Congestive Heart Failure 130425 en

Quality-Based Procedures:
Clinical Handbook for

Congestive Heart Failure

Health Quality Ontario &
Ministry of Health and Long-Term Care

April 2013

Quality-Based Procedures: Clinical Handbook for Congestive Heart Failure 2
Table of Contents
Table of Contents ........................................................................................................................................ 2
List of Abbreviations .................................................................................................................................. 3
Preface .......................................................................................................................................................... 5
Key Principles ............................................................................................................................................................... 6
Purpose ........................................................................................................................................................ 8
Introduction to Quality-Based Procedures ............................................................................................... 9
What Are We Moving Towards? ................................................................................................................................. 10
How Will We Get There? ............................................................................................................................................ 11
What Are Quality-Based Procedures? ......................................................................................................................... 12
How Will Quality-Based Procedures Encourage Innovation in Health Care Delivery? .............................................. 15
Methods ...................................................................................................................................................... 16
Overview of the HQO Episode of Care Analysis Approach........................................................................................ 16
Defining the Scope of the Episode of Care .................................................................................................................. 19
Developing the Episode of Care Pathway Model ........................................................................................................ 20
Identifying Recommended Practices ........................................................................................................................... 21
Description of Congestive Heart Failure ................................................................................................ 25
Recommended CHF Cohort Definition and Patient Grouping Approach .......................................... 26
Initial CHF Cohort Inclusion/Exclusion Criteria ......................................................................................................... 26
Inclusion/Exclusion Criteria for QBP Funding Purposes ............................................................................................ 28
CHF In-Hospital Patient Journey ................................................................................................................................. 31
Factors Contributing to CHF Patient Complexity ....................................................................................................... 33
Recommended Practices for CHF ........................................................................................................... 35
Development of the Episode of Care Pathway ............................................................................................................ 35
CHF Episode of Care Pathway Model ......................................................................................................................... 39
Performance Measurement ...................................................................................................................... 57
Performance Indicators ................................................................................................................................................ 59
Implementation of Best Practices ............................................................................................................ 61
Special Considerations for Cost Bundling ................................................................................................................... 61
Implementation of Best Practices ................................................................................................................................ 63
Role of Multidisciplinary Teams ................................................................................................................................. 64
Service Capacity Planning ........................................................................................................................................... 64
Expert Panel Membership ....................................................................................................................... 65
Appendices ................................................................................................................................................. 67
Appendix I: CHF Patient GroupICD-10-CA Details ............................................................................................... 67
Appendix II: Rapid Review Methodology ................................................................................................................... 71

List of Abbreviations
ACC/AHA American College of Cardiology/American Heart Association
ACE Angiotensin-converting enzyme
ALC Alternate level of care
ARB Angiotensin receptor blocker
BIPAP Bilevel positive airway pressure
CACS Comprehensive Ambulatory Care Classification System
CCI Canadian Classification of Health Interventions
CCS Canadian Cardiovascular Society
CHF Congestive heart failure
CIHI Canadian Institute for Health Information
CMG Case Mix Group
COPD Chronic obstructive pulmonary disease
CPAP Continuous positive airway pressure
DAD Discharge Abstract Database
DRG Diagnosis-Related Group
ECFAA Excellent Care for All Act
ED Emergency department
EHMRG Emergency Heart Failure Mortality Risk Grade
ESC European Society of Cardiology
Expert Panel Episode of Care for Congestive Heart Failure Expert Advisory Panel
HBAM Health-Based Allocation Model
HFSA Heart Failure Society of America
HIG HBAM Inpatient Grouper
HQO Health Quality Ontario
HSFR Health System Funding Reform
HSIMI Health System Information Management and Investment
ICD-10-CA International Classification of Diseases, 10th Revision (Canadian Edition)
ICES Institute for Clinical Evaluative Sciences
IDEAS Improving the Delivery of Excellence Across Sectors
IV Intravenous
LACE Length of stay, acuity of admission, comorbidity of patient, emergency department use
LHIN Local Health Integration Network
LTC Long-term care

MCC Major Clinical Category
Ministry Ministry of Health and Long-Term Care
MLPA Ministry-LHIN Performance Agreement
NACRS National Ambulatory Care Referral System
NICE National Institute for Health and Clinical Excellence
OCCI Ontario Case Costing Initiative
OHTAC Ontario Health Technology Advisory Committee
PBF Patient-Based Funding
QBP Quality-Based Procedures
QIP Quality Improvement Plan
STEMI ST segment elevation myocardial infarction
THETA Toronto Health Economics and Technology Assessment

Preface
The content in this document has been developed through collaborative efforts between the Ministry of
Health and Long-Term Care (Ministry), Health Quality Ontario (HQO), and the HQO Episode of Care
for Congestive Heart Failure (CHF) Expert Advisory Panel (Expert Panel).

The template for the Quality-Based Procedures Clinical Handbook and all content in Section 1
(Purpose) and Section 2 (Introduction) were provided in standard form by the Ministry. All other
content was developed by HQO with input from the Expert Panel.

To consider the content of this document in the appropriate context, it is imperative to take note of the
specific deliverables that the Ministry tasked HQO with developing for this Clinical Handbook. The
following is an excerpt from the HQOMinistry Accountability Agreement for fiscal year 2012/13:

To guide HQOs support to the funding reform, HQO will:

1. Conduct analyses/consultation in the following priority areas in support of funding strategy
implementation for the 2013/14 fiscal year:
a) Chronic Obstructive Pulmonary Disease,
b) Congestive Heart Failure, and
c) Stroke.

2. Include in their analyses/consultation noted in clause 21, consultations with clinicians and
scientists who have knowledge and expertise in the identified priority areas, either by
convening a reference group or engaging an existing resource of clinicians/scientists.

3. Work with the reference group to:
a) Define the population/patient cohorts for analysis,
b) Define the appropriate episode of care for analysis in each cohort, and
c) Seek consensus on a set of evidence-based clinical pathways and standards of care for
each episode of care.

4. Submit to the Ministry their draft report as a result of the consultations/analysis outlined in
clause 22 above on October 31
st
and its final report on November 30
th
, and include in this a
summary of its clinical engagement process.

Following sign-off on the Accountability Agreement, the Ministry subsequently asked HQO to also
develop the following additional content for each of the 3 assigned clinical areas:

a) Guidance on the development of performance indicators, aligned with the recommended episodes
of care to inform the Ministrys Quality-Based Procedure (QBP) Integrated Scorecard.

b) Guidance on the real-world implementation of recommended practices contained in the Clinical
Handbook, with a focus on implications for multi-disciplinary teams, service capacity planning
considerations and new data collection requirements.

Key Principles
At the start of this project, discussions between HQO, the 3 Episode of Care Expert Advisory Panels and
the Ministry established a set of key principles or ground rules to guide this evolving work:

HQOs work will not involve costing or pricing. All costing and pricing work related to the QBP
funding methodology will be completed by the Ministry using a standardized approach, informed
by the content produced by HQO. This principle also extended to the deliberations of the Expert
Panels, where discussions were steered away from considering the dollar cost of particular
interventions or models of care and instead focused on quality considerations and non-cost
measures of utilization, such as length of stay.
The scope of this phase of work will focus on hospital care. Given that the Ministrys QBP
efforts for 2013/14 focus largely on hospital payment, HQO was asked to adopt a similar focus
with its work on episodes of care. Notwithstanding, all 3 Expert Panels emphasized the importance
of extending this analysis beyond hospital care alone to also examine post-acute and community
care. CHF is a chronic disease that spans all parts of the continuum of care, with hospitalization
being only one piece of this continuum; future efforts will also need to address community-based
care to have full impact on all parts of the health system.
Recognizing the importance of this issue, the Ministry has communicated that, following the initial
phase of deliverables, work will continue in all 3 clinical areas to extend the episodes of care to
include community-based services.
Recommended practices, supporting evidence, and policy applications will be reviewed and
updated at least every 2 years. The limited 4-month timeframe provided for the completion of
this work meant that many of the recommended practices in this document could not be assessed
with the full rigour and depth of HQOs established evidence-based analysis process. Recognizing
this limitation, HQO reserves the right to revisit the recommended practices and supporting
evidence at a later date by conducting a full evidence-based analysis or to update this document
with relevant new published research. In cases where the episode of care models are updated, any
policy applications informed by the models should also be similarly updated.
Consistent with this principle, the Ministry has stated that the QBP models will be reviewed at least
every 2 years.
Recommended practices should reflect the best patient care possible, regardless of cost or
barriers to access. HQO and the Expert Panels were instructed to focus on defining best practice
for an ideal episode of care, regardless of cost implications or potential barriers to access. Hence,
the resulting cost implications of the recommended episodes of care are not known. However, all 3
Expert Panels have discussed a number of barriers that will challenge implementation of their
recommendations across the province. These include gaps in measurement capabilities for tracking
many of the recommended practices, shortages in health human resources and limitations in
community-based care capacity across many parts of the province.
Some of these barriers and challenges are briefly addressed in the section Implementation of Best
Practices. However, the Expert Panels noted that, with the limited time they were provided to
address these issues, the considerations outlined here should only be viewed as an initial starting
point towards a comprehensive analysis of these challenges.
Finally: HQO and the CHF Episode of Care Expert Panel recognize that given the limitations of their
mandate, much of the ultimate impact of this content will depend on subsequent work by the Ministry to
incorporate the analysis and advice contained in this document into the Quality-Based Procedures policy

framework and funding methodology. This will be complex work, and it will be imperative to ensure that
any new funding mechanisms deployed are well-aligned with the recommendations of the Expert Panel.

Nevertheless, the Expert Panel believes that, regardless of the outcome of efforts to translate this content
into hospital funding methodology, the recommended practices in this document can also provide the
basis for setting broader provincial standards of care for CHF. These standards could be linked not only to
funding mechanisms, but to other health system change levers such as guidelines and care pathways,
performance measurement and reporting, program planning and quality improvement activities.

Purpose
Provided by the Ministry of Health and Long-Term Care

This Clinical Handbook has been created to serve as a compendium of the evidence-based rationale and
clinical consensus driving the development of the policy framework and implementation approach for
CHF patients seen in hospitals.

This handbook is intended for a clinical audience. It is not, however, intended to be used as a clinical
reference guide by clinicians and will not be replacing existing guidelines and funding applied to
clinicians. Evidence-informed pathways and resources have been included in this handbook for your
convenience.

Introduction to Quality-Based Procedures
Provided by the Ministry of Health and Long-Term Care

Quality-Based Procedures (QBPs) are an integral part of Ontarios Health System Funding Reform
(HSFR) and a key component of Patient-Based Funding (PBF). This reform plays a key role in advancing
the governments quality agenda and its Action Plan for Health Care. HSFR has been identified as an
important mechanism to strengthen the link between the delivery of high quality care and fiscal
sustainability.

Ontarios health care system has been living under global economic uncertainty for a considerable time.
Simultaneously, the pace of growth in health care spending has been on a collision course with the
provincial governments deficit recovery plan.

In response to these fiscal challenges and to strengthen the commitment towards the delivery of high
quality care, the Excellent Care for All Act (ECFAA) received royal assent in June 2010. ECFAA is a
key component of a broad strategy that improves the quality and value of the patient experience by
providing them with the right evidence-informed health care at the right time and in the right place.
ECFAA positions Ontario to implement reforms and develop the levers needed to mobilize the delivery of
high quality, patient-centred care.

Ontarios Action Plan for Health Careadvances the principles of ECFAA, reflecting quality as the
primary driver to system solutions, value, and sustainability.

What Are We Moving Towards?
Prior to the introduction of HSFR, a significant proportion of hospital funding was allocated through a
global funding approach, with specific funding for some select provincial programs and wait times
services. However, a global funding approach reduces incentives for health service providers to adopt best
practices that result in better patient outcomes in a cost-effective manner.

To support the paradigm shift from a culture of cost containment to that of quality improvement, the
Ontario government is committed to moving towards a patient-centred, evidence-informed funding model
that reflects local population needs and contributes to optimal patient outcomes (Figure 1).

PBF models have been implemented internationally since 1983. Ontario is one of the last leading
jurisdictions to move down this path. This puts the province in a unique position to learn from
international best practices and the lessons others learned during implementation, thus creating a funding
model that is best suited for Ontario.

PBF supports system capacity planning and quality improvement through directly linking funding to
patient outcomes. PBF provides an incentive to health care providers to become more efficient and
effective in their patient management by accepting and adopting best practices that ensure Ontarians get
the right care at the right time and in the right place.

Figure 1: Current and Future States of Health System Funding

Current State Current State
How do we get there?
Based on a lump sum, outdated
historical funding
Fragmented system planning
Funding not linked to outcomes
Does not recognize efficiency,
standardization and adoption of best
practices
Maintains sector specific silos
Transparent, evidence-based to better
reflect population needs
Supports system service capacity
planning
Supports quality improvement
Encourages provider adoption of best
practice through linking funding to
activity and patient outcomes
Ontarians will get the right care, at the
right place and at the right time
Strong Clinical
Engagement
Current Agency
Infrastructure
Knowledge to Action
Toolkits
Meaningful
Performance
Evaluation Feedback
System Capacity
Building for Change
and Improvement
Future State Future State

How Will We Get There?
The Ministry of Health and Long-Term Care has adopted a 3-year implementation strategy to phase in a
PBF model and will make modest funding shifts starting in fiscal year 2012/13. A 3-year outlook has
been provided to support planning for upcoming funding policy changes.

The Ministry has released a set of tools and guiding documents to further support the field in adopting the
funding model changes. For example, a QBP interim list has been published for stakeholder consultation
and to promote transparency and sector readiness. The list is intended to encourage providers across the
continuum to analyze their service provision and infrastructure in order to improve clinical processes and,
where necessary, build local capacity.

The successful transition from the current, provider-centred funding model towards a patient-centred
model will be catalyzed by a number of key enablers and field supports. These enablers translate to actual
principles that guide the development of the funding reform implementation strategy related to QBPs.
These principles further translate into operational goals and tactical implementation (Figure 2).

Figure 2: Principles Guiding Implementation of Quality-Based Procedures
Abbreviations: HSFR, Health System Funding Reform; HSIMI, Health System Information Management and Investment: IDEAS, Improving the Delivery
of Excellence Across Sectors; LHIN, Local Health Integration Network; QBP. Quality-Based Procedures.

Principles for developing QBP
implementation strategy
Principles for developing QBP
implementation strategy
Sector Engagement
Clinical expert panels
Provincial Programs Quality Collaborative
Overall HSFR Governance structure in
place that includes key stakeholders
LHIN/CEO Meetings
Operationalization of principles to
tactical implementation (examples)
Operationalization of principles to
tactical implementation (examples)
Balanced Evaluation
Integrated Quality Based Procedures
Scorecard
Alignment with Quality Improvement Plans
Cross-Sectoral Pathways
Evidence-Based
Development of best practice patient
clinical pathways through clinical expert
advisors and evidence-based analyses
Transparency
Publish practice standards and evidence
underlying prices for QBPs
Routine communication and consultation
with the field
Knowledge Transfer
Applied Learning Strategy/ IDEAS
Tools and guidance documents
HSFR Helpline; HSIMI website (repository
of HSFR resources)

What Are Quality-Based Procedures?
QBPs involve clusters of patients with clinically related diagnoses or treatments. CHF was chosen as a
QBP using an evidence- and quality-based selection framework that identifies opportunities for process
improvements, clinical redesign, improved patient outcomes, enhanced patient experience, and potential
cost savings.

The evidence-based framework used data from the Discharge Abstract Database (DAD) adapted by the
Ministry of Health and Long-Term Care for its Health-Based Allocation Model (HBAM) repository. The
HBAM Inpatient Grouper (HIG) groups inpatients based on their diagnosis or their treatment for the
majority of their inpatient stay. Day surgery cases are grouped in the National Ambulatory Care Referral
System (NACRS) by the principal procedure they received. Additional data were used from the Ontario
Case Costing Initiative (OCCI). Evidence in publications from Canada and other jurisdictions and World
Health Organization reports was also used to assist with the patient clusters and the assessment of
potential opportunities.

