The time of my life.

Abstract

That old adage ‘‘time flies’’ seemed so strange when I was younger, but now it seems like a way of life. It is hard to believe that my tenure as President of AAHFN has ended and that this is my last President’s Column. This final column will recap my Presidential Address, entitled ‘‘Raising the Bar of Heart Failure Care: It’s Our Duty and Responsibility,’’ as presented at the 4th Annual Meeting in Boston, MA on June 27, 2008. In 2001, the Institute of Medicine published ‘‘Crossing the Quality Chasm’’ and stressed the importance of quality health care for patients and populations within the United States. Quality was defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Using examples of the documented disconnect between what is known to be quality care and the actual norm in clinical practice, a number of attributes for improving quality were proposed, including patient-centered, safe, effective, efficient, equitable, and timely care. Since then, a vast number of quality initiatives have been implemented, including but not limited to, the Department of Health and Human Services National Quality Initiative (2001), the Joint Commission ORYX discharge criteria (2002), the Medicare Prescription Drug, Improvement, and Modernization Act (2003), the Centers for Medicare and Medicaid Services Deficit Reduction Act (2005), and the Tax Relief and Health Care Act (2006). Public reporting and financial incentives were implemented as tools to drive improvements in clinical quality, patient-centeredness, and efficiency. While these initiatives initially focused on the care provided to hospitalized patients, they have been expanded to outpatient care as well. Today, hospitals are ranked by the relative value of the care provided, and these rankings are expected to effect reimbursement as our government moves toward pay for performance. But have these quality initiatives closed the quality chasm? The answer is somewhat, depending on what parameter is evaluated and what metric is used to measure it. As an example, from Optimize-HF, having an established process for addressing the ORYX criteria and the ACC/AHA measures in heart failure results in performance improvement over time, as measured by improved adherence to the quality standards of care. However, research has demonstrated that not all of these measures translate into improved outcomes (reduced mortality and/ or hospitalization) posthospitalization. In fact, use of an ACE inhibitor or an angiotensin receptor blocker at the time of discharge was the only item associated with a reduction in these clinical outcomes 60 to 90 days postdischarge. The importance and efficacy of b-blockers in heart failure to halt and/or reverse disease progression is well known, and yet none of the current performance measures include b-blockers, particularly specific evidencebased agents, as a quality metric. Yet, also from OptimizeHF, prescription of a b-blocker at discharge was strongly associated with reduced morbidity and mortality. It seems as if there are a number of possible explanations for why the quality chasm continues, but 2 seem especially pertinent, in my mind. One revolves around the issue of education and knowledge. As we all know, not all education becomes knowledge. If that were true, there would be no need for spell check on computers. The application of information into practice remains clinically challenging, despite the availability of and accessibility to established tools, order sets, clinical pathways, etc. targeting enhanced adherence to performance measures. In reality, we are all creatures of habit and do many things rotely. While change is difficult, in health care it is necessary, and failure to practice contemporarily is unacceptable. The consequences are far greater and affect quality of life, longevity, and other important outcomes for patients, for families, and for society. We must continue to do our part in raising the bar for quality in heart failure—both for what the guidelines recommend and for what quality measures mandate. The other big issue focuses on awareness. To date, no celebrity has shared their diagnosis of heart failure with the public. This is very unlike other diseases or conditions in which celebrities heighten awareness through disclosure of personal information. Think of breast cancer, and many individuals come to mind: Melissa Etheridge, Edie Falco, Olivia Newton John. The list goes on and on. Think of heart failure, and many individuals come to mind, but only after they have died: George Carlin, Don Ho, Yolanda King. The impact factor is markedly reduced when awareness comes after death. It adds to the common misperception that heart failure is a terminal diagnosis. We must continue to spread the word about heart failure: the risks for developing it and how to reduce those risks, the early signs and symptoms of heart failure, treatment options using drugs, devices, or both, and that many individuals can and do lead a high-quality life for many years. Raising the bar in heart failure care requires acceptance that ‘‘we’ve always done it this way’’ attitudes are longer tolerable and that higher standards are necessary to achieve the objective of excellence and improved outcomes for our patients. Much hard work, stamina, and perseverance are required, as only those individuals and institutions with these traits will be successful. As nurses, our duty to public welfare is paramount, and we accept responsibility every day through our judgments and decisions made about the care given to patients. But this care is not just our own individual actions or inactions. Rather, it includes the judgments and decisions made by our physician colleagues and other members of the health