Congestive Heart Failure 130425 En

Quality-Based Procedures:

Clinical Handbook for

Congestive Heart Failure

Health Quality Ontario &

Ministry of Health and Long-Term Care

April 2013

Quality-Based Procedures: Clinical Handbook for Congestive Heart Failure 2

Table of Contents

Table of Contents ........................................................................................................................................ 2

List of Abbreviations .................................................................................................................................. 3

Preface .......................................................................................................................................................... 5 Key Principles ............................................................................................................................................................... 6

Purpose ........................................................................................................................................................ 8

Introduction to Quality-Based Procedures ............................................................................................... 9 What Are We Moving Towards? ................................................................................................................................. 10 How Will We Get There? ............................................................................................................................................ 11 What Are Quality-Based Procedures? ......................................................................................................................... 12 How Will Quality-Based Procedures Encourage Innovation in Health Care Delivery? .............................................. 15

Methods ...................................................................................................................................................... 16 Overview of the HQO Episode of Care Analysis Approach........................................................................................ 16 Defining the Scope of the Episode of Care .................................................................................................................. 19 Developing the Episode of Care Pathway Model ........................................................................................................ 20 Identifying Recommended Practices ........................................................................................................................... 21

Description of Congestive Heart Failure ................................................................................................ 25

Recommended CHF Cohort Definition and Patient Grouping Approach .......................................... 26 Initial CHF Cohort Inclusion/Exclusion Criteria ......................................................................................................... 26 Inclusion/Exclusion Criteria for QBP Funding Purposes ............................................................................................ 28 CHF In-Hospital Patient Journey ................................................................................................................................. 31 Factors Contributing to CHF Patient Complexity ....................................................................................................... 33

Recommended Practices for CHF ........................................................................................................... 35 Development of the Episode of Care Pathway ............................................................................................................ 35 CHF Episode of Care Pathway Model ......................................................................................................................... 39

Performance Measurement ...................................................................................................................... 57 Performance Indicators ................................................................................................................................................ 59

Implementation of Best Practices ............................................................................................................ 61 Special Considerations for Cost Bundling ................................................................................................................... 61 Implementation of Best Practices ................................................................................................................................ 63 Role of Multidisciplinary Teams ................................................................................................................................. 64 Service Capacity Planning ........................................................................................................................................... 64

Expert Panel Membership ....................................................................................................................... 65

Appendices ................................................................................................................................................. 67 Appendix I: CHF Patient Group—ICD-10-CA Details ............................................................................................... 67 Appendix II: Rapid Review Methodology ................................................................................................................... 71


List of Abbreviations

ACC/AHA American College of Cardiology/American Heart Association ACE Angiotensin-converting enzyme ALC Alternate level of care

ARB Angiotensin receptor blocker BIPAP Bilevel positive airway pressure CACS Comprehensive Ambulatory Care Classification System CCI Canadian Classification of Health Interventions CCS Canadian Cardiovascular Society CHF Congestive heart failure CIHI Canadian Institute for Health Information

CMG Case Mix Group

COPD Chronic obstructive pulmonary disease

CPAP Continuous positive airway pressure

DAD Discharge Abstract Database

DRG Diagnosis-Related Group

ECFAA Excellent Care for All Act

ED Emergency department

EHMRG Emergency Heart Failure Mortality Risk Grade

ESC European Society of Cardiology

Expert Panel Episode of Care for Congestive Heart Failure Expert Advisory Panel

HBAM Health-Based Allocation Model

HFSA Heart Failure Society of America

HIG HBAM Inpatient Grouper

HQO Health Quality Ontario

HSFR Health System Funding Reform

HSIMI Health System Information Management and Investment

ICD-10-CA International Classification of Diseases, 10th Revision (Canadian Edition)

ICES Institute for Clinical Evaluative Sciences

IDEAS Improving the Delivery of Excellence Across Sectors

IV Intravenous

LACE Length of stay, acuity of admission, comorbidity of patient, emergency department use

LHIN Local Health Integration Network

LTC Long-term care


MCC Major Clinical Category

Ministry Ministry of Health and Long-Term Care

MLPA Ministry-LHIN Performance Agreement

NACRS National Ambulatory Care Referral System

NICE National Institute for Health and Clinical Excellence

OCCI Ontario Case Costing Initiative

OHTAC Ontario Health Technology Advisory Committee

PBF Patient-Based Funding

QBP Quality-Based Procedures

QIP Quality Improvement Plan

STEMI ST segment elevation myocardial infarction

THETA Toronto Health Economics and Technology Assessment


Preface

The content in this document has been developed through collaborative efforts between the Ministry of

Health and Long-Term Care (“Ministry”), Health Quality Ontario (HQO), and the HQO Episode of Care

for Congestive Heart Failure (CHF) Expert Advisory Panel (“Expert Panel”).

The template for the Quality-Based Procedures Clinical Handbook and all content in Section 1

(“Purpose”) and Section 2 (“Introduction”) were provided in standard form by the Ministry. All other

content was developed by HQO with input from the Expert Panel.

To consider the content of this document in the appropriate context, it is imperative to take note of the

specific deliverables that the Ministry tasked HQO with developing for this Clinical Handbook. The

following is an excerpt from the HQO–Ministry Accountability Agreement for fiscal year 2012/13:

To guide HQO’s support to the funding reform, HQO will:

1. Conduct analyses/consultation in the following priority areas in support of funding strategy

implementation for the 2013/14 fiscal year:

a) Chronic Obstructive Pulmonary Disease,

b) Congestive Heart Failure, and

c) Stroke.

2. Include in their analyses/consultation noted in clause 21, consultations with clinicians and

scientists who have knowledge and expertise in the identified priority areas, either by

convening a reference group or engaging an existing resource of clinicians/scientists.

3. Work with the reference group to:

a) Define the population/patient cohorts for analysis,

b) Define the appropriate episode of care for analysis in each cohort, and

c) Seek consensus on a set of evidence-based clinical pathways and standards of care for

each episode of care.

4. Submit to the Ministry their draft report as a result of the consultations/analysis outlined in

clause 22 above on October 31st and its final report on November 30th, and include in this a

summary of its clinical engagement process.

Following sign-off on the Accountability Agreement, the Ministry subsequently asked HQO to also

develop the following additional content for each of the 3 assigned clinical areas:

a) Guidance on the development of performance indicators, aligned with the recommended episodes

of care to inform the Ministry’s Quality-Based Procedure (QBP) Integrated Scorecard.

b) Guidance on the real-world implementation of recommended practices contained in the Clinical

Handbook, with a focus on implications for multi-disciplinary teams, service capacity planning

considerations and new data collection requirements.


Key Principles

At the start of this project, discussions between HQO, the 3 Episode of Care Expert Advisory Panels and

the Ministry established a set of key principles or “ground rules” to guide this evolving work:

HQO’s work will not involve costing or pricing. All costing and pricing work related to the QBP

funding methodology will be completed by the Ministry using a standardized approach, informed

by the content produced by HQO. This principle also extended to the deliberations of the Expert

Panels, where discussions were steered away from considering the dollar cost of particular

interventions or models of care and instead focused on quality considerations and non-cost

measures of utilization, such as length of stay.

The scope of this phase of work will focus on hospital care. Given that the Ministry’s QBP

efforts for 2013/14 focus largely on hospital payment, HQO was asked to adopt a similar focus

with its work on episodes of care. Notwithstanding, all 3 Expert Panels emphasized the importance

of extending this analysis beyond hospital care alone to also examine post-acute and community

care. CHF is a chronic disease that spans all parts of the continuum of care, with hospitalization

being only one piece of this continuum; future efforts will also need to address community-based

care to have full impact on all parts of the health system.

Recognizing the importance of this issue, the Ministry has communicated that, following the initial

phase of deliverables, work will continue in all 3 clinical areas to extend the episodes of care to

include community-based services.

Recommended practices, supporting evidence, and policy applications will be reviewed and

updated at least every 2 years. The limited 4-month timeframe provided for the completion of

this work meant that many of the recommended practices in this document could not be assessed

with the full rigour and depth of HQO’s established evidence-based analysis process. Recognizing

this limitation, HQO reserves the right to revisit the recommended practices and supporting

evidence at a later date by conducting a full evidence-based analysis or to update this document

with relevant new published research. In cases where the episode of care models are updated, any

policy applications informed by the models should also be similarly updated.

Consistent with this principle, the Ministry has stated that the QBP models will be reviewed at least

every 2 years.

Recommended practices should reflect the best patient care possible, regardless of cost or

barriers to access. HQO and the Expert Panels were instructed to focus on defining best practice

for an ideal episode of care, regardless of cost implications or potential barriers to access. Hence,

the resulting cost implications of the recommended episodes of care are not known. However, all 3

Expert Panels have discussed a number of barriers that will challenge implementation of their

recommendations across the province. These include gaps in measurement capabilities for tracking

many of the recommended practices, shortages in health human resources and limitations in

community-based care capacity across many parts of the province.

Some of these barriers and challenges are briefly addressed in the section “Implementation of Best

Practices.” However, the Expert Panels noted that, with the limited time they were provided to

address these issues, the considerations outlined here should only be viewed as an initial starting

point towards a comprehensive analysis of these challenges.

Finally: HQO and the CHF Episode of Care Expert Panel recognize that given the limitations of their

mandate, much of the ultimate impact of this content will depend on subsequent work by the Ministry to

incorporate the analysis and advice contained in this document into the Quality-Based Procedures policy


framework and funding methodology. This will be complex work, and it will be imperative to ensure that

any new funding mechanisms deployed are well-aligned with the recommendations of the Expert Panel.

Nevertheless, the Expert Panel believes that, regardless of the outcome of efforts to translate this content

into hospital funding methodology, the recommended practices in this document can also provide the

basis for setting broader provincial standards of care for CHF. These standards could be linked not only to

funding mechanisms, but to other health system change levers such as guidelines and care pathways,

performance measurement and reporting, program planning and quality improvement activities.


Purpose

Provided by the Ministry of Health and Long-Term Care

This Clinical Handbook has been created to serve as a compendium of the evidence-based rationale and

clinical consensus driving the development of the policy framework and implementation approach for

CHF patients seen in hospitals.

This handbook is intended for a clinical audience. It is not, however, intended to be used as a clinical

reference guide by clinicians and will not be replacing existing guidelines and funding applied to

clinicians. Evidence-informed pathways and resources have been included in this handbook for your

convenience.


Introduction to Quality-Based Procedures

Provided by the Ministry of Health and Long-Term Care

Quality-Based Procedures (QBPs) are an integral part of Ontario’s Health System Funding Reform

(HSFR) and a key component of Patient-Based Funding (PBF). This reform plays a key role in advancing

the government’s quality agenda and its Action Plan for Health Care. HSFR has been identified as an

important mechanism to strengthen the link between the delivery of high quality care and fiscal

sustainability.

Ontario’s health care system has been living under global economic uncertainty for a considerable time.

Simultaneously, the pace of growth in health care spending has been on a collision course with the

provincial government’s deficit recovery plan.

In response to these fiscal challenges and to strengthen the commitment towards the delivery of high

quality care, the Excellent Care for All Act (ECFAA) received royal assent in June 2010. ECFAA is a

key component of a broad strategy that improves the quality and value of the patient experience by

providing them with the right evidence-informed health care at the right time and in the right place.

ECFAA positions Ontario to implement reforms and develop the levers needed to mobilize the delivery of

high quality, patient-centred care.

Ontario’s Action Plan for Health Care advances the principles of ECFAA, reflecting quality as the

primary driver to system solutions, value, and sustainability.


What Are We Moving Towards?

Prior to the introduction of HSFR, a significant proportion of hospital funding was allocated through a

global funding approach, with specific funding for some select provincial programs and wait times

services. However, a global funding approach reduces incentives for health service providers to adopt best

practices that result in better patient outcomes in a cost-effective manner.

To support the paradigm shift from a culture of cost containment to that of quality improvement, the

Ontario government is committed to moving towards a patient-centred, evidence-informed funding model

that reflects local population needs and contributes to optimal patient outcomes (Figure 1).

PBF models have been implemented internationally since 1983. Ontario is one of the last leading

jurisdictions to move down this path. This puts the province in a unique position to learn from

international best practices and the lessons others learned during implementation, thus creating a funding

model that is best suited for Ontario.

PBF supports system capacity planning and quality improvement through directly linking funding to

patient outcomes. PBF provides an incentive to health care providers to become more efficient and

effective in their patient management by accepting and adopting best practices that ensure Ontarians get

the right care at the right time and in the right place.

Figure 1: Current and Future States of Health System Funding

Current StateCurrent State How do we get there?

Based on a lump sum, outdated

historical funding

Fragmented system planning

Funding not linked to outcomes

Does not recognize efficiency,

standardization and adoption of best

practices

Maintains sector specific silos

Transparent, evidence-based to better

reflect population needs

Supports system service capacity

planning

Supports quality improvement

Encourages provider adoption of best

practice through linking funding to

activity and patient outcomes

Ontarians will get the right care, at the

right place and at the right time

Strong Clinical

Engagement

Current Agency

Infrastructure

Knowledge to Action Toolkits

Meaningful

Performance

Evaluation Feedback

System Capacity

Building for Change

and Improvement

Future StateFuture State


How Will We Get There?

The Ministry of Health and Long-Term Care has adopted a 3-year implementation strategy to phase in a

PBF model and will make modest funding shifts starting in fiscal year 2012/13. A 3-year outlook has

been provided to support planning for upcoming funding policy changes.

The Ministry has released a set of tools and guiding documents to further support the field in adopting the

funding model changes. For example, a QBP interim list has been published for stakeholder consultation

and to promote transparency and sector readiness. The list is intended to encourage providers across the

continuum to analyze their service provision and infrastructure in order to improve clinical processes and,

where necessary, build local capacity.

The successful transition from the current, provider-centred funding model towards a patient-centred

model will be catalyzed by a number of key enablers and field supports. These enablers translate to actual

principles that guide the development of the funding reform implementation strategy related to QBPs.

These principles further translate into operational goals and tactical implementation (Figure 2).

Figure 2: Principles Guiding Implementation of Quality-Based Procedures Abbreviations: HSFR, Health System Funding Reform; HSIMI, Health System Information Management and Investment: IDEAS, Improving the Delivery of Excellence Across Sectors; LHIN, Local Health Integration Network; QBP. Quality-Based Procedures.

Principles for developing QBP implementation strategy

Principles for developing QBP implementation strategy

Sector Engagement

Clinical expert panels

Provincial Programs Quality Collaborative

Overall HSFR Governance structure in

place that includes key stakeholders

LHIN/CEO Meetings

Operationalization of principles to tactical implementation (examples)Operationalization of principles to tactical implementation (examples)

Balanced Evaluation

Integrated Quality Based Procedures

Scorecard

Alignment with Quality Improvement Plans

Cross-Sectoral Pathways

Evidence-Based

Development of best practice patient

clinical pathways through clinical expert

advisors and evidence-based analyses

Transparency

Publish practice standards and evidence

underlying prices for QBPs

Routine communication and consultation

with the field

Knowledge Transfer

Applied Learning Strategy/ IDEAS

Tools and guidance documents

HSFR Helpline; HSIMI website (repository

of HSFR resources)


What Are Quality-Based Procedures?

QBPs involve clusters of patients with clinically related diagnoses or treatments. CHF was chosen as a

QBP using an evidence- and quality-based selection framework that identifies opportunities for process

improvements, clinical redesign, improved patient outcomes, enhanced patient experience, and potential

cost savings.

The evidence-based framework used data from the Discharge Abstract Database (DAD) adapted by the

Ministry of Health and Long-Term Care for its Health-Based Allocation Model (HBAM) repository. The

HBAM Inpatient Grouper (HIG) groups inpatients based on their diagnosis or their treatment for the

majority of their inpatient stay. Day surgery cases are grouped in the National Ambulatory Care Referral

System (NACRS) by the principal procedure they received. Additional data were used from the Ontario

Case Costing Initiative (OCCI). Evidence in publications from Canada and other jurisdictions and World

Health Organization reports was also used to assist with the patient clusters and the assessment of

potential opportunities.

