- AMI

| MEASURE | TOP 10% | USA | WV |
| --- | --- | --- | --- |
| ACEI for LV dysfunction | 100 | 75 | 71 |
| Smoking counseling | 100 | 75 | 75 |
| ASA on arrival | 100 | 91 | 90 |
| ASA on discharge | 100 | 86 | 84 |
| Beta blocker on arrival | 100 | 83 | 86 |
| Beta blocker on discharge | 100 | 84 | 86 |
| PTCA within 90 minutes | 70 | 37 | 39 |
| Lytics within 30 minutes | 100 | 37 | 37 |

## CMS Hospital Compare DataHeart Failure

|  | Top 10% | USA | WV |
| --- | --- | --- | --- |
| ACEI in CHF for LV dysfunction | 100 | 74 | 71 |
| Smoking counseling | 100 | 65 | 74 |
| Assess LV function | 98 | 78 | 75 |
| Discharge instructions | 88 | 45 | 49 |

**CMS Hospital Compare Data****Heart Failure**

## I hate those ACS orders!

## Slide 30

## “Patient” Problems”

- Patients who sneak into the hospital
- Apply admission orders
- Patients who sneak out of hospital
- Code room, secondary diagnoses
- Patients with new diagnosis in hospital

## “Institutional” Issues

- It’s really not the institution, it’s the people who work there.
- Administrators
- Physicians
- Nurses
- QA departments
- Coders, medical records

## Physician issues

- Resistance to use of admission orders
- How can we streamline them?
- Is there some way to include more automatic items?
- Resistance to use of discharge instructions
- Use of computerized systems
- Incentives, through payers?
- Threats, medical records sanctions
- Public reporting of physician specific care

## For more information...

- Deborah Ruppert, R.N., Project Director
- West Virginia Coalition for Quality Health Care
- 100 Association Drive
- Charleston, WV 25311-1571
-  304 344-9744 ; _druppert@wvha.org  _
- Or
- Amy Carte, RN-C, Manager
- West Virginia Cardiovascular Health Program
- 350 Capitol Street   Room 206
- Cha-rleston, WV  25301
- 304 558-6258 _[amycarte@wvdhhr.org](mailto:amycarte@wvdhhr.org)_
- _[www.wvheart.org](http://www.wvheart.org/)__ _

**Notes:**
Highlight web site with patient information
Mention handouts in pkt:

## Questions and answers