8 - Performance Measurement, Staffing, and Facilities Requirements for Observation Unit Heart Failure Management

Editors: Peacock, W. Frank

Title: Short Stay Management of Heart Failure, 1st Edition

Copyright ©2006 Lippincott Williams & Wilkins

> Table of Contents > 8 - Performance Measurement, Staffing, and Facilities Requirements for Observation Unit Heart Failure Management

8

Performance Measurement, Staffing, and Facilities Requirements for Observation Unit Heart Failure Management

Nancy M. Albert

When planning to open a heart failure (HF) management program in a chest pain center (also known as a short stay or observation unit), there are behind-the-scenes aspects to consider that promote optimal patient outcomes. Even though emergency care quality indicators are not specific to HF management, a substantive HF program should meet performance standards deemed important to inpatient and ambulatory HF care. Thus, the purpose of this chapter is to discuss performance measurement specific to HF care. Staffing and facilities requirements are discussed because they provide the structure and process aspects of a quality HF program that advances performance scores to improve patient quality of life, decrease morbidity, and reduce the quantity and length of hospitalization episodes.

Performance Management

No specific HF performance measures exist for a HF management program in a short stay unit setting. Performance measures were developed for hospitalized and ambulatory patients with HF by national organizations (Table 8-1) to improve the quality and consistency of care that hospitalized patients receive and to provide expectations of quality ambulatory care for programs that wish to be certified as a HF disease management program.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) developed the HF Core Measure Set in 2002 as one of four initial priority focus areas for hospital core measure development. Measuring the processes and outcomes of hospital care for patients with HF increases health care provider awareness that HF is a highly prevalent condition, uses more Medicare dollars for diagnosis and treatment than any other diagnosis, and is a common Medicare diagnosis-related group, reflecting

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frequent hospitalizations.1 The four standardized core measures set for hospitalized patients are discharge instructions, assessment of left ventricular function, use of an angiotensin-converting enzyme inhibitor (ACEI) in patients with left ventricular dysfunction, and smoking cessation advice and counseling. These measures provide a starting point for addressing key aspects of HF care.