The evidence-based framework assessed patients using 4 perspectives, as presented in Figure 3. This

evidence-based framework has identified QBPs that have the potential to both improve quality outcomes

and reduce costs.

Figure 3: Evidence-Based Framework

• Does the clinical group contribute to a significant proportion of total costs?

• Is there significant variation across providers in unit costs/ volumes/ efficiency?

• Is there potential for cost savings or efficiency improvement through more consistent

practice?

• How do we pursue quality and improve efficiency?

• Is there potential areas for integration across the care continuum?

• Is there a clinical evidence base for an established standard of care and/or

care pathway? How strong is the evidence?

• Is costing and utilization information available to inform development of

reference costs and pricing?

• What activities have the potential for bundled payments and integrated care?

• Are there clinical leaders able to champion change in this

area?

• Is there data and reporting infrastructure in place?

• Can we leverage other initiatives or reforms related to

practice change (e.g. Wait Time, Provincial Programs)?

• Is there variation in clinical outcomes across providers,

regions and populations?

• Is there a high degree of observed practice variation across

providers or regions in clinical areas where a best practice or

standard exists, suggesting such variation is inappropriate?


Practice Variation

The DAD stores every Canadian patient discharge, coded and abstracted, for the past 50 years. This

information is used to identify patient transition through the acute care sector, including discharge

locations, expected lengths of stay and readmissions for each and every patient, based on their diagnosis

and treatment, age, gender, comorbidities and complexities, and other condition-specific data. A

demonstrated large practice or outcome variance may represent a significant opportunity to improve

patient outcomes by reducing this practice variation and focusing on evidence-informed practice. A large

number of “Beyond Expected Days” for length of stay and a large standard deviation for length of stay

and costs are flags to such variation. Ontario has detailed case-costing data for all patients discharged

from a case-costing hospital from as far back as 1991, as well as daily utilization and cost data by

department, by day, and by admission.

Availability of Evidence

A significant amount of Canadian and international research has been undertaken to develop and guide

clinical practice. Using these recommendations and working with the clinical experts, best practice

guidelines and clinical pathways can be developed for these QBPs, and appropriate evidence-informed

indicators can be established to measure performance.

Feasibility/Infrastructure for Change

Clinical leaders play an integral role in this process. Their knowledge of the patients and the care

provided or required represents an invaluable component of assessing where improvements can and

should be made. Many groups of clinicians have already provided evidence for rationale-for-care

pathways and evidence-informed practice.

Cost Impact

The selected QBP should have no fewer than 1,000 cases per year in Ontario and represent at least 1% of

the provincial direct cost budget. While cases that fall below these thresholds may, in fact, represent

improvement opportunity, the resource requirements to implement a QBP may inhibit the effectiveness

for such a small patient cluster, even if there are some cost efficiencies to be found. Clinicians may still

work on implementing best practices for these patient subgroups, especially if they align with the change

in similar groups. However, at this time, there will be no funding implications. The introduction of

evidence into agreed-upon practice for a set of patient clusters that demonstrate opportunity as identified

by the framework can directly link quality with funding.


Figure 4: Quality-Based Procedures Evidence-Based Framework for CHF Abbreviations: ALC, alternate level of care; CHF, congestive heart failure; CMG, Case Mix Group; ICES, Institute for Clinical Evaluative Sciences; LACE, length of stay, acuity of admission, comorbidity of patient, emergency department use; LHIN, Local Health Integration Network; LTC, long-term care; MLPA, Ministry-LHIN Performance Agreement; QIP, Quality Improvement Plan; THETA, Toronto Health Economics and Technology Assessment. Source: Ministry of Health and Long-Term Care

Cost Impact

• 19,396 annual acute inpatient hospitalizations for CHF

• Total acute inpatient cost: $166.985M, extensive post-

acute care costs in rehabilitation, home care and LTC

• 4th highest costing CMG by total cost

• 26,829 ALC days, costing ~$17M

• Highest readmissions within 30 days at 21%

representing for a total acute inpatient cost of $37.87M

Feasibility /Capacity for Change

• Baker Report singled out CHF as key condition to focus on

• Indicators for CHF readmissions currently in MLPA and QIPs

• Tools such as LACE screening index currently being tested

• Key focus area for Avoidable Hospitalizations Living Labs Communities; clinical expert table will be established to secure agreement on care pathway and quality markers

• Coordinated table to discuss options related to payment approaches (e.g. bundled payments across acute and post acute physician services) to follow development of quality standards

• THETA recently completed a report on Heart Failure Clinics

Availability of Evidence

• Evidence demonstrating significant reduction in CHF readmissions is possible through implementation of interventions that include:

• use of heart failure clinics,

• outpatient follow up,

• care coordination post discharge,

• telehealth interventions

• Transitional Care intervention for CHF used advanced practice nurses to achieve 34 per cent reductions in readmission and 39 per cent reduction in mean total cost

• University of Ottawa Heart Institute’s Telehealth program reduced 30-day readmissions by 54 percent with savings up to $20,000 per patient

Practice Variation

• Hospitalization rates vary from 39.43 to 96.68 per 100,000

residents across LHINs

• Readmission rates vary from 18% to 25% across LHINs

• Large variations in ALC rates for CHF patients across LHINs and

hospitals

• Inconsistent use of heart failure clinics and cardiac rehab across

the province

• Inconsistent access to cardiologists across province

• Upcoming discussions with ICES scientific experts to take place

to identify clinical variation in outcomes for CHF patients


How Will Quality-Based Procedures Encourage Innovation

in Health Care Delivery?

Implementing evidence-informed pricing for the targeted QBPs will encourage health care providers to

adopt best practices in their care delivery models and maximize their efficiency and effectiveness.

Moreover, best practices that are defined by clinical consensus will be used to understand required

resource utilization for the QBPs and further assist in developing evidence-informed pricing.

Implementation of a “price x volume” strategy for targeted clinical areas will motivate providers to:

adopt best practice standards

re-engineer their clinical processes to improve patient outcomes

develop innovative care delivery models to enhance the experience of patients

Clinical process improvement may include better discharge planning, eliminating duplicate or

unnecessary investigations, and paying greater attention to the prevention of adverse events, that is,

postoperative complications. These practice changes, together with adoption of evidence-informed

practices, will improve the overall patient experience and clinical outcomes and help create a sustainable

model for health care delivery.


Methods

Overview of the HQO Episode of Care Analysis Approach

In order to produce this work, Health Quality Ontario (HQO) has developed a novel methodology known

as an episode of care analysis that draws conceptually and methodologically from several of HQO’s core

areas of expertise:

Health technology assessment: Recommended practices incorporate components of HQO’s

evidence-based analysis methodology and draw from the recommendations of the Ontario Health

Technology Advisory Committee (OHTAC).

Case mix grouping and funding methodology: Cohort and patient group definitions use clinical

input to adapt and refine case mix methodologies from the Canadian Institute for Health Information

(CIHI) and the Ontario Health-Based Allocation Model (HBAM).

Clinical practice guidelines and pathways: Recommended practices synthesize guidance from

credible national and international guideline bodies, with attention to the strength of evidence

supporting each piece of guidance.

Analysis of empirical data: Expert Advisory Panel recommendations were supposed by descriptive

and multivariate analysis of Ontario administrative data (e.g., Discharge Abstract Database [DAD]

and National Ambulatory Care Reporting System [NACRS]) and data from disease-based clinical

data sets (e.g., the Ontario Stroke Audit [OSA] and Enhanced Feedback For Effective Cardiac

Treatment [EFFECT] databases).

Clinical engagement: All aspects of this work were guided and informed by leading clinicians,

scientists and administrators with a wealth of knowledge and expertise in the clinical area of focus.

The development of the episode of care analysis involves the following key steps:

1. Defining cohorts and patient groups

2. Defining the scope of the episode of care

3. Developing the episode of care model

4. Identifying recommended practices, including the Rapid Review process

The following sections describe each of these steps in further detail.


Defining Cohorts, Patient Groups, and Complexity Factors

At the outset of this project, the Ministry of Health and Long-Term Care provided HQO with a broad

description of each assigned clinical population (e.g., CHF), and asked HQO to work with the Expert

Panels to define inclusion and exclusion criteria for the cohort they would examine using data elements

from routinely reported provincial administrative databases. It was also understood that each of these

populations might encompass multiple distinct subpopulations (referred to as “patient groups”) with

significantly different clinical characteristics. For example, the CHF population includes subpopulations

with heart failure, myocarditis and cardiomyopathies. These patient groups each have very different levels

of severity, different treatment pathways, and different distributions of expected resource utilization.

Consequently, these groups may need to be reimbursed differently from a funding policy perspective.

Conceptually, the process employed here for defining cohorts and patient groups shares many similarities

with methods used around the world for the development of case mix methodologies, such as Diagnosis-

Related Groups (DRGs) or the Canadian Institute for Health Information’s (CIHI) Case Mix Groups.

Case mix methodologies have been used since the late 1970s to classify patients into groups that are

similar in terms of both clinical characteristics and resource utilization for the purposes of payment,

budgeting and performance measurement.1 Typically, these groups are developed using statistical

methods such as classification and regression tree analysis to cluster patients with similar costs based on

common diagnoses, procedures, age, and other variables. After the initial patient groups have been

established based on statistical criteria, clinicians are often engaged to ensure that the groups are clinically

meaningful. Patient groups are merged, split, and otherwise reconfigured until the grouping algorithm

reaches a satisfactory compromise between cost prediction, clinical relevance, and usability. Most modern

case mix methodologies and payment systems also include a final layer of patient complexity factors that

modify the resource weight (or price) assigned to each group upward or downward. These can include

comorbidities, use of selected interventions, long- or short-stay status, and social factors.

In contrast with these established methods for developing case mix systems, the patient classification

approach that the Ministry asked HQO and the Expert Panels to undertake is unusual in that it begins with

the input of clinicians rather than with statistical analysis of resource utilization. The Expert Panels were

explicitly instructed not to focus on cost considerations, but instead to rely on their clinical knowledge of

those patient characteristics that are commonly associated with differences in indicated treatments and

expected resource utilization. Expert Panel discussions were also informed by summaries of relevant

literature and descriptive tables containing Ontario administrative data.

Based on this information, the Expert Panels recommended a set of inclusion and exclusion criteria to

define each disease cohort. Starting with establishing the ICD-10-CA2 diagnosis codes included for the

population, the Expert Panels then excluded diagnoses with significantly different treatment protocols

from the general population, including pediatric cases and patients with very rare disorders. Next, the

Expert Panels recommended definitions for major patient groups within the cohort. Finally, the Expert

Panels identified patient characteristics that they believe would contribute to additional resource

utilization for patients within each group. This process generated a list of factors ranging from commonly

occurring comorbidities to social characteristics such as housing status.

In completing the process described above, the Expert Panel encountered some noteworthy challenges:

1 Fetter RB, Shin Y, Freeman JL, Averill RF, Thompson JD. Case mix definition by diagnosis-related groups. Med Care. 1980 Feb;18(2):iii, 1-53. 2 International Classification of Diseases, 10th Revision (Canadian Edition).


1. Absence of clinical data elements capturing important patient complexity factors. The

Expert Panels quickly discovered that a number of important patient-based factors related to the

severity of patients’ conditions or their expected utilization are not routinely collected in Ontario

hospital administrative data. These include both key clinical measures (such as FEV1 / FVC for

chronic obstructive pulmonary disease [COPD] patients and AlphaFIM®3 scores for stroke

patients) as well as important social characteristics (such as caregiver status).4 For stroke and

CHF, some of these key clinical variables have been collected in the past through the OSA and

EFFECT datasets, respectively. However, these datasets were limited to a group of participating

hospitals and at this time are not funded for future data collection.

2. Focus on a single disease grouping within a broader case mix system. While the Expert Panels

were asked to recommend inclusion/exclusion criteria only for the populations tasked to them, the

3 patient populations assigned to HQO are a small subset of the many patient groups under

consideration for Quality-Based Procedures. This introduced some additional complications when

defining population cohorts; after the Expert Panels had recommended their initial patient cohort

definitions (based largely on diagnosis), the Ministry informed the Expert Panels that there were a

number of other patient groups planned for future Quality-Based Procedure (QBP) funding efforts

that overlapped with the cohort definitions.

For example, while the vast majority of patients discharged from hospital with a most responsible

diagnosis of COPD receive largely ward-based medical care, a small group of COPD-diagnosed

patients receive much more cost-intensive interventions such as lung transplants or resections.

Based on their significantly different resource utilization, the Ministry’s HBAM grouping

algorithm assigns these patients to a different HBAM Inpatient Grouper (HIG) group from the

general COPD population. Given this methodological challenge, the Ministry requested that the

initial cohorts defined by the Expert Panels be modified to exclude patients that receive selected

major interventions. It is expected that these patients may be assigned to other QBP patient

groups in the future. This document presents both the initial cohort definition defined by the

Expert Panel and the modified definition recommended by the Ministry.

In short, the final cohorts and patient groups described here should be viewed as a compromise solution

based on currently available data sources and the parameters of the Ministry’s HBAM grouping

methodology.

3 The Functional Independence Measure (FIM) is a composite measure consisting of 18 items assessing 6 areas of function. These fall into 2 basic domains; physical (13 items) and cognitive (5 items). Each item is scored on a 7-point Likert scale indicative of the amount of assistance required to perform each item (1 = total assistance, 7 = total independence). A simple summed score of 18–126 is obtained where 18 represents complete dependence / total assistance and 126 represents complete independence. 4 For a comprehensive discussion of important data elements for capturing various patient risk factors, see Iezzoni LI, editor. Range of risk factors. In Iezzoni LI (Ed.) Risk adjustment for measuring health care outcomes, 4th ed. Chicago: Health Administration Press; 2012. p. 29-76.


Defining the Scope of the Episode of Care

HQO’s episode of care analysis draws on conceptual theory from the emerging worldwide use of episode-

based approaches for performance measurement and payment. Averill et al,5 Hussey et al,6 and Rosen and

Borzecki7 describe the key parameters required for defining an appropriate episode of care:

Index event: The event or time point triggering the start of the episode. Examples of index

events include admission for a particular intervention, presentation at the emergency

department (ED) or the diagnosis of a particular condition.

Endpoint: The event or time point triggering the end of the episode. Examples of endpoints

include death, 30 days following hospital discharge, or a “clean period” with no relevant

health care service utilization for a defined window of time.

Scope of services included: While an “ideal” episode of care might capture all health and

social care interventions received by the patient from index event to endpoint, in reality not

all these services may be relevant to the objectives of the analysis. Hence, the episode may

exclude some types of services such as prescription drugs or services tied to other unrelated

conditions.

Ideally, the parameters of an episode of care are defined based on the nature of the disease or health

problem studied and the intended applications of the episode (e.g., performance measurement, planning,

or payment). For HQO’s initial work here, many of these key parameters were set in advance by the

Ministry based on the government’s QBP policy parameters. For example, in 2013/14 the QBPs will

focus on reimbursing acute care, and do not include payments for physicians or other non-hospital

providers. These policy parameters resulted in there being limited flexibility to examine non-hospital

elements such as community-based care or readmissions.

Largely restricted to a focus on hospital care, the Chairs of the Expert Panels recommended that the

episodes of care for all 3 conditions begin with a patient’s presentation to the ED (rather than limit the

analysis to the inpatient episode) in order to provide scope to examine criteria for admission. Similarly,

each of the Expert Panels ultimately also included some elements of postdischarge care in the scope of the

episode in relation to discharge planning in the hospital and the transition to community services.

5 Averill RF, Goldfield NI, Hughes JS, Eisenhandler J, Vertrees JC (2009). Developing a prospective payment system based on episodes of care. J Ambul Care Manage. 32(3):241-51. 6 Hussey PS, Sorbero ME, Mehrotra A, Liu H, Damberg CL (2009). Episode-based performance measurement and payment: making it a reality. Health Affairs. 28(5):1406-17. 7 Rosen AK, Borzecki AM Windows of observation. In Iezzoni LI, ed. Risk adjustment for measuring health care outcomes, 4th ed. Chicago: Health Administration Press; 2012. p. 71-94.


