Race-based disparity improves HF outpatient care, CDS could help more

While race-based differences in evidence-based heart failure (HF) care may be decreasing in outpatient cardiology practices, deploying clinical decision support (CDS) and performance feedback may facilitate equitable improvements in HF in the outpatient settings, regardless of race, according to findings from the IMPROVE HF registry.

The study was published in the May/June issue of the Journal of the National Medical Association.

“Despite the increased risk of HF morbidity and mortality among blacks and the dissemination of national, evidence-based treatment guidelines, a number of studies in diverse clinical settings indicate that black patients are less likely to receive guideline-recommended medical and device therapies for HF,” the study authors wrote (J Card Fail 2007;13(3):189-196/Heart Rhythm 2009;6(3):325-331). Due to these findings and others, several professional organizations and government agencies have stated targeted goals to eliminate the disparities.

“However, few studies have examined whether process-of-care interventions in the outpatient setting result in similar clinical improvements for black and white patients and reduce or eliminate disparities in care,” the researchers wrote.

With this study, Dwight W. Reynolds, MD, chief of the cardiovascular section at the University of Oklahoma College of Medicine, in Oklahoma City, and colleagues sought to evaluate whether a practice-based performance improvement intervention is associated with similar improvements in evidence-based care for black, white and race-undocumented patients.

The IMPROVE HF registry is a longitudinal evaluation of a performance improvement intervention on use of evidence-based therapies for outpatients with HF or prior MI and left ventricular ejection fraction less than or equal to 35 percent. Data were available for 7,605 patients. The researchers analyzed changes in use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, aldosterone antagonist, cardiac resynchronization therapy, implantable cardioverter-defibrillator therapy, anticoagulant for atrial fibrillation and HF education by patient race (black, white or undocumented/missing). Multivariate analyses identified variables independently associated with changes in each therapy.

There were 686 black patients (9 percent) and 3,238 white patients (42.6 percent), and race was undocumented for 3,537 (46.5 percent).

Reynolds et al reported that the baseline use of beta-blockers and aldosterone antagonists was significantly higher in black patients than in the other two groups, and use of aldosterone antagonists and HF education was higher among black patients at 24 months.

Post-intervention use of four of seven therapies increased equitably for the three groups, and treatment rates were similar between black and white patients for five of seven individual quality measures. Improvements in care were independent of race, according to the authors.

“This study cannot address what the impact of a performance improvement program would be in reducing or eliminating race-based disparities,” Reynolds et al concluded. Therefore, they suggested that further study is necessary to determine if the approach used in IMPROVE HF can be generalized to other practice settings and reduce or eliminate differences in care to a similar degree.

Medtronic, based in Minneapolis, sponsored the IMPROVE HF registry and this study.