EDITORIAL COMMENT
Stepping Outside of the HeartUsing Nontraditional Patient Characteristics to Understand and Improve Outcomes*
Lakshmi Venkitachalam, PhD and
John A. Spertus, MD, MPH*
Saint Luke's Mid America Heart Institute and the University of Missouri–Kansas City, Kansas City, Missouri
* Reprint requests and correspondence: Dr. John A. Spertus, Saint Luke's Mid America Heart Institute and the University of Missouri–Kansas City, 4401 Wornall Road, Kansas City, Missouri 64111 (Email: spertusj{at}umkc.edu).
Key Words: heart failure • aging • prognosis • mobility • dementia
Never before in the history of American health care has there been such momentum for quality improvement. A key impetus and road map for these efforts has been the Institute of Medicine's landmark report, "Crossing the Quality Chasm: A New Health System for the 21st Century" (1), that has challenged us to redesign our health care system to ensure safety, effectiveness, equity, timeliness, efficiency, and patient-centeredness. This emphasis, particularly on patient-centeredness, underscores patients as a unique constellation of risk factors and disease severity characteristics that warrant consideration when designing optimal therapeutic strategies. Then again, to date, most efforts at quantifying health care quality focus only upon individual diseases, with little attention to the recognition or treatment of other prognostically important conditions that can also influence patients' outcomes and the selection of the most appropriate treatment.
Heart failure (HF) is an increasingly prevalent condition that imposes a substantial burden on afflicted patients and the U.S. health care system (2,3). It is the most expensive diagnosis-related group and a leading cause of hospitalizations, especially in patients older than 65 years of age (4,5). The elderly represent an important challenge to the IOM goal of patient-centered care, because they often have multiple medical comorbidities (e.g., diabetes, stroke, ischemic heart disease), including several that are relatively unique to older patients (e.g., cognitive disorders, frailty), that affect prognosis. Additionally, this particular cohort of patients may have unique preferences regarding their therapeutic goals (quality of life vs. survival) (6,7) that can influence decision making and dictate treatment choices. Understanding the association of comorbidities in general, and age-associated impairments in specific, with HF outcomes may provide more refined estimates of patients' prognosis and can support the more rational application of traditional HF treatments while also identifying novel targets for intervention.
In this issue of the Journal, Chaudhry et al. (8) present a unique analysis highlighting the association of 2 geriatric conditions—impaired mobility and dementia—with 30-day and 5-year mortality following HF admission. In multivariable models that included traditional clinical factors, the presence of these comorbidities were among the strongest predictors of short- and long-term mortality. Of particular interest was the comparable risk estimates between these "geriatric" outcomes and more commonly appreciated clinical risk factors. Patients with mobility impairment or dementia were twice as likely to die at 30 days and 5 years, risks similar to those observed with elevated serum creatinine and low ejection fraction. In fact, the addition of these geriatric conditions to conventional risk factors in mortality models greatly improved risk classification of HF patients. Although, and as acknowledged by the investigators, the reported findings must be viewed in the context of certain limitations, these findings from the only nationally representative database of HF admissions available in the elderly carry immense significance.
First, this report offers a valuable insight into the prognostic importance of outcomes determinants that are particularly relevant to the elderly population, which is the age group most afflicted with HF. Population-based studies of older adults have long established the importance of functional status and its influence on health outcomes (9–12). The present report, from enhanced Medicare data, takes this important area of investigation to the next level by explicitly seeking and defining data elements that are not included in routine billing records but are needed to better prognosticate patients' outcomes. Whereas heart failure severity, serum sodium, creatinine, and ejection fraction clearly influenced patients' outcomes, factors not directly related to HF severity were equally, if not more, important in determining survival. These findings underscore the uniqueness of patients in that even those patients with similar degrees of heart failure might be expected to have markedly different survival rates based upon other potentially modifiable comorbid conditions. They also form the foundation for future research, which can test the influence of supportive treatment of mobility disorders as a means to improve mortality. If successful, optimal heart failure management may improve from not only considering the specific disease of interest, but also recognizing and addressing the constellation of comorbidities that affect each patient.