The evidence-based framework assessed patients using 4 perspectives, as presented in Figure 3. This
evidence-based framework has identified QBPs that have the potential to both improve quality outcomes
and reduce costs.

Figure 3: Evidence-Based Framework

Does the clinical group contribute to a significant proportion of total costs?
Is there significant variation across providers in unit costs/ volumes/ efficiency?
Is there potential for cost savings or efficiency improvement through more consistent
practice?
How do we pursue quality and improve efficiency?
Is there potential areas for integration across the care continuum?
Is there a clinical evidence base for an established standard of care and/or
care pathway? How strong is the evidence?
Is costing and utilization information available to inform development of
reference costs and pricing?
What activities have the potential for bundled payments and integrated care?
Are there clinical leaders able to champion change in this
area?
Is there data and reporting infrastructure in place?
Can we leverage other initiatives or reforms related to
practice change (e.g. Wait Time, Provincial Programs)?
Is there variation in clinical outcomes across providers,
regions and populations?
Is there a high degree of observed practice variation across
providers or regions in clinical areas where a best practice or
standard exists, suggesting such variation is inappropriate?

Practice Variation
The DAD stores every Canadian patient discharge, coded and abstracted, for the past 50 years. This
information is used to identify patient transition through the acute care sector, including discharge
locations, expected lengths of stay and readmissions for each and every patient, based on their diagnosis
and treatment, age, gender, comorbidities and complexities, and other condition-specific data. A
demonstrated large practice or outcome variance may represent a significant opportunity to improve
patient outcomes by reducing this practice variation and focusing on evidence-informed practice. A large
number of Beyond Expected Days for length of stay and a large standard deviation for length of stay
and costs are flags to such variation. Ontario has detailed case-costing data for all patients discharged
from a case-costing hospital from as far back as 1991, as well as daily utilization and cost data by
department, by day, and by admission.

Availability of Evidence
A significant amount of Canadian and international research has been undertaken to develop and guide
clinical practice. Using these recommendations and working with the clinical experts, best practice
guidelines and clinical pathways can be developed for these QBPs, and appropriate evidence-informed
indicators can be established to measure performance.

Feasibility/Infrastructure for Change
Clinical leaders play an integral role in this process. Their knowledge of the patients and the care
provided or required represents an invaluable component of assessing where improvements can and
should be made. Many groups of clinicians have already provided evidence for rationale-for-care
pathways and evidence-informed practice.

Cost Impact
The selected QBP should have no fewer than 1,000 cases per year in Ontario and represent at least 1% of
the provincial direct cost budget. While cases that fall below these thresholds may, in fact, represent
improvement opportunity, the resource requirements to implement a QBP may inhibit the effectiveness
for such a small patient cluster, even if there are some cost efficiencies to be found. Clinicians may still
work on implementing best practices for these patient subgroups, especially if they align with the change
in similar groups. However, at this time, there will be no funding implications. The introduction of
evidence into agreed-upon practice for a set of patient clusters that demonstrate opportunity as identified
by the framework can directly link quality with funding.


Figure 4: Quality-Based Procedures Evidence-Based Framework for CHF
Abbreviations: ALC, alternate level of care; CHF, congestive heart failure; CMG, Case Mix Group; ICES, Institute for Clinical Evaluative Sciences;
LACE, length of stay, acuity of admission, comorbidity of patient, emergency department use; LHIN, Local Health Integration Network; LTC, long-term
care; MLPA, Ministry-LHIN Performance Agreement; QIP, Quality Improvement Plan; THETA, Toronto Health Economics and Technology
Assessment.
Source: Ministry of Health and Long-Term Care

Cost Impact
19,396 annual acute inpatient hospitalizations for CHF
Total acute inpatient cost: $166.985M, extensive post-
acute care costs in rehabilitation, home care and LTC
4
th
highest costing CMG by total cost
26,829 ALC days, costing ~$17M
Highest readmissions within 30 days at 21%
representing for a total acute inpatient cost of $37.87M
Feasibility /Capacity for Change
Baker Report singled out CHF as key condition to focus on
Indicators for CHF readmissions currently in MLPA and QIPs
Tools such as LACE screening index currently being tested
Key focus area for Avoidable Hospitalizations Living Labs
Communities; clinical expert table will be established to secure
agreement on care pathway and quality markers
Coordinated table to discuss options related to payment
approaches (e.g. bundled payments across acute and post acute
physician services) to follow development of quality standards
THETA recently completed a report on Heart Failure Clinics
Availability of Evidence
Evidence demonstrating significant reduction in CHF
readmissions is possible through implementation of
interventions that include:
use of heart failure clinics,
outpatient follow up,
care coordination post discharge,
telehealth interventions
Transitional Care intervention for CHF used advanced
practice nurses to achieve 34 per cent reductions in
readmission and 39 per cent reduction in mean total cost
University of Ottawa Heart Institutes Telehealth program
reduced 30-day readmissions by 54 percent with savings
up to $20,000 per patient
Practice Variation
Hospitalization rates vary from 39.43 to 96.68 per 100,000
residents across LHINs
Readmission rates vary from 18%to 25% across LHINs
Large variations in ALC rates for CHF patients across LHINs and
hospitals
Inconsistent use of heart failure clinics and cardiac rehab across
the province
Inconsistent access to cardiologists across province
Upcoming discussions with ICES scientific experts to take place
to identify clinical variation in outcomes for CHF patients

How Will Quality-Based Procedures Encourage Innovation
in Health Care Delivery?
Implementing evidence-informed pricing for the targeted QBPs will encourage health care providers to
adopt best practices in their care delivery models and maximize their efficiency and effectiveness.
Moreover, best practices that are defined by clinical consensus will be used to understand required
resource utilization for the QBPs and further assist in developing evidence-informed pricing.
Implementation of a price x volume strategy for targeted clinical areas will motivate providers to:
adopt best practice standards
re-engineer their clinical processes to improve patient outcomes
develop innovative care delivery models to enhance the experience of patients
Clinical process improvement may include better discharge planning, eliminating duplicate or
unnecessary investigations, and paying greater attention to the prevention of adverse events, that is,
postoperative complications. These practice changes, together with adoption of evidence-informed
practices, will improve the overall patient experience and clinical outcomes and help create a sustainable
model for health care delivery.

Methods
Overview of the HQO Episode of Care Analysis Approach
In order to produce this work, Health Quality Ontario (HQO) has developed a novel methodology known
as an episode of care analysis that draws conceptually and methodologically from several of HQOs core
areas of expertise:

Health technology assessment: Recommended practices incorporate components of HQOs
evidence-based analysis methodology and draw from the recommendations of the Ontario Health
Technology Advisory Committee (OHTAC).
Case mix grouping and funding methodology: Cohort and patient group definitions use clinical
input to adapt and refine case mix methodologies from the Canadian Institute for Health Information
(CIHI) and the Ontario Health-Based Allocation Model (HBAM).
Clinical practice guidelines and pathways: Recommended practices synthesize guidance from
credible national and international guideline bodies, with attention to the strength of evidence
supporting each piece of guidance.
Analysis of empirical data: Expert Advisory Panel recommendations were supposed by descriptive
and multivariate analysis of Ontario administrative data (e.g., Discharge Abstract Database [DAD]
and National Ambulatory Care Reporting System [NACRS]) and data from disease-based clinical
data sets (e.g., the Ontario Stroke Audit [OSA] and Enhanced Feedback For Effective Cardiac
Treatment [EFFECT] databases).
Clinical engagement: All aspects of this work were guided and informed by leading clinicians,
scientists and administrators with a wealth of knowledge and expertise in the clinical area of focus.

The development of the episode of care analysis involves the following key steps:
1. Defining cohorts and patient groups
2. Defining the scope of the episode of care
3. Developing the episode of care model
4. Identifying recommended practices, including the Rapid Review process

The following sections describe each of these steps in further detail.

Defining Cohorts, Patient Groups, and Complexity Factors
At the outset of this project, the Ministry of Health and Long-Term Care provided HQO with a broad
description of each assigned clinical population (e.g., CHF), and asked HQO to work with the Expert
Panels to define inclusion and exclusion criteria for the cohort they would examine using data elements
from routinely reported provincial administrative databases. It was also understood that each of these
populations might encompass multiple distinct subpopulations (referred to as patient groups) with
significantly different clinical characteristics. For example, the CHF population includes subpopulations
with heart failure, myocarditis and cardiomyopathies. These patient groups each have very different levels
of severity, different treatment pathways, and different distributions of expected resource utilization.
Consequently, these groups may need to be reimbursed differently from a funding policy perspective.

Conceptually, the process employed here for defining cohorts and patient groups shares many similarities
with methods used around the world for the development of case mix methodologies, such as Diagnosis-
Related Groups (DRGs) or the Canadian Institute for Health Informations (CIHI) Case Mix Groups.
Case mix methodologies have been used since the late 1970s to classify patients into groups that are
similar in terms of both clinical characteristics and resource utilization for the purposes of payment,
budgeting and performance measurement.
1
Typically, these groups are developed using statistical
methods such as classification and regression tree analysis to cluster patients with similar costs based on
common diagnoses, procedures, age, and other variables. After the initial patient groups have been
established based on statistical criteria, clinicians are often engaged to ensure that the groups are clinically
meaningful. Patient groups are merged, split, and otherwise reconfigured until the grouping algorithm
reaches a satisfactory compromise between cost prediction, clinical relevance, and usability. Most modern
case mix methodologies and payment systems also include a final layer of patient complexity factors that
modify the resource weight (or price) assigned to each group upward or downward. These can include
comorbidities, use of selected interventions, long- or short-stay status, and social factors.

In contrast with these established methods for developing case mix systems, the patient classification
approach that the Ministry asked HQO and the Expert Panels to undertake is unusual in that it begins with
the input of clinicians rather than with statistical analysis of resource utilization. The Expert Panels were
explicitly instructed not to focus on cost considerations, but instead to rely on their clinical knowledge of
those patient characteristics that are commonly associated with differences in indicated treatments and
expected resource utilization. Expert Panel discussions were also informed by summaries of relevant
literature and descriptive tables containing Ontario administrative data.

Based on this information, the Expert Panels recommended a set of inclusion and exclusion criteria to
define each disease cohort. Starting with establishing the ICD-10-CA
2
diagnosis codes included for the
population, the Expert Panels then excluded diagnoses with significantly different treatment protocols
from the general population, including pediatric cases and patients with very rare disorders. Next, the
Expert Panels recommended definitions for major patient groups within the cohort. Finally, the Expert
Panels identified patient characteristics that they believe would contribute to additional resource
utilization for patients within each group. This process generated a list of factors ranging from commonly
occurring comorbidities to social characteristics such as housing status.

In completing the process described above, the Expert Panel encountered some noteworthy challenges:

1 Fetter RB, Shin Y, Freeman JL, Averill RF, Thompson JD. Case mix definition by diagnosis-related groups. Med Care. 1980 Feb;18(2):iii, 1-53.
2
International Classification of Diseases, 10th Revision (Canadian Edition).


1. Absence of clinical data elements capturing important patient complexity factors. The
Expert Panels quickly discovered that a number of important patient-based factors related to the
severity of patients conditions or their expected utilization are not routinely collected in Ontario
hospital administrative data. These include both key clinical measures (such as FEV1 / FVC for
chronic obstructive pulmonary disease [COPD] patients and AlphaFIM
3
scores for stroke
patients) as well as important social characteristics (such as caregiver status).
4
For stroke and
CHF, some of these key clinical variables have been collected in the past through the OSA and
EFFECT datasets, respectively. However, these datasets were limited to a group of participating
hospitals and at this time are not funded for future data collection.
2. Focus on a single disease grouping within a broader case mix system. While the Expert Panels
were asked to recommend inclusion/exclusion criteria only for the populations tasked to them, the
3 patient populations assigned to HQO are a small subset of the many patient groups under
consideration for Quality-Based Procedures. This introduced some additional complications when
defining population cohorts; after the Expert Panels had recommended their initial patient cohort
definitions (based largely on diagnosis), the Ministry informed the Expert Panels that there were a
number of other patient groups planned for future Quality-Based Procedure (QBP) funding efforts
that overlapped with the cohort definitions.

For example, while the vast majority of patients discharged from hospital with a most responsible
diagnosis of COPD receive largely ward-based medical care, a small group of COPD-diagnosed
patients receive much more cost-intensive interventions such as lung transplants or resections.
Based on their significantly different resource utilization, the Ministrys HBAM grouping
algorithm assigns these patients to a different HBAM Inpatient Grouper (HIG) group from the
general COPD population. Given this methodological challenge, the Ministry requested that the
initial cohorts defined by the Expert Panels be modified to exclude patients that receive selected
major interventions. It is expected that these patients may be assigned to other QBP patient
groups in the future. This document presents both the initial cohort definition defined by the
Expert Panel and the modified definition recommended by the Ministry.

In short, the final cohorts and patient groups described here should be viewed as a compromise solution
based on currently available data sources and the parameters of the Ministrys HBAM grouping
methodology.

3 The Functional Independence Measure (FIM) is a composite measure consisting of 18 items assessing 6 areas of function. These fall into 2 basic
domains; physical (13 items) and cognitive (5 items). Each item is scored on a 7-point Likert scale indicative of the amount of assistance required to
perform each item (1 = total assistance, 7 = total independence). A simple summed score of 18126 is obtained where 18 represents complete
dependence / total assistance and 126 represents complete independence.
4 For a comprehensive discussion of important data elements for capturing various patient risk factors, see Iezzoni LI, editor. Range of risk factors. In
Iezzoni LI (Ed.) Risk adjustment for measuring health care outcomes, 4
th
ed. Chicago: Health Administration Press; 2012. p. 29-76.

Defining the Scope of the Episode of Care
HQOs episode of care analysis draws on conceptual theory from the emerging worldwide use of episode-
based approaches for performance measurement and payment. Averill et al,
5
Hussey et al,
6
and Rosen and
Borzecki
7
describe the key parameters required for defining an appropriate episode of care:

Index event: The event or time point triggering the start of the episode. Examples of index
events include admission for a particular intervention, presentation at the emergency
department (ED) or the diagnosis of a particular condition.
Endpoint: The event or time point triggering the end of the episode. Examples of endpoints
include death, 30 days following hospital discharge, or a clean period with no relevant
health care service utilization for a defined window of time.
Scope of services included: While an ideal episode of care might capture all health and
social care interventions received by the patient from index event to endpoint, in reality not
all these services may be relevant to the objectives of the analysis. Hence, the episode may
exclude some types of services such as prescription drugs or services tied to other unrelated
conditions.

Ideally, the parameters of an episode of care are defined based on the nature of the disease or health
problem studied and the intended applications of the episode (e.g., performance measurement, planning,
or payment). For HQOs initial work here, many of these key parameters were set in advance by the
Ministry based on the governments QBP policy parameters. For example, in 2013/14 the QBPs will
focus on reimbursing acute care, and do not include payments for physicians or other non-hospital
providers. These policy parameters resulted in there being limited flexibility to examine non-hospital
elements such as community-based care or readmissions.

Largely restricted to a focus on hospital care, the Chairs of the Expert Panels recommended that the
episodes of care for all 3 conditions begin with a patients presentation to the ED (rather than limit the
analysis to the inpatient episode) in order to provide scope to examine criteria for admission. Similarly,
each of the Expert Panels ultimately also included some elements of postdischarge care in the scope of the
episode in relation to discharge planning in the hospital and the transition to community services.

5 Averill RF, Goldfield NI, Hughes JS, Eisenhandler J, Vertrees JC (2009). Developing a prospective payment system based on episodes of care. J
Ambul Care Manage. 32(3):241-51.
6 Hussey PS, Sorbero ME, Mehrotra A, Liu H, Damberg CL (2009). Episode-based performance measurement and payment: making it a reality. Health
Affairs. 28(5):1406-17.
7 Rosen AK, Borzecki AM Windows of observation. In Iezzoni LI, ed. Risk adjustment for measuring health care outcomes, 4
th
ed. Chicago: Health
Administration Press; 2012. p. 71-94.