Developing the Episode of Care Pathway Model

HQO has developed a model that brings together the key components of the episode of care analysis

through an integrated schematic. The model is structured around the parameters defined for the episode of

care, including boundaries set by the index event and endpoints, segmentation (or stratification) of

patients into the defined patient groups, and relevant services included in the episode. The model

describes the pathway of each patient case included in the defined cohort, from initial presentation

through segmentation into one of the defined patient groups based on their characteristics, and finally

through the subsequent components of care that they receive before reaching discharge or death.

While the model bears some resemblance to a clinical pathway, it is not intended to be used as a

traditional operational pathway for implementation in a particular care setting. Rather, the model presents

the critical decision points and phases of treatment within the episode of care, respectively referred to

here as clinical assessment nodes and care modules. Clinical assessment nodes (CANs) provide patient-

specific criteria for whether a particular case proceeds down one branch of the pathway or another. Once

patients move down a particular branch, they then receive a set of recommended practices that are

clustered together as a care module. Care modules represent the major phases of care that patients receive

within a hospital episode, such as treatment in the ED, care on the ward, and discharge planning. The

process for identifying the recommended practices within each CAN and care module is described in the

next section.

Drawing from the concept of decision analytic modelling, the episode of care model includes crude

counts (N) and proportions (Pr) of patients proceeding down each branch of the pathway model. For the 3

conditions studied in this exercise, these counts were determined based on annual utilization data from the

DAD, NACRS, and (for CHF and stroke) clinical registry data.

Figure 5 provides an illustrative example of a care module and CAN:

Figure 5: Sample Episode of Care Pathway Model Abbreviations: CAN, clinical assessment node; N, crude counts; Pr, proportions.

Care

Module

Patient presents at the emergency department CAN

Responding to treatment (N = 20,000; Pr = 85%)

Responding to treatment (N = 23,000; Pr = 15%)

N = 43,000 Pr = 1.0


Identifying Recommended Practices

Each CAN and care module in the episode of care model contains a set of recommended practices

reviewed and agreed upon through the Expert Panel. The end goal communicated by the Ministry for the

QBP methodology is to develop cost estimates for the recommended practices and aggregate these to

determine a total “best practice cost” for an ideal episode of care to inform the pricing of the QBP.

In keeping with HQO’s mandate to support evidence-based care, considerable attention has been paid to

ensure that the recommended practices here are supported by the best available evidence. For this process,

HQO considers the gold standard of evidence to be official OHTAC recommendations. While there are

many other organizations that release high quality clinical guidance based on rigorous standards of

evidence, OHTAC recommendations are considered the highest grade of evidence in this process for

several reasons:

Consistency: While many guidance bodies issue disease-specific recommendations, OHTAC

produces guidance in all disease areas, providing a common evidence framework across all the

clinical areas analyzed.

Economic modelling: OHTAC recommendations are generally supported by economic

modelling to determine the cost-effectiveness of an intervention, whereas many guidance bodies

assess only effectiveness.

Contextualization: In contrast with recommendations and analyses from international bodies,

OHTAC recommendations are developed through the contextualization of evidence for Ontario.

This ensures that the evidence is relevant for the Ontario health system context.

Notwithstanding these strengths, it is also crucial to mention several important limitations in the mandate

and capacity of OHTAC to provide a comprehensive range of evidence to support HQO’s episode of care

analyses:

Focus on non-drug technologies: While evidence shows that various in-hospital drugs are

effective in treating all 3 of the patient populations analyzed, OHTAC traditionally does not

consider pharmaceuticals under its mandate. Recently, OHTAC has reviewed some drug

technologies in comparison with non-drug technologies for a given population as part of mega-

analyses.

Capacity constraints: There are a considerable number of candidate practices and interventions

that require consideration for each episode of care. As OHTAC makes recommendations largely

based on evidence-based analyses supplied by HQO, it may be limited in its capacity to undertake

new reviews in all required areas.

Focus on high quality evidence: OHTAC uses the GRADE criteria8 to assess the strength of

evidence for an intervention, with randomized controlled trials (RCTs) considered the gold

standard of evidence here. Not every practice within an episode of care may be appropriate or

feasible to study through an RCT. For example, some interventions may be regarded as accepted

clinical practice, while others may be unethical to evaluate as part of a clinical trial.

Thus, in situations where OHTAC recommendations do not exist, HQO’s episode of care analysis makes

use of other sources of evidence:

8 Guyatt GH, Oxman AD, Schunemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011;64(4):380-2.


Guidance from other evidence-based organizations: Each of the Expert Panels recommended

credible existing sources of evidence-based guidance, such as the Global Initiative for Chronic

Obstructive Lung Disease (GOLD) guidelines for COPD. Recommendations from these bodies

were included along with their assessment of the evidence supporting the recommendation.

Analysis of empirical data: The Expert Panels reviewed the results of descriptive and multivariate

analysis using empirical data, including administrative data sources and clinical data sources such

as the EFFECT database.

Expert consensus: In areas that the Expert Panels saw as important but where evidence was

limited or nonexistent, the Expert Panels relied on consensus agreement while noting the need for

further research in these areas.

Figure 6: Example Illustrating the Alignment of OHTAC COPD Practice Recommendations with the Scope of Practices Reviewed Through the COPD Episode of Care Abbreviations: COPD, chronic obstructive pulmonary disease; OHTAC. Ontario Health Technology Advisory Committee; QBF, Quality-Based Funding.

The process for identifying recommended practices involves the following steps:

1. Reviewing existing guidance from OHTAC and other selected evidence-based bodies and

extracting all candidate practices for each care module and CAN;

2. Consulting with members of the Expert Panel for additional candidate interventions not included

in the guidance reviewed;

3. Reviewing and summarizing the strength of evidence cited for each candidate intervention in the

guidance literature, where it exists and is clearly stated;

4. Summarizing the results of steps 1 to 3 above for each phase of the episode of care model and

presenting the summary to the Expert Panel for review;

5. Facilitating discussion by the Expert Panel members on contextualizing the candidate practices

for the Ontario health system and arriving at a consensus recommendation; and

6. Identifying gaps in the evidence that the Expert Panel agreed are high value candidates for

research questions for rapid reviews (see below) and future evidence-based analyses.

Non-invasive Ventilation

Pulmonary rehabilitationfollowing acute exacerbation

Vaccinations

Long-term oxygentherapy

Pulmonary rehabilitation forstable COPD patients

Short-actingbronchodilators

Corticosteroids

Antibiotics

In-hospital diagnostics

Long-acting maintenance bronchodilators

Community-based diagnosis and assessment

Community-basedmultidisciplinary care

OHTAC mega-analysis QBF episode of care

Evidence-based practices for COPD


Rapid Reviews

In order to address cases where a gap in the evidence is identified and prioritized for further analysis in

step 6 (above), HQO has developed a rapid evidence review process that is able to operate within the

compressed timeframe of this exercise, recognizing that a full evidence-based analysis would be

impractical given the short timelines.

For each question, the rapid review analysis began with a literature review using OVID MEDLINE,

OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative

Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for

Reviews and Dissemination database, for studies published from January 1, 2000, to October 2012.

Abstracts were reviewed by a single reviewer and full-text articles were obtained for those studies

meeting the eligibility criteria. Reference lists were also examined for any additional relevant studies not

identified through the search.

Articles were reviewed if they were:

English language full-text reports

published between January 1, 2008, and October 2012

health technology assessments, systematic reviews, and meta-analyses

If systematic reviews were not available, RCTs, observational studies, case reports, and editorials were

selected.

The methodological quality of systematic reviews was assessed using the Assessment of Multiple

Systematic Reviews (AMSTAR) measurement tool.9 The quality of the body of evidence for each

outcome was examined according to the GRADE Working Group criteria.8 The overall quality was

determined to be very low, low, moderate, or high using a step-wise, structural methodology.

Study design was the first consideration; the starting assumption was that RCTs are high quality, whereas

observational studies are low quality. Five additional factors—risk of bias, inconsistency, indirectness,

imprecision, and publication bias—were then taken into account. Limitations or serious limitations in

these areas resulted in downgrading the quality of evidence. Finally, 3 factors that could raise the quality

of evidence were considered: large magnitude of effect, dose response gradient, and accounting for all

residual confounding.8

For more detailed information, please refer to the latest series of GRADE articles.8

As stated by the GRADE Working Group,7 the final quality score can be interpreted using the following

definitions:

9 Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of sytematic reviews. BMC Med Res Methodol. 2007;7(10).


High Very confident that the true effect lies close to the estimate of the effect

Moderate Moderately confident in the effect estimate—the true effect is likely to be close to the

estimate of the effect, but there is a possibility that it is substantially different

Low Confidence in the effect estimate is limited—the true effect may be substantially

different from the estimate of the effect

Very Low Very little confidence in the effect estimate—the true effect is likely to be

substantially different from the estimate of effect


Description of Congestive Heart Failure

CHF is a complex clinical syndrome of symptoms and signs suggesting that the heart muscle is weakened

and the heart as a pump is impaired; it is caused by structural or functional abnormalities and is the

leading cause of hospitalization in elderly Ontarians. Between 1997 and 2007, there were 419,552 cases

of heart failure in Ontario, with 216,190 requiring admission to hospital.10 Slightly more women (51%)

than men had heart failure, and 80% of the overall cohort was age 65 or older.10 The prognosis for

patients is poor; CHF is associated with high mortality.

10 Yeung DF, Boom NC, Guo H, Lee DS, Schultz S, Tu J. Trends in the incidence and outcomes of heart failure in Ontario, Canada: 1997 to 2007, CMAJ 2012.


Recommended CHF Cohort Definition and

Patient Grouping Approach

Initial CHF Cohort Inclusion/Exclusion Criteria

The CHF pathway has been developed for adult patients presenting to Ontario’s EDs with a major

diagnosis of CHF. These patients are admitted to an inpatient bed, transferred to another hospital, or

discharged from the ED. Patients with a primary diagnosis of CHF received from another hospital or who

develop CHF during their stay in hospital are not included in this pathway.

For QBP funding purposes, cases are included only if CHF-related diagnoses are assigned as the “Most

Responsible Diagnosis” for an acute inpatient (DAD data) or as the “Main Problem” for an ED patient

(NACRS data) and have not had a “major qualifying procedure” performed.

The following age ranges, diagnosis codes (International Classification of Diseases, 10th Revision

(Canadian Edition) [ICD-10-CA]), and diagnosis types were used to define the CHF population for this

episode of care analysis:

a) Age: Persons aged 20 years and older. CHF is predominantly a disease of older individuals; the

largest cohort of patients is those 75 years of age or over. Patients under age 20 with CHF are quite

rare, and their disease tends to result from congenital factors; the care pathway and treatment

protocols for such patients are likely to be substantially different. The Expert Panel developed the

CHF care pathway for adult patients using the 20-year age threshold used in many Institute for

Clinical Evaluative Sciences (ICES) studies.

b) Diagnosis codes: The ICD-10-CA codes used to define the cohort of patients with CHF are listed

below.

I50.x Heart failure, left ventricular dysfunction, etc

I25.5 Ischemic cardiomyopathy

I40.x, I41.x Myocarditis

I42.x, I43.x Cardiomyopathies

I11.x plus I50.x (secondary Dx) Hypertensive heart disease plus heart failure, left ventricular

dysfunction

I13.x plus I50.x (secondary Dx) Hypertensive heart disease and renal disease plus heart failure,

left ventricular dysfunction)

Appendix I shows the ICD-10-CA details for the CHF patient groups.

c) Diagnosis types: The following diagnosis types are included in the CHF patient definition:

• Acute inpatient cases include Most Responsible Diagnosis codes—the diagnosis determined as

the diagnosis or condition held most responsible for the greatest portion of the length of stay or

greatest use of resources.

• Emergency department cases include Main Problem codes—the diagnosis or condition

determined to be most responsible for the greatest proportion of the length of stay or greatest use

of resources.


As noted above, using the DAD and the NACRS databases, the following codes defined the CHF

population:

• Most responsible diagnosis of “I50.X” “I25.5” “I40.X” “I41.X” “I42.X” “I43.X”

OR

• Most responsible diagnosis of “I11.X” and comorbidity “I50.X” code

OR

• Most responsible diagnosis of “I13.X” and comorbidity “I50.X” code

It should be noted that comorbidity diagnoses are only with diagnosis type “1” pre-admit

comorbidity, “2” post-admit comorbidity, or “W”, “X”, “Y” service transfer diagnosis.

d) Typical CHF patients: In the DAD, typical patients include those coded as both “typical” and “short

stay” using the Health Based Allocation Model Inpatient Grouper (HIG). Deaths, transfers, sign-outs,

and long-stay outliers are considered atypical cases. Table 1 shows the breakdown of CHF patients by

type and distribution of the resource intensity weights for 2010/11.

Table 1: CHF Patients for 2010/2011

Case Type

Number of Cases

Weight (Mean)

Weight (Minimum)

Weight (50th Percentile)

Weight (Median)

Weight (75th Percentile)

Weight (Maximum)

All 22,342 1.89 0.24 0.98 1.06 1.84 134.77

Atypical 3,298 4.76 0.24 1.04 2.85 5.38 134.77

Typical 19,044 1.39 0.26 0.98 1.06 1.29 40.66

Abbreviation: CHF, congestive heart failure. Data source: DAD 2010/11.

The Expert Panel considered both typical and atypical patients in the development of the CHF care

pathway. The Expert Panel felt that smaller hospitals would need to transfer patients to other acute

care hospitals with more appropriate resources, such as catheterization laboratories.


Inclusion/Exclusion Criteria for QBP Funding Purposes

During the development of the episode of care pathway, the MOHLTC representatives explained the

challenges of the CHF cohort definitions into the QBP funding methodology. To align the CHF cohort to

the present HIGs, the following ICD-10-CA diagnosis codes, diagnosis types, and ICD-10 Canadian

Classification of Health Interventions (CCI) intervention exclusion criteria are recommended for the

purposes of funding CHF through the QBP funding mechanism:

a) Age: Age greater than or equal to 20 years at time of admission.

b) Diagnosis codes: The ICD-10-CA most responsible diagnosis codes are listed below.

I50.x Heart failure, left ventricular dysfunction, etc

I40.x, I41.x Myocarditis


I42.x, I43.x Cardiomyopathies

I11.x plus I50.x (secondary Dx) Hypertensive heart disease plus heart failure, left ventricular

dysfunction

I13.x plus I50.x (secondary Dx) Hypertensive heart disease and renal disease plus heart

failure, left ventricular dysfunction)

c) Intervention: Patients are not assigned to an intervention-based HIG cell, given the current

methodology. (i.e., Major Clinical Category [MCC] partition variable is not “I”) CMG algorithms

used by the Ministry for QBP funding typically assign cases to groups based on either principal

intervention (typically a major qualifying procedure, such as a surgery) or in cases where there is

no major qualifying procedure, by Most Responsible Diagnosis. There is a need for CMGs to be

mutually exclusive: that is, the logic of the grouping algorithm should assign a case to 1 group or

another—not both.

When the MCC partition variable “I” is included, CHF patients fall into many HIGs. Table 2 shows the

HIG distribution of CHF inpatients; using the existing CMG funding methodology and 2011/12 inpatient

data, most of the 22,435 admitted CHF patients as defined by the Expert Panel fall into 3 HIGs

(highlighted).


Table 2: CHF Cohort Distribution by Health-Based Allocation Model Inpatient Groupers, 2011/12

Abbreviations: CHF, congestive heart failure; HIG, HBAM Inpatient Grouper; MCC, Major Clinical Category; MI, myocardial infarction.

Data source: DAD 2011/12.

Cases assigned to an intervention-based HIG cell are likely to be more advanced and funded using a

different episode of care pathway (to be developed in the future). As a result, for funding purposes, the

MCC partition “I” has been excluded from the current pathway.