TABLE 8-1 Performance Measures in Heart Failure

Measure
O = Outpatient
I = Inpatient
Source Description Rationale
Patient education—predischarge [I] or during an ambulatory visit [O] including drug doses and frequency [O] ACC/AHA; JCAHO Documentation that patients received written instructions or educational materials that includes content on activity level, diet, medication administration, follow-up appointment, weight monitoring, and understanding symptoms and what to do if they worsen Nonadherence to HF therapies and selfcare is often a cause of rehospitalization. Knowledge of HF prognosis and care expectations is a prerequisite to self-care and therapy adherence.22,23 An effective management strategy is close attention and follow-up of prescribed medications to proactively recognize potential interactions and minimize adverse effects.22
Assessment of left ventricular systolic function—I and O ACC/AHA; JCAHO Documentation that left ventricular function was previously assessed, assessed in hospital, or there are plans to assess postdischarge—I Other assessment methods, in combination (history, physical exam, chest x-ray, and ECG), are unreliable for distinguishing between left ventricular systolic dysfunction, preserved left ventricular function, or a noncardiac etiology.22
Use of ACEI or ARB in patients with left ventricular systolic dysfunction—I and O ACC/AHA—ACEI or ARB; JCAHO—ACEI Documentation of prescribing an ACEI or ARB in patients with systolic HF (prior to discharge—I) when there are no contraindications documented Multiple large, randomized studies of ACEIs in patients with systolic HF showed that it alleviated symptoms, improved clinical status, enhanced quality of life, and reduced the risk of death and hospitalization.22
Use of betablocker in patients with left ventricular systolic dysfunction—I and O OPTIMIZEHF researchers Documentation of prescribing a betablocker with known benefit in patients with systolic HF (prior to discharge—I) when there are no contraindications documented Multiple large, randomized studies of beta-blockade in patients with systolic HF showed that it alleviated symptoms, improved clinical status, enhanced quality of life, and reduced the risk of death and hospitalization.22
Smoking cessation counseling and advice—I and O ACC/AHA; JCAHO In adults with a history of smoking cigarettes (defined as smoking in the last 1 year prior to admission), documentation of smoking cessation counseling or advice (prior to discharge—I) Smoking has cardiotoxic effects.22 Many deaths in the United States are attributed to a smoking-related illness. Additionally, up to one half of patients with cardiovascular disease begin smoking again within 12 months of their diagnosis.24
Use of warfarin in patients with HF and atrial fibrillation —I and O ACC/AHA In patients with chronic or recurrent (persistent, permanent, or paroxysmal) atrial fibrillation, documentation of prescribing warfarin (prior to discharge —I) when there are no contraindications documented Stasis of blood in the fibrillating atria may predispose patients to systemic or pulmonary emboli. Prevention of thromboembolic events is an essential element of HF treatment.25
Initial laboratory tests—O ACC/AHA Initial laboratory evaluation to include urinalysis and serum testing for complete blood count, basic serum electrolytes (including serum creatinine), calcium, magnesium, blood lipids, glycohemoglobin, and thyroid stimulating hormone Hyper- and hypothyroidism can be a primary or contributing cause of HF. Other laboratory tests can reveal illnesses or disorders that exacerbate or cause HF.22
Weight measurement —O ACC/AHA; JCAHO Obtain a weight at each visit; assess for weight change, reflecting a change in volume status Provides clues about volume status that is essential in determining sodium status (excess or deficiencies) that may precipitate the need for diuretic therapy, self-care knowledge/adherence in low-sodium diet and fluid management (in volume overload) or changes in drug therapies (hypovolemia).22
Blood pressure measurement—O ACC/AHA; JCAHO Obtain a blood pressure at each visit Elevated systolic and diastolic blood pressure is a risk for development of HF,22 and high blood pressure in HF portends worse outcomes (due to worsened left ventricular remodeling).22
Assessment of clinical symptoms of (excess) volume overload—O ACC/AHA Assess for dyspnea, fatigue, and orthopnea at each visit Same rationale as weight monitoring.
Assessment of clinical signs of (excess) volume overload—O ACC/AHA Assess for peripheral edema, rales, hepatomegaly, ascites, S3 or S4 gallop, and elevated jugular venous pressure at each visit Same rationale as weight monitoring.
Assessment of activity level—O ACC/AHA Assess level of activity using a standardized scale or tool at every visit to evaluate the impact of HF on activity level (functional status) Questions about level of activity might provide greater insight into functional limitations than asking about symptoms experienced because many patients curtail activities when symptoms interfere.22
Assessment of return for emergency care or admission to the hospital—O JCAHOa 90-day return for emergency care or hospitalization for HF after the index emergency care discharge for HF Hospital discharges for HF rose 157% from 1979 to 2002.24 Risk of hospitalization, return emergency care visit, and death within 3 months of discharge from emergency care for HF was high: 61% of patients, in a single-center study.26
Screened for or given influenza vaccination—O JCAHOa The number of patients with HF who are screened for or given an influenza vaccination In patients with HF, influenza can lead to a complex HF decompensation and death. Influenza is a serious concern for patients with HF because there is a high risk for complications, hospitalization, and worse outcomes. A vaccination may prevent needless illness and hospitalization.5
Screened for or given pneumococcal vaccination—O JCAHOa The number of patients with HF who are screened for or given a pneumococcal vaccination Same rationale as influenza vaccine; high rate of death from a preventable bacterial disease. Pneumococcal infection can increase HF exacerbation, hospitalization, morbidity, and mortality.5
ACC, American College of Cardiology; ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; ECG, electrocardiography; HF, heart failure; JCAHO, Joint Commission on Accreditation of Healthcare Organizations.
aThese standardized HF measurements are exclusive to JCAHO as part of their disease-specific care certification. They have been posted for public comment (now closed to comments) but have not been finalized.

In addition to the four JCAHO core measures, researchers from the Organized Program to Initiate Lifesaving Treatment in Hospitalized patients with Heart Failure (OPTIMIZE-HF), a registry and performance improvement program for patients hospitalized with HF, found that discharge use

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of a beta-blocker was safe and well tolerated, improved treatment rates, and was associated with lower risk of mortality.2 Researchers concluded that the data were compelling enough to warrant adding discharge use of a beta-blocker as an HF performance measure.2

The American College of Cardiology (ACC) and American Heart Association (AHA) developed performance measures for chronic HF. In addition to the four JCAHO core predischarge hospital measurements, a fifth measure was applied: use of an anticoagulant in patients with atrial fibrillation. In these performance measures, use of an ACEI was expanded to include angiotensin receptor blockade as an equivalent drug class.3

