Research Showing How to Improve Care for Heart Failure Rarely Reforms Services or Shapes Policy
Many patients suffering from chronic heart failure do not benefit from research demonstrating how to improve their care because the research rarely finds its way into routine clinical practice in the United States, according to a RAND Corporation study.
Among 16 U.S.-based research projects that outlined ways to improve the health of patients with heart failure, only two continued providing those innovative services to their own patients, even after demonstrating substantial improvements, according the study published in the March edition of the Journal of the American Geriatric Society.
“Research that shows us how to improve patients' lives, while reducing the cost of treating chronic heart failure, was abandoned without moving these good ideas into clinical practice,” said Dr. Joanne Lynn, a RAND Health researcher and the study's senior author. “This is a vivid example of how a strong body of research findings can just fail to have an impact on the health care that Americans can get.”
Even when the federal Medicare program initiated an effort to improve care for chronic heart failure, lawmakers directed the program to use methods that had not been tested through careful clinical trials, according to the study.
Chronic heart failure affects about 5 million people in the United States and is characterized by progressive weakening of the heart, which loses its ability to fully pump blood. There is no cure for the illness, although many treatments can slow its progression and reduce patients' suffering. About 550,000 people nationally are diagnosed with the disease each year.
Chronic heart failure mostly affects the elderly and is the most common reason that Medicare recipients are hospitalized, as well as being the diagnosis that generates the most costs for Medicare
A number of research projects have created and tested methods to improve care for patients with chronic heart failure. Those improvement efforts usually target patients after they are hospitalized and provide patient education, early medical response to worsening symptoms, and enhanced home monitoring.
Researchers conducted their study by searching medical journals published over the past four decades to find reports of intervention projects designed to improve care for patients with chronic heart failure.
The researchers identified 30 studies of high-quality projects that demonstrated improvement for patients, including 16 studies that had been conducted in the United States. The study surveyed authors of the medical reports to see what had happened to each project after the research funding ended.
Of the 15 U.S.-based projects that provided information, researchers found that 13 ended after demonstrating success, primarily because of financial constraints. Of the two that continued, only one expanded after its demonstration phase to include more patients.
Researchers found that about half of the improvement projects conducted in other countries became permanent, often being sponsored by government agencies.
The authors of the U.S.-based projects rated the quality of care for chronic heart failure in their community lower than did their peers from other nations, according to the study.
Today's report suggests that the improvement projects in the United States did not continue because Medicare's payment system generally does not reward health providers who find ways to keep patients out of the hospital.
“The fact that quality improvement programs for heart failure are not available for most Medicare beneficiaries can be traced to payment arrangements that penalize health providers who deliver largely unpaid services that reduce hospital care,” Lynn said. “Sometimes every provider loses money by providing optimal care. That is a situation that makes it pretty hard to develop and sustain improvement.”
In 2004, Medicare reform legislation directed federal officials to adopt a system to improve care for chronic heart failure.
But the strategies outlined in the legislation – primarily telephone-based management services to huge numbers of patients – have not been tested by clinical trials, according to the RAND study. All of the 30 studies examined by RAND enrolled patients in the researchers' own care systems, with precise diagnoses and careful consent, and the intervention was highly individualized. Because the very different methods in the Congressional demonstration have not been tested, no one can predict whether the measures will improve care and reduce spending, according to the study.
“What was striking was that the published reports of the many trials did not mention the fact that the project had already shut down, the authors did not call for reform in payment policy, the professional and consumer organizations involved did not champion the cause, and the debates over the Medicare legislation did not appear to take account of the differences between what had been studied and what was being proposed,” Lynn said.
“It is as if health services research, in this case at least, was utterly disconnected from implementation in practice and from the political process,” Lynn said. “We should probably revise the responsibilities of researchers and funders to begin to require an investment in implementation of good ideas, once proven.”
Other authors of the study are Hsien Seow of the Bloomberg School of Public Health of Johns Hopkins University, Dr. Christopher O. Phillips of the Cleveland Clinic, Dr. Michael W. Rich of Washington University, Dr. John A. Spertus of the Mid America Heart Institute and the University of Missouri-Kansas City, and Dr. Harlan M. Krumholz of Yale University.
The research paper is titled “Isolation of Health Services Research from Practice and Policy: The Example of Chronic Heart Failure Management.” Support for the project was provided by the RAND Corporation and the Agency for Healthcare Research and Quality.
RAND Health, a division of the RAND Corporation, is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care quality, costs and delivery, among other topics.
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