Developing the Episode of Care Pathway Model
HQO has developed a model that brings together the key components of the episode of care analysis
through an integrated schematic. The model is structured around the parameters defined for the episode of
care, including boundaries set by the index event and endpoints, segmentation (or stratification) of
patients into the defined patient groups, and relevant services included in the episode. The model
describes the pathway of each patient case included in the defined cohort, from initial presentation
through segmentation into one of the defined patient groups based on their characteristics, and finally
through the subsequent components of care that they receive before reaching discharge or death.

While the model bears some resemblance to a clinical pathway, it is not intended to be used as a
traditional operational pathway for implementation in a particular care setting. Rather, the model presents
the critical decision points and phases of treatment within the episode of care, respectively referred to
here as clinical assessment nodes and care modules. Clinical assessment nodes (CANs) provide patient-
specific criteria for whether a particular case proceeds down one branch of the pathway or another. Once
patients move down a particular branch, they then receive a set of recommended practices that are
clustered together as a care module. Care modules represent the major phases of care that patients receive
within a hospital episode, such as treatment in the ED, care on the ward, and discharge planning. The
process for identifying the recommended practices within each CAN and care module is described in the
next section.

Drawing from the concept of decision analytic modelling, the episode of care model includes crude
counts (N) and proportions (Pr) of patients proceeding down each branch of the pathway model. For the 3
conditions studied in this exercise, these counts were determined based on annual utilization data from the
DAD, NACRS, and (for CHF and stroke) clinical registry data.

Figure 5 provides an illustrative example of a care module and CAN:

Figure 5: Sample Episode of Care Pathway Model
Abbreviations: CAN, clinical assessment node; N, crude counts; Pr, proportions.

Care
Module
Patient presents at the
emergency department
CAN
Responding to treatment
(N = 20,000; Pr = 85%)
Responding to treatment
(N = 23,000; Pr = 15%)
N = 43,000
Pr = 1.0

Identifying Recommended Practices
Each CAN and care module in the episode of care model contains a set of recommended practices
reviewed and agreed upon through the Expert Panel. The end goal communicated by the Ministry for the
QBP methodology is to develop cost estimates for the recommended practices and aggregate these to
determine a total best practice cost for an ideal episode of care to inform the pricing of the QBP.

In keeping with HQOs mandate to support evidence-based care, considerable attention has been paid to
ensure that the recommended practices here are supported by the best available evidence. For this process,
HQO considers the gold standard of evidence to be official OHTAC recommendations. While there are
many other organizations that release high quality clinical guidance based on rigorous standards of
evidence, OHTAC recommendations are considered the highest grade of evidence in this process for
several reasons:

Consistency: While many guidance bodies issue disease-specific recommendations, OHTAC
produces guidance in all disease areas, providing a common evidence framework across all the
clinical areas analyzed.
Economic modelling: OHTAC recommendations are generally supported by economic
modelling to determine the cost-effectiveness of an intervention, whereas many guidance bodies
assess only effectiveness.
Contextualization: In contrast with recommendations and analyses from international bodies,
OHTAC recommendations are developed through the contextualization of evidence for Ontario.
This ensures that the evidence is relevant for the Ontario health system context.

Notwithstanding these strengths, it is also crucial to mention several important limitations in the mandate
and capacity of OHTAC to provide a comprehensive range of evidence to support HQOs episode of care
analyses:

Focus on non-drug technologies: While evidence shows that various in-hospital drugs are
effective in treating all 3 of the patient populations analyzed, OHTAC traditionally does not
consider pharmaceuticals under its mandate. Recently, OHTAC has reviewed some drug
technologies in comparison with non-drug technologies for a given population as part of mega-
analyses.
Capacity constraints: There are a considerable number of candidate practices and interventions
that require consideration for each episode of care. As OHTAC makes recommendations largely
based on evidence-based analyses supplied by HQO, it may be limited in its capacity to undertake
new reviews in all required areas.
Focus on high quality evidence: OHTAC uses the GRADE criteria
8
to assess the strength of
evidence for an intervention, with randomized controlled trials (RCTs) considered the gold
standard of evidence here. Not every practice within an episode of care may be appropriate or
feasible to study through an RCT. For example, some interventions may be regarded as accepted
clinical practice, while others may be unethical to evaluate as part of a clinical trial.

Thus, in situations where OHTAC recommendations do not exist, HQOs episode of care analysis makes
use of other sources of evidence:

8 Guyatt GH, Oxman AD, Schunemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of Clinical
Epidemiology. J Clin Epidemiol. 2011;64(4):380-2.

Guidance from other evidence-based organizations: Each of the Expert Panels recommended
credible existing sources of evidence-based guidance, such as the Global Initiative for Chronic
Obstructive Lung Disease (GOLD) guidelines for COPD. Recommendations from these bodies
were included along with their assessment of the evidence supporting the recommendation.
Analysis of empirical data: The Expert Panels reviewed the results of descriptive and multivariate
analysis using empirical data, including administrative data sources and clinical data sources such
as the EFFECT database.
Expert consensus: In areas that the Expert Panels saw as important but where evidence was
limited or nonexistent, the Expert Panels relied on consensus agreement while noting the need for
further research in these areas.

Figure 6: Example Illustrating the Alignment of OHTAC COPD Practice Recommendations with the
Scope of Practices Reviewed Through the COPD Episode of Care
Abbreviations: COPD, chronic obstructive pulmonary disease; OHTAC. Ontario Health Technology Advisory Committee; QBF, Quality-Based Funding.

The process for identifying recommended practices involves the following steps:

1. Reviewing existing guidance from OHTAC and other selected evidence-based bodies and
extracting all candidate practices for each care module and CAN;
2. Consulting with members of the Expert Panel for additional candidate interventions not included
in the guidance reviewed;
3. Reviewing and summarizing the strength of evidence cited for each candidate intervention in the
guidance literature, where it exists and is clearly stated;
4. Summarizing the results of steps 1 to 3 above for each phase of the episode of care model and
presenting the summary to the Expert Panel for review;
5. Facilitating discussion by the Expert Panel members on contextualizing the candidate practices
for the Ontario health system and arriving at a consensus recommendation; and
6. Identifying gaps in the evidence that the Expert Panel agreed are high value candidates for
research questions for rapid reviews (see below) and future evidence-based analyses.

Non-invasive Ventilation
Pulmonary rehabilitation
following acute exacerbation
Vaccinations
Long-term oxygen
therapy
Pulmonary
rehabilitation for
stable COPD patients
Short-acting
bronchodilators
Corticosteroids
Antibiotics
In-hospital
diagnostics
Long-acting maintenance
bronchodilators
Community-based
diagnosis and assessment
Community-based
multidisciplinary care
OHTAC mega-analysis
QBF episode of care
Evidence-based practices for COPD

Rapid Reviews
In order to address cases where a gap in the evidence is identified and prioritized for further analysis in
step 6 (above), HQO has developed a rapid evidence review process that is able to operate within the
compressed timeframe of this exercise, recognizing that a full evidence-based analysis would be
impractical given the short timelines.

For each question, the rapid review analysis began with a literature review using OVID MEDLINE,
OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative
Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for
Reviews and Dissemination database, for studies published from January 1, 2000, to October 2012.
Abstracts were reviewed by a single reviewer and full-text articles were obtained for those studies
meeting the eligibility criteria. Reference lists were also examined for any additional relevant studies not
identified through the search.

Articles were reviewed if they were:
English language full-text reports
published between January 1, 2008, and October 2012
health technology assessments, systematic reviews, and meta-analyses

If systematic reviews were not available, RCTs, observational studies, case reports, and editorials were
selected.

The methodological quality of systematic reviews was assessed using the Assessment of Multiple
Systematic Reviews (AMSTAR) measurement tool.
9
The quality of the body of evidence for each
outcome was examined according to the GRADE Working Group criteria.
8
The overall quality was
determined to be very low, low, moderate, or high using a step-wise, structural methodology.

Study design was the first consideration; the starting assumption was that RCTs are high quality, whereas
observational studies are low quality. Five additional factorsrisk of bias, inconsistency, indirectness,
imprecision, and publication biaswere then taken into account. Limitations or serious limitations in
these areas resulted in downgrading the quality of evidence. Finally, 3 factors that could raise the quality
of evidence were considered: large magnitude of effect, dose response gradient, and accounting for all
residual confounding.
8

For more detailed information, please refer to the latest series of GRADE articles.
8

As stated by the GRADE Working Group,
7
the final quality score can be interpreted using the following
definitions:

9 Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the
methodological quality of sytematic reviews. BMC Med Res Methodol. 2007;7(10).


High Very confident that the true effect lies close to the estimate of the effect
Moderate Moderately confident in the effect estimatethe true effect is likely to be close to the
estimate of the effect, but there is a possibility that it is substantially different
Low Confidence in the effect estimate is limitedthe true effect may be substantially
different from the estimate of the effect
Very Low Very little confidence in the effect estimatethe true effect is likely to be
substantially different from the estimate of effect

Description of Congestive Heart Failure
CHF is a complex clinical syndrome of symptoms and signs suggesting that the heart muscle is weakened
and the heart as a pump is impaired; it is caused by structural or functional abnormalities and is the
leading cause of hospitalization in elderly Ontarians. Between 1997 and 2007, there were 419,552 cases
of heart failure in Ontario, with 216,190 requiring admission to hospital.
10
Slightly more women (51%)
than men had heart failure, and 80% of the overall cohort was age 65 or older.
10
The prognosis for
patients is poor; CHF is associated with high mortality.

10
Yeung DF, Boom NC, Guo H, Lee DS, Schultz S, Tu J. Trends in the incidence and outcomes of heart failure in Ontario, Canada: 1997 to 2007,
CMAJ 2012.

Recommended CHF Cohort Definition and
Patient Grouping Approach
Initial CHF Cohort Inclusion/Exclusion Criteria
The CHF pathway has been developed for adult patients presenting to Ontarios EDs with a major
diagnosis of CHF. These patients are admitted to an inpatient bed, transferred to another hospital, or
discharged from the ED. Patients with a primary diagnosis of CHF received from another hospital or who
develop CHF during their stay in hospital are not included in this pathway.

For QBP funding purposes, cases are included only if CHF-related diagnoses are assigned as the Most
Responsible Diagnosis for an acute inpatient (DAD data) or as the Main Problem for an ED patient
(NACRS data) and have not had a major qualifying procedure performed.

The following age ranges, diagnosis codes (International Classification of Diseases, 10th Revision
(Canadian Edition) [ICD-10-CA]), and diagnosis types were used to define the CHF population for this
episode of care analysis:

a) Age: Persons aged 20 years and older. CHF is predominantly a disease of older individuals; the
largest cohort of patients is those 75 years of age or over. Patients under age 20 with CHF are quite
rare, and their disease tends to result from congenital factors; the care pathway and treatment
protocols for such patients are likely to be substantially different. The Expert Panel developed the
CHF care pathway for adult patients using the 20-year age threshold used in many Institute for
Clinical Evaluative Sciences (ICES) studies.

b) Diagnosis codes: The ICD-10-CA codes used to define the cohort of patients with CHF are listed
below.
I50.x Heart failure, left ventricular dysfunction, etc
I25.5 Ischemic cardiomyopathy
I40.x, I41.x Myocarditis
I42.x, I43.x Cardiomyopathies
I11.x plus I50.x (secondary Dx) Hypertensive heart disease plus heart failure, left ventricular
dysfunction
I13.x plus I50.x (secondary Dx) Hypertensive heart disease and renal disease plus heart failure,
left ventricular dysfunction)

Appendix I shows the ICD-10-CA details for the CHF patient groups.

c) Diagnosis types: The following diagnosis types are included in the CHF patient definition:
Acute inpatient cases include Most Responsible Diagnosis codesthe diagnosis determined as
the diagnosis or condition held most responsible for the greatest portion of the length of stay or
greatest use of resources.
Emergency department cases include Main Problem codesthe diagnosis or condition
determined to be most responsible for the greatest proportion of the length of stay or greatest use
of resources.

As noted above, using the DAD and the NACRS databases, the following codes defined the CHF
population:
Most responsible diagnosis of I50.X I25.5 I40.X I41.X I42.X I43.X
OR
Most responsible diagnosis of I11.X and comorbidity I50.X code
OR
Most responsible diagnosis of I13.X and comorbidity I50.X code

It should be noted that comorbidity diagnoses are only with diagnosis type 1 pre-admit
comorbidity, 2 post-admit comorbidity, or W, X, Y service transfer diagnosis.

d) Typical CHF patients: In the DAD, typical patients include those coded as both typical and short
stay using the Health Based Allocation Model Inpatient Grouper (HIG). Deaths, transfers, sign-outs,
and long-stay outliers are considered atypical cases. Table 1 shows the breakdown of CHF patients by
type and distribution of the resource intensity weights for 2010/11.

Table 1: CHF Patients for 2010/2011
Case
Type
Number
of Cases
Weight
(Mean)
Weight
(Minimum)
Weight (50
th

Percentile)
Weight
(Median)
Weight (75
th

Percentile)
Weight
(Maximum)
All 22,342 1.89 0.24 0.98 1.06 1.84 134.77
Atypical 3,298 4.76 0.24 1.04 2.85 5.38 134.77
Typical 19,044 1.39 0.26 0.98 1.06 1.29 40.66
Abbreviation: CHF, congestive heart failure.
Data source: DAD 2010/11.

The Expert Panel considered both typical and atypical patients in the development of the CHF care
pathway. The Expert Panel felt that smaller hospitals would need to transfer patients to other acute
care hospitals with more appropriate resources, such as catheterization laboratories.

Inclusion/Exclusion Criteria for QBP Funding Purposes
During the development of the episode of care pathway, the MOHLTC representatives explained the
challenges of the CHF cohort definitions into the QBP funding methodology. To align the CHF cohort to
the present HIGs, the following ICD-10-CA diagnosis codes, diagnosis types, and ICD-10 Canadian
Classification of Health Interventions (CCI) intervention exclusion criteria are recommended for the
purposes of funding CHF through the QBP funding mechanism:
a) Age: Age greater than or equal to 20 years at time of admission.
b) Diagnosis codes: The ICD-10-CA most responsible diagnosis codes are listed below.
I50.x Heart failure, left ventricular dysfunction, etc
I40.x, I41.x Myocarditis
I42.x, I43.x Cardiomyopathies
I11.x plus I50.x (secondary Dx) Hypertensive heart disease plus heart failure, left ventricular
dysfunction
I13.x plus I50.x (secondary Dx) Hypertensive heart disease and renal disease plus heart
failure, left ventricular dysfunction)
c) Intervention: Patients are not assigned to an intervention-based HIG cell, given the current
methodology. (i.e., Major Clinical Category [MCC] partition variable is not I) CMG algorithms
used by the Ministry for QBP funding typically assign cases to groups based on either principal
intervention (typically a major qualifying procedure, such as a surgery) or in cases where there is
no major qualifying procedure, by Most Responsible Diagnosis. There is a need for CMGs to be
mutually exclusive: that is, the logic of the grouping algorithm should assign a case to 1 group or
anothernot both.

When the MCC partition variable I is included, CHF patients fall into many HIGs. Table 2 shows the
HIG distribution of CHF inpatients; using the existing CMG funding methodology and 2011/12 inpatient
data, most of the 22,435 admitted CHF patients as defined by the Expert Panel fall into 3 HIGs
(highlighted).


Table 2: CHF Cohort Distribution by Health-Based Allocation Model Inpatient Groupers, 2011/12

Abbreviations: CHF, congestive heart failure; HIG, HBAM Inpatient Grouper; MCC, Major Clinical Category; MI, myocardial infarction.

Cases assigned to an intervention-based HIG cell are likely to be more advanced and funded using a
different episode of care pathway (to be developed in the future). As a result, for funding purposes, the
MCC partition I has been excluded from the current pathway.