Although the JCAHO and ACC/AHA HF core measures and OPTIMIZE-HF beta-blocker measure were developed for patients hospitalized with HF, they should be applied in a short stay HF management program. These six core measures are easy to assess and implement when facility planning includes the resources necessary for patient education, left ventricular function assessment, and ordering of core HF medications. Of note, in a study of JCAHO core measures applied at a two-campus university hospital health care system, availability of standardized order forms, computer discharge instructions, and education materials did not lead to improvement in core measures scores; however, a dedicated nurse practitioner implementing resources led to rapid and sustained improvements.4 Clearly, having a champion to develop, implement, and continually monitor the quality of care patients receive is an asset to HF management program success. In a short stay unit setting that does not use a dedicated advance practice nurse, nursing and physician personnel who make up the team must understand the importance of consistent application of core performance measures to achieve outcomes consistent with long-term goals of HF management: to cause reversal or prevent progression of left ventricular remodeling.

Performance measures have been developed for ambulatory HF management programs by ACC/AHA3 and JCAHO.5 Table 8.1 includes 15 performance measures, many of which are essential to both inpatient and outpatient HF care. There is not 100% agreement in stated performance measures by ACC/AHA and JCAHO; however, each measure is an essential element in improving specific clinical HF care. Because a short stay unit visit is uniquely different from an in-patient hospital stay or a chronic ambulatory visit, the 15 ACC/AHA and JCAHO performance measure profiles should be applied in a short stay HF management program but require some revision to fully apply. In Table 8-2, four measures from Table 8-1 were modified for use in a short stay HF management program. Rationale for the suggested changes is provided in Table 8-2.

Thus far, performance measures have been described with rationale for use. Placing words on paper is much easier than developing and implementing systems that promote reaching predetermined benchmarks for each performance standard. The next sections discuss staffing and facilities requirements that will help programs meet performance measures.

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TABLE 8-2 Modified Performance Measurements for a Short Stay HF Management Program

Measure Description Rationale for Modification
Assessment of left ventricular systolic function Documentation that left ventricular function was previously assessed or assessed during short-stay visit. If previous assessment reported diastolic dysfunction and was <1 year ago, repeat assessment during short stay visit. Chest x-ray and ECG are insufficient in determining specific cardiac abnormalities. The treatment plan, including medication and intervention therapies, is based on left ventricular function and ejection fraction percent.22 A change in clinical status due to previous therapies provides useful information about next steps in therapy.22
Use of ACEI or ARB in patients with left ventricular systolic dysfunction Same as Table 8-1; however, “use” includes ensuring the right dose and using with a diuretic agent if current status includes volume overload. A short stay visit provides an opportunity to titrate ACEI or ARB therapy based on clinical status, comorbid conditions, and current dose. Because of favorable effects on survival, treatment should not be delayed unless contraindications or adverse effects exist. Higher dosage is more likely to reduce hospitalizations but not symptoms or mortality. Goal: achieve prespecified doses used in large, clinical trials (target dosage).22
Use of beta-blocker in patients with left ventricular systolic dysfunction Same as Table 8-1; however, “use” includes ensuring the right drug, the right dose, and concurrent use of diuretic therapy if fluid overload (to maintain sodium and fluid balance and prevent exacerbation of fluid overload). A short stay visit provides an opportunity to ensure betablocker therapy is appropriate based on chronic HF guidelines. Beta-blockers do not have a class effect. Three agents (carvedilol, metoprolol succinate, and bisoprolol) are safe and effective for use in systolic HF in patients who are clinically stable.22 Initiate at low dose and uptitrate in gradual increments to prespecified target dose (based on dosages used in large clinical trials).22 Patients are more likely to remain on beta-blocker therapy after discharge when it is initiated prior to hospital discharge.227
Initial laboratory tests Same as Table 8-1 (initial evaluation) plus the following at each encounter: complete blood count, basic serum electrolytes (including serum creatinine), and BNP level. In patients with acute dyspnea treated in an emergency care department, rapid BNP measurement improved evaluation and treatment and reduced costs of treatment and length of time to discharge.28
Other measures from Table 8-1 Same as Table 8-1 Same as Table 8-1
ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; BNP, B-type natriuretic peptide; ECG, electrocardiography; HF, heart failure.