HIG HIG Description COUNT PERCENT

143 Disease of Pleura 4 0.0

160 Heart or Lung Transplant 36 0.2

161 Implantation of Cardioverter/Defibrillator 300 1.3

162 Cardiac Valve Replacement 11 0.0

163 Major Cardiothoracic Intervention with Pump 42 0.2

164 Major Cardiothoracic Intervention without Pump 15 0.1

166 Coronary Artery Bypass Graft with Coronary Angiogram with MI/Shock/Arrest with Pump 4 0.0

167 Coronary Artery Bypass Graft with Coronary Angiogram with MI/Shock/Arrest without Pump 1 0.0

168 Coronary Artery Bypass Graft with Coronary Angiogram without MI/Shock/Arrest with Pump 2 0.0

172 Coronary Artery Bypass Graft without Coronary Angiogram without MI/Shock/Arrest with/without Pump6 0.0

173 Minor Cardiothoracic Intervention 6 0.0

174 Pacemaker Implantation/Removal Except Cardioverter/Defibrillator Implant 174 0.8

175 Percutaneous Coronary Intervention with MI/Shock/Arrest/Heart Failure 95 0.4

176 Percutaneous Coronary Intervention without MI/Shock/Arrest/Heart Failure 6 0.0

177 Management of Pacemaker Battery/Epicardial Lead 11 0.0

178 Percutaneous Transluminal Cardiothoracic Intervention except Percutaneous Coronary Intervention 11 0.0

179 Cardiac Conduction System Intervention 13 0.1

180 Amputation of Limb except Hand/Foot 4 0.0

181 Abdominal Aorta Intervention 1 0.0

182 Bypass/Extraction of Vein/Artery of Limb 4 0.0

183 Amputation of Hand/Foot 4 0.0

185 Other/Miscellaneous Vascular Intervention 32 0.1

195 Heart Failure with Coronary Angiogram 979 4.4

196 Heart Failure without Coronary Angiogram 19,368 86.3

197 Hypertensive Disease except Benign Hypertension 81 0.4

209 Other/Miscellaneous Cardiac Disorder 1,000 4.5

571 Newborn/Neonate 1500+ gm with Major Cardiovascular Intervention 1 0.0

600 Newborn/Neonate 2500+ grams, Other Moderate Problem 1 0.0

601 Newborn/Neonate 2500+ grams, Other Minor Problem 1 0.0

617 Intervention with Blood/Lymphatic System Diagnosis except Neoplasm 1 0.0

905 MCC 05 Unrelated Intervention 220 1.0

992 Stillbirth 1 0.0


Table 3 shows the distribution of CHF inpatients across the included (i.e., non–intervention-based) HIGs

to be used for QBP funding.

Table 3: Distribution of CHF Patients Across Included HIGs

Abbreviations: CHF, congestive heart failure; HBAM, Health-Based Allocation Model; HIG, HBAM Inpatient Grouper.


Table 4 shows the distribution of CHF patients in the ED using the Comprehensive Ambulatory Care

Classification System (CACS).

Table 4: Distribution of CHF Patients in ED Across CACS Cells

CACS CACS Description Patients with CHF Diagnosis

Codes, n

All Patients in These CACS

Cells, n

A001 Dead on arrival 8 696

A002 Left without being seen or triaged and not seen 2 193,799

B001 Cardiovascular condition with acute admission/transfer 18,506 97,974

B051 Emergency visit interventions 233 73,648

B053 Interventions generally performed by non-emergency department service: other 19 1,559

B121 Congestive heart failure 8,645 8,645

B122 Other disease or disorder cardiac system 203 278,635

C154 Pleurocentesis 3 41

E201 Cardiovascular disorders 4 115

E202 Congestive heart failure 27 27

Abbreviation: CACS, Comprehensive Ambulatory Care Classification System; CHF, congestive heart failure; ED, emergency department.

Data source: NACRS 2011/12.

For funding purposes, the Ministry will be considering methods of dealing with low-volume CACS cells.

HIG HIG_desc COUNT PERCENT

143 Disease of Pleura 4 0.0

195 Heart Failure with Coronary Angiogram 979 4.6

196 Heart Failure without Coronary Angiogram 19,368 90.4

197 Hypertensive Disease except Benign Hypertension 81 0.4

209 Other/Miscellaneous Cardiac Disorder 1,000 4.7

600 Newborn/Neonate 2500+ grams, Other Moderate Problem 1 0.0

601 Newborn/Neonate 2500+ grams, Other Minor Problem 1 0.0

992 Stillbirth 1 0.0


CHF In-Hospital Patient Journey

At the initial Expert Panel meetings, the CHF patient journey was mapped out. Patient presentation at the

ED with suspected CHF was established as the index event, and administrative data were used to inform

and guide the CHF patient journey in hospital. Using CIHI administrative databases, the disposition of

ED patients and admitted patients was reviewed. In 2010/11, 62.5% of patients presenting to the ED with

main problem reported as CHF were admitted (Table 5).

Table 5: ED CHF Patient Visit Dispositions, Ontario, 2010/11

Visit Disposition Frequency %

01 – Discharged home (private dwelling, not an institution; no support services) 8,819 30.54

02 – Client register, left without being seen, or treated by a service provider — —

03 – Client triaged and then left the emergency department; not seen by physician or primary care provider

2 0.01

04 – Client triaged, registered and assessed by a service provider and left without treatment

7 0.02

05 – Client triaged, registered, and assessed by a service provider and treatment initiated; left against medical advice before treatment completed

101 0.35

06 – Admitted into reporting facility as an inpatient to critical care unit or operating room directly from an ambulatory care visit functional centre

2,151 7.45

07 – Admitted into reporting facility as an inpatient to another unit of the reporting facility directly from the ambulatory care visit functional centre

15,895 55.05

08 – Transferred to another acute care facility directly from the ambulatory care visit functional centre

818 2.83

09 – Transferred to another non-acute care facility directly from an ambulatory care visit functional centre

28 0.1

10 – Death after arrival (DAA)—patient expires after initiation of the ambulatory care visit; resuscitative measures (e.g., CPR) may occur during the visit but are not successful

78 0.27

11 – Death on arrival (DOA)—patient is dead on arrival to the ambulatory care service; generally there is no intent to resuscitate (for example, perform CPR); includes cases where the patient is brought in for pronouncement of death

8 0.03

12 – Intra-facility transfer to day surgery 2 0.01

13 – Intra-facility transfer to the emergency department — —

14 – Intra-facility transfer to clinic 42 0.15

Abbreviations: CHF, congestive heart failure; CPR, cardiopulmonary resuscitation; ED, emergency department.

Data source: NACRS 2010/11.


The Expert Panel also investigated CHF patients transferred from other facilities, and the types of

facilities transferring patients. For 2010/11, 13% of transferred CHF patients were from acute care

facilities. Table 6 shows the number of CHF patients transferred to Ontario’s acute care hospitals in

2010/11, as reported in the DAD. After careful consideration, the Expert Panel opted to treat CHF

patients transferred from other institutions as a special cohort; these patients are excluded from the

episode of care pathway model developed for this report.

Table 6: CHF Patients Transferred From Other Institutions, 2010/11

From Institution by Type Frequency Percent

0 – Organized outpatient department of reporting facility 1 0.02

1 – Acute care 722 13.06

2 – General rehabilitation facility 111 2.01

3 – Chronic care facility 108 1.95

4 – Nursing home 1,189 21.5

5 – Psychiatric facility 16 0.29

6 – Unclassified or other type of facility 71 1.28

7 – Special rehabilitation facility 11 0.2

8 – Home care 577 10.43

9 – Home for the aged 1,563 28.26

N – Ambulatory care 1,161 20.99

Abbreviation: CHF, congestive heart failure.


Finally, the Expert Panel reviewed discharge disposition data for CHF patients admitted from the ED

(Table 7). The majority of admitted CHF patients are discharged home, with 21% requiring supportive

services.

Table 7: Discharge Disposition for CHF Patients, 2010/11

Discharge Disposition Total Percent

01 – Transferred to another facility providing inpatient hospital care (includes other acute, sub-acute, psychiatric, rehabilitation, cancer centre/agency, pediatric hospital, etc.)

863 3.84

02 – Transferred to a long-term care facility (personal care home, auxiliary care, nursing home, extended care, home for the aged, senior’s home, etc.)

2,858 12.73

03 – Transferred to other (palliative care/hospice, addiction treatment centre, etc.) 103 0.46

04 – Discharged to a home setting with support services (senior’s lodge, attendant care, home care, Meals on Wheels, homemaking, supportive housing, etc.)

4,716 21.01

05 – Discharged home 11,719 52.20

06 – Signed out (against medical advice) 169 0.75

07 – Died 2,022 9.01

Total 22,450 100.00

Abbreviation: CHF, congestive heart failure.


Based on the above data, the Expert Panel established the ED visit disposition to include patient returning

home or to his/her place of residence, patient transferred to another acute care facility, admission to the

hospital, or death.


Factors Contributing to CHF Patient Complexity

Using 2010/11 DAD data, the Expert Panel reviewed pre- and postadmission comorbidities. Preadmission

comorbidities are conditions that existed prior to admission and have been assigned an ICD-10-CA code

that satisfies the requirements for determining cormorbidity (Table 8). Similarly, postadmission

comorbidities are conditions that arise following admission (Table 9).

Table 8: CHF Preadmission Comorbidities, Top 30

ICD-10 Description Number Percent

I48.0 Atrial fibrillation 3,977 9.61

J18.9 Pneumonia, unspecified 2,076 5.02

N17.9 Acute renal failure, unspecified 1,898 4.59

I10.0 Benign hypertension 1,224 2.96

N39.0 Urinary tract infection, site not specified 1,162 2.81

D64.9 Anaemia, unspecified 1,042 2.52

E11.52 Type 2 diabetes mellitus with certain circulatory complications 969 2.34

J90 Pleural effusion, not elsewhere classified 959 2.32

Z51.5 Palliative care 951 2.30

I25.10 Atherosclerotic heart disease of native coronary artery 802 1.94

J44.1 Chronic obstructive pulmonary disease with acute exacerbation, unspecified 796 1.92

E11.23 Type 2 diabetes mellitus with established or advanced kidney disease (N08.3-) 740 1.79

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection 718 1.74

I21.4 Acute subendocardial myocardial infarction 693 1.67

J44.9 Chronic obstructive pulmonary disease, unspecified 559 1.35

E11.64 Type 2 diabetes mellitus with poor control, so described 556 1.34

E87.1 Hypo-osmolality and hyponatraemia 523 1.26

N18.9 Chronic kidney disease, unspecified 517 1.25

E87.6 Hypokalaemia 478 1.16

I35.0 Aortic (valve) stenosis 430 1.04

L03.11 Cellulitis of lower limb 415 1.00

E87.5 Hyperkalaemia 385 0.93

I25.5 Ischaemic cardiomyopathy 352 0.85

I27.2 Other secondary pulmonary hypertension 349 0.84

I50.0 Congestive heart failure 349 0.84

I42.0 Dilated cardiomyopathy 298 0.72

I95.9 Hypotension, unspecified 282 0.68

I48.1 Atrial flutter 238 0.58

D50.9 Iron deficiency anaemia, unspecified 234 0.57

E86.0 Dehydration 232 0.56

Abbreviations: CHF, congestive heart failure; ICD-10, International Classification of Diseases, 10th Revision.



Table 9: CHF Postadmission Comorbidities, Top 20

ICD-10 Description Number Percent

N39.0 Urinary tract infection, site not specified 530 8.03

N17.9 Acute renal failure, unspecified 341 5.16

E87.6 Hypokalaemia 261 3.95

I95.9 Hypotension, unspecified 205 3.10

J18.9 Pneumonia, unspecified 203 3.07

I48.0 Atrial fibrillation 168 2.54

I46.9 Cardiac arrest, unspecified 139 2.10

R33 Retention of urine 110 1.67

E11.63 Type 2 diabetes mellitus with hypoglycaemia 109 1.65

E87.5 Hyperkalaemia 105 1.59

A04.7 Enterocolitis due to Clostridium difficile 104 1.57

J96.0 Acute respiratory failure 102 1.54

E87.1 Hypo-osmolality and hyponatraemia 100 1.51

F05.9 Delirium, unspecified 99 1.50

I46.0 Cardiac arrest with successful resuscitation 93 1.41

A09.9 Gastroenteritis and colitis of unspecified origin 90 1.36

I21.4 Acute subendocardial myocardial infarction 85 1.29

J96.9 Respiratory failure, unspecified 77 1.17

R57.0 Cardiogenic shock 77 1.17

I47.2 Ventricular tachycardia 75 1.14

Abbreviations: CHF, congestive heart failure; ICD-10, International Classification of Diseases, 10th Revision.


Pre- and postadmission comorbidities are not included in the current episode of care pathway for the

“typical” CHF case. Following completion of the current pathway, the Expert Panel may consider the

implications of commonly occurring comorbidities, such as pneumonia, acute renal failure, and diabetes.

While it is expected that the foundational pathway will remain the same, the inclusion of comorbidities

may result in the recommendation of additional interventions in each care module.


Recommended Practices for CHF

Development of the Episode of Care Pathway

As discussed in the Methods chapter, the Expert Panel developed the episode of care pathway by

reviewing the literature related to quality of care for CHF patients; CHF clinical practice guidelines; and

the results of analyses performed on empirical data from the EFFECT database at ICES. The following

sections describe the evidence review and analyses performed.

Review of Literature

The Expert Panel identified areas in which a review of the evidence was important to the development of

the CHF pathway. The research questions and related grades of evidence are shown Table 10. A

description of the rapid review methodology is provided in Appendix II. The full rapid reviews for each

question are provided in Appendix III.

Table 10: Rapid Review Research Questions and Quality of Evidence

Research Question Quality of Evidence

What is the diagnostic accuracy of in-hospital BNP measurement for HF? What is the prognostic accuracy of BNP for triage of HF patients when used in the emergency department?

What is the prognostic accuracy of in-hospital BNP measurement for HF before hospital discharge?

No studies were identified that specifically assessed the prognostic accuracy of BNP for triage of HF patients when used in the emergency department or in-hospital BNP measurement for HF before hospital discharge.

There is moderate quality evidence that BNP testing to diagnose HF in patients presenting to the emergency department with acute dyspnea does not significantly reduce mortality or rehospitalization.

What is the diagnostic accuracy of a chest x-ray for identifying pulmonary infection as a precipitant of an acute HF episode?

No studies that examined the accuracy of x-rays for diagnosing pneumonia as the precipitant of an acute HF event were identified.

All of the guidelines reviewed comment on the importance of diagnosing pulmonary infections such as pneumonia as a potential precipitant of an acute heart failure event.

What is the effectiveness of coronary revascularization in ischemic heart failure patients?

Moderate-quality evidence suggests that coronary revascularization improves survival compared to medical therapy in patients with CAD and significant left ventricular systolic dysfunction, and for those in whom treatable targets are identified. Decisions to perform revascularization in these patients should not be overly influenced by imaging-defined myocardial viability status, as an association with clinical outcomes was not shown. The routine use of SVR as an adjunct to CABG coronary revascularization is not supported by the evidence.

What is the safety and effectiveness of EMAA in hospitalized acute HF patients?

No studies were identified that examined the safety and effectiveness of EMAA in hospitalized acute HF patients

What is the effectiveness of ECG telemetry monitoring among patients hospitalized with acute HF in comparison to standard care?

No high-quality evidence was identified that evaluated the effectiveness of ECG telemetry monitoring among patients with acute HF.

Based on expert opinion, clinical practice guidelines recommend the use of continuous ECG monitoring among patients with acute HF. The AHA practice standards for in-hospital ECG monitoring and the CCS recommend continuous ECG monitoring among all patients with acute HF. The ESC and HFSA guidelines recommend continuous ECG monitoring among acute HF patients treated with inotropes, based on the increased risk of arrhythmia and myocardial ischemia associated with these agents.

What is the effectiveness of in-hospital insertion of an ICD or of CRT in patients hospitalized for acute CHF compared with those patients not hospitalized for acute CHF who receive the device or the procedure via pre-planned, elective surgery.

