Basic provider education alone is not useful to facili tate implementation of practice guidelines (Level of

Evidence: A)

3. The use of performance measures based on practice guidelines may be useful to improve quality of care. (Level of Evidence: B)

4. Statements by and support of local opinion leaders can be helpful to facilitate implementation of practice guidelines.(Level of Evidence: A)

Class IIb

Multidisciplinary disease-management programs for patients at low risk for hospital admission or clinical deterioration may be considered to facilitate imple- mentation of practice guidelines. (Level of Evidence: B)

Class III

1. Dissemination of guidelines without more intensive behavioral change efforts is not useful to facilitate implementation of practice guidelines. (Level of Evidence: A)

2. Basic provider education alone is not useful to facili- tate implementation of practice guidelines. (Level of Evidence: A)

Despite the publication of evidence-based guidelines (147, 675), the current care of patients with HF remains subopti- mal. Numerous studies document underutilization of key processes of care, such as use of ACEIs in patients with decreased systolic function and the measurement of LVEF (513, 676, 677). The overall quality of inpatient care for HF as judged by both explicit and implicit standards is variable, with lower quality associated with higher readmission rates and mortality (491, 678, 679). Many HF admissions may be prevented with good outpatient care (680). The literature on

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care compared with patients in the control group. However, it is not clear which elements of disease-management pro- grams are crucial for success. In addition, it is not known whether such interventions are feasible in settings with lim- ited resources and personnel and among diverse patient pop- ulations.

8.3. Performance Measures

Performance measures are standards of care for a particular illness or condition that are designed to assess and subse- quently improve the quality of medical care. Performance measures are chosen on the basis of the knowledge or assumption that the particular item is linked to improved patient outcomes. In the field of HF, such measures might include documentation of the level of LV function, medica- tions used, or patient education measures. These measures can be used either internally within an organization or pub- licly to compare the performance of providers, hospitals, and healthcare organizations. In theory, performance measures could improve care by encouraging providers to compete on the basis of quality as opposed to cost, empowering con- sumers to make informed choices in the marketplace, pro- viding incentives to providers to concentrate on certain dis- eases or processes of care, and supplying information to aid with internal quality improvement. The evidence is mixed, but some studies indicate that performance measures can improve health outcomes (688).

The ACC and AHA are collaborating with a variety of organizations to develop and implement performance meas- ures. ACC/AHA practice guidelines are useful starting points for performance measures, but several considerations apply: 1) ACC/AHA practice guidelines are designed for improving the care of individual patients. Performance measures are generally used for improving the care of populations of patients. Although significant overlap exists in these goals, performance measures need to take into account additional factors, such as ease of data collection, simplicity of stan- dards, calculation of sufficient numbers of patients for whom the measure would apply, and provision of flexibility for clinically diverse situations. 2) In general, most performance measures should be chosen from Class I and Class III prac- tice guideline recommendations; however, given the addi- tional factors involved in improving the care of populations of patients, Class IIa recommendations may be suitable in selected situations. 3) Opportunities should be given for cli- nicians to describe why a particular performance measure may not be appropriate for an individual patient.

8.4. Roles of Generalist Physicians and

Cardiologists

Insufficient evidence exists to allow for recommendations about the most appropriate roles for generalist physicians and cardiologists in the care of patients with HF. Several studies indicate that primary care physicians as a group have less knowledge about HF and adhere to guidelines less close- ly than cardiologists (689-691). Some studies have noted bet- ter patient outcomes in patients cared for by cardiologists than in those cared for by generalist physicians (692, 693), whereas another study reported that cardiologists deliver more costly care that is accompanied by a trend toward improved survival (694). Despite these observations, pri- mary care physicians with knowledge and experience in HF should be able to care for most patients with uncomplicated HF. By contrast, patients who remain symptomatic despite basic medical therapy may benefit from care directed by con- sulting physicians who have special expertise and training in the care of patients with HF.

Do generalist physicians and cardiologists provide similar levels of care for the noncardiac comorbid conditions fre- quently present in patients with HF? What is the optimal time for referral to a specialist? What is the most effective system of comanagement of patients by generalists and cardiolo- gists? What is the most cost-effective entry point into a dis- ease-management program? Regardless of the ultimate answers to these questions, all physicians and other health- care providers must advocate and follow care practices that have been shown to improve patient outcomes. If a physician is not comfortable following a specific recommendation (e.g., the use of beta-blockers), then the physician should refer the patient to someone with expertise in HF. A collabo- rative model in which generalist and specialist physicians work together to optimize the care of patients with HF is likely to be most fruitful.

STAFF

American College of Cardiology

Christine W. McEntee, Chief Executive Officer Marie J. Temple, Specialist, Practice Guidelines

Joseph M. Allen, MA, Director, Clinical Decision Support

American Heart Association

M. Cass Wheeler, Chief Executive Officer

Rose Marie Robertson, MD, FACC, FAHA, Chief Science Officer

Kathryn A. Taubert, PhD, FAHA, Senior Science Advisor

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APPENDIX 1.ACC/AHA Committee to Revise the 2001 Guidelines for the Evaluation and Management of Chronic Heart Failure—Relationships With