In the care of patients with heart failure, several interventions employed at or near discharge-both "current" (established) and "emerging" (more recently identified) therapies-have been positively associated with patient survival. These treatments, referred to as process-of-care measures, may be considered indications of appropriate care and may be useful in evaluating and improving heart failure care. Despite guidelines and research indicating the benefits of these interventions, standardizing care and improving outcomes in heart failure patients has proven to be complicated. Using data from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting, researchers examined the relationships between outpatient providers' adherence to seven heart failure process-of-care measures and clinical outcomes.

Medical records of 15,177 patients with heart failure (median age, 70 years; 71% men; median left ventricular ejection fraction, 25%) treated in 167 U.S. outpatient cardiology practices were reviewed at baseline and at 12 and 24 months. The 24-month mortality rate was 22.1%. The four current process-of-care measures (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, [beta]-blocker use, heart failure education, and anticoagulation for atrial fibrillation or flutter) are recommended in guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA). The three emerging measures were the use of cardiac resynchronization therapy, implantable cardioverter-defibrillators, and aldosterone antagonists.

All four ACC-AHA measures were independently associated with improved 24-month survival. The use of cardiac resynchronization therapy and implantable cardioverter-defibrillators were also independently associated with improved survival, although aldosterone antagonist use was not.

Two composite, or summary, analyses were also performed: a total composite measure, defined as the "percentage of the total indicated quality measures provided," and an all-or-none care measure, defined as the "proportion of patients who received each quality measure for which they were clinically eligible." Both were independently associated with improved survival. The all-or-none care scores also revealed that for each 10% improvement in composite care, the odds of death by 24 months was 13% lower.

The findings indicate that the therapies assessed in this study "are effective treatments that must be routinely incorporated into the plan of care," said a study coauthor, Nancy M. Albert, director of nursing research and innovation and clinical nurse specialist in the Kaufman Center for Heart Failure at the Cleveland Clinic, in an interview with AJN. Patient education is important, said Albert, but it's not enough. Nurses are key team members who can provide ongoing assessment of evidence-based therapy use in accordance with guideline recommendations, she said, adding that nurses should be actively engaged in monitoring the quality of care to minimize gaps in its delivery. When gaps appear, nurses can assist in determining the root causes and work with the team to develop processes that will minimize them. Improving conformity in the use of guideline-based care recommendations, said Albert, is "the best chance of improving clinical outcomes.-Karen Rosenberg

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