Clinical study
The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure

A complete list of the MISCHF study participating institutions and investigators can be found in an appendix to Philbin et al (12).
https://doi.org/10.1016/S0002-9343(00)00544-1Get rights and content

Abstract

PURPOSE: Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.

PATIENTS AND METHODS: This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a “usual care” control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.

RESULTS: Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of −1.1 days (95% confidence interval [CI]: −2.9 to 0.7 days, P = 0.18) and in hospital charges of −$817 (95% CI: −$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.

CONCLUSIONS: The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.

Section snippets

Hospitals

The design of the Management to Improve Survival in Congestive Heart Failure (MISCHF) Study has been reported (12). In brief, 10 acute care community hospitals in upstate New York participated in this trial. None offered programs of tertiary care, such as cardiac transplantation, for patients with heart failure. This study was approved by the institutional review boards of all participating centers.

The study involved two sequential phases. During the baseline period (April 1, 1995, to December

Results

During the baseline period, we collected data on 762 patients with heart failure at intervention hospitals and 640 patients at control hospitals. During the postintervention phase, we collected data on 840 patients at intervention hospitals and 664 patients at control hospitals. Among all patients, 56% were women and 97% were Caucasian. The mean (± SD) age of the patients was 76 ± 11 years; 89% were in NYHA functional class III or IV when admitted. Of the 1,694 patients for whom information

Discussion

The goal of this study was to assess whether an attempt to organize and implement a voluntary, regional, collaborative, multihospital quality improvement program would result in more favorable changes in quality and outcomes than usual care. However, despite establishing conditions that favored implementation and use of a critical pathway, the quality improvement intervention resulted in no increase in the use of pathways and had mixed and statistically nonsignificant effects on five

References (38)

  • E.F Philbin et al.

    The influence of race and gender on process of care, resource utilization, and hospital-based outcomes in congestive heart failure

    Am J Cardiol

    (1998)
  • S Weingarten et al.

    Reducing lengths of stay for patients hospitalized for chest pain using medical practice guidelines and opinion leaders

    Am J Cardiol

    (1993)
  • E.F Philbin et al.

    The relationship between hospital length of stay and rate of death in heart failure

    Heart Lung

    (1997)
  • E.F Philbin et al.

    Prediction of hospital readmission for heart failuredevelopment of a simple risk score based on administrative data

    J Am Coll Cardiol

    (1999)
  • J.B O’Connell et al.

    Economic impact of heart failure in the United Statestime for a different approach

    J Heart Lung Transplant

    (1994)
  • Domanski MJ, Garg R, Yusuf S. Prognosis in congestive heart failure. In: Hosenpud JD, Greenberg BH, eds. Congestive...
  • E.F Philbin

    Factors determining angiotensin-converting enzyme inhibitor use in heart failure in the community setting

    Clin Cardiol

    (1998)
  • S Hanumanthu et al.

    Effect of a heart failure program on hospitalization frequency and exercise tolerance

    Circulation

    (1997)
  • M.W Rich et al.

    A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure

    N Engl J Med

    (1995)
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    Supported in part by VHA Empire State, Inc., and grants from the New York State Department of Health (grant numbers C 011191, C 011696, and C 013333).

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