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Staffing

To determine staffing needs in a short stay unit HF management program, a review of the literature included studies of patients treated in an emergency care short stay unit, in a hospital, and in an outpatient setting. Very few groups prospectively studied the safety, cost, and outcomes of HF management in an emergency department short stay unit, and there were no randomized trials that compared outcomes of an emergency care–based short stay unit HF management program with a hospital admission.6,7 Of the published emergency care, hospital, and outpatient management studies, no information on staffing was reported in study designs except to describe caregiver type in programs as combination physician/nurse, advance practice nurse, multidisciplinary (i.e., home care nursing or pharmacist involvement), or physician led.

Because staffing was not a theme found in the literature, studies were reviewed of HF management by caregiver. There were many reports of differences in outcomes by physician caregiver type. Cardiologist participation improved guideline adherence,8 reduced the risk of composite death and cardiovascular hospitalization in outpatients8 and in newly hospitalized patients,9 increased use of diagnostic testing, and improved clinical outcomes in hospitalized patients.10 In a self-report study design between primary care physicians and cardiologists, cardiologists were more likely to conform to published guidelines for chronic HF than were internists and family practitioners,11 and when cardiologists were compared with HF specialty cardiologists, HF specialists were more likely to conform to chronic HF guidelines than cardiologists.12 In a survey of family physicians and cardiologists, family physicians had less understanding of

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chronic HF pathophysiology and how treatment differed according to underlying disease processes. Family physicians were more likely to overestimate the risk of ACEI and warfarin use, resulting in underprescribing of therapies.13 In a retrospective cohort study conducted with national databases, cardiology care and cardiology care mixed with general practitioner care was associated with improved survival compared with general practitioner care alone.14 In a qualitative study of HF in primary care, perceived obstacles to evidence-based diagnosis and management were lack of time and expertise.15 Physicians reported having difficulty with diagnosis (due to nonspecific symptoms) and not having confidence in initiating an ACEI. Moreover, many general practitioners were unaware of the impact of ACEIs on morbidity and mortality.15

The literature provides evidence that there is a gap between science and practice by physician caregiver type. There was no literature that compared HF care by emergency care physicians, general practitioners, cardiologists, or HF specialty cardiologists; however, emergency care physicians may be similar to general practitioners in that they must have a broad range of knowledge to care for a broad patient population. Their focus in training is more likely to be on emergent and acute situations rather than conditions that fall into the category of chronic care. Thus, emergency care physicians who oversee HF management programs in a short stay unit may require additional knowledge and training to provide HF care that is consistent with adherence to national HF guidelines.

No research literature was found on nurse staffing requirements for a short-stay HF management program. There were articles in the literature of “specialized” HF or cardiovascular nurses providing care that led to improved outcomes over usual care. However, in most cases, the setting was a HF disease management program led by HF specialty cardiologists. Advanced practice nurses (nurse practitioners or clinical nurse specialists) provided some aspects of care but did not provide independent care.16,17 In other reports, nurses worked collaboratively with physiotherapists, social workers, and case managers.18,19 Thus, encouragement and support must be provided to all caregivers involved in clinical management. Nurse caregivers, who are likely to be responsible for patient education, must be properly educated before they can teach others. In a study of nursing knowledge of HF patient education principles, nurses who regularly cared for patients with HF had a mean score of 75% correct on a survey of statements applicable to patient education principles. Scores were highest for HF specialty nurses and lowest for cardiology floor nurses.20 Therefore, emergency care nurses responsible for patient education may also require additional education.

Short stay unit nurses are responsible for patient assessment, drug delivery and monitoring, review of laboratory results, and discharge planning. To facilitate optimal collaboration with physician colleagues, nurses must understand HF pathophysiology, treatment strategies, and performance measures so they can augment and optimize care. Although there were no reports that compared nurse caregiver type, discussed using an advance

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practice nurse in the short-stay setting as a primary care provider, or assessed emergency care nurse caregiver knowledge of patient education principles, a few points can be made: (a) a team approach may meet the needs of patients with chronic HF better than an approach in which the emergency care physician is the sole short stay unit provider; (b) nurses with advanced degrees, skills, and training are capable of being a primary care provider in the management of chronically ill patients with HF once the diagnosis of decompensated HF has been made and the patient is deemed stable enough to allow for short stay care; and (c) emergency care nurses may require new (ongoing) knowledge to meet performance measures in HF pathophysiology, assessment, management, and patient education.