No studies were identified that examined the effectiveness of in-hospital insertion of an ICD or CRT in patients hospitalized for acute CHF compared with those patients who receive the devices via pre-planned, elective surgery.


Research Question Quality of Evidence

What is the diagnostic accuracy of an ECG for identifying ischemia as a precipitant for an acute HF episode?

No studies were identified that examined the accuracy of ECGs for diagnosing ischemia as the precipitant to an acute HF event in a HF population.

All 5 of the guidelines reviewed commented on the importance of using ECG in diagnosing the precipitants for an acute HF event.

Are in-hospital performance indicators for the in-hospital management of heart failure effective at improving patient outcomes?

There is very low quality evidence that in-hospital performance indicators for in-hospital heart failure management are effective at improving patient outcomes, in particular, reducing mortality and rehospitalization. (GRADE: Very low)

Is there an increased risk of mortality for HF patients administered dobutamine, milrinone, or nitroprusside in hospital?

No studies were identified that examined in-hospital milrinone or nitroprusside therapy for the management of HF.

In a meta-analysis of 3 identified RCTs, there was no evidence of a statistically significant increase in mortality risk compared with placebo for patients with moderate to severe heart failure who were administered dobutamine in hospital (GRADE quality of evidence: very low).

Careful consideration is required in formulating recommendations regarding the clinical utility of dobutamine for moderate to severe heart failure decompensation in hospital, based on the quality of the body of evidence and the limitations of the component studies.

What is the effectiveness of IABPs in the management of patients hospitalized with acute HF?

No high quality evidence on the use of IABPs in hospitalized patients with HF was identified through the systematic literature search. Therefore no conclusions could be made on its use in hospitalized patients with HF.

What is the effectiveness of PACs in patients hospitalized with acute HF?

The RCTs identified in patients hospitalized with HF did not show a statistically significant mortality benefit with the use of PACs compared to clinical assessment. A higher rate of infections associated with the PAC compared to clinical assessment was reported in 1 RCT. Other complications associated with PACs were reported, but their rates were not compared to a control group. The RCT excluded patients who were likely to require PACs within 24 hours following randomization, possibly affecting the generalizability of the results. This is based on moderate quality evidence.

What is the effect of intravenous nitroglycerin or nesiritide on renal function and risk of mortality for heart failure inpatients?

No systematic reviews, meta-analyses, or health technology assessments on the safety and effectiveness of nitroglycerin or nesiritide were identified in the literature search. No RCTs were identified evaluating the safety of nitroglycerin.

One large multicentre RCT addressed these questions with regard to nesiritide. (16) No statistically significant increase in risk of mortality (GRADE: moderate) or renal dysfunction (GRADE: high) was found, compared to placebo.

Abbreviations: AHA, American Heart Association; BNP, B-type natriuretic peptide; CCS, Canadian Cardiovascular Society; CHF, congestive heart failure; CRT, cardiac resynchronization therapy; ECG, electrocardiogram; EMAA, early mobilization and ambulation; ESC, European Society of Cardiology; HF, heart failure; HFSA, Heart Failure Society of America; IABP, intra-aortic balloon pump; ICD, implantable cardioverter defibrillator; PAC, pulmonary artery catheter; RCT, randomized controlled trial.


Review of CHF Clinical Practice Guidelines

The Expert Panel reviewed CHF clinical practice guidelines from the following organizations:

Canadian Cardiovascular Society (CCS)11,12,13

National Institute for Health and Clinical Excellence (NICE)14

European Society of Cardiology (ESC)15

Heart Failure Society of America (HFSA)16

American College of Cardiology/American Heart Association (ACC/AHA)17

A comparison chart of the various guidelines was created to guide the development of the CHF pathway.

Review of Empirical Evidence

The Expert Panel used real-world data to examine the prevalence of candidate processes of care in

accordance with the domains described by consensus expert panels to assist with the following:

assigning prevalence rates to various quality indicators according to unit of initial disposition

understanding processes of care that are most strongly associated with outcomes (i.e., 30-day

mortality or rehospitalization)

identifying potential areas of need for further evaluation

The analysis was done using the major diagnosis of CHF from the EFFECT data at ICES. The EFFECT

data were collected in 2005 for 86 hospitals, using chart abstraction of 125 patients consecutive per

hospital.18 The data were restricted to those admitted through ED and used the Framingham definition of

heart failure (which represents 91% of all heart failure).

The Expert Panel also reviewed the Emergency Heart Failure Mortality Risk Grade (EHMRG), a risk-

stratification method developed by ICES for the prediction of 7-day mortality in all patients with CHF

who present to the ED. Risk-adjustment models for 30-day death or rehospitalization were developed, and

the relationship between candidate process variables and risk-adjusted outcomes (30 day death or

rehospitalization) were examined.

The EMHRG score was developed from a multicentre study of 86 hospitals in Ontario.18 The study

included a population-based random sample of 12,591 patients presenting to the ED from 2004 to 2007.

Using a method of age-standardized coefficient–based weights similar to that used for the Framingham

risk score, the researchers developed a scoring system calculated by summing integer scores for

categorical variables and weights for the value of continuous variables (where the value of the continuous

variable was multiplied by its weight). The variables used in the EMHRG calculation are patient age,

systolic blood pressure, whether the patient was transported by emergency medical services, heart rate,

oxygen saturation, creatinine, potassium and troponin concentration, if the patient has active cancer or

receive metolazone at home. Although the EHMRG tool is well developed and validated, the ED

11 Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: Diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials; Can J Cardiol Vol 25 No 2 February 2009. 12 Canadian Cardiovascular Society Consensus Conference guidelines on heart failure – 2008 update: Best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies; Can J Cardiol Vol 24 No 1 January 2008. 13 The 2011 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Sleep Apnea, Renal Dysfunction, Mechanical Circulatory Support, and Palliative Care; Canadian Journal of Cardiology 27 (2011) 319–338. 14 NICE Clinical Guideline No 108; Chronic Heart Failure National clinical guideline for diagnosis and management in primary and secondary care; August 2010. 15 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008, European Heart Journal (2008) 29, 2388–2442. 16 HFSA 2010 Guideline Executive Summary; Journal of Cardiac Failure Vol. 16 No. 6 2010. 17 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the International Society for Heart and Lung Transplantation; Circulation 2009;119;1977-2016. 18 Lee D et al., Prediction of Heart Failure Mortality in Emergent Care: A Cohort Study. Ann Internal Medicine 2012: 156(11):767-775.


physician community needs to adopt this tool or a risk-stratification method to guide decisions about

whether to treat the CHF patient in the ED or admit to hospital for treatment.

The Expert Panel made the following conclusions after reviewing the results of the analyses.

1. It is possible to stratify and establish hospital disposition using variables in the EHMRG tool,

other clinical variables and responsiveness to dieresis variable.

2. Precipitating factors by initial hospital disposition are ischemia and valvular heart disease.

3. End-of-life care by initial hospital disposition includes advanced-care directives.

4. High-cost technology/interventions by initial disposition include coronary angiography

appropriateness for those with ischemia.

5. Discharge planning by initial hospital disposition should include physician follow-up and

cardiology follow-up, particularly among higher-risk patients.

6. Discharge disposition by initial hospital disposition should include hospice/palliative care.

7. Quality indicators at discharge and follow-up should include angiotensin-converting enzyme

(ACE) inhibitors/angiotensin receptor blockers (ARBs) and diuretics management

8. In-hospital quality indicators by initial hospital disposition should include ACE inhibitors/ARBs

and recording of daily weights

9. Counselling at discharge by initial hospital disposition should include medication management

and activity.


CHF Episode of Care Pathway Model

The Expert Panel developed the CHF episode of care pathway model after carefully reviewing the

evidence obtained in the rapid review process, the clinical practice guidelines, and the results of the

analyses performed. A pathway using the principles of decision analytic modelling was developed,

including clinical assessment nodes and care modules that list the resources required (including

interventions, procedures, and diagnostics) based on the best available evidence, empirical evidence from

ICES heart failure registry data, and expert consensus.

Phases of the Patient Journey

The Expert Panel recommended 4 phases of the patient journey while the patient is hospitalized and

consuming resources in an inpatient bed:

1. Acute stabilization phase (first 12 to 24 hours after admission), where the clinical status of the

patient is assessed and causes of symptoms are identified

2. Sub-acute stabilization phase (e.g., 24 to 96 hours after admission)

3. Discharge preparation phase (e.g., day 2 to hospital discharge)

4. Transitional care phase (e.g., hospital discharge or 24 hours prior to discharge to 8 to 12 weeks

after discharge)

Figure 7 shows the different phases of care. Times are displayed to illustrate the overlap of phases and

have not been confirmed by the Expert Panel.

Figure 7: Phases of the Patient Journey While Hospitalized


Episode of Care Pathway

As described above, the Expert Panel developed the episode of care pathway for CHF patients as shown

in Figure 8 using empirical evidence from the heart failure registry data and consensus of the Expert

Panel members. The CHF patient population, defined by ICD-10-CA codes, was further refined by

excluding special CHF patient cohorts. Special populations for whom the heart failure episode of care

pathway should not apply include the following:

1. Primary dialysis patients

2. Pre-transplant patients (i.e., those actively being considered for cardiac transplantation or on the

transplant list) and post-transplant patients

3. Patients transferred into hospitals from other institutions (i.e., in-hospital transfers)

4. Critical care outreach patients (i.e., higher-intensity patients managed in lower-intensity units due

to limited coronary care or intensive care unit bed availability)

5. Patients with more additional active chronic medical condition(s) that require(s) acute

stabilization management (e.g., active COPD, stroke, ST segment elevation myocardial infarction

[STEMI], non-STEMI active bleeding, etc.).

The care-pathway is intended to reflect the CHF-specific management stream only and does not take into

account other active treatments that might affect human resources, investigations, treatment, length of

stay, or quality of care.


Figure 8: CHF Episode of Care Pathway


Clinical Assessment Node: ED Risk Stratification and Responsiveness to Diuresis

When a patient presents in the ED with suspected CHF, a number of investigations are required as

recommended by clinical guidelines and supported by the Expert Panel. Table 11 describes the initial

investigations recommended in the CCS 2008 guidelines (similar to guidance from other organizations

such as NICE, ESC, HFSA, and ACC/AHA).

Table 11: ED Risk Stratification and Responsiveness to Diuresis—Recommended Practice

Recommended Practice Relevant Evidence

Initial investigations should include the following:

serum creatinine and electrolyte levels

troponin measurements

complete blood count

electrocardiogram

chest x-ray and an echocardiogram if no recent echocardiogram is available (class I, level C)

Heart rate, blood pressure and oxygen saturation should be measured frequently until the patient is stabilized (class IIa, level C).

Canadian Cardiovascular Society (CCS)

National Institute for Health and Clinical Excellence (NICE)

European Society of Cardiology (ESC)

Heart Failure Society of America (HFSA)

American College of Cardiology/American Heart Association (ACC/AHA)

The Expert Panel recommends that patients presenting to hospital with acute CHF be classified into the

following 3 broad groups for the purposes of establishing care pathways and defining major groups for

QBP funding:

1. Low-intensity: These patients can be treated in the ED or in outpatient settings and discharged

home without requiring an inpatient admission.

2. Average-intensity: These patients require admission to inpatient care with normal nurse-to-

patient staffing.

3. High-intensity: These patients require ventilation (either noninvasive or invasive ventilation)

and/or admission to an intensive care unit with higher nurse-to-patient staffing.

It is recognized that these 3 patient groups are largely based on level of care. The Expert Panel has

identified a number of high-risk markers:

respiratory distress

hypoxemia

severity of pulmonary edema

poorly responsive to ED Lasix

hemodynamic compromise

significant arrhythmias

positive troponin

concomitant acute life-threatening directives


The Expert Panel suggests that an acute heart failure risk score—for example, the EHMRG— be

calculated to assist with clinical decision-making and predicting the 7-day mortality risk of CHF patients

(predicted mortality risk increases incrementally with higher EHMRG risk score). As a general guide,

patients who are low-risk (e.g., EHMRG quintiles 1 and 2) can be considered for discharge home if they

have responded to initial treatment in the ED, provided that there are no other considerations (e.g.,

advanced-directives, severe dementia, estimated impact of admission on life-expectancy, bed-availability,

etc.). Patients who are high-risk (e.g., EHMRG quintile 5) can be considered for admission to a higher-

intensity unit.

Ultimately, the decision to admit is based on clinical judgment and the availability of hospital resources.

Note: a full review of the evidence is required to determine the essential markers and defined thresholds

for the 3 CHF patient groups (high-intensity, average-intensity, and low-intensity).

Admitted Patients The Expert Panel identified 2 pathways branches for admitted patients based on severity:

1. High-intensity case-mix-adjusted patient

2. Average-intensity case-mix-adjusted patient

The high-intensity case-mix-adjusted patient implies that a patient is high-risk enough to necessitate a 1:1

nurse-to-patient ratio. Similarly, the lower-intensity case-mix-adjusted patient implies that a patient is of

sufficiently low risk to be managed with the usual hospital-ward 1:5 nurse-to-patient ratio.

The case-mix adjustment implies that the high-intensity as well as average-intensity care pathway

corresponds to an individual of average comorbidity for CHF patients in the province of Ontario. An

individual who has higher-than-average or lower-than-average comorbidity would not necessarily alter

the patient intensity level or the care pathway, but rather the cost bundle associated with the care pathway.

The rationale for cost adjustments for case-mix variation is based on the understanding that care intensity

and length of stay correlate with the management of other (non–heart failure–related) chronic conditions.

Such management of other comorbidities is not taken into account in this care pathway. Case-mix cost

attribution could use a number of different methodologies, including resource intensity weights.

The mean total length of hospital stay for the high-intensity and low-intensity patients using the 2005

EFFECT database and the 2010/11 DAD database are:

High-intensity (2005 EFFECT) - 8.8 days (SD = 8) with mean length of ward stay of 5.0

days (SD = 8.2)

High-intensity (2010/11) - 12.2 days (SD = 21.3)

Low-intensity (2005 EFFECT) - 8.5 days (SD = 10.7)

Low-intensity (2010/11) - 8.8 days (SD = 15.1)


Care Module: Acute Stabilization Phase

Tables 12 and 13 highlight the Expert Panel recommendations based on the analysis of CHF registry data

at ICES, expert consensus and CHF guidelines. The prevalence/proportions of patients have been

included using ICES data. They are weighted to reflect 2 factors: Framingham-defined vs. total heart

failure per hospital and the size of the hospital. Some of the recommendations in the tables are briefly

discussed in the subsections below.

Table 12: Acute Stabilization Care Module: High-Intensity Patient

Mechanical ventilation (Pr = 9.5%)

BIPAP (Pr = 25.95%)

IV inotropes and/or IV vasodilators (Pr = 17.2%)

Diuretic monitoring and management, acute phase

Identifying and treating precipitating factors

o Echocardiography

o Cardiac catheterization

o Noninvasive cardiac imaging

Evidence-based pharmacotherapy management, acute phase

Telemetry

Advanced care discussions and directives (Pr = 13.96%)

Noninvasive imaging for those who are not ideal candidates for cardiac catheterization

Oxygen

IV Lasix

Ultrafiltration (consider if necessary)

Intensive PA monitoring

Other (IABP, assistive devices) Abbreviations: BIPAP, bilevel positive airway pressure; IABP, intra-aortic balloon pump; IV, intravenous; PA, pulmonary artery; Pr, prevalence.

Table 13: Acute Stabilization Care Module: Low-Intensity Patient

BIPAP (Pr = 4.47%)

Telemetry

Diuretic monitoring and management, acute phase

Identifying and treating precipitating factors

o Echocardiography (Pr = 50.1%)

o Cardiac catheterization (Pr = 3.76%)

o Noninvasive cardiac imaging

Evidence-based pharmacotherapy management, acute phase

Advanced care discussions and directives (Pr =13.8%)

DNR (Pr =15.8%)

PO Lasix

Oxygen (consider if appropriate)

IV Lasix

Noninvasive imaging for those who are not ideal candidates for cardiac catheterization

Abbreviations: BIPAP, bilevel positive airway pressure; DNR, do not resuscitate; IV, intravenous; PO, per os (by mouth); Pr, prevalence.