HIG HIG Description COUNT PERCENT
143 Disease of Pleura 4 0.0
160 Heart or Lung Transplant 36 0.2
161 Implantation of Cardioverter/Defibrillator 300 1.3
162 Cardiac Valve Replacement 11 0.0
163 Major Cardiothoracic Intervention with Pump 42 0.2
164 Major Cardiothoracic Intervention without Pump 15 0.1
166 Coronary Artery Bypass Graft with Coronary Angiogram with MI/Shock/Arrest with Pump 4 0.0
167 Coronary Artery Bypass Graft with Coronary Angiogram with MI/Shock/Arrest without Pump 1 0.0
168 Coronary Artery Bypass Graft with Coronary Angiogram without MI/Shock/Arrest with Pump 2 0.0
172 Coronary Artery Bypass Graft without Coronary Angiogram without MI/Shock/Arrest with/without Pump 6 0.0
173 Minor Cardiothoracic Intervention 6 0.0
174 Pacemaker Implantation/Removal Except Cardioverter/Defibrillator Implant 174 0.8
175 Percutaneous Coronary Intervention with MI/Shock/Arrest/Heart Failure 95 0.4
176 Percutaneous Coronary Intervention without MI/Shock/Arrest/Heart Failure 6 0.0
177 Management of Pacemaker Battery/Epicardial Lead 11 0.0
178 Percutaneous Transluminal Cardiothoracic Intervention except Percutaneous Coronary Intervention11 0.0
179 Cardiac Conduction System Intervention 13 0.1
180 Amputation of Limb except Hand/Foot 4 0.0
181 Abdominal Aorta Intervention 1 0.0
182 Bypass/Extraction of Vein/Artery of Limb 4 0.0
183 Amputation of Hand/Foot 4 0.0
185 Other/Miscellaneous Vascular Intervention 32 0.1
195 Heart Failure with Coronary Angiogram 979 4.4
196 Heart Failure without Coronary Angiogram 19,368 86.3
197 Hypertensive Disease except Benign Hypertension 81 0.4
209 Other/Miscellaneous Cardiac Disorder 1,000 4.5
571 Newborn/Neonate 1500+ gm with Major Cardiovascular Intervention 1 0.0
600 Newborn/Neonate 2500+ grams, Other Moderate Problem 1 0.0
601 Newborn/Neonate 2500+ grams, Other Minor Problem 1 0.0
617 Intervention with Blood/Lymphatic System Diagnosis except Neoplasm 1 0.0
905 MCC 05 Unrelated Intervention 220 1.0
992 Stillbirth 1 0.0

Table 3 shows the distribution of CHF inpatients across the included (i.e., nonintervention-based) HIGs
to be used for QBP funding.

Table 3: Distribution of CHF Patients Across Included HIGs

Abbreviations: CHF, congestive heart failure; HBAM, Health-Based Allocation Model; HIG, HBAM Inpatient Grouper.

Table 4 shows the distribution of CHF patients in the ED using the Comprehensive Ambulatory Care
Classification System (CACS).

Table 4: Distribution of CHF Patients in ED Across CACS Cells
CACS CACS Description Patients with
CHF Diagnosis
Codes, n
All Patients in
These CACS
Cells, n
A001 Dead on arrival 8 696
A002 Left without being seen or triaged and not seen 2 193,799
B001 Cardiovascular condition with acute admission/transfer 18,506 97,974
B051 Emergency visit interventions 233 73,648
B053
Interventions generally performed by non-emergency
department service: other 19 1,559
B121 Congestive heart failure 8,645 8,645
B122 Other disease or disorder cardiac system 203 278,635
C154 Pleurocentesis 3 41
E201 Cardiovascular disorders 4 115
E202 Congestive heart failure 27 27
Abbreviation: CACS, Comprehensive Ambulatory Care Classification System; CHF, congestive heart failure; ED, emergency department.
Data source: NACRS 2011/12.

For funding purposes, the Ministry will be considering methods of dealing with low-volume CACS cells.

HIG HIG_desc COUNT PERCENT
143 Disease of Pleura 4 0.0
195 Heart Failure with Coronary Angiogram 979 4.6
196 Heart Failure without Coronary Angiogram 19,368 90.4
197 Hypertensive Disease except Benign Hypertension 81 0.4
209 Other/Miscellaneous Cardiac Disorder 1,000 4.7
600 Newborn/Neonate 2500+ grams, Other Moderate Problem 1 0.0
601 Newborn/Neonate 2500+ grams, Other Minor Problem 1 0.0
992 Stillbirth 1 0.0

CHF In-Hospital Patient Journey
At the initial Expert Panel meetings, the CHF patient journey was mapped out. Patient presentation at the
ED with suspected CHF was established as the index event, and administrative data were used to inform
and guide the CHF patient journey in hospital. Using CIHI administrative databases, the disposition of
ED patients and admitted patients was reviewed. In 2010/11, 62.5% of patients presenting to the ED with
main problem reported as CHF were admitted (Table 5).

Table 5: ED CHF Patient Visit Dispositions, Ontario, 2010/11
Visit Disposition Frequency %
01 Discharged home (private dwelling, not an institution; no support services) 8,819 30.54
02 Client register, left without being seen, or treated by a service provider
03 Client triaged and then left the emergency department; not seen by physician or
primary care provider
2 0.01
04 Client triaged, registered and assessed by a service provider and left without
treatment
7 0.02
05 Client triaged, registered, and assessed by a service provider and treatment
initiated; left against medical advice before treatment completed
101 0.35
06 Admitted into reporting facility as an inpatient to critical care unit or operating room
directly from an ambulatory care visit functional centre
2,151 7.45
07 Admitted into reporting facility as an inpatient to another unit of the reporting facility
directly from the ambulatory care visit functional centre
15,895 55.05
08 Transferred to another acute care facility directly from the ambulatory care visit
functional centre
818 2.83
09 Transferred to another non-acute care facility directly from an ambulatory care visit
functional centre
28 0.1
10 Death after arrival (DAA)patient expires after initiation of the ambulatory care
visit; resuscitative measures (e.g., CPR) may occur during the visit but are not
successful
78 0.27
11 Death on arrival (DOA)patient is dead on arrival to the ambulatory care service;
generally there is no intent to resuscitate (for example, perform CPR); includes cases
where the patient is brought in for pronouncement of death
8 0.03
12 Intra-facility transfer to day surgery 2 0.01
13 Intra-facility transfer to the emergency department
14 Intra-facility transfer to clinic 42 0.15
Abbreviations: CHF, congestive heart failure; CPR, cardiopulmonary resuscitation; ED, emergency department.
Data source: NACRS 2010/11.

The Expert Panel also investigated CHF patients transferred from other facilities, and the types of
facilities transferring patients. For 2010/11, 13% of transferred CHF patients were from acute care
facilities. Table 6 shows the number of CHF patients transferred to Ontarios acute care hospitals in
2010/11, as reported in the DAD. After careful consideration, the Expert Panel opted to treat CHF
patients transferred from other institutions as a special cohort; these patients are excluded from the
episode of care pathway model developed for this report.

Table 6: CHF Patients Transferred From Other Institutions, 2010/11
From Institution by Type Frequency Percent
0 Organized outpatient department of reporting facility 1 0.02
1 Acute care 722 13.06
2 General rehabilitation facility 111 2.01
3 Chronic care facility 108 1.95
4 Nursing home 1,189 21.5
5 Psychiatric facility 16 0.29
6 Unclassified or other type of facility 71 1.28
7 Special rehabilitation facility 11 0.2
8 Home care 577 10.43
9 Home for the aged 1,563 28.26
N Ambulatory care 1,161 20.99

Finally, the Expert Panel reviewed discharge disposition data for CHF patients admitted from the ED
(Table 7). The majority of admitted CHF patients are discharged home, with 21% requiring supportive
services.

Table 7: Discharge Disposition for CHF Patients, 2010/11
Discharge Disposition Total Percent
01 Transferred to another facility providing inpatient hospital care (includes other
acute, sub-acute, psychiatric, rehabilitation, cancer centre/agency, pediatric hospital,
etc.)
863 3.84
02 Transferred to a long-term care facility (personal care home, auxiliary care,
nursing home, extended care, home for the aged, seniors home, etc.)
2,858 12.73
03 Transferred to other (palliative care/hospice, addiction treatment centre, etc.) 103 0.46
04 Discharged to a home setting with support services (seniors lodge, attendant
care, home care, Meals on Wheels, homemaking, supportive housing, etc.)
4,716 21.01
05 Discharged home 11,719 52.20
06 Signed out (against medical advice) 169 0.75
07 Died 2,022 9.01
Total 22,450 100.00

Based on the above data, the Expert Panel established the ED visit disposition to include patient returning
home or to his/her place of residence, patient transferred to another acute care facility, admission to the
hospital, or death.

Factors Contributing to CHF Patient Complexity
Using 2010/11 DAD data, the Expert Panel reviewed pre- and postadmission comorbidities. Preadmission
comorbidities are conditions that existed prior to admission and have been assigned an ICD-10-CA code
that satisfies the requirements for determining cormorbidity (Table 8). Similarly, postadmission
comorbidities are conditions that arise following admission (Table 9).

Table 8: CHF Preadmission Comorbidities, Top 30
ICD-10 Description Number Percent
I48.0 Atrial fibrillation 3,977 9.61
J18.9 Pneumonia, unspecified 2,076 5.02
N17.9 Acute renal failure, unspecified 1,898 4.59
I10.0 Benign hypertension 1,224 2.96
N39.0 Urinary tract infection, site not specified 1,162 2.81
D64.9 Anaemia, unspecified 1,042 2.52
E11.52 Type 2 diabetes mellitus with certain circulatory complications 969 2.34
J90 Pleural effusion, not elsewhere classified 959 2.32
Z51.5 Palliative care 951 2.30
I25.10 Atherosclerotic heart disease of native coronary artery 802 1.94
J44.1 Chronic obstructive pulmonary disease with acute exacerbation, unspecified 796 1.92
E11.23 Type 2 diabetes mellitus with established or advanced kidney disease (N08.3-) 740 1.79
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection 718 1.74
I21.4 Acute subendocardial myocardial infarction 693 1.67
J44.9 Chronic obstructive pulmonary disease, unspecified 559 1.35
E11.64 Type 2 diabetes mellitus with poor control, so described 556 1.34
E87.1 Hypo-osmolality and hyponatraemia 523 1.26
N18.9 Chronic kidney disease, unspecified 517 1.25
E87.6 Hypokalaemia 478 1.16
I35.0 Aortic (valve) stenosis 430 1.04
L03.11 Cellulitis of lower limb 415 1.00
E87.5 Hyperkalaemia 385 0.93
I25.5 Ischaemic cardiomyopathy 352 0.85
I27.2 Other secondary pulmonary hypertension 349 0.84
I50.0 Congestive heart failure 349 0.84
I42.0 Dilated cardiomyopathy 298 0.72
I95.9 Hypotension, unspecified 282 0.68
I48.1 Atrial flutter 238 0.58
D50.9 Iron deficiency anaemia, unspecified 234 0.57
E86.0 Dehydration 232 0.56
Abbreviations: CHF, congestive heart failure; ICD-10, International Classification of Diseases, 10th Revision.

Table 9: CHF Postadmission Comorbidities, Top 20
ICD-10 Description Number Percent
N39.0 Urinary tract infection, site not specified 530 8.03
N17.9 Acute renal failure, unspecified 341 5.16
E87.6 Hypokalaemia 261 3.95
I95.9 Hypotension, unspecified 205 3.10
J18.9 Pneumonia, unspecified 203 3.07
I48.0 Atrial fibrillation 168 2.54
I46.9 Cardiac arrest, unspecified 139 2.10
R33 Retention of urine 110 1.67
E11.63 Type 2 diabetes mellitus with hypoglycaemia 109 1.65
E87.5 Hyperkalaemia 105 1.59
A04.7 Enterocolitis due to Clostridium difficile 104 1.57
J96.0 Acute respiratory failure 102 1.54
E87.1 Hypo-osmolality and hyponatraemia 100 1.51
F05.9 Delirium, unspecified 99 1.50
I46.0 Cardiac arrest with successful resuscitation 93 1.41
A09.9 Gastroenteritis and colitis of unspecified origin 90 1.36
I21.4 Acute subendocardial myocardial infarction 85 1.29
J96.9 Respiratory failure, unspecified 77 1.17
R57.0 Cardiogenic shock 77 1.17
I47.2 Ventricular tachycardia 75 1.14
Abbreviations: CHF, congestive heart failure; ICD-10, International Classification of Diseases, 10th Revision.

Pre- and postadmission comorbidities are not included in the current episode of care pathway for the
typical CHF case. Following completion of the current pathway, the Expert Panel may consider the
implications of commonly occurring comorbidities, such as pneumonia, acute renal failure, and diabetes.
While it is expected that the foundational pathway will remain the same, the inclusion of comorbidities
may result in the recommendation of additional interventions in each care module.

Recommended Practices for CHF
Development of the Episode of Care Pathway
As discussed in the Methods chapter, the Expert Panel developed the episode of care pathway by
reviewing the literature related to quality of care for CHF patients; CHF clinical practice guidelines; and
the results of analyses performed on empirical data from the EFFECT database at ICES. The following
sections describe the evidence review and analyses performed.

Review of Literature
The Expert Panel identified areas in which a review of the evidence was important to the development of
the CHF pathway. The research questions and related grades of evidence are shown Table 10. A
description of the rapid review methodology is provided in Appendix II. The full rapid reviews for each
question are provided in Appendix III.

Table 10: Rapid Review Research Questions and Quality of Evidence
Research Question Quality of Evidence
What is the diagnostic accuracy of in-hospital BNP
measurement for HF?
What is the prognostic accuracy of BNP for triage of
HF patients when used in the emergency department?
What is the prognostic accuracy of in-hospital BNP
measurement for HF before hospital discharge?
No studies were identified that specifically assessed the prognostic
accuracy of BNP for triage of HF patients when used in the emergency
department or in-hospital BNP measurement for HF before hospital
discharge.
There is moderate quality evidence that BNP testing to diagnose HF in
patients presenting to the emergency department with acute dyspnea
does not significantly reduce mortality or rehospitalization.
What is the diagnostic accuracy of a chest x-ray for
identifying pulmonary infection as a precipitant of an
acute HF episode?

No studies that examined the accuracy of x-rays for diagnosing
pneumonia as the precipitant of an acute HF event were identified.
All of the guidelines reviewed comment on the importance of diagnosing
pulmonary infections such as pneumonia as a potential precipitant of an
acute heart failure event.
What is the effectiveness of coronary
revascularization in ischemic heart failure patients?
Moderate-quality evidence suggests that coronary revascularization
improves survival compared to medical therapy in patients with CAD
and significant left ventricular systolic dysfunction, and for those in
whom treatable targets are identified. Decisions to perform
revascularization in these patients should not be overly influenced by
imaging-defined myocardial viability status, as an association with
clinical outcomes was not shown. The routine use of SVR as an adjunct
to CABG coronary revascularization is not supported by the evidence.
What is the safety and effectiveness of EMAA in
hospitalized acute HF patients?
No studies were identified that examined the safety and effectiveness of
EMAA in hospitalized acute HF patients
What is the effectiveness of ECG telemetry monitoring
among patients hospitalized with acute HF in
comparison to standard care?

No high-quality evidence was identified that evaluated the effectiveness
of ECG telemetry monitoring among patients with acute HF.
Based on expert opinion, clinical practice guidelines recommend the use
of continuous ECG monitoring among patients with acute HF. The AHA
practice standards for in-hospital ECG monitoring and the CCS
recommend continuous ECG monitoring among all patients with acute
HF. The ESC and HFSA guidelines recommend continuous ECG
monitoring among acute HF patients treated with inotropes, based on
the increased risk of arrhythmia and myocardial ischemia associated
with these agents.
What is the effectiveness of in-hospital insertion of an
ICD or of CRT in patients hospitalized for acute CHF
compared with those patients not hospitalized for
acute CHF who receive the device or the procedure
via pre-planned, elective surgery.
No studies were identified that examined the effectiveness of in-hospital
insertion of an ICD or CRT in patients hospitalized for acute CHF
compared with those patients who receive the devices via pre-planned,
elective surgery.

