Checklist for Heart Failure Treatments Improves Adherence to Guideline-Directed Treatment and Outcomes in Patients with Chronic Heart Failure with Reduced Ejection Fraction
Doungporn Ruthirago MD*, Nattawut Wongpraparut MD*, Saowanee Naowapanich RN*, Akarin Nimmannit MD**, Suthipol Udompunturak MSc***, Rungtiwa Pongakasira BSc****
Affiliation : * Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand ** Office for Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand *** Clinical Epidemiology Unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand **** Her Majesty’s Cardiac Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Background : Chronic heart failure (HF) with reduced ejection fraction is a common cause of hospital admission. Patients
who do not take medications for secondary prevention as described in the guidelines have significantly poorer long-term
outcomes. Physicians may forget to prescribe these medications when contraindications to taking them no longer exist.
Safety checklists have been found to decrease morbidity and mortality in a number of conditions and procedures.
Objective : To investigate whether implementation of a HF checklist can improve physician adherence to the American
College of Cardiology/American Heart Association (ACC/AHA) 2009 treatment guidelines in patients with chronic HF with
reduced ejection fraction and the treatment outcomes.
Material and Method: This prospective cohort with historical controlled cohort study compared a control group and an
intervention group of patients recently diagnosed with HF with reduced ejection fraction within six months by an
echocardiography that were treated at Siriraj Hospital’s outpatient cardiology clinic. Patients in the control group were
diagnosed between January and October 2011, and patients in the intervention group were diagnosed between January and
October 2012. The control group received normal care without use of the HF checklist. The medical records of control
group were retrospectively reviewed to collect the data at the first visit and the two follow-up visits at 3- and 6-month. HF
checklist was attached inside the outpatient medical record of patients in the intervention group at the first visit and the two
follow-up visits. The physicians completed the HF checklists before prescribing medications. The medical records of
intervention group were reviewed at the end of the study.
Results : Ninety-three patients were included. Rate of adherence to medications, such as beta-blockers, angiotensin-converting
enzyme inhibitors, and aldosterone antagonists was significantly improved in the intervention group at first visit after
enrollment and at the 3- and 6-month follow-up visits. Mean blood pressure was significantly lower in the intervention group
at six months. The 6-month readmission rate was lower in the intervention group than in the control group (4.7% vs. 20.8%,
p = 0.027). There was a trend toward lower 6-month mortality rate in the intervention group.
Conclusion : Implementation of a HF checklist in patients with chronic HF with reduced ejection fraction improved both
physician adherence to ACC/AHA 2009 guidelines and clinical outcomes, resulting in fewer cardiovascular hospitalizations
and a trend toward lower mortality rate.
Keywords : Chronic systolic heart failure, Heart failure checklist, Medication, Guideline adherence