Diuretic Monitoring and Management, Acute Phase Table 14 shows recommended practice for diuretic monitoring and management in the acute phase.

Table 14: Diuretic Monitoring and Management—Acute Phase

Recommended Practice Relevant Evidence

Recording of:

Daily weights

6-hour input/output

Salt restriction (2 g/day) (low level of evidence)

Possible fluid restriction (2 L/day)

Electrolytes

Renal function

Chest x-ray

Canadian Cardiovascular Society (CCS)

National Institute of Health and Clinical Excellence (NICE)

European Society of Cardiology (ESC)

Heart Failure Society of America (HFSA)

American College of Cardiology/American Heart Association (ACC/AHA)

The frequency of laboratory and x-ray follow-up should remain discretionary. Each patient should have a

daily record of weights and measurement of 6-hour input/output. The frequency of electrolyte and renal

function monitoring depends on the dose and administration of Lasix (i.e., higher doses necessitate closer

monitoring). The frequency of chest x-rays depends on the baseline extent of pulmonary edema, a

patient’s clinical status, and his/her responsiveness to diuretics. Diuretic management approaches should

take an “early and frequently” approach. Those at higher intensity should receive an intravenous (IV)

Lasix bolus every 6 to 12 hours or a continuous IV infusion.19 Those at lower intensity should also begin

with IV Lasix daily or BID.

Guiding principles in patients hospitalized with acute heart failure

The Expert Panel discussed the central importance of adequately relieving congestion during admission

for CHF. A number of panel members further shared that there are likely to be opportunities to broadly

improve the approach to diuretic use in hospitals by minimizing variation in diuretic management and

possible underdosing of diuretics. Given this discussion, the Expert Panel explored building some general

principles around diuretic-based management into the Expert Panel’s definition of an episode of care for

CHF.

Each Expert Panel member shared what he/she considered to be best practice general principles

for diuretic-based management. Members gave advice on principles/guidance related to the following:

1. Common dosing regimens for diuretic-naive patients vs. diuretic-experienced patients

2. Special populations that require special consideration for diuretic dosing

3. Key monitoring parameters that should be used to adjust the diuretic treatment plan

4. Common scenarios that are often associated with diuretic management that is too

conservative/underdosed

19 Felker, D.M et al.; Diuretic Strategies in Patients with Acute Decompensated Heart Failure, N Engl J Med 2011; 364:797-805, March 3, 2011.

http://www.nejm.org/toc/nejm/364/9/


Table 15 shows the recommendations from the clinical practice guidelines on diuretics for CHF patients. Table 15: Diuretic Recommendations in Acute Heart Failure

CCS 2006 ESC 2012 ACC/AHA 2009 HFSA 2010 NICE 2010

Tailored diuretic therapy is recommended for all symptomatic patients

Class III/IV: combination diuretic therapy with spironolactone

No specific dosage recommendations

Includes table on practical considerations in the treatment of heart failure with loop diuretics (e.g., managing hypokalemia, renal failure, inadequate response to diuretic)

No specific dosage recommendations for acute admissions for heart failure

Starting dose for chronic heart failure: 20–40 mg

Stage C (patients with current or prior symptoms): diuretics for fluid retention

The hospitalized patient: IV loop diuretic at higher than or equal to chronic oral daily dose. If inadequate, response consider higher doses, addition of another diuretic (e.g., metolazone) or continuous infusion

Initial IV doses for severe heart failure: furosemide 40 mg

Loop diuretics for patients with fluid overload

Acute decompensated heart failure: IV loop diuretics

If inadequate response, consider Increasing dose, addition of metolazone or continuous infusion

Diuretics routinely used for relief of congestive symptoms and fluid retention

Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; CCS, Canadian Cardiovascular Society; ESC, European Society of Cardiology; HFSA, Heart Failure Society of America; IV, intravenous; NICE, National Institute for Health and Clinical Excellence.

Identifying and Treating Precipitating Factors The Expert Panel recommended that efforts to identify precipitating factors should include exploration of

all the usual known factors, including medication and dietary noncompliance. However, precipitating

factors should focus on the identification of 2 particular prognostic indicators that have been shown to

correlate with poorer 30-day outcomes of death or recurrent hospitalization: the presence of myocardial

ischemia and/or the worsening of valvular heart disease, either of which would be severe enough to

possibly warrant surgical or interventional procedures.

Evaluation for precipitating factors must also include the application of a risk-stratification process, to

help clinicians decide whether the patient should or should not undergo cardiac catheterization. For

example, in a patient presenting to hospital with heart failure, positive testing for troponins and/or ECG

changes that could be consistent with myocardial ischemia might indicate the presence of underlying

acute coronary syndrome or extensive coronary ischemia. Many such patients may have had prior cardiac

catheterization and may have already been deemed a patient best deemed for conservative medical

management. For others (e.g., new heart failure in a patient who has not had prior cardiac catheterization),

a positive troponin test may indicate the need for coronary angiography. Similarly, each patient should be

screened for severe valvular heart disease or mechanical heart complications that may have served as a

precipitating cause.

Most patients should be considered for 2D echocardiography for assessment of left ventricular systolic

and diastolic function and underlying valvular disease. Should severe valvular heart disease be found, the

patient should be considered for cardiac catheterization. Nonetheless, as with coronary angiography

above, many exceptions may occur, and each patient must be evaluated on a case-by-case basis.

The Expert Panel recommended the implementation of a process that requires doctors to document that

they have considered the patient for cardiac catheterization or noninvasive cardiac imaging for evaluation

of coronary ischemia or valvular abnormality, and that the patient was deemed either an appropriate or an


inappropriate candidate, along with the reason. An implementation process such as the one suggested

above will at least ensure that all providers think about precipitating factors and address the 2 that are

most prognostically important. Figure 9: Precipitating Factor Node

Evidence-Based Pharmacotherapy Management, Acute Phase The timing for the initiation of ACE inhibitors/ARBs and β-blockers in acute heart failure is unclear.

Patients who have been on these medications prior to hospital arrival should continue them during

hospitalization. For patients who have been introduced recently to β-blockers and have acute

decompensated heart failure associated with the increase, consideration should be given to cutting the

dose in half if they are in severe pulmonary edema. However, health care providers should be discouraged

from discontinuing ACE inhibitors/ARBs and β-blockers unless the patient is hemodynamically unstable.

For those not already receiving these evidence-based medications, ACE inhibitors/ARBs should be

initiated early if the patient is hemodynamically stable. However, initiation of β-blockers should begin

only once patient has been diuresed and is stable from a pulmonary congestion standpoint. For both

medications, doses should be started low and titrated slowly. The use of other evidence-based

pharmacotherapy (e.g., aldosterone receptor antagonists ) should be left to the discretion of the health care

provider.

Telemetry No high-quality evidence was identified in the rapid review that evaluated the effectiveness of ECG

telemetry monitoring among patients with acute CHF. Based on expert opinion, clinical practice

guidelines suggest the use of continuous ECG monitoring among patients with acute CHF. The AHA

Assessment for ischemia

Clinical suspicion

ECG abnormalities

Troponin (+)

New heart failure

Eligible and

appropriate for

coronary

intervention

Yes

Coronary angiography +/-

revascularization; (Pr<15% cath; Pr<5%

PCI; Pr<5% CABG); medical

management for IHD may also be

required.

Uncertain

Non-invasive risk-stratification

should be undertaken either in-

hospital or during transition; medical

management for IHD should be

considered

Reason must be done on chart

(e.g., previously assessed and

patient known to be medical

management); medical

management for IHD should be

considered

Assessment of LV

function and valvular

heart disease (e.g., 2D

echocardiography)

Eligible and

appropriate for

valve repair or

surgery

Yes

Surgery or

interventional

cardiology (Pr:<5%)

Uncertain

No

Cardiology or cardiac

surgery referral

Reason must be

documented on chart


practice standards for in-hospital ECG monitoring suggest continuous ECG monitoring among all patients

with acute CHF. The ESC and HFSA guidelines recommend continuous ECG monitoring among acute

CHF patients treated with inotropes, based on the increased risk of arrhythmia and myocardial ischemia

with these agents.

The Expert Panel recommends the use of telemetry, but this intervention needs to be reassessed.

Furthermore, hospitals using telemetry should develop policies identifying patients’ eligibility and timing

for reassessment. A sample policy could read as follows:

The physician or nurse practitioner who assumes responsibility for telemetry monitoring should

review the telemetry record and assess the need for continued telemetry monitoring 48 hours after

initiation and then every 24 hours thereafter. If a telemetry-monitored patient’s rhythm is

unremarkable during a 24-hour period, the telemetry nurse may contact the responsible team to

reassess the need for continued telemetry monitoring. The decision to discontinue telemetry will be

made by the physician/nurse practitioner who assumes responsibility for telemetry monitoring, or the

critical care unit staff cardiologist when the urgent need arises to clear channels for other patients.

Summary Table 16: Summary of Recommendations for the Acute Stabilization Phase (First 12–24 Hours)

Recommendations (Intervention/Resources)

High-Intensity Case-Mix-Adjusted Patient

Low-Intensity Case-Mix-Adjusted Patient

Mechanical ventilation ✓ —

BIPAP ✓ Consider if appropriate

Oxygen ✓ Consider if appropriate

IV Lasix ✓ Consider if appropriate

IV vasoactive agents ✓ —

PO Lasix ✓

Telemetry ✓ Consider if appropriate and available

1:1 nurse-to-patient staffing ratio ✓ No; typical inpatient medical ward staffing ratio acceptable

ACE inhibitors/ARBs Consider if appropriate Consider if appropriate

β-blockers — Consider if appropriate

Ultrafiltration Consider if appropriate —

Intensive PA monitoring ✓ —

Other (IABP, assistive devices) ✓ —

Monitor electrolytes, renal function, troponins, chest x-ray

✓ ✓

(chest x-ray if appropriate)

Record fluid input/output ✓ ✓

Record weight — ✓

Other therapies (e.g., consider Aspirin, IV heparin, statins if troponins-positive)

✓ ✓

Assessment of precipitating factors ✓ ✓

Discuss advanced directives ✓ ✓

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BIPAP, bilevel positive airway pressure; IABP, intra-aortic balloon pump; IV, intravenous; PA, pulmonary artery; PO, per os (by mouth).


Clinical Assessment Node: Reassessment and Re-evaluation

Tables 17 and 18 show the recommendations of the Expert Panel with respect to the reassessment and re-

evaluation clinical assessment node.

Table 17: Reassessment and Re-evaluation: High-Intensity Case-Mix-Adjusted Patienta

Re-evaluate underlying and precipitating cause o Echocardiography o Cardiac catheterization o Noninvasive cardiac imaging

Screen for complications (e.g., arrhythmia, urosepsis, chronic obstructive pulmonary disease, renal failure, pneumonia)

Continue management and monitoring as per care pathway

Discuss advanced directives

Withdrawal from therapy aNode 3, Figure 8, CHF episode of care pathway.

Table 18: Reassessment and Re-evaluation: Low- Intensity Case-Mix-Adjusted Patienta

Re-evaluate underlying and precipitating cause o Echocardiography o Cardiac catheterization o Noninvasive cardiac imaging

Screen for complications (e.g., arrhythmia, urosepsis, chronic obstructive pulmonary disease, renal failure, pneumonia)

Continue management and monitoring as per care pathway

Discuss advanced directives

Withdrawal from therapy aNode 5, Figure 8, CHF episode of care pathway.


Care Module: Sub-acute Stabilization Phase

The Expert Panel gave guidance on the management of CHF patients in the sub-acute management phase,

as shown in Table 19. The CCS, NICE, ESC, HFSA, and ACC/AHA have all highlighted these areas in

their guidelines.

Table 19: Sub-acute Care Module

Diuretic monitoring and management (sub-acute phase)

Early mobilization

Evidence-based pharmacotherapy management (sub-acute phase)

Other heart failure management considerations

Diuretic Monitoring and Management (Sub-acute Phase) Diuretic monitoring and management in the sub-acute phase is similar to that of the acute phase,

recognizing that the patient is now more stable, has less pulmonary congestion and has been responsive to

more intensive diuretics. Weight and input/output should still be recorded daily. Electrolytes and renal

function can be monitored daily, every second day, or every third day, depending on the patient’s clinical

status, dose of Lasix, responsiveness to therapy, and prior electrolyte or renal laboratory abnormalities.

Early Mobilization The Expert Panel recommends early mobilization as a new approach to in-hospital heart failure

management. The mobilization/activity care map should follow early-mobilization maps for other care

pathways (e.g., COPD). Mobilization depends upon responsiveness to diuresis, and activities such as

walking should not be encouraged for patients with severe residual pulmonary congestion or refractory

heart failure. Nevertheless, for most patients, activities should be scaled from sitting up in bed to sitting in

a chair with bathroom privileges, to walking (in the room and on the ward). Patients should be

encouraged to mobilize (with walking) at least once every 6 hours during daytime waking hours.

Evidence-Based Pharmacotherapy Management (Sub-acute Phase) Similar to the acute phase, patients in the sub-acute phase should be treated with β-blockers (assuming

there is no absolute contraindication), and ACE inhibitors/ARBs. Nitrates ± vasodilators should be used

in patients intolerant of or with contraindications to ACE inhibitors/ARBs. Again, the focus (in treatment-

naïve patients) should be on initiating therapy at low doses and titrating slowly. The use of aldosterone

receptor antagonists should be left to the discretion of the treating health care providers.

Other Heart Failure Management Considerations Other heart failure management considerations may include continuous positive airway pressure (CPAP)

for patients with confirmed sleep apnea and as recommended by a sleep specialist. Nitrates can be

considered for preload reduction. Digoxin can be considered for residual heart failure if symptoms persist

despite otherwise optimal therapy. Patients can be considered for an implantable cardioverter defibrillator

(ICD) or cardiac resynchronization therapy (CRT) at the discretion of the treating physician. The decision

to insert ICD/CRT devices should occur following optimization of heart failure therapy and reassessment

of ejection fraction, unless the patient who requires the ICD presents with ventricular arrhythmia.


Care Module: Advanced Heart Failure

After reassessment and re-evaluation, a small number of patients (approximately 1.3%) may follow an

advanced heart failure pathway. Table 20 shows some of the interventions included in the pathway.

Table 20: Advanced Heart Failure Management

Ultrafiltration or dialysis

Cardiac resynchronization therapy

PCI or CABG

Valve repair/replacement

Transplantation assessment

LVAD

Transplantation Abbreviations: CABG, coronary artery bypass graft; LVAD, left ventricular assist device; PCI, percutaneous coronary intervention.


Care Module: Discharge Phase

A sub-panel was created to review the discharge-planning phase and explore the transitional care phase,

which is a continuation of the CHF episode of care into the community. The sub-panel adopted the Naylor

et al. (2011) definition of transitional care as “a broad range of time-limited services designed to ensure

health care continuity, avoid preventable poor outcomes among at-risk populations and promote the safe

and timely transfer of patients from one level of care to another or from one type of setting to another.”20

The few available definitions of hospital discharge planning indicate that it is a process that takes place

between hospital admission and the discharge event.21 Predischarge communication is important as a start

to the transitional care process: it provides an opportunity to summarize the visit, teach patients how to

safely care for themselves at home, and address any remaining questions or concerns. Discharge planning

helps patients communicate with caregivers and primary care providers about how best to manage chronic

needs after leaving the hospital.22

As shown in Figure 7, there are 2 discharge modules in the episode of care pathway: discharge from the

ED and discharge after admission. To establish the discharge planning modules and to begin

understanding the evidence relating to the transitional care phase, the sub-panel reviewed the OHTAC

reports Discharge Planning in Chronic Conditions: An Evidence-Based Analysis23 and Recommendation:

Specialized Community Based Care for Chronic Disease24, as well as the HQO BestPath Transitional

Care report and the CCS, NICE, ESC, HFSA, and ACC/AHA guidelines. Through its review and

consultation with experts in the field of transitional care, the sub-panel found that there were randomized

controlled trials, systematic reviews and meta-analyses on inpatient hospital-to-home discharge planning,

but no studies for ED-to-home discharge. The sub-panel decided that both discharge planning modules

would be similar for this report.