Research Question Quality of Evidence
What is the diagnostic accuracy of an ECG for
identifying ischemia as a precipitant for an acute HF
episode?

No studies were identified that examined the accuracy of ECGs for
diagnosing ischemia as the precipitant to an acute HF event in a HF
population.
All 5 of the guidelines reviewed commented on the importance of using
ECG in diagnosing the precipitants for an acute HF event.
Are in-hospital performance indicators for the in-
hospital management of heart failure effective at
improving patient outcomes?
There is very low quality evidence that in-hospital performance
indicators for in-hospital heart failure management are effective at
improving patient outcomes, in particular, reducing mortality and
rehospitalization. (GRADE: Very low)
Is there an increased risk of mortality for HF patients
administered dobutamine, milrinone, or nitroprusside
in hospital?

No studies were identified that examined in-hospital milrinone or
nitroprusside therapy for the management of HF.
In a meta-analysis of 3 identified RCTs, there was no evidence of a
statistically significant increase in mortality risk compared with placebo
for patients with moderate to severe heart failure who were administered
dobutamine in hospital (GRADE quality of evidence: very low).
Careful consideration is required in formulating recommendations
regarding the clinical utility of dobutamine for moderate to severe heart
failure decompensation in hospital, based on the quality of the body of
evidence and the limitations of the component studies.
What is the effectiveness of IABPs in the management
of patients hospitalized with acute HF?

No high quality evidence on the use of IABPs in hospitalized patients
with HF was identified through the systematic literature search.
Therefore no conclusions could be made on its use in hospitalized
patients with HF.
What is the effectiveness of PACs in patients
hospitalized with acute HF?

The RCTs identified in patients hospitalized with HF did not show a
statistically significant mortality benefit with the use of PACs compared
to clinical assessment. A higher rate of infections associated with the
PAC compared to clinical assessment was reported in 1 RCT. Other
complications associated with PACs were reported, but their rates were
not compared to a control group. The RCT excluded patients who were
likely to require PACs within 24 hours following randomization, possibly
affecting the generalizability of the results. This is based on moderate
quality evidence.
What is the effect of intravenous nitroglycerin or
nesiritide on renal function and risk of mortality for
heart failure inpatients?

No systematic reviews, meta-analyses, or health technology
assessments on the safety and effectiveness of nitroglycerin or nesiritide
were identified in the literature search. No RCTs were identified
evaluating the safety of nitroglycerin.
One large multicentre RCT addressed these questions with regard to
nesiritide. (16) No statistically significant increase in risk of mortality
(GRADE: moderate) or renal dysfunction (GRADE: high) was found,
compared to placebo.
Abbreviations: AHA, American Heart Association; BNP, B-type natriuretic peptide; CCS, Canadian Cardiovascular Society; CHF, congestive heart
failure; CRT, cardiac resynchronization therapy; ECG, electrocardiogram; EMAA, early mobilization and ambulation; ESC, European Society of
Cardiology; HF, heart failure; HFSA, Heart Failure Society of America; IABP, intra-aortic balloon pump; ICD, implantable cardioverter defibrillator; PAC,
pulmonary artery catheter; RCT, randomized controlled trial.

Review of CHF Clinical Practice Guidelines
The Expert Panel reviewed CHF clinical practice guidelines from the following organizations:
Canadian Cardiovascular Society (CCS)
11,12,13

National Institute for Health and Clinical Excellence (NICE)
14

European Society of Cardiology (ESC)
15

Heart Failure Society of America (HFSA)
16

American College of Cardiology/American Heart Association (ACC/AHA)
17

A comparison chart of the various guidelines was created to guide the development of the CHF pathway.

Review of Empirical Evidence
The Expert Panel used real-world data to examine the prevalence of candidate processes of care in
accordance with the domains described by consensus expert panels to assist with the following:
assigning prevalence rates to various quality indicators according to unit of initial disposition
understanding processes of care that are most strongly associated with outcomes (i.e., 30-day
mortality or rehospitalization)
identifying potential areas of need for further evaluation
The analysis was done using the major diagnosis of CHF from the EFFECT data at ICES. The EFFECT
data were collected in 2005 for 86 hospitals, using chart abstraction of 125 patients consecutive per
hospital.
18
The data were restricted to those admitted through ED and used the Framingham definition of
heart failure (which represents 91% of all heart failure).

The Expert Panel also reviewed the Emergency Heart Failure Mortality Risk Grade (EHMRG), a risk-
stratification method developed by ICES for the prediction of 7-day mortality in all patients with CHF
who present to the ED. Risk-adjustment models for 30-day death or rehospitalization were developed, and
the relationship between candidate process variables and risk-adjusted outcomes (30 day death or
rehospitalization) were examined.

The EMHRG score was developed from a multicentre study of 86 hospitals in Ontario.
18
The study
included a population-based random sample of 12,591 patients presenting to the ED from 2004 to 2007.
Using a method of age-standardized coefficientbased weights similar to that used for the Framingham
risk score, the researchers developed a scoring system calculated by summing integer scores for
categorical variables and weights for the value of continuous variables (where the value of the continuous
variable was multiplied by its weight). The variables used in the EMHRG calculation are patient age,
systolic blood pressure, whether the patient was transported by emergency medical services, heart rate,
oxygen saturation, creatinine, potassium and troponin concentration, if the patient has active cancer or
receive metolazone at home. Although the EHMRG tool is well developed and validated, the ED

11
Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: Diagnosis and management of right-sided heart
failure, myocarditis, device therapy and recent important clinical trials; Can J Cardiol Vol 25 No 2 February 2009.
12
Canadian Cardiovascular Society Consensus Conference guidelines on heart failure 2008 update: Best practices for the transition of care of heart
failure patients, and the recognition, investigation and treatment of cardiomyopathies; Can J Cardiol Vol 24 No 1 January 2008.
13
The 2011 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Sleep Apnea, Renal Dysfunction, Mechanical
Circulatory Support, and Palliative Care; Canadian Journal of Cardiology 27 (2011) 319338.
14
NICE Clinical Guideline No 108; Chronic Heart Failure National clinical guideline for diagnosis and management in primary and secondary care;
August 2010.
15
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008, European Heart Journal (2008) 29, 23882442.
16
HFSA 2010 Guideline Executive Summary; Journal of Cardiac Failure Vol. 16 No. 6 2010.
17
2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the International Society for
Heart and Lung Transplantation; Circulation 2009;119;1977-2016.
18
Lee D et al., Prediction of Heart Failure Mortality in Emergent Care: A Cohort Study. Ann Internal Medicine 2012: 156(11):767-775.

physician community needs to adopt this tool or a risk-stratification method to guide decisions about
whether to treat the CHF patient in the ED or admit to hospital for treatment.

The Expert Panel made the following conclusions after reviewing the results of the analyses.
1. It is possible to stratify and establish hospital disposition using variables in the EHMRG tool,
other clinical variables and responsiveness to dieresis variable.
2. Precipitating factors by initial hospital disposition are ischemia and valvular heart disease.
3. End-of-life care by initial hospital disposition includes advanced-care directives.
4. High-cost technology/interventions by initial disposition include coronary angiography
appropriateness for those with ischemia.
5. Discharge planning by initial hospital disposition should include physician follow-up and
cardiology follow-up, particularly among higher-risk patients.
6. Discharge disposition by initial hospital disposition should include hospice/palliative care.
7. Quality indicators at discharge and follow-up should include angiotensin-converting enzyme
(ACE) inhibitors/angiotensin receptor blockers (ARBs) and diuretics management
8. In-hospital quality indicators by initial hospital disposition should include ACE inhibitors/ARBs
and recording of daily weights
9. Counselling at discharge by initial hospital disposition should include medication management
and activity.

CHF Episode of Care Pathway Model
The Expert Panel developed the CHF episode of care pathway model after carefully reviewing the
evidence obtained in the rapid review process, the clinical practice guidelines, and the results of the
analyses performed. A pathway using the principles of decision analytic modelling was developed,
including clinical assessment nodes and care modules that list the resources required (including
interventions, procedures, and diagnostics) based on the best available evidence, empirical evidence from
ICES heart failure registry data, and expert consensus.

Phases of the Patient Journey
The Expert Panel recommended 4 phases of the patient journey while the patient is hospitalized and
consuming resources in an inpatient bed:
1. Acute stabilization phase (first 12 to 24 hours after admission), where the clinical status of the
patient is assessed and causes of symptoms are identified
2. Sub-acute stabilization phase (e.g., 24 to 96 hours after admission)
3. Discharge preparation phase (e.g., day 2 to hospital discharge)
4. Transitional care phase (e.g., hospital discharge or 24 hours prior to discharge to 8 to 12 weeks
after discharge)

Figure 7 shows the different phases of care. Times are displayed to illustrate the overlap of phases and
have not been confirmed by the Expert Panel.

Figure 7: Phases of the Patient Journey While Hospitalized

Episode of Care Pathway
As described above, the Expert Panel developed the episode of care pathway for CHF patients as shown
in Figure 8 using empirical evidence from the heart failure registry data and consensus of the Expert
Panel members. The CHF patient population, defined by ICD-10-CA codes, was further refined by
excluding special CHF patient cohorts. Special populations for whom the heart failure episode of care
pathway should not apply include the following:
1. Primary dialysis patients
2. Pre-transplant patients (i.e., those actively being considered for cardiac transplantation or on the
transplant list) and post-transplant patients
3. Patients transferred into hospitals from other institutions (i.e., in-hospital transfers)
4. Critical care outreach patients (i.e., higher-intensity patients managed in lower-intensity units due
to limited coronary care or intensive care unit bed availability)
5. Patients with more additional active chronic medical condition(s) that require(s) acute
stabilization management (e.g., active COPD, stroke, ST segment elevation myocardial infarction
[STEMI], non-STEMI active bleeding, etc.).

The care-pathway is intended to reflect the CHF-specific management stream only and does not take into
account other active treatments that might affect human resources, investigations, treatment, length of
stay, or quality of care.


Figure 8: CHF Episode of Care Pathway


Clinical Assessment Node: ED Risk Stratification and Responsiveness to Diuresis
When a patient presents in the ED with suspected CHF, a number of investigations are required as
recommended by clinical guidelines and supported by the Expert Panel. Table 11 describes the initial
investigations recommended in the CCS 2008 guidelines (similar to guidance from other organizations
such as NICE, ESC, HFSA, and ACC/AHA).

Table 11: ED Risk Stratification and Responsiveness to DiuresisRecommended Practice
Recommended Practice Relevant Evidence
Initial investigations should include the following:
serum creatinine and electrolyte levels
troponin measurements
complete blood count
electrocardiogram
chest x-ray and an echocardiogram if no recent
echocardiogram is available (class I, level C)
Heart rate, blood pressure and oxygen saturation should
be measured frequently until the patient is stabilized
(class IIa, level C).
National Institute for Health and Clinical Excellence
(NICE)
American College of Cardiology/American Heart
Association (ACC/AHA)

The Expert Panel recommends that patients presenting to hospital with acute CHF be classified into the
following 3 broad groups for the purposes of establishing care pathways and defining major groups for
QBP funding:
1. Low-intensity: These patients can be treated in the ED or in outpatient settings and discharged
home without requiring an inpatient admission.
2. Average-intensity: These patients require admission to inpatient care with normal nurse-to-
patient staffing.
3. High-intensity: These patients require ventilation (either noninvasive or invasive ventilation)
and/or admission to an intensive care unit with higher nurse-to-patient staffing.

It is recognized that these 3 patient groups are largely based on level of care. The Expert Panel has
identified a number of high-risk markers:
respiratory distress
hypoxemia
severity of pulmonary edema
poorly responsive to ED Lasix
hemodynamic compromise
significant arrhythmias
positive troponin
concomitant acute life-threatening directives


The Expert Panel suggests that an acute heart failure risk scorefor example, the EHMRG be
calculated to assist with clinical decision-making and predicting the 7-day mortality risk of CHF patients
(predicted mortality risk increases incrementally with higher EHMRG risk score). As a general guide,
patients who are low-risk (e.g., EHMRG quintiles 1 and 2) can be considered for discharge home if they
have responded to initial treatment in the ED, provided that there are no other considerations (e.g.,
advanced-directives, severe dementia, estimated impact of admission on life-expectancy, bed-availability,
etc.). Patients who are high-risk (e.g., EHMRG quintile 5) can be considered for admission to a higher-
intensity unit.

Ultimately, the decision to admit is based on clinical judgment and the availability of hospital resources.

Note: a full review of the evidence is required to determine the essential markers and defined thresholds
for the 3 CHF patient groups (high-intensity, average-intensity, and low-intensity).

Admitted Patients
The Expert Panel identified 2 pathways branches for admitted patients based on severity:
1. High-intensity case-mix-adjusted patient
2. Average-intensity case-mix-adjusted patient

The high-intensity case-mix-adjusted patient implies that a patient is high-risk enough to necessitate a 1:1
nurse-to-patient ratio. Similarly, the lower-intensity case-mix-adjusted patient implies that a patient is of
sufficiently low risk to be managed with the usual hospital-ward 1:5 nurse-to-patient ratio.

The case-mix adjustment implies that the high-intensity as well as average-intensity care pathway
corresponds to an individual of average comorbidity for CHF patients in the province of Ontario. An
individual who has higher-than-average or lower-than-average comorbidity would not necessarily alter
the patient intensity level or the care pathway, but rather the cost bundle associated with the care pathway.
The rationale for cost adjustments for case-mix variation is based on the understanding that care intensity
and length of stay correlate with the management of other (nonheart failurerelated) chronic conditions.
Such management of other comorbidities is not taken into account in this care pathway. Case-mix cost
attribution could use a number of different methodologies, including resource intensity weights.

The mean total length of hospital stay for the high-intensity and low-intensity patients using the 2005
EFFECT database and the 2010/11 DAD database are:

High-intensity (2005 EFFECT) - 8.8 days (SD = 8) with mean length of ward stay of 5.0
days (SD = 8.2)
High-intensity (2010/11) - 12.2 days (SD = 21.3)
Low-intensity (2005 EFFECT) - 8.5 days (SD = 10.7)
Low-intensity (2010/11) - 8.8 days (SD = 15.1)


Care Module: Acute Stabilization Phase
Tables 12 and 13 highlight the Expert Panel recommendations based on the analysis of CHF registry data
at ICES, expert consensus and CHF guidelines. The prevalence/proportions of patients have been
included using ICES data. They are weighted to reflect 2 factors: Framingham-defined vs. total heart
failure per hospital and the size of the hospital. Some of the recommendations in the tables are briefly
discussed in the subsections below.

Table 12: Acute Stabilization Care Module: High-Intensity Patient
Mechanical ventilation (Pr = 9.5%)
BIPAP (Pr = 25.95%)
IV inotropes and/or IV vasodilators (Pr = 17.2%)
Diuretic monitoring and management, acute phase
Identifying and treating precipitating factors
o Echocardiography
o Cardiac catheterization
o Noninvasive cardiac imaging
Evidence-based pharmacotherapy management, acute phase
Telemetry
Advanced care discussions and directives (Pr = 13.96%)
Noninvasive imaging for those who are not ideal candidates for cardiac catheterization
Oxygen
IV Lasix
Ultrafiltration (consider if necessary)
Intensive PA monitoring
Other (IABP, assistive devices)
Abbreviations: BIPAP, bilevel positive airway pressure; IABP, intra-aortic balloon pump; IV, intravenous; PA, pulmonary artery; Pr, prevalence.

Table 13: Acute Stabilization Care Module: Low-Intensity Patient
BIPAP (Pr = 4.47%)
Telemetry
Diuretic monitoring and management, acute phase
Identifying and treating precipitating factors
o Echocardiography (Pr = 50.1%)
o Cardiac catheterization (Pr = 3.76%)
Evidence-based pharmacotherapy management, acute phase
Advanced care discussions and directives (Pr =13.8%)
DNR (Pr =15.8%)
PO Lasix
Oxygen (consider if appropriate)
IV Lasix
Noninvasive imaging for those who are not ideal candidates for cardiac catheterization
Abbreviations: BIPAP, bilevel positive airway pressure; DNR, do not resuscitate; IV, intravenous; PO, per os (by mouth); Pr, prevalence.