To facilitate the application of guidelines and performance measures, clinical leadership should be sought. This can be in the form of a cardiologist, HF specialty cardiologist, or advance practice nurse with HF specialty training. Changing and aligning the behavior of clinicians and managers will not be an easy task for the clinical leader. The ACC uses the Guidelines Applied in Practice (GAP) project and the AHA uses the Get with the Guidelines (GWTG) project to apply HF guidelines in practice. In both of these projects, effective clinical leadership is the key to achieving behavioral changes. Clinical leaders are center stage in motivating peers to achieve benchmarks for each performance measure and in influencing administration to provide resources that will facilitate goals.21 When a clinical leader has a professional association with a national organization that ensures the scientific integrity of the recommendations for care, provides incentives for delivering optimal care, and aids in developing a leadership role, pressure for quality improvement intensifies and the need to manage change that supports the application of guidelines will be paramount.21

Part of the role of the clinical leader will be to structure the environment so that health care providers automatically deliver care that matches guideline recommendations. This requires tools that simplify and provide focus of HF care expectations by embedding evidence-based care into the care itself. In a HF management program for a short stay unit, some examples are as follows: preprinted HF admission order set; preprinted HF discharge planning checklist; HF discharge sheet; HF medication therapies list that includes the right drugs in each class, dosage steps from initial to target dosing, side and adverse effects, contraindications, and associated electrolyte monitoring; patient education handouts/booklet or video; and performance improvement prospective data collection flowsheets for assessment and medication administration. As noted earlier, availability of tools is not enough; they must be used by all health care providers and supported by institutional management.4,21 Examples of tools are available in the ACC/AHA Clinical Performance Measures document3 and through the GAP and GWTG projects.

A multidisciplinary team can provide patient support at a cost. Other professional caregivers that may benefit a short-stay HF management program are a pharmacist, social worker, gerontologist, echocardiographer,

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case manager, and nutritionist. Personnel resources allow nurses and physicians more time to focus on immediate HF care needs while knowing that psychosocial, economic, cultural, and other needs are being met by skilled team members. It is unknown whether using skilled multidisciplinary team members to deliver HF management or deal with issues associated with HF management adherence in a short stay unit leads to improvement in quality HF care or clinical outcomes such as reduced rehospitalization, improved quality of life, or improved adherence to self-care behaviors.

Facilities Requirements

To achieve benchmark scores for the performance measures outlined in Table 8-1, facility requirements or enhancements may be needed, based on current operations and resources. Rationale for facility requirements is provided in Table 8-1.

Equipment for appropriate assessment is necessary for optimal investigation of diagnosis or HF cause, especially for echocardiography, B-type natriuretic peptide (BNP) laboratory testing, electrocardiography, and radiology. It is not necessary that the HF management program have exclusive use of equipment. Equipment can be shared by multiple departments or care providers can be sent to the short-stay area to perform services, as needed. Specialized equipment availability may not be needed around the clock because the patient is treated for a 23-hour period; however, delays in testing could lead to misdiagnosis, mismanagement, misappropriation of patient disposition, and increased cost of care. Table 8-3 lists ancillary facility resources that can benefit health care providers in care planning and implementation.

Materials that augment patient education and forms/algorithms that promote health care provider delivery of medical treatments should be developed, readily available for use, and consistently used by team members when patients meet criteria. Patient education materials (paper, video, and telehealth materials) can be costly when purchased from a vendor, and they may not be up-to-date with guideline recommendations. Developing patient education materials in-house requires attention to reading level; use of pictures, color, and formatting to make specific messages stand out; study of content for simplicity, accuracy, and thoroughness (including information on prognosis); and messages about who to contact for a variety of needs. In-house development can also be expensive, especially if the number of orders placed per shipment is low and/or health care providers or service availability is frequently altered.

Prespecified forms can augment documentation of routinely performed activities and remind providers of care expectations related to performance measures. When knowledgeable personnel use prespecified forms and algorithms to advance care and ensure care consistency, patients benefit by receiving optimal care and the system benefits by meeting or exceeding care expectations known to improve quality of care, morbidity, and

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mortality. Patient education and health care provider forms may require the services of a dedicated person or team to develop and revise content and maintain supplies. In addition, special computer software may be needed to create materials.