The OHTAC report Discharge Planning in Chronic Conditions: An Evidence-Based Analysis

summarized the following interventions:

Predischarge interventions

– Patient education

– Discharge planning

– Medication reconciliation

– Appointment scheduled before discharge

Postdischarge interventions

– Timely primary care physician communication

– Timely clinic follow-up

– Follow-up telephone call

– Postdischarge hotline

– Home visit

Interventions bridging the transition

– Transition coach

– Patient-centred discharge instructions

– Provider continuity

20 Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. The care span: the importance of transitional care in achieving health reform. Health Aff. 2011;30(4):746-54. 21 Holland DE, Harris MR. Discharge planning, transitional care, coordination of care and continuity of care: clarifying concepts and terms from the hospital perspective. Home Health Care Serv Q. 2007;26(4):3-19. 22 Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. Forthcoming 2012. 23 Ontario Health Technology Assessment Series; Vol. 12: No. TBA, pp. 1–70, July 2012 24 Ontario Health Technology Assessment Series; Vol. 12: No. 20, pp. 1–60, November 2012


Using the above interventions, clinical guidelines and expert advice, the sub-panel established the

discharge-planning module for the episode of care pathway. Individualized discharge planning includes

communication of weight and creatinine at discharge, evaluation of care needed at home and the ability to

attend follow-up visits with a family physician and specialist.

Table 21 shows the components of the discharge-planning module. According to the OHTAC report, the

evidence supports the use of individualized discharge planning, and studies have shown a significant

reduction in readmissions favouring individualized discharge planning. However, the risk of readmission

prior to discharge should be assessed.

Table 21: Discharge Planning Module

Diuretic monitoring and management

Evidence-based pharmacotherapy

Other relevant medical therapies

Counselling o Medication management o Lifestyle (alcohol, smoking) o Daily weight and self-monitoring o Diet o Physical activity o Advanced care directives

Predischarge functional capacity and mobility assessment

Predischarge cognitive and social support assessment

Physician appointments o General practitioner/family physician identified, and follow-up visit scheduled within 2 weeks of

discharge o Ambulatory care specialty follow-up (cardiology or internal medicine)

Timely documentation

o Discharge notes dictated and sent to primary care (and relevant other) provider(s) within 1 week (ideally within 48 to 72 hours of hospital discharge)

Diuretic Monitoring and Management Patients should be on a standing Lasix order and followed by a heart failure clinic. Daily input/outputs

and weights should be recorded.

Evidence-Based Pharmacotherapy All patients without absolute contraindications should be receiving ACE inhibitors/ARBs and β-blockers.

If patients cannot tolerate ACE inhibitors/ARBs or cannot take them due to contraindications, they should

be receiving hydralazine and nitrates. The use of aldosterone receptor antagonists should be left to the

discretion of the provider; the ESC 2012 guidelines recommend the use of aldosterone receptor

antagonists.

Other Relevant Medical Therapies Other heart failure management considerations may include CPAP for patients with confirmed sleep

apnea, if recommended by a sleep specialist. Additional therapies may include statins and antiplatelets for

patients with ischemic heart disease or anticoagulation for patients with atrial fibrillation.


Counselling Education should be provided for patients and family members/caregivers on the symptoms and signs of

worsening heart failure and how to respond. Consider also assessing health literacy: hospitals should

adapt their education programs based on health literacy or learning disabilities and have materials

available in different languages.

The guidelines recommend counselling on medication management, lifestyle (e.g., smoking), daily weight

and self-monitoring, diet (e.g., salt restriction, fluid intake), physical activity, and advanced care

directives. The counselling strategy will likely require multiple in-hospital allied health professionals

(e.g., pharmacists, social worker, nursing), and would incur costs. Medication reconciliation at discharge

should involve the community pharmacist.

Predischarge Functional Capacity and Mobility Assessment Available evidence has demonstrated that functional capacity is an important predictor of outcomes

among patients with CHF, and accordingly, may be used to help prognostically risk-stratify hospitalized

patients as they are discharged into community settings.25 For example, at least 1 study has determined

that patients hospitalized with acute decompensated heart failure who cannot achieve 200 metres in a 6-

minute walk test (6MWT) at discharge have a significantly higher risk of death or rehospitalization than

those able to achieve 200 metres or greater (equivalent to an activity intensity level of approximately 2

METs ).26 Although the 6 MWT is known to have prognostic value, implementing it in a clinical setting

may be challenging. Additional challenges include potential delay in discharge due to lack of availability

of staff to perform a proper 6 MWT, since the volume of CHF patients in a hospital can be significant,

increasing the workload of physiotherapists and nurses.

Accordingly, all patients (with the exception of those deemed to be at the end of life and those unable to

mobilize due to neurologic or musculoskeletal abnormalities) should undergo some objective physical

activity assessment prior to discharge. The Expert Panel recommends that the local hospital decide on the

appropriate assessment. For example, clinicians can use a 6MWT or a low-level (modified) protocol on a

treadmill or cyclometer exercise test. Patients unable to pass the mobilization test should either remain in

hospital or be discharged under close supervision (i.e., rapid heart failure assessment clinic).

The Expert Panel recommended that the costs for providing the above tests (with respect to human

resources and equipment) for functional capacity assessment should be included in the care bundle for all

eligible patients surviving to discharge.

Predischarge Cognitive and Social Support Assessment Before discharge, patients will require cognitive and/or social support assessment. Cognitive assessment

should be done by trained staff. The process will require additional human resources and should be

included in the care bundle for all eligible patients surviving to discharge.

Physician Appointments General practitioner/family physician follow-up

The Expert Panel recommends that a primary care or specialty care visit should occur within 2 weeks of

discharge. Each CHF patient discharged from hospital or the ED should be followed up by both their

primary and specialty care providers.

25 Am Heart J. 2008 Feb;155(2):200-7. Epub 2007 Nov 26 26 J Card Fail. 2009 Mar;15(2):130-5. Epub 2008 Dec 5

http://www.ncbi.nlm.nih.gov/pubmed/18215587

http://www.ncbi.nlm.nih.gov/pubmed/19254672


The Expert Panel recognized that the tagging of whether or not a patient has a primary care physician

needs to be done consistently. Some patients do not have family physicians, making it impossible to

schedule physician follow-up after discharge from hospital. The Expert Panel agreed that in such cases,

the hospital should provide transitional care until the patient can be handed off.

In addition, some primary care physicians may see CHF patients only rarely. It may be a challenge for

such physicians to develop schedules that allow availability for follow-up of CHF patients discharged

from hospital.

Ambulatory care specialty follow-up

The Expert Panel recommends that CHF patients discharged from hospital be referred to a specialized

community-based heart failure clinic within 2 weeks of discharge. OHTAC recommends that

“Mechanisms that enable rapid access (within 1–3 days) to specialized care should be built into the model

of heart failure clinics.”27

Timely Documentation The Expert Panel recommends that discharge notes be dictated and sent to primary care (and relevant

other) provider(s) within 1 week of patient discharge, but preferably within 48 hours.

27 Ontario Health Technology Assessment Series; Vol. 12: No. 20, pp. 1–60, November 2012


Transitional Care Pathway

Although there is a process for transitional care in approximately 80 to 90% of hospitals in Ontario, this

practice is not standardized throughout the province (OHTAC, 2012).28 Through discussions at the sub-

panel meetings, it was established that transitional care in Ontario is likely more of an organic process,

with varying elements tailored to suit the needs of the community (e.g., some hospitals may have

discharge planners, while some may use the services of Community Care Access Centres).

A multidisciplinary approach is suggested for transitional care, with the involvement of family physicians

and family health teams, nurses (potentially through the Community Care Access Centres or other Local

Health Integration Network–funded programs), community pharmacists, occupational therapists, social

workers and dietitians.

In Ontario, there are many interventions within a region addressing different aspects of transition of care,

but there is a need for better coordination of care. Many issues were discussed related to the present

transition of care models, including the lack of standardized interventions; the lack of risk stratification to

prevent community nurses and therapists being deployed to all CHF patients on discharge; and the lack of

cost analyses related to interventions. For these reasons, the Expert Panel supports the implementation of

specialized community-based heart failure clinics in Ontario.

28 Ontario Health Technology Assessment Series; Vol. 12: No. 20, pp. 1–60, November 2012


Performance Measurement

The Expert Panel was requested by the Ministry to provide recommendations related to CHF performance

indicators. The intent is for these recommendations to inform the development of a “QBF Integrated

Scorecard” for CHF, which would track a number of indicators related to the episode of care and

recommended practices for CHF. Similar scorecards are to be developed for other clinical areas that are

subject to QBF funding.

A rapid review of the evidence was done to investigate whether performance indicators for in-hospital

heart failure management were effective at improving patient outcomes. No meta-analyses, health

technology assessments or systematic reviews were identified, but 2 guideline reports were identified that

reported on performance indicators for in-hospital heart failure management: the 2010 CCS guidelines for

the diagnosis and management of heart failure update29 and the American College of Cardiology

Foundation (ACCF)/AHA Task Force on Performance Measures and the American Medical Association–

Physician Consortium for Performance Improvement (AMA-PCPI) 2011 Performance Measures for

Adults with Heart Failure30. A summary of the performance indicators listed in the CCS guidelines is

shown in Table 22. The ACCF/AHA–AMA-PCPI 2011 performance measures report similar

performance indicators.

Overall, the relationship between specific performance measures and patient outcomes remains unclear.

Reasons for this include the following:

Methodological limitations of the studies, such as nonrandomized designs and limited followup

Many commonly assessed performance indicators have not been shown in clinical trials to reduce

mortality and prevent hospitalization

While some performance indicators may have been met (such as smoking cessation counselling),

the manner in which they were delivered may have been suboptimal

Baseline adherence to performance indicators such as ACE inhibitors in eligible patients was

already high in some studies, making further improvements in patient outcomes more difficult to

demonstrate

29 Howlett JG, McKelvie RS, Costigan J, Ducharme A, Estrella-Holder E, Ezekowitz JA, et al. The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs. Can J Cardiol. 2010;26(4):185-202. 30 Bonow RO, Sadwin LB, Sikkema JD, Sincak CA, Spertus J, Torcson PJ, et al. ACCF/AHA/AMA-PCPI 2011 performance measures for adults with heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement. Circulation. 2012;125(19):2382-401.


Table 22: Summary of Performance Indicators for Heart Failure by Development Group

Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CAD, coronary artery disease; CCB, calcium channel blocker; CVD, cardiovascular disease; CXR, chest x-ray; ECG, electrocardiogram; ICD, implantable cardioverter defibrillator; LV, left ventricle; PVD, peripheral vascular disease.

Indicator Canadian Cardiovascular

Outcomes Research Team

(CCORT) inpatient

American Heart Association/

American College of Cardiology

(AHA/ACC) inpatient

Joint Commission on Accreditation of

Healthcare Organizations

(JCAHO)

Organized Program to Initiate Lifesaving

Treatment in Hospitalized

Patients with Heart Failure

(OPTIMIZE-HF)

Assessing the Care of Vulnerable Elders Project

(ACOVE)

Therapeutics

ACEi and/or ARB if LV systolic dysfunction in eligible patients x x x x x

Use of beta blockers in eligible patients x x x x

Use of statins in eligible patients if underlying CAD, PVD, CVD, or diabetes x

Aldosterone antagonists for eligible patients x

Anticoagulants for atrial fibrillation x x x

Use of ICD in eligible patients

Avoid 1st and 2nd generation CCBs if LV systolic dysfunction x

Avoid type 1 antiarrhythmic agents if LV systolic dysfunction (unless ICD in place)

x

Investigations

Outpatient assessment including or more of regular volume assessment, weight, blood pressure, activity level

x x

Appropriate baseline blood/urine tests, ECG, CXR x

Appropriate biochemical monitoring of renal function and electrolytes x

Assessment of LV function x x x x x

Measure digoxin levels if toxicity suspected x

Education and follow-up

HF patient education/discharge instructions x x x x x

Outpatient follow-up within 4 weeks

Advice on smoking cessation x x x


Although there are measures in Ontario related to the quality of care provided to CHF patients, very few

of the Expert Panel’s recommended practices can be captured in current Ontario hospital administrative

datasets, and beyond routine administrative data. For example, ED risk stratification is a critical clinical

assessment node in the care pathway model. It is important that all variables needed to derive the

EMHRG score are mandatory so that they can be documented as process indicators. In this way, the

EMHRG score can be derived in retrospect to see if/how patients are triaged according to these indicators.

Clinical registries similar to the Ontario Stroke Audit or the EFFECT database for CHF need to be

developed to routinely collect data and measure the quality of care provided to CHF patients.

Performance Indicators

The Expert Panel developed a list of quality indicators that can be used to measure whether patients

follow the CHF episode of care pathway developed in this clinical handbook. Indicators were selected to

reflect a few best-practice surrogates, which may provide a foundation for ensuring that hospitals are

adhering to some general evidence-based principles across the CHF care pathway. With the compressed

timelines for the selection of indicators, a scientifically validated methodology (such as a Delphi

approach) for identifying and prioritizing current measures and new measures for development was not

possible. However, using a similar process, the Expert Panel selected 11 indicators that are considered

developmental. These indicators can be recalibrated using detailed chart abstraction if they do not serve as

a surrogate for best-practice care.

The indicators selected are shown in Table 23, below.


Table 23: Proposed Performance Indicators

Clinical Assessment Node/Care Module

Area of Interest for Measurement

Indicator Concept

ED risk stratification and responsiveness to diuresis node

Identification and documentation of risk (this will be important to the decision-making process)

Was a risk-stratification method used to identify whether a CHF patient was high-intensity (risk) vs. average-intensity (risk) vs. low-intensity (ED observation and discharge)? Risk stratification should be based on the following parameters: oxygen saturation, serial troponin, renal function, responsiveness to ED diuresis, chest x-ray (alveolar pulmonary edema), etc.

Acute stabilization module Diuretic management and monitoring

Was the patient’s weight recorded daily?

High-intensity CHF patients: Are serum electrolytes

(sodium, potassium, renal function) being monitored daily for 3 days and then reassessed?

Low-intensity CHF patients: Are serum electrolytes

(sodium, potassium, renal function) being monitored every 1 to 2 days and then reassessed?

Discharge phase module

Evidence-based pharmacotherapy

Was the patient given ACE inhibitors or ARBs at discharge if EF < 40%? Yes/No; if no, why not?

Was the patient given β-blockers at discharge? Yes/No; if no, why not?

Counselling Was medication counseling provided? Yes/No; if no, why not?

Was end-of-life/advanced-care discussion at least once during hospitalization? Yes/No; if no, why not?

Predischarge functional capacity and mobility assessment

Walkability test (treadmill, 6MWT, walking on ward); did patient demonstrate that he/she can achieve ≥2 METs? Yes/no/not done; if no, physiotherapy assessment needed prior to discharge; if not done, state reason

Physician appointments Is the patient given a confirmed scheduled appointment date with outpatient general practitioner, specialist or attending physician within 2 weeks of discharge?

Is the patient referred to heart failure clinic? Yes/no; if no, state reason

Predischarge cognitive and social support assessment

Was CCAC/homecare assessment done?

Abbreviations: 6MWT, 6 minute walking test; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CCAC, Community Care Access Centre; CHF, congestive heart failure; ED, emergency department; EF, ejection fraction; MET, metabolic equivalent.


Implementation of Best Practices

After formulating the majority of their recommendations, the Expert Panel was asked by

the Ministry to provide high-level advice around implementation, including specific

recommendations focused on the following areas:

implementation of best practices

impact on multidisciplinary teams

system program and capacity planning required

change management and support for change required

Special Considerations for Cost Bundling

1. The current CIHI clinical administrative datasets informed the development of the CHF episode

of care pathway. To use the pathway for funding purposes, additional data must be collected

routinely. Cost datasets such as the Ontario Cost Distribution Methodology and OCCI have

utilization information that can be helpful in the costing of the care pathway model. Although

detailed microcosting and utilization data are available in hospitals’ OCCI data, the data

submitted by hospitals to the Ministry is aggregated. A detailed data collection and submission

plan must be developed to support the implementation of the CHF episode of care pathway model

for funding purposes.