Diuretic Monitoring and Management, Acute Phase
Table 14 shows recommended practice for diuretic monitoring and management in the acute phase.

Table 14: Diuretic Monitoring and ManagementAcute Phase
Recommended Practice Relevant Evidence
Recording of:
Daily weights
6-hour input/output
Salt restriction (2 g/day) (low level of evidence)
Possible fluid restriction (2 L/day)
Electrolytes
Renal function
Chest x-ray
National Institute of Health and Clinical Excellence
(NICE)
American College of Cardiology/American Heart
Association (ACC/AHA)

The frequency of laboratory and x-ray follow-up should remain discretionary. Each patient should have a
daily record of weights and measurement of 6-hour input/output. The frequency of electrolyte and renal
function monitoring depends on the dose and administration of Lasix (i.e., higher doses necessitate closer
monitoring). The frequency of chest x-rays depends on the baseline extent of pulmonary edema, a
patients clinical status, and his/her responsiveness to diuretics. Diuretic management approaches should
take an early and frequently approach. Those at higher intensity should receive an intravenous (IV)
Lasix bolus every 6 to 12 hours or a continuous IV infusion.
19
Those at lower intensity should also begin
with IV Lasix daily or BID.

Guiding principles in patients hospitalized with acute heart failure
The Expert Panel discussed the central importance of adequately relieving congestion during admission
for CHF. A number of panel members further shared that there are likely to be opportunities to broadly
improve the approach to diuretic use in hospitals by minimizing variation in diuretic management and
possible underdosing of diuretics. Given this discussion, the Expert Panel explored building some general
principles around diuretic-based management into the Expert Panels definition of an episode of care for
CHF.

Each Expert Panel member shared what he/she considered to be best practice general principles
for diuretic-based management. Members gave advice on principles/guidance related to the following:
1. Common dosing regimens for diuretic-naive patients vs. diuretic-experienced patients
2. Special populations that require special consideration for diuretic dosing
3. Key monitoring parameters that should be used to adjust the diuretic treatment plan
4. Common scenarios that are often associated with diuretic management that is too
conservative/underdosed

19 Felker, D.M et al.; Diuretic Strategies in Patients with Acute Decompensated Heart Failure, N Engl J Med 2011; 364:797-805, March 3, 2011.


Table 15 shows the recommendations from the clinical practice guidelines on diuretics for CHF patients.

Table 15: Diuretic Recommendations in Acute Heart Failure
CCS 2006 ESC 2012 ACC/AHA 2009 HFSA 2010 NICE 2010
Tailored diuretic therapy
is recommended for all
symptomatic patients
Class III/IV:
combination diuretic
therapy with
spironolactone
No specific dosage
recommendations
Includes table on
practical considerations
in the treatment of
heart failure with loop
diuretics (e.g.,
managing
hypokalemia, renal
failure, inadequate
response to diuretic)
No specific dosage
recommendations for
acute admissions for
heart failure
Starting dose for
chronic heart failure:
2040 mg
Stage C (patients with
current or prior
symptoms): diuretics
for fluid retention
The hospitalized
patient: IV loop
diuretic at higher than
or equal to chronic
oral daily dose. If
inadequate, response
consider higher
doses, addition of
another diuretic (e.g.,
metolazone) or
continuous infusion
Initial IV doses for
severe heart failure:
furosemide 40 mg
Loop diuretics for
patients with fluid
overload
Acute
decompensated
heart failure: IV
loop diuretics
If inadequate
response, consider
Increasing dose,
addition of
metolazone or
continuous infusion

Diuretics
routinely used
for relief of
congestive
symptoms and
fluid retention
Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; CCS, Canadian Cardiovascular Society; ESC, European
Society of Cardiology; HFSA, Heart Failure Society of America; IV, intravenous; NICE, National Institute for Health and Clinical Excellence.

I dentifying and Treating Precipitating Factors
The Expert Panel recommended that efforts to identify precipitating factors should include exploration of
all the usual known factors, including medication and dietary noncompliance. However, precipitating
factors should focus on the identification of 2 particular prognostic indicators that have been shown to
correlate with poorer 30-day outcomes of death or recurrent hospitalization: the presence of myocardial
ischemia and/or the worsening of valvular heart disease, either of which would be severe enough to
possibly warrant surgical or interventional procedures.

Evaluation for precipitating factors must also include the application of a risk-stratification process, to
help clinicians decide whether the patient should or should not undergo cardiac catheterization. For
example, in a patient presenting to hospital with heart failure, positive testing for troponins and/or ECG
changes that could be consistent with myocardial ischemia might indicate the presence of underlying
acute coronary syndrome or extensive coronary ischemia. Many such patients may have had prior cardiac
catheterization and may have already been deemed a patient best deemed for conservative medical
management. For others (e.g., new heart failure in a patient who has not had prior cardiac catheterization),
a positive troponin test may indicate the need for coronary angiography. Similarly, each patient should be
screened for severe valvular heart disease or mechanical heart complications that may have served as a
precipitating cause.

Most patients should be considered for 2D echocardiography for assessment of left ventricular systolic
and diastolic function and underlying valvular disease. Should severe valvular heart disease be found, the
patient should be considered for cardiac catheterization. Nonetheless, as with coronary angiography
above, many exceptions may occur, and each patient must be evaluated on a case-by-case basis.

The Expert Panel recommended the implementation of a process that requires doctors to document that
they have considered the patient for cardiac catheterization or noninvasive cardiac imaging for evaluation
of coronary ischemia or valvular abnormality, and that the patient was deemed either an appropriate or an


inappropriate candidate, along with the reason. An implementation process such as the one suggested
above will at least ensure that all providers think about precipitating factors and address the 2 that are
most prognostically important.

Figure 9: Precipitating Factor Node

Evidence-Based Pharmacotherapy Management, Acute Phase
The timing for the initiation of ACE inhibitors/ARBs and -blockers in acute heart failure is unclear.
Patients who have been on these medications prior to hospital arrival should continue them during
hospitalization. For patients who have been introduced recently to -blockers and have acute
decompensated heart failure associated with the increase, consideration should be given to cutting the
dose in half if they are in severe pulmonary edema. However, health care providers should be discouraged
from discontinuing ACE inhibitors/ARBs and -blockers unless the patient is hemodynamically unstable.

For those not already receiving these evidence-based medications, ACE inhibitors/ARBs should be
initiated early if the patient is hemodynamically stable. However, initiation of -blockers should begin
only once patient has been diuresed and is stable from a pulmonary congestion standpoint. For both
medications, doses should be started low and titrated slowly. The use of other evidence-based
pharmacotherapy (e.g., aldosterone receptor antagonists ) should be left to the discretion of the health care
provider.

Telemetry
No high-quality evidence was identified in the rapid review that evaluated the effectiveness of ECG
telemetry monitoring among patients with acute CHF. Based on expert opinion, clinical practice
guidelines suggest the use of continuous ECG monitoring among patients with acute CHF. The AHA

Assessment for ischemia
Clinical suspicion
ECG abnormalities
Troponin (+)
New heart failure

Eligible and
appropriate for
coronary
intervention
Yes
Coronary angiography +/-
revascularization; (Pr<15% cath; Pr<5%
PCI; Pr<5% CABG); medical
management for IHD may also be
required.
Uncertain
Non-invasive risk-stratification
should be undertaken either in-
hospital or during transition; medical
management for IHD should be
considered
Reason must be done on chart
(e.g., previously assessed and
patient known to be medical
management); medical
management for IHD should be
considered
Assessment of LV
function and valvular
heart disease (e.g., 2D
echocardiography)
Eligible and
appropriate for
valve repair or
surgery
Yes
Surgery or
interventional
cardiology (Pr:<5%)
Uncertain
No
Cardiology or cardiac
surgery referral
Reason must be
documented on chart


practice standards for in-hospital ECG monitoring suggest continuous ECG monitoring among all patients
with acute CHF. The ESC and HFSA guidelines recommend continuous ECG monitoring among acute
CHF patients treated with inotropes, based on the increased risk of arrhythmia and myocardial ischemia
with these agents.

The Expert Panel recommends the use of telemetry, but this intervention needs to be reassessed.
Furthermore, hospitals using telemetry should develop policies identifying patients eligibility and timing
for reassessment. A sample policy could read as follows:

The physician or nurse practitioner who assumes responsibility for telemetry monitoring should
review the telemetry record and assess the need for continued telemetry monitoring 48 hours after
initiation and then every 24 hours thereafter. If a telemetry-monitored patients rhythm is
unremarkable during a 24-hour period, the telemetry nurse may contact the responsible team to
reassess the need for continued telemetry monitoring. The decision to discontinue telemetry will be
made by the physician/nurse practitioner who assumes responsibility for telemetry monitoring, or the
critical care unit staff cardiologist when the urgent need arises to clear channels for other patients.

Summary
Table 16: Summary of Recommendations for the Acute Stabilization Phase (First 1224 Hours)
Recommendations
(Intervention/Resources)
High-Intensity
Case-Mix-Adjusted Patient
Low-Intensity
Case-Mix-Adjusted Patient
Mechanical ventilation
BIPAP Consider if appropriate
Oxygen Consider if appropriate
IV Lasix Consider if appropriate
IV vasoactive agents
PO Lasix
Telemetry Consider if appropriate and
available
1:1 nurse-to-patient staffing ratio No; typical inpatient medical
ward staffing ratio acceptable
ACE inhibitors/ARBs Consider if appropriate Consider if appropriate
-blockers Consider if appropriate
Ultrafiltration Consider if appropriate
Intensive PA monitoring
Other (IABP, assistive devices)
Monitor electrolytes, renal function, troponins,
chest x-ray

(chest x-ray if appropriate)
Record fluid input/output
Record weight
Other therapies (e.g., consider Aspirin, IV
heparin, statins if troponins-positive)

Assessment of precipitating factors
Discuss advanced directives
Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BIPAP, bilevel positive airway pressure; IABP, intra-aortic
balloon pump; IV, intravenous; PA, pulmonary artery; PO, per os (by mouth).


Clinical Assessment Node: Reassessment and Re-evaluation
Tables 17 and 18 show the recommendations of the Expert Panel with respect to the reassessment and re-
evaluation clinical assessment node.

Table 17: Reassessment and Re-evaluation: High-Intensity Case-Mix-Adjusted Patient
a

Re-evaluate underlying and precipitating cause
o Echocardiography
Screen for complications (e.g., arrhythmia, urosepsis, chronic obstructive pulmonary disease, renal failure,
pneumonia)
Continue management and monitoring as per care pathway
Withdrawal from therapy
a
Node 3, Figure 8, CHF episode of care pathway.

Table 18: Reassessment and Re-evaluation: Low- Intensity Case-Mix-Adjusted Patient
a

Re-evaluate underlying and precipitating cause
o Echocardiography
Screen for complications (e.g., arrhythmia, urosepsis, chronic obstructive pulmonary disease, renal failure,
pneumonia)
Continue management and monitoring as per care pathway
Withdrawal from therapy
aNode 5, Figure 8, CHF episode of care pathway.


Care Module: Sub-acute Stabilization Phase
The Expert Panel gave guidance on the management of CHF patients in the sub-acute management phase,
as shown in Table 19. The CCS, NICE, ESC, HFSA, and ACC/AHA have all highlighted these areas in
their guidelines.

Table 19: Sub-acute Care Module
Diuretic monitoring and management (sub-acute phase)
Early mobilization

Evidence-based pharmacotherapy management (sub-acute phase)
Other heart failure management considerations

Diuretic Monitoring and Management (Sub-acute Phase)
Diuretic monitoring and management in the sub-acute phase is similar to that of the acute phase,
recognizing that the patient is now more stable, has less pulmonary congestion and has been responsive to
more intensive diuretics. Weight and input/output should still be recorded daily. Electrolytes and renal
function can be monitored daily, every second day, or every third day, depending on the patients clinical
status, dose of Lasix, responsiveness to therapy, and prior electrolyte or renal laboratory abnormalities.

Early Mobilization
The Expert Panel recommends early mobilization as a new approach to in-hospital heart failure
management. The mobilization/activity care map should follow early-mobilization maps for other care
pathways (e.g., COPD). Mobilization depends upon responsiveness to diuresis, and activities such as
walking should not be encouraged for patients with severe residual pulmonary congestion or refractory
heart failure. Nevertheless, for most patients, activities should be scaled from sitting up in bed to sitting in
a chair with bathroom privileges, to walking (in the room and on the ward). Patients should be
encouraged to mobilize (with walking) at least once every 6 hours during daytime waking hours.

Evidence-Based Pharmacotherapy Management (Sub-acute Phase)
Similar to the acute phase, patients in the sub-acute phase should be treated with -blockers (assuming
there is no absolute contraindication), and ACE inhibitors/ARBs. Nitrates vasodilators should be used
in patients intolerant of or with contraindications to ACE inhibitors/ARBs. Again, the focus (in treatment-
nave patients) should be on initiating therapy at low doses and titrating slowly. The use of aldosterone
receptor antagonists should be left to the discretion of the treating health care providers.

Other Heart Failure Management Considerations
Other heart failure management considerations may include continuous positive airway pressure (CPAP)
for patients with confirmed sleep apnea and as recommended by a sleep specialist. Nitrates can be
considered for preload reduction. Digoxin can be considered for residual heart failure if symptoms persist
despite otherwise optimal therapy. Patients can be considered for an implantable cardioverter defibrillator
(ICD) or cardiac resynchronization therapy (CRT) at the discretion of the treating physician. The decision
to insert ICD/CRT devices should occur following optimization of heart failure therapy and reassessment
of ejection fraction, unless the patient who requires the ICD presents with ventricular arrhythmia.


Care Module: Advanced Heart Failure
After reassessment and re-evaluation, a small number of patients (approximately 1.3%) may follow an
advanced heart failure pathway. Table 20 shows some of the interventions included in the pathway.

Table 20: Advanced Heart Failure Management
Ultrafiltration or dialysis
Cardiac resynchronization therapy
PCI or CABG
Valve repair/replacement
Transplantation assessment
LVAD
Transplantation
Abbreviations: CABG, coronary artery bypass graft; LVAD, left ventricular assist device; PCI, percutaneous coronary intervention.


Care Module: Discharge Phase
A sub-panel was created to review the discharge-planning phase and explore the transitional care phase,
which is a continuation of the CHF episode of care into the community. The sub-panel adopted the Naylor
et al. (2011) definition of transitional care as a broad range of time-limited services designed to ensure
health care continuity, avoid preventable poor outcomes among at-risk populations and promote the safe
and timely transfer of patients from one level of care to another or from one type of setting to another.
20

The few available definitions of hospital discharge planning indicate that it is a process that takes place
between hospital admission and the discharge event.
21
Predischarge communication is important as a start
to the transitional care process: it provides an opportunity to summarize the visit, teach patients how to
safely care for themselves at home, and address any remaining questions or concerns. Discharge planning
helps patients communicate with caregivers and primary care providers about how best to manage chronic
needs after leaving the hospital.
22

As shown in Figure 7, there are 2 discharge modules in the episode of care pathway: discharge from the
ED and discharge after admission. To establish the discharge planning modules and to begin
understanding the evidence relating to the transitional care phase, the sub-panel reviewed the OHTAC
reports Discharge Planning in Chronic Conditions: An Evidence-Based Analysis
23
and Recommendation:
Specialized Community Based Care for Chronic Disease
24
, as well as the HQO BestPath Transitional
Care report and the CCS, NICE, ESC, HFSA, and ACC/AHA guidelines. Through its review and
consultation with experts in the field of transitional care, the sub-panel found that there were randomized
controlled trials, systematic reviews and meta-analyses on inpatient hospital-to-home discharge planning,
but no studies for ED-to-home discharge. The sub-panel decided that both discharge planning modules
would be similar for this report.