TABLE 8-3 Ancillary Facility Resources That May Be Considered

Resources Purpose
Impedance cardiography Hemodynamic assessment and monitoring during aggressive management
Electrocardiogram with S3 and S4 phonocardiogram features Assessment of S3 (diastolic volume overload) and S4 (systolic ventricular overload)
Written care algorithms developed for specific interventions or situations Promotes nurse-mediated care that can increase efficiency and throughput
Small videocassette or digital video player Patients learn more easily via demonstration. Some patient education videos use demonstration to teach education principles
Patient care cubicle/room signs Aids health care professionals to recognize patient limitations and/or care activities so that any encounter with a patient can be maximized (i.e., record intake and output, 2,000-mg sodium diet, fluid restriction of 2 L, weight before discharge)
Computer with web capabilities and printer to review and print heart failure data from a patient's internal hemodynamic monitor or implantable cardioverter defibrillator Patients can download data from an implantable pacemaker type device from their home, over normal telephone lines. Access to data provides objective evidence of current condition that can be used in determining diagnosis, treatment plan, and prognosis.

Facilities requirements must include systems that promote routine influenza and pneumococcal vaccination, documentation of assessment and treatments (signs and symptoms; laboratory testing; weight; functional status; medication classes, dosage, and side effects), documentation of patient education delivered, and documentation of delivered care compared with performance measure quality benchmarks. A quality monitor coordinator can devote time to chart review, data collection and entry of data into an electronic database, communication of outcomes, and replanning of services to enhance outcomes, as needed. There is no evidence that using a dedicated nurse or other professional person to promote evidence-based practice in a short-stay setting leads to enhanced performance or promotes patient health beyond what can be accomplished by training all nurses and

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other personnel working in the unit. Strengthening all personnel's level of understanding of HF principles is a first step in ensuring consistent communication, care delivery, and documentation of care delivery so that redundancies in care and billing can be eliminated. When a team approach is used, sharing of data, accountabilities, health care provider patterns, and finances can be shared and reviewed more critically.

Summary

There are many gaps in best practice in regard to implementing a short-stay HF management program. Performance expectations need to be adapted from in-patient and ambulatory measures and modified to match the setting. It will be important to conduct research on performance measures in a short-stay environment so that standards of care are tailored to this setting. Staffing requirements include a clinical HF leader who can champion the program not just during development but over time. Other staffing requirements consistent with best practice suggest that knowledgeable nurses can augment physician care and that both physicians and nurses require education in HF, at least initially. Facilities resources can not only improve throughput for patients but also optimize care services that improve health care provider assessment, diagnosis, and management capabilities. Availability of well-developed patient education materials can enhance patient knowledge and improve self-care after discharge. A well-developed HF management program will have given considerable attention to performance measures, staffing, and facilities resources before program implementation.

References

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2. Fonorow G, Abraham W, Albert N, et al. Should beta blocker use at the time of hospital discharge be included as a heart failure performance measure? A report from OPTIMIZE- HF. J Cardiac Fail 2005;11[Suppl]:S182.

3. American College of Cardiology/American Heart Association Task Force on Performance Measures. ACC/AHA clinical performance measures for adults with chronic heart failure. J Am Coll Cardiol 2005;46:1144–1178.

4. Ennis S, Moore S, Zichitella G, et al. Impact of a dedicated in-patient heart failure program on JCAHO core measures of heart failure care. J Cardiac Fail 2005;11[Suppl]:S183.

5. Joint Commission on Accreditation of Healthcare Organizations. Disease specific care. Request for public comment on disease-specific care standardized heart failure measure set. Available at http://jcaho.org/dscc/dsc/performance+measures/heart+failure+measure+ set.htm (accessed September 23, 2005).

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8. Ansari M, Alexander M, Tutar A, et al. Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting. J Am Coll Cardiol 2003;41:62–68.

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9. Jong P, Gong Y, Liu PP, et al. Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists. Circulation 2003;108:184–191.

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21. Eagle KA, Garson AJ, Beller GA, Sennett C. Closing the gap between science and practice: the need for professional leadership. Health Affairs 2003;22:196–201.

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