The second important insight from the work of Chaudhry et al. (8) is the marked lack of recognition of potentially modifiable conditions in routine hospital care, as exemplified by the observation that 1 in 3 patients lacked documentation about their mobility status. In this regard, it is important to note and appreciate the efforts taken by the investigators to enhance the Medicare administrative data with details from direct chart abstraction to maximize access to this information. To their credit, the investigators did not assume that "missing" mobility data was equivalent to no mobility problems and, in fact, found a poorer prognosis among those with missing mobility data as compared with those whose mobility was reported to be normal. Noting that patients' mobility status was not even recorded in patients' admission, progress, nursing, or discharge notes highlights how little attention is given to this important and common comorbidity and highlights a potential opportunity to elevate care.
Interestingly, this problem of failing to record important diagnoses is not unique to HF patients and emphasizes important missed opportunities to identify, and potentially intervene upon, high-risk patients (13). Given that most prognostic models from administrative data leverage only those elements that are recorded for billing purposes (14–16), this study highlights the value of enriching such datasets with prognostically important clinical data to support more accurate estimations of patients' outcomes, both for clinical care and quality assessment efforts. What is needed to better advance quality is the development of a minimal clinical dataset that is provided, along with billing codes, to capture a broader spectrum of clinical information. Models for such a dataset have been tested in the American Heart Association's Get With the Guidelines (17) and the American College of Cardiology's National Cardiovascular Data Registries (18). Developing the infrastructure to refine these data collection efforts and to link them with Medicare billing data is an important opportunity to advance the field.
A third insight from this study is its potential implication on health care policy. The reported prognostic influence of geriatric conditions is also likely to extend to other comorbid conditions (e.g., depression) (19), reflecting the heterogeneity of patients. Patients' health status can also be independently associated with, and carry similar if not greater, importance as the traditional clinical factors currently used in our risk-adjustment models (20,21). Moreover, mortality is not the only relevant outcome for which risk-adjustment models are needed to assess the quality of care. Quantifying outcomes such as readmission and health status are equally important to patients and society. To this end, the Centers for Medicare and Medicaid Services launched a road map for quality improvement that emphasizes measuring and reporting on quality. A recent manifestation of this effort, the Hospital Compare website (22) was undertaken to make publicly available hospital performance data based on selected outcomes, including 30-day mortality and readmission rates for acute myocardial infarction and HF in Medicare beneficiaries. Whereas these performance measures are critical for improving quality of care, this report by Chaudhry et al. (8) suggests that the current risk adjustment models might be improved by the inclusion of additional data elements, such as mobility disorders, other geriatric conditions, or patients' health status. This further underscores the potential value in creating a clinically rich minimal dataset to link with the administrative Medicare claims so that more accurate risk-adjusted outcomes estimates could be made and new insights from top-performing hospitals gleaned to serve as a foundation for dissemination of best practices and quality improvement.
Patients form the core of health care delivery and, as such, any movement aimed at quality improvement must be geared toward a patient-centered approach. The early 20th century witnessed a call to "view patient treatment from the concrete point of view of the care of the individual and not from the abstract point of view of the treatment of disease" (23). Since then, American medicine has witnessed a plethora of therapeutic modalities targeted specifically at disease processes, while consequently drifting away from a patient-centered, holistic approach. Chronic diseases in the elderly, especially HF, must be recognized as occurring within a complex construct of unique medical, behavioral, psychosocial, and economic factors that requires a holistic approach that should be individually tailored to meet each patient's needs and expectations. In this regard, the recent interest in evaluating and improving health care quality marks a critical time in medical history as it offers a crucial opportunity to restructure a fragmented system fraught with missed opportunities. As vanguards of this system, we, the researchers, clinicians and policy makers, are charged with the unique responsibility of identifying and advancing measures to improve patient-centeredness as the foundation for higher quality health care. Efforts such as those undertaken by Chaudhry et al. (8) are important steps in this process and serve as a reminder of the importance of putting patients, and not just their diseases, at the forefront of health care quality.
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Footnotes
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* Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. 
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References
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