The OHTAC report Discharge Planning in Chronic Conditions: An Evidence-Based Analysis
summarized the following interventions:
Predischarge interventions
Patient education
Discharge planning
Medication reconciliation
Appointment scheduled before discharge
Postdischarge interventions
Timely primary care physician communication
Timely clinic follow-up
Follow-up telephone call
Postdischarge hotline
Home visit
Interventions bridging the transition
Transition coach
Patient-centred discharge instructions
Provider continuity

20 Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. The care span: the importance of transitional care in achieving health reform. Health
Aff. 2011;30(4):746-54.
21 Holland DE, Harris MR. Discharge planning, transitional care, coordination of care and continuity of care: clarifying concepts and terms from the
hospital perspective. Home Health Care Serv Q. 2007;26(4):3-19.
22 Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. Forthcoming 2012.
23 Ontario Health Technology Assessment Series; Vol. 12: No. TBA, pp. 170, July 2012
24 Ontario Health Technology Assessment Series; Vol. 12: No. 20, pp. 160, November 2012


Using the above interventions, clinical guidelines and expert advice, the sub-panel established the
discharge-planning module for the episode of care pathway. Individualized discharge planning includes
communication of weight and creatinine at discharge, evaluation of care needed at home and the ability to
attend follow-up visits with a family physician and specialist.

Table 21 shows the components of the discharge-planning module. According to the OHTAC report, the
evidence supports the use of individualized discharge planning, and studies have shown a significant
reduction in readmissions favouring individualized discharge planning. However, the risk of readmission
prior to discharge should be assessed.

Table 21: Discharge Planning Module
Diuretic monitoring and management
Evidence-based pharmacotherapy
Other relevant medical therapies
Counselling
o Medication management
o Lifestyle (alcohol, smoking)
o Daily weight and self-monitoring
o Diet
o Physical activity
o Advanced care directives
Predischarge functional capacity and mobility assessment
Predischarge cognitive and social support assessment
Physician appointments
o General practitioner/family physician identified, and follow-up visit scheduled within 2 weeks of
discharge
o Ambulatory care specialty follow-up (cardiology or internal medicine)
Timely documentation
o Discharge notes dictated and sent to primary care (and relevant other) provider(s) within 1 week
(ideally within 48 to 72 hours of hospital discharge)

Diuretic Monitoring and Management
Patients should be on a standing Lasix order and followed by a heart failure clinic. Daily input/outputs
and weights should be recorded.

Evidence-Based Pharmacotherapy
All patients without absolute contraindications should be receiving ACE inhibitors/ARBs and -blockers.
If patients cannot tolerate ACE inhibitors/ARBs or cannot take them due to contraindications, they should
be receiving hydralazine and nitrates. The use of aldosterone receptor antagonists should be left to the
discretion of the provider; the ESC 2012 guidelines recommend the use of aldosterone receptor
antagonists.

Other Relevant Medical Therapies
Other heart failure management considerations may include CPAP for patients with confirmed sleep
apnea, if recommended by a sleep specialist. Additional therapies may include statins and antiplatelets for
patients with ischemic heart disease or anticoagulation for patients with atrial fibrillation.


Counselling
Education should be provided for patients and family members/caregivers on the symptoms and signs of
worsening heart failure and how to respond. Consider also assessing health literacy: hospitals should
adapt their education programs based on health literacy or learning disabilities and have materials
available in different languages.

The guidelines recommend counselling on medication management, lifestyle (e.g., smoking), daily weight
and self-monitoring, diet (e.g., salt restriction, fluid intake), physical activity, and advanced care
directives. The counselling strategy will likely require multiple in-hospital allied health professionals
(e.g., pharmacists, social worker, nursing), and would incur costs. Medication reconciliation at discharge
should involve the community pharmacist.

Predischarge Functional Capacity and Mobility Assessment
Available evidence has demonstrated that functional capacity is an important predictor of outcomes
among patients with CHF, and accordingly, may be used to help prognostically risk-stratify hospitalized
patients as they are discharged into community settings.
25
For example, at least 1 study has determined
that patients hospitalized with acute decompensated heart failure who cannot achieve 200 metres in a 6-
minute walk test (6MWT) at discharge have a significantly higher risk of death or rehospitalization than
those able to achieve 200 metres or greater (equivalent to an activity intensity level of approximately 2
METs

).
26
Although the 6 MWT is known to have prognostic value, implementing it in a clinical setting
may be challenging. Additional challenges include potential delay in discharge due to lack of availability
of staff to perform a proper 6 MWT, since the volume of CHF patients in a hospital can be significant,
increasing the workload of physiotherapists and nurses.

Accordingly, all patients (with the exception of those deemed to be at the end of life and those unable to
mobilize due to neurologic or musculoskeletal abnormalities) should undergo some objective physical
activity assessment prior to discharge. The Expert Panel recommends that the local hospital decide on the
appropriate assessment. For example, clinicians can use a 6MWT or a low-level (modified) protocol on a
treadmill or cyclometer exercise test. Patients unable to pass the mobilization test should either remain in
hospital or be discharged under close supervision (i.e., rapid heart failure assessment clinic).

The Expert Panel recommended that the costs for providing the above tests (with respect to human
resources and equipment) for functional capacity assessment should be included in the care bundle for all
eligible patients surviving to discharge.

Predischarge Cognitive and Social Support Assessment
Before discharge, patients will require cognitive and/or social support assessment. Cognitive assessment
should be done by trained staff. The process will require additional human resources and should be
included in the care bundle for all eligible patients surviving to discharge.

Physician Appointments
General practitioner/family physician follow-up
The Expert Panel recommends that a primary care or specialty care visit should occur within 2 weeks of
discharge. Each CHF patient discharged from hospital or the ED should be followed up by both their
primary and specialty care providers.

25 Am Heart J. 2008 Feb;155(2):200-7. Epub 2007 Nov 26
26 J Card Fail. 2009 Mar;15(2):130-5. Epub 2008 Dec 5


The Expert Panel recognized that the tagging of whether or not a patient has a primary care physician
needs to be done consistently. Some patients do not have family physicians, making it impossible to
schedule physician follow-up after discharge from hospital. The Expert Panel agreed that in such cases,
the hospital should provide transitional care until the patient can be handed off.

In addition, some primary care physicians may see CHF patients only rarely. It may be a challenge for
such physicians to develop schedules that allow availability for follow-up of CHF patients discharged
from hospital.

Ambulatory care specialty follow-up
The Expert Panel recommends that CHF patients discharged from hospital be referred to a specialized
community-based heart failure clinic within 2 weeks of discharge. OHTAC recommends that
Mechanisms that enable rapid access (within 13 days) to specialized care should be built into the model
of heart failure clinics.
27

Timely Documentation
The Expert Panel recommends that discharge notes be dictated and sent to primary care (and relevant
other) provider(s) within 1 week of patient discharge, but preferably within 48 hours.

27
Ontario Health Technology Assessment Series; Vol. 12: No. 20, pp. 160, November 2012


Transitional Care Pathway
Although there is a process for transitional care in approximately 80 to 90% of hospitals in Ontario, this
practice is not standardized throughout the province (OHTAC, 2012).
28
Through discussions at the sub-
panel meetings, it was established that transitional care in Ontario is likely more of an organic process,
with varying elements tailored to suit the needs of the community (e.g., some hospitals may have
discharge planners, while some may use the services of Community Care Access Centres).

A multidisciplinary approach is suggested for transitional care, with the involvement of family physicians
and family health teams, nurses (potentially through the Community Care Access Centres or other Local
Health Integration Networkfunded programs), community pharmacists, occupational therapists, social
workers and dietitians.

In Ontario, there are many interventions within a region addressing different aspects of transition of care,
but there is a need for better coordination of care. Many issues were discussed related to the present
transition of care models, including the lack of standardized interventions; the lack of risk stratification to
prevent community nurses and therapists being deployed to all CHF patients on discharge; and the lack of
cost analyses related to interventions. For these reasons, the Expert Panel supports the implementation of
specialized community-based heart failure clinics in Ontario.

28
Ontario Health Technology Assessment Series; Vol. 12: No. 20, pp. 160, November 2012


Performance Measurement
The Expert Panel was requested by the Ministry to provide recommendations related to CHF performance
indicators. The intent is for these recommendations to inform the development of a QBF Integrated
Scorecard for CHF, which would track a number of indicators related to the episode of care and
recommended practices for CHF. Similar scorecards are to be developed for other clinical areas that are
subject to QBF funding.

A rapid review of the evidence was done to investigate whether performance indicators for in-hospital
heart failure management were effective at improving patient outcomes. No meta-analyses, health
technology assessments or systematic reviews were identified, but 2 guideline reports were identified that
reported on performance indicators for in-hospital heart failure management: the 2010 CCS guidelines for
the diagnosis and management of heart failure update
29
and the American College of Cardiology
Foundation (ACCF)/AHA Task Force on Performance Measures and the American Medical Association
Physician Consortium for Performance Improvement (AMA-PCPI) 2011 Performance Measures for
Adults with Heart Failure
30
. A summary of the performance indicators listed in the CCS guidelines is
shown in Table 22. The ACCF/AHAAMA-PCPI 2011 performance measures report similar
performance indicators.

Overall, the relationship between specific performance measures and patient outcomes remains unclear.
Reasons for this include the following:
Methodological limitations of the studies, such as nonrandomized designs and limited followup
Many commonly assessed performance indicators have not been shown in clinical trials to reduce
mortality and prevent hospitalization
While some performance indicators may have been met (such as smoking cessation counselling),
the manner in which they were delivered may have been suboptimal
Baseline adherence to performance indicators such as ACE inhibitors in eligible patients was
already high in some studies, making further improvements in patient outcomes more difficult to
demonstrate

29
Howlett JG, McKelvie RS, Costigan J, Ducharme A, Estrella-Holder E, Ezekowitz JA, et al. The 2010 Canadian Cardiovascular Society guidelines for
the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management,
and quality improvement/assurance programs. Can J Cardiol. 2010;26(4):185-202.
30
Bonow RO, Sadwin LB, Sikkema JD, Sincak CA, Spertus J, Torcson PJ, et al. ACCF/AHA/AMA-PCPI 2011 performance measures for adults with
heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the
American Medical Association-Physician Consortium for Performance Improvement. Circulation. 2012;125(19):2382-401.


Table 22: Summary of Performance Indicators for Heart Failure by Development Group
Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CAD, coronary artery disease; CCB, calcium channel blocker; CVD, cardiovascular disease; CXR, chest x-ray;
ECG, electrocardiogram; ICD, implantable cardioverter defibrillator; LV, left ventricle; PVD, peripheral vascular disease.
Indicator Canadian
Cardiovascular
Outcomes
Research Team
(CCORT)
inpatient
American Heart
Association/
American College
of Cardiology
(AHA/ACC)
inpatient
Joint
Commission on
Accreditation of
Healthcare
Organizations
(JCAHO)
Organized Program
to Initiate
Lifesaving
Treatment in
Hospitalized
Patients with Heart
Failure
(OPTIMIZE-HF)
Assessing the Care
of Vulnerable
Elders Project
(ACOVE)

Therapeutics
ACEi and/or ARB if LV systolic dysfunction in eligible patients x x x x x
Use of beta blockers in eligible patients x x x x
Use of statins in eligible patients if underlying CAD, PVD, CVD, or diabetes x
Aldosterone antagonists for eligible patients x
Anticoagulants for atrial fibrillation x x x
Use of ICD in eligible patients
Avoid 1
st
and 2
nd
generation CCBs if LV systolic dysfunction x
Avoid type 1 antiarrhythmic agents if LV systolic dysfunction (unless ICD in
place)
x
Investigations
Outpatient assessment including or more of regular volume assessment,
weight, blood pressure, activity level
x x
Appropriate baseline blood/urine tests, ECG, CXR x
Appropriate biochemical monitoring of renal function and electrolytes x
Assessment of LV function x x x x x
Measure digoxin levels if toxicity suspected x
Education and follow-up
HF patient education/discharge instructions x x x x x
Outpatient follow-up within 4 weeks
Advice on smoking cessation
x x x


Although there are measures in Ontario related to the quality of care provided to CHF patients, very few
of the Expert Panels recommended practices can be captured in current Ontario hospital administrative
datasets, and beyond routine administrative data. For example, ED risk stratification is a critical clinical
assessment node in the care pathway model. It is important that all variables needed to derive the
EMHRG score are mandatory so that they can be documented as process indicators. In this way, the
EMHRG score can be derived in retrospect to see if/how patients are triaged according to these indicators.
Clinical registries similar to the Ontario Stroke Audit or the EFFECT database for CHF need to be
developed to routinely collect data and measure the quality of care provided to CHF patients.

Performance Indicators
The Expert Panel developed a list of quality indicators that can be used to measure whether patients
follow the CHF episode of care pathway developed in this clinical handbook. Indicators were selected to
reflect a few best-practice surrogates, which may provide a foundation for ensuring that hospitals are
adhering to some general evidence-based principles across the CHF care pathway. With the compressed
timelines for the selection of indicators, a scientifically validated methodology (such as a Delphi
approach) for identifying and prioritizing current measures and new measures for development was not
possible. However, using a similar process, the Expert Panel selected 11 indicators that are considered
developmental. These indicators can be recalibrated using detailed chart abstraction if they do not serve as
a surrogate for best-practice care.

The indicators selected are shown in Table 23, below.


Table 23: Proposed Performance Indicators
Clinical Assessment
Node/Care Module
Area of Interest for
Measurement
Indicator Concept
ED risk stratification and
responsiveness to diuresis
node
Identification and
documentation of risk (this
will be important to the
decision-making process)
Was a risk-stratification method used to identify
whether a CHF patient was high-intensity (risk) vs.
average-intensity (risk) vs. low-intensity (ED
observation and discharge)?
Risk stratification should be based on the following
parameters: oxygen saturation, serial troponin, renal
function, responsiveness to ED diuresis, chest x-ray
(alveolar pulmonary edema), etc.
Acute stabilization module Diuretic management and
monitoring
Was the patients weight recorded daily?
High-intensity CHF patients: Are serum electrolytes
(sodium, potassium, renal function) being monitored
daily for 3 days and then reassessed?
Low-intensity CHF patients: Are serum electrolytes
(sodium, potassium, renal function) being monitored
every 1 to 2 days and then reassessed?
Discharge phase module

Evidence-based
pharmacotherapy
Was the patient given ACE inhibitors or ARBs at
discharge if EF < 40%? Yes/No; if no, why not?
Was the patient given -blockers at discharge?
Yes/No; if no, why not?
Counselling Was medication counseling provided? Yes/No; if no,
why not?
Was end-of-life/advanced-care discussion at least
once during hospitalization? Yes/No; if no, why not?
Predischarge functional
capacity and mobility
assessment
Walkability test (treadmill, 6MWT, walking on ward);
did patient demonstrate that he/she can achieve 2
METs? Yes/no/not done; if no, physiotherapy
assessment needed prior to discharge; if not done,
state reason
Physician appointments Is the patient given a confirmed scheduled
appointment date with outpatient general practitioner,
specialist or attending physician within 2 weeks of
discharge?
Is the patient referred to heart failure clinic? Yes/no; if
no, state reason
Predischarge cognitive and
social support assessment
Was CCAC/homecare assessment done?
Abbreviations: 6MWT, 6 minute walking test; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CCAC, Community Care
Access Centre; CHF, congestive heart failure; ED, emergency department; EF, ejection fraction; MET, metabolic equivalent.