2. The care pathway model does not specifically take into account case-mix complexity from

chronic conditions other than heart failure. Accordingly, we use the term case-mix-adjusted to

reflect that this care pathway should represent an individual of “average” case-mix complexity.

However, available evidence using Ontario data has demonstrated that length of stay within both

high-intensity and low-intensity units is highly variable and depends on case-mix complexity and

the number of coexisting chronic diseases. Cost bundling should continue to take into account the

case-mix complexity/resource intensity weight methodology in some manner.

3. The care pathways in urban vs. rural hospitals may vary significantly because of differences in

service availability and patient populations. CHF patients generally admitted to tertiary/teaching

facilities have greater cardiac illness severity. Most importantly, the prevalence or proportions of

patients expected to follow different pathway, investigative or treatment streams (i.e., in the

diagram represented as Pr = ), will vary according to hospital type. Cost bundling should reflect

such geographical and hospital-type differences.

4. Many quality-of-care variables will be expected to contribute minimally to costs (e.g.,

documenting daily weights), while other variables could have far-reaching cost implications to

the system as a whole (increasing access to home-care, follow-up physician services, cardiac

rehabilitation, etc.). Low-cost items could be included as “incentives” to the cost bundle, while

higher-cost items may necessitate a different cost bundle strategy, with greater cost-estimate

granularity and precision.

5. Counselling costs should be factored into the care bundle of all patients surviving to discharge.

6. It will not be possible to promote the movement of appropriate patients to ambulatory settings

and achieve the associated cost efficiencies without addressing out-of-hospital incentives for best

practices (examples of this include the development of specialized community-based heart failure

clinics in Ontario).


Specialized Community-Based Heart Failure Clinics in Ontario

The Expert Panel supports the implementation of specialized community-based heart failure clinics for

transitional care. Based on moderate to high quality evidence of improved patient and health system

outcomes through specialized community-based care (intermediate care), in 2012 OHTAC recommended

the following31:

Access to specialized community-based care (intermediate care) should be made available for

patients with chronic diseases and whose diseases are becoming uncontrollable despite primary

care.

Recognizing that primary care is the optimal way of treating and coordinating care of patients

with comorbidities, patients should be returned to primary care for further follow-up with a

revised treatment plan once they have been stabilized in intermediate care.

Recognizing the complexities of these recommendations, HQO should develop a high-level

implementation plan that would provide advice regarding the adoption of these recommendations.

In addition, Local Health Integration Networks should be approached to seek their interest in

implementing OHTAC intermediate care recommendations in collaboration with experts.

Evidence-based standards for multidisciplinary community-based care derived from EBAs,

economic analyses, and field evaluation studies, as appropriate, should be derived for each of the

chronic diseases.

Health Quality Ontario should consider developing quality performance indicators based on these

standards of care, tracking adherence to these standards and using this evidence base for

developing quality-based funding.

With respect to the CHF episode of care, OHTAC made the following recommendations relating to

standards of care for specialized multidisciplinary heart failure clinics. These standards were endorsed by

a CCN expert working group. The following is a summary from OHTAC Recommendation: Specialized

Community Based Care for Chronic Disease.32

Evidence-Based Components

1. Active medication titration to evidence-based target doses should be a key priority of heart failure

clinics.

2. Care should be consistent with evidence-based guidelines for the management of heart failure.

3. Health-care professionals should provide education, self-management training, and counselling to

patients and their informal caregivers. Special efforts should be made to encourage informal

caregivers to participate in patient management to ensure knowledge translation has been

successful whenever possible.

4. Mechanisms that enable appropriately frequent follow-up should be built into the model of heart

failure clinics.

31 http://www.hqontario.ca/portals/0/Documents/eds/ohtac-recommendation-specialized-care.pdf 32 http://www.hqontario.ca/portals/0/Documents/eds/ohtac-recommendation-specialized-care.pdf


Expert Opinion-Based Components

1. Mechanisms that enable rapid access (within 1–3 days) to specialized care should be built into the

model of heart failure clinics.

2. A structure of the roles and responsibilities, collaboration, and communication between heart

failure specialists, primary care providers, and hospital inpatient physicians should be developed

and implemented to facilitate efficient and effective seamless care.

3. Once the patients are stabilized, heart failure clinics need to demonstrate that patients are referred

back to primary care with a care management plan.

4. HQO will work with experts, CCN and heart failure clinics to develop and promulgate standards

to be followed by heart failure clinics and their referral base throughout the LHINs.

The Expert Panel recommends that CHF patients discharged from hospital be referred to a specialized

community-based heart failure clinic within 2 weeks of discharge. There was acknowledgement that more

heart failure clinics need to be established throughout the province to prevent delays follow-up.

Implementation of Best Practices

Provincial Versus Local Care Pathways

It should be recognized that the practices recommended in this clinical handbook have been defined at an

aspirational provincial level to guide all hospitals across the province. This is not intended to be an

operational care pathway: individual providers will have to implement these best practices based on their

own local circumstances and available capacities. In many cases, implementation of these

recommendations will be challenged by local arrangements or availability of services. For example, the

Expert Panel discussed variation across the province in the provision of ventilation: while some hospitals

provide noninvasive ventilation in a general medical ward, others only provide it in intensive care units.

Track Current Practice Against Recommended Practices

As discussed in Section 5, many of the practices recommended by the Expert Panel are not currently

tracked in any consistent way at either the local or provincial level. Thus, it is difficult to know what the

gap is between current and ideal CHF practice, and how much this gap varies across organizations and

parts of the province. A key objective of developing a CHF performance measurement strategy should be

to enable organizations to track, audit, and evaluate the implementation of care pathways and

recommended practices at the organizational level. Through such monitoring, variances can be identified,

progress monitored, and the pathway can be refined over time.


Role of Multidisciplinary Teams

One of the important issues in CHF care discussed by the Expert Panel is the lack of dedicated teams and

resources in Ontario for CHF. In stroke care, for example, the Ontario Stroke Strategy has led to the

widespread use of dedicated stroke units and interdisciplinary stroke teams. Such dedicated units and

teams are much less common for CHF. The Expert Panel discussed a promising area for further research

in evaluating the difference in outcomes between CHF patients cared for in nonspecialized teams and/or

units with those cared for by specialized CHF teams and/or units (e.g., cardiology). Further work is

required to define what constitutes a specialized team and to assess the feasibility of establishing these

teams in hospitals of different sizes across the province.

Service Capacity Planning

The Ministry was interested in advice from the Expert Panel about capacity planning and shifts across

care settings for CHF. The most important issue identified by the Expert Panel is inconsistent capacity in

and access to ICU beds and heart failure clinics once patients are discharged. This is a major opportunity

area for the Ministry, Local Health Integration Networks, hospitals, CCACs and other service providers to

work together to improve outcomes for CHF patients and to also impact rates of unplanned readmissions.

The Expert Panel supports the recommendation that the roles and responsibilities, collaboration, and

communication between heart failure specialists, primary care providers, and hospital inpatient physicians

should be developed and implemented to facilitate efficient, effective, seamless care.


Expert Panel Membership

Expert Panel for Health Quality Ontario: ‘Episode of Care’ for Congestive Heart Failure

Name Role Organization

Dr. David Alter

Senior Scientist Institute for Clinical Evaluative Sciences Research Program Director and Associate Staff, The Cardiac and Secondary Prevention Program at the Toronto Rehabilitation Institute-UHN

Associate Professor of Medicine, University of Toronto

Dr. Douglas Lee Scientist Institute for Clinical Evaluative Sciences

Dr. Catherine Demers Associate Professor Division of Cardiology, Department of Medicine McMaster University

Dr. Susanna Mak Cardiologist University of Toronto, Department of Medicine, Division of Cardiology, Mount Sinai Hospital

Dr. Lisa Mielniczuk Medical Director, Pulmonary Hypertension Clinic

University of Ottawa Heart Institute

Dr. Peter Liu President, International Society of Cardiomyopathy and Heart Failure of the World Heart Federation

Director, National C-CHANGE Program Scientific Director/VP Research, University of Ottawa Heart Institute

Professor of Medicine


Dr. Robert McKelvie

Professor of Medicine, Cardiologist

McMaster University, Hamilton Health Sciences

Dr. Malcolm Arnold

Professor of Medicine University of Western Ontario, London Health Sciences Centre

Dr. Stuart Smith

Chief of Cardiovascular Services

Director, Heart Failure Program

St. Mary’s General Hospital

Dr. Atilio Costa Vitali Assistant Professor of Medicine

Division of Clinical Science

Sudbury Regional Hospital

Dr. Jennifer Everson Physician Lead Hamilton Niagara Haldimand Brant Local Health Integration Network

Dr. Lee Donohue Family Physician Ottawa

Linda Belford Nurse Practitioner, Practice Leader PMCC

University Health Network


Jane MacIver Nurse Practitioner Heart Failure/Heart Transplant

University Health Network

Sharon Yamashita Clinical Coordinator, Critical Care

Sunnybrook Health Sciences Centre

Claudia Bucci Clinical Coordinator, Cardiovascular Diseases

Sunnybrook Health Sciences Centre

Andrea Rawn Evidence Based Care Program Coordinator

Grey Bruce Health Network

Darlene Wilson Registered Nurse Heart Function Clinic, Trillium Health Centre

Kari Kostiw Clinical Coordinator

Health Sciences North

Ramsey Lake Health Centre

Janet Parr CHF Patient

Heather Sherrard Vice President, Clinical Services


Sue Wojdylo Manager, Case Costing Lakeridge Health

Jane Chen Manager of Case Costing University Health Network

Nancy Hunter LHIN Liaison & Business Development

Cardiac Care Network of Ontario

Ministry Representatives

Gary Coleridge Senior Program Consultant Ministry of Health and Long-Term Care

Louie Luo Senior Methodologist Ministry of Health and Long-Term Care


Appendices

Appendix I: CHF Patient Group—ICD-10-CA Details

I50 Heart failure Includes:

Additional code from (E10-E14) with fourth and fifth digits .52 to classify any associated diabetes

mellitus

Additional code from (I11) (hypertensive heart disease) or (I13) (hypertensive heart and renal

disease) for heart failure due to hypertension

Excludes:

Complicating:

abortion or ectopic or molar pregnancy (O00-O07) (O08.8)

obstetric surgery and procedures (O75.4)

Following cardiac surgery or due to presence of cardiac prosthesis (I97.1)

Neonatal cardiac failure (P29.0)

I50.0 Congestive heart failure

Includes:

Congestive heart disease (CHF)

Right ventricular failure (secondary to left heart failure)

Excludes: fluid overload NOS (E87.7)

I50.1 Left ventricular failure

Includes:

Cardiac asthma

Left heart failure

I50.9 Heart failure, unspecified

Includes:

Cardiac, heart or myocardial failure NOS

I40 Acute myocarditis I40.0 Infective myocarditis

Includes:

Septic myocarditis

Additional code (B95-B97) to identify infectious agent

I40.1 Isolated myocarditis

I40.8 Other acute myocarditis

I40.9 Acute myocarditis, unspecified


I41 Myocarditis in diseases classified elsewhere I41.0 Myocarditis in bacterial diseases classified elsewhere

Includes:

Myocarditis:

diphtheritic (A36.8)

gonococcal (A54.8)

meningococcal (A39.5)

syphilitic (A52.0)

tuberculous (A18.8)

I41.1 Myocarditis in viral diseases classified elsewhere

Includes:

Influenzal myocarditis (acute):

avian influenza virus identified (J09)

other virus identified (J10.8)

virus not identified (J11.8)

Mumps myocarditis (B26.8)

I41.2 Myocarditis in other infectious and parasitic diseases classified elsewhere

Includes:

Myocarditis in:

Chagas’ disease:

(acute) (B57.0)

(chronic) (B57.2)

toxoplasmosis (B58.8)

I41.8 Myocarditis in other diseases classified elsewhere

Includes:

Rheumatoid myocarditis (M05.3)

Sarcoid myocarditis (D86.8)

I42 Cardiomyopathy Excludes:

Cardiomyopathy complicating:

pregnancy (O99.4)

puerperium (O90.3)

Ischemic cardiomyopathy (I25.5)

I42.0 Dilated cardiomyopathy

Includes: Congestive cardiomyopathy

I42.1 Obstructive hypertrophic cardiomyopathy

Includes: Hypertrophic subaortic stenosis

I42.2 Other hypertrophic cardiomyopathy

Includes: Nonobstructive hypertrophic cardiomyopathy


I42.3 Endomyocardial (eosinophilic) disease

Includes:

Endomyocardial (tropical) fibrosis

Löffler’s endocarditis

I42.4 Endocardial fibroelastosis

Includes: Congenital cardiomyopathy

I42.5 Other restrictive cardiomyopathy

Includes: Constrictive cardiomyopathy NOS

I42.6 Alcoholic cardiomyopathy

I42.7 Cardiomyopathy due to drugs and other external agents

Additional external cause code to identify cause

I42.8 Other cardiomyopathies

I42.9 Cardiomyopathy, unspecified

Includes:

Cardiomyopathy (primary) (secondary) NOS

Additional code from category (E10-E14) with fourth and fifth characters .52 to classify any

associated

diabetes mellitus

I43 Cardiomyopathy in diseases classified elsewhere I43.0 Cardiomyopathy in infectious and parasitic diseases classified elsewhere

Includes: Cardiomyopathy in diphtheria (A36.8)

I43.1 Cardiomyopathy in metabolic diseases

Includes: Cardiac amyloidosis (E85.-)

I43.2 Cardiomyopathy in nutritional diseases

Includes: Nutritional cardiomyopathy NOS (E63.9)

I43.8 Cardiomyopathy in other diseases classified elsewhere

Includes:

Gouty tophi of heart (M10.0)

Thyrotoxic heart disease (E05.9)



Hypertensive heart disease and CHF patients

These ICD-10-CA codes must include the CHF codes I50.X

I11 Hypertensive heart disease

Includes:

Hypertensive heart disease NOS

Use additional code to identify any (congestive) heart failure (I50.-) due to hypertension

I13 Hypertensive heart and renal disease

Includes:

Any condition in I11 with any condition in I12 disease:

cardiorenal

cardiovascular renal

hypertensive heart and renal disease NOS

Use additional code to identify any:

(chronic) kidney disease (failure) (N18.- , N19) due to hypertension

heart failure (I50.-) due to hypertension


Appendix II: Rapid Review Methodology

Table A1 outlines the process and components comprising the Evidence Development and Standards

Branch Rapid Review process.

Table A1: Rapid Review Methodology

Steps Components

1. Develop research question Develop PICOS in consultation with experts, end users, applicant, etc.

Limited scoping of question (e.g., Blue Cross Blue Shield, AETNA, CIGNA)

Determine study selection criteria (inclusion/exclusion)

Determine a maximum of 2 outcomes to GRADE in step 5

2. Conduct literature search 5 years

English

MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination

SRs, MAs, HTAs (establish in advance that these study designs exist for your topic; if not, request RCTs and guidelines as well)

3. Screen and select studies Selection of SR, MA, HTA

Rate SRs with AMSTAR

Retrieve primary studies from SR, MA, HTA for step 4

4. Conduct data extraction and analysisa Extract data on 2 outcomes from primary studies

5. Apply GRADE assessment outcomesa GRADE maximum of 2 outcomes

6. Write up findings Write findings using Rapid Review template

Abbreviations: AMSTAR, Assessing the Methodological Quality of Systematic Reviews; HTA, health technology assessment; MA, meta-analysis; PICOS, population, intervention, comparison, outcome, setting; SR, systematic review. aThese steps are required if the identified SR, MA, and/or HTA did not use GRADE to assess relevant outcomes.