Implementation of Best Practices
After formulating the majority of their recommendations, the Expert Panel was asked by
the Ministry to provide high-level advice around implementation, including specific
recommendations focused on the following areas:
implementation of best practices
impact on multidisciplinary teams
system program and capacity planning required
change management and support for change required

Special Considerations for Cost Bundling
1. The current CIHI clinical administrative datasets informed the development of the CHF episode
of care pathway. To use the pathway for funding purposes, additional data must be collected
routinely. Cost datasets such as the Ontario Cost Distribution Methodology and OCCI have
utilization information that can be helpful in the costing of the care pathway model. Although
detailed microcosting and utilization data are available in hospitals OCCI data, the data
submitted by hospitals to the Ministry is aggregated. A detailed data collection and submission
plan must be developed to support the implementation of the CHF episode of care pathway model
for funding purposes.
2. The care pathway model does not specifically take into account case-mix complexity from
chronic conditions other than heart failure. Accordingly, we use the term case-mix-adjusted to
reflect that this care pathway should represent an individual of average case-mix complexity.
However, available evidence using Ontario data has demonstrated that length of stay within both
high-intensity and low-intensity units is highly variable and depends on case-mix complexity and
the number of coexisting chronic diseases. Cost bundling should continue to take into account the
case-mix complexity/resource intensity weight methodology in some manner.
3. The care pathways in urban vs. rural hospitals may vary significantly because of differences in
service availability and patient populations. CHF patients generally admitted to tertiary/teaching
facilities have greater cardiac illness severity. Most importantly, the prevalence or proportions of
patients expected to follow different pathway, investigative or treatment streams (i.e., in the
diagram represented as Pr = ), will vary according to hospital type. Cost bundling should reflect
such geographical and hospital-type differences.
4. Many quality-of-care variables will be expected to contribute minimally to costs (e.g.,
documenting daily weights), while other variables could have far-reaching cost implications to
the system as a whole (increasing access to home-care, follow-up physician services, cardiac
rehabilitation, etc.). Low-cost items could be included as incentives to the cost bundle, while
higher-cost items may necessitate a different cost bundle strategy, with greater cost-estimate
granularity and precision.
5. Counselling costs should be factored into the care bundle of all patients surviving to discharge.
6. It will not be possible to promote the movement of appropriate patients to ambulatory settings
and achieve the associated cost efficiencies without addressing out-of-hospital incentives for best
practices (examples of this include the development of specialized community-based heart failure
clinics in Ontario).


Specialized Community-Based Heart Failure Clinics in Ontario
The Expert Panel supports the implementation of specialized community-based heart failure clinics for
transitional care. Based on moderate to high quality evidence of improved patient and health system
outcomes through specialized community-based care (intermediate care), in 2012 OHTAC recommended
the following
31
:
Access to specialized community-based care (intermediate care) should be made available for
patients with chronic diseases and whose diseases are becoming uncontrollable despite primary
care.
Recognizing that primary care is the optimal way of treating and coordinating care of patients
with comorbidities, patients should be returned to primary care for further follow-up with a
revised treatment plan once they have been stabilized in intermediate care.
Recognizing the complexities of these recommendations, HQO should develop a high-level
implementation plan that would provide advice regarding the adoption of these recommendations.
In addition, Local Health Integration Networks should be approached to seek their interest in
implementing OHTAC intermediate care recommendations in collaboration with experts.
Evidence-based standards for multidisciplinary community-based care derived from EBAs,
economic analyses, and field evaluation studies, as appropriate, should be derived for each of the
chronic diseases.
Health Quality Ontario should consider developing quality performance indicators based on these
standards of care, tracking adherence to these standards and using this evidence base for
developing quality-based funding.

With respect to the CHF episode of care, OHTAC made the following recommendations relating to
standards of care for specialized multidisciplinary heart failure clinics. These standards were endorsed by
a CCN expert working group. The following is a summary from OHTAC Recommendation: Specialized
Community Based Care for Chronic Disease.
32

Evidence-Based Components
1. Active medication titration to evidence-based target doses should be a key priority of heart failure
clinics.
2. Care should be consistent with evidence-based guidelines for the management of heart failure.
3. Health-care professionals should provide education, self-management training, and counselling to
patients and their informal caregivers. Special efforts should be made to encourage informal
caregivers to participate in patient management to ensure knowledge translation has been
successful whenever possible.
4. Mechanisms that enable appropriately frequent follow-up should be built into the model of heart
failure clinics.

31
http://www.hqontario.ca/portals/0/Documents/eds/ohtac-recommendation-specialized-care.pdf
32
http://www.hqontario.ca/portals/0/Documents/eds/ohtac-recommendation-specialized-care.pdf


Expert Opinion-Based Components
1. Mechanisms that enable rapid access (within 13 days) to specialized care should be built into the
model of heart failure clinics.
2. A structure of the roles and responsibilities, collaboration, and communication between heart
failure specialists, primary care providers, and hospital inpatient physicians should be developed
and implemented to facilitate efficient and effective seamless care.
3. Once the patients are stabilized, heart failure clinics need to demonstrate that patients are referred
back to primary care with a care management plan.
4. HQO will work with experts, CCN and heart failure clinics to develop and promulgate standards
to be followed by heart failure clinics and their referral base throughout the LHINs.

The Expert Panel recommends that CHF patients discharged from hospital be referred to a specialized
community-based heart failure clinic within 2 weeks of discharge. There was acknowledgement that more
heart failure clinics need to be established throughout the province to prevent delays follow-up.

Implementation of Best Practices
Provincial Versus Local Care Pathways
It should be recognized that the practices recommended in this clinical handbook have been defined at an
aspirational provincial level to guide all hospitals across the province. This is not intended to be an
operational care pathway: individual providers will have to implement these best practices based on their
own local circumstances and available capacities. In many cases, implementation of these
recommendations will be challenged by local arrangements or availability of services. For example, the
Expert Panel discussed variation across the province in the provision of ventilation: while some hospitals
provide noninvasive ventilation in a general medical ward, others only provide it in intensive care units.

Track Current Practice Against Recommended Practices
As discussed in Section 5, many of the practices recommended by the Expert Panel are not currently
tracked in any consistent way at either the local or provincial level. Thus, it is difficult to know what the
gap is between current and ideal CHF practice, and how much this gap varies across organizations and
parts of the province. A key objective of developing a CHF performance measurement strategy should be
to enable organizations to track, audit, and evaluate the implementation of care pathways and
recommended practices at the organizational level. Through such monitoring, variances can be identified,
progress monitored, and the pathway can be refined over time.


Role of Multidisciplinary Teams
One of the important issues in CHF care discussed by the Expert Panel is the lack of dedicated teams and
resources in Ontario for CHF. In stroke care, for example, the Ontario Stroke Strategy has led to the
widespread use of dedicated stroke units and interdisciplinary stroke teams. Such dedicated units and
teams are much less common for CHF. The Expert Panel discussed a promising area for further research
in evaluating the difference in outcomes between CHF patients cared for in nonspecialized teams and/or
units with those cared for by specialized CHF teams and/or units (e.g., cardiology). Further work is
required to define what constitutes a specialized team and to assess the feasibility of establishing these
teams in hospitals of different sizes across the province.

Service Capacity Planning
The Ministry was interested in advice from the Expert Panel about capacity planning and shifts across
care settings for CHF. The most important issue identified by the Expert Panel is inconsistent capacity in
and access to ICU beds and heart failure clinics once patients are discharged. This is a major opportunity
area for the Ministry, Local Health Integration Networks, hospitals, CCACs and other service providers to
work together to improve outcomes for CHF patients and to also impact rates of unplanned readmissions.
The Expert Panel supports the recommendation that the roles and responsibilities, collaboration, and
communication between heart failure specialists, primary care providers, and hospital inpatient physicians
should be developed and implemented to facilitate efficient, effective, seamless care.


Expert Panel Membership
Expert Panel for Health Quality Ontario: Episode of Care for Congestive Heart Failure
Name Role Organization
Dr. David Alter

Senior Scientist Institute for Clinical Evaluative Sciences Research
Program Director and Associate Staff, The Cardiac
and Secondary Prevention Program at the Toronto
Rehabilitation Institute-UHN
Associate Professor of Medicine, University of Toronto
Dr. Douglas Lee Scientist Institute for Clinical Evaluative Sciences
Dr. Catherine Demers Associate Professor Division of Cardiology, Department of Medicine
McMaster University
Dr. Susanna Mak Cardiologist University of Toronto, Department of Medicine,
Division of Cardiology, Mount Sinai Hospital
Dr. Lisa Mielniczuk Medical Director, Pulmonary
Hypertension Clinic
University of Ottawa Heart Institute
Dr. Peter Liu President, International
Society of Cardiomyopathy
and Heart Failure of the
World Heart Federation

Director, National C-
CHANGE Program

Scientific Director/VP
Research, University of
Ottawa Heart Institute

Professor of Medicine
Dr. Robert McKelvie

Professor of Medicine,
Cardiologist
McMaster University, Hamilton Health Sciences
Dr. Malcolm Arnold

Professor of Medicine University of Western Ontario, London Health
Sciences Centre
Dr. Stuart Smith

Chief of Cardiovascular
Services
Director, Heart Failure
Program
St. Marys General Hospital
Dr. Atilio Costa Vitali Assistant Professor of
Medicine
Division of Clinical Science
Sudbury Regional Hospital
Dr. Jennifer Everson Physician Lead Hamilton Niagara Haldimand Brant Local Health
Integration Network
Dr. Lee Donohue Family Physician Ottawa
Linda Belford Nurse Practitioner, Practice
Leader PMCC
University Health Network


Jane MacIver Nurse Practitioner Heart
Failure/Heart Transplant
University Health Network
Sharon Yamashita Clinical Coordinator, Critical
Care
Sunnybrook Health Sciences Centre
Claudia Bucci Clinical Coordinator,
Cardiovascular Diseases
Sunnybrook Health Sciences Centre
Andrea Rawn Evidence Based Care
Program Coordinator
Grey Bruce Health Network
Darlene Wilson Registered Nurse Heart Function Clinic, Trillium Health Centre
Kari Kostiw Clinical Coordinator

Health Sciences North
Ramsey Lake Health Centre
Janet Parr CHF Patient
Heather Sherrard Vice President, Clinical
Services
Sue Wojdylo Manager, Case Costing Lakeridge Health
Jane Chen Manager of Case Costing University Health Network
Nancy Hunter LHIN Liaison & Business
Development
Cardiac Care Network of Ontario
Ministry Representatives
Gary Coleridge Senior Program Consultant Ministry of Health and Long-Term Care
Louie Luo Senior Methodologist Ministry of Health and Long-Term Care


Appendices
Appendix I: CHF Patient GroupICD-10-CA Details
I50 Heart failure
I ncludes:
Additional code from (E10-E14) with fourth and fifth digits .52 to classify any associated diabetes
mellitus
Additional code from (I11) (hypertensive heart disease) or (I13) (hypertensive heart and renal
disease) for heart failure due to hypertension

Excludes:
Complicating:
abortion or ectopic or molar pregnancy (O00-O07) (O08.8)
obstetric surgery and procedures (O75.4)
Following cardiac surgery or due to presence of cardiac prosthesis (I97.1)
Neonatal cardiac failure (P29.0)

I50.0 Congestive heart failure
I ncludes:
Congestive heart disease (CHF)
Right ventricular failure (secondary to left heart failure)

Excludes: fluid overload NOS (E87.7)

I50.1 Left ventricular failure
I ncludes:
Cardiac asthma
Left heart failure

I50.9 Heart failure, unspecified
I ncludes:
Cardiac, heart or myocardial failure NOS

I40 Acute myocarditis
I40.0 Infective myocarditis
I ncludes:
Septic myocarditis
Additional code (B95-B97) to identify infectious agent

I40.1 Isolated myocarditis

I40.8 Other acute myocarditis

I40.9 Acute myocarditis, unspecified


I41 Myocarditis in diseases classified elsewhere
I41.0 Myocarditis in bacterial diseases classified elsewhere
I ncludes:
Myocarditis:
diphtheritic (A36.8)
gonococcal (A54.8)
meningococcal (A39.5)
syphilitic (A52.0)
tuberculous (A18.8)

I41.1 Myocarditis in viral diseases classified elsewhere
I ncludes:
Influenzal myocarditis (acute):
avian influenza virus identified (J09)
other virus identified (J10.8)
virus not identified (J11.8)
Mumps myocarditis (B26.8)

I41.2 Myocarditis in other infectious and parasitic diseases classified elsewhere
I ncludes:
Myocarditis in:
Chagas disease:
(acute) (B57.0)
(chronic) (B57.2)
toxoplasmosis (B58.8)

I41.8 Myocarditis in other diseases classified elsewhere
I ncludes:
Rheumatoid myocarditis (M05.3)
Sarcoid myocarditis (D86.8)

I42 Cardiomyopathy
Excludes:
Cardiomyopathy complicating:
pregnancy (O99.4)
puerperium (O90.3)
Ischemic cardiomyopathy (I25.5)

I42.0 Dilated cardiomyopathy
I ncludes: Congestive cardiomyopathy

I42.1 Obstructive hypertrophic cardiomyopathy
I ncludes: Hypertrophic subaortic stenosis

I42.2 Other hypertrophic cardiomyopathy
I ncludes: Nonobstructive hypertrophic cardiomyopathy


I42.3 Endomyocardial (eosinophilic) disease
I ncludes:
Endomyocardial (tropical) fibrosis
Lfflers endocarditis

I42.4 Endocardial fibroelastosis
I ncludes: Congenital cardiomyopathy

I42.5 Other restrictive cardiomyopathy
I ncludes: Constrictive cardiomyopathy NOS

I42.6 Alcoholic cardiomyopathy

I42.7 Cardiomyopathy due to drugs and other external agents
Additional external cause code to identify cause

I42.8 Other cardiomyopathies

I42.9 Cardiomyopathy, unspecified
I ncludes:
Cardiomyopathy (primary) (secondary) NOS
Additional code from category (E10-E14) with fourth and fifth characters .52 to classify any
associated
diabetes mellitus

I43 Cardiomyopathy in diseases classified elsewhere
I43.0 Cardiomyopathy in infectious and parasitic diseases classified elsewhere
I ncludes: Cardiomyopathy in diphtheria (A36.8)

I43.1 Cardiomyopathy in metabolic diseases
I ncludes: Cardiac amyloidosis (E85.-)

I43.2 Cardiomyopathy in nutritional diseases
I ncludes: Nutritional cardiomyopathy NOS (E63.9)

I43.8 Cardiomyopathy in other diseases classified elsewhere
I ncludes:
Gouty tophi of heart (M10.0)
Thyrotoxic heart disease (E05.9)



Hypertensive heart disease and CHF patients
These ICD-10-CA codes must include the CHF codes I50.X
I11 Hypertensive heart disease
I ncludes:
Hypertensive heart disease NOS
Use additional code to identify any (congestive) heart failure (I50.-) due to hypertension

I13 Hypertensive heart and renal disease
I ncludes:
Any condition in I11 with any condition in I12 disease:
cardiorenal
cardiovascular renal
hypertensive heart and renal disease NOS
Use additional code to identify any:
(chronic) kidney disease (failure) (N18.- , N19) due to hypertension
heart failure (I50.-) due to hypertension


Appendix II: Rapid Review Methodology
Table A1 outlines the process and components comprising the Evidence Development and Standards
Branch Rapid Review process.

Table A1: Rapid Review Methodology
Steps Components
1. Develop research question Develop PICOS in consultation with experts, end users,
applicant, etc.
Limited scoping of question (e.g., Blue Cross Blue Shield,
AETNA, CIGNA)
Determine study selection criteria (inclusion/exclusion)
Determine a maximum of 2 outcomes to GRADE in step 5
2. Conduct literature search 5 years
English
MEDLINE, EMBASE, Cochrane, Centre for Reviews and
Dissemination
SRs, MAs, HTAs (establish in advance that these study designs
exist for your topic; if not, request RCTs and guidelines as well)
3. Screen and select studies Selection of SR, MA, HTA
Rate SRs with AMSTAR
Retrieve primary studies from SR, MA, HTA for step 4
4. Conduct data extraction and analysis
a
Extract data on 2 outcomes from primary studies
5. Apply GRADE assessment outcomes
a
GRADE maximum of 2 outcomes
6. Write up findings Write findings using Rapid Review template
Abbreviations: AMSTAR, Assessing the Methodological Quality of Systematic Reviews; HTA, health technology assessment; MA, meta-analysis;
PICOS, population, intervention, comparison, outcome, setting; SR, systematic review.
a
These steps are required if the identified SR, MA, and/or HTA did not use GRADE to assess relevant outcomes.

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