Use of clinical indicators succeeded in supporting clinicians to monitor practice standards and to realize change in systems of care and clinician behaviour.

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in‐hospital and after‐hospital care, patient self‐care, and hospital–community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6‐month baseline period and included: ➢clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); ➢educational interventions (seminars, academic detailing); ➢regular performance feedback; ➢patient self‐management strategies; and ➢hospital–community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before–after study design to assess program impact, significantly more program patients compared with historical controls received: ➢ACS: Angiotensin‐converting enzyme (ACE) inhibitors and lipid‐lowering agents at discharge, aspirin and β‐blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. ➢CHF: Assessment for reversible precipitants, use of prophylaxis for deep‐venous thrombosis, β‐blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk‐adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P = 0.06) and from 13.4% to 10.1% (P = 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P = 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

The prevalence of heart failure (HF) continues to rise, driven by an ageing population, increasing rates of obesity and diabetes, and better survival in patients with cardiovascular disease.1 While HF is associated with substantial morbidity and mortality, a number of treatments have been shown to improve outcomes in large-scale randomised controlled trials (RCT), including pharmacological inhibition of the renin-angiotensin system (with or without neprilysin inhibition), betablockers, mineralocorticoid receptor antagonists, sinus node inhibition, cardiac resynchronisation therapy with biventricular pacing, implantable cardioverter defibrillators and multidisciplinary models of care. [2][3][4] In order to realise the benefits of these treatments, however, we need to consider how patients were selected for these RCT and how the treatments were delivered.The adoption of innovative models of care and the delivery of device therapies can be particularly challenging, given that they are highly dependent on the individual operators and rely on substantial infrastructure and staffing support. At first glance, it would appear that the administration of pharmacological therapies for HF should be relatively straightforward, but such therapies are also highly dependent on the individual prescribers, rely on substantial infrastructure and staffing support, and involve real complexities around medication persistence and patient adherence.In this review, we will discuss medication titration in HF and consider whether or not it is too complex in the real-world setting.We conducted a literature search in November and December 2016 using PubMed. Keywords included 'heart failure', which was used in combination with 'medication' or 'therapy' and 'titration' or 'up-titration', 'dose' or 'target dose'. We also searched reference lists of relevant primary studies and systematic reviews. We used no language or date restrictions. All types of study design were included where medication titration was a primary endpoint. Clinical Trials Evaluating Medications in Heart FailureLarge-scale randomised controlled trials (RCTs) have demonstrated that angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta-blockers and mineralocorticoid receptor antagonists all improve clinical outcomes in patients with HF associated with a reduced left ventricular ejection fraction (HFrEF). 5-12Indeed, such studies suggest that the combination of an ACEI, betablocker and mineralocorticoid receptor antagonist should translate to a 60-70 % relative risk reduction in all-cause mortality. 13 Nevertheless, it is likely that the balance between benefit and harm varies according to patient age, disease severity, associated comorbidities and approaches to monitoring and medication titration. An example of the impact of comorbidities was demonstrated by an individual patient data meta-analysis of the beta-blocker RCTs, in which the benefits were only observed in patients in sinus rhythm, there was no reduction in hospitalisation or...

The National Heart Foundation of Australia assembled an expert panel to provide guidance on policy and system changes to improve the quality of care for people with chronic heart failure (CHF). The recommendations have the potential to reduce emergency presentations, hospitalisations and premature death among patients with CHF. Best-practice management of CHF involves evidence-based, multidisciplinary, patient-centred care, which leads to better health outcomes. A CHF care model is required to achieve this. Although CHF management programs exist, ensuring access for everyone remains a challenge. This is particularly so for Aboriginal and Torres Strait Islander peoples, those from non-metropolitan areas and lower socioeconomic backgrounds, and culturally and linguistically diverse populations. Lack of data and inadequate identification of people with CHF prevents efficient patient monitoring, limiting information to improve or optimise care. This leads to ineffectiveness in measuring outcomes and evaluating the CHF care provided. Expanding current cardiac registries to include patients with CHF and developing mechanisms to promote data linkage across care transitions are essential. As the prevalence of CHF rises, the demand for multidisciplinary workforce support will increase. Workforce planning should provide access to services outside of large cities, one of the main challenges it is currently facing. To enhance community-based management of CHF, general practitioners should be empowered to lead care. Incentive arrangements should favour provision of care for Aboriginal and Torres Strait Islander peoples, those from lower socioeconomic backgrounds and rural areas, and culturally and linguistically diverse populations. Ongoing research is vital to improving systems of care for people with CHF. Future research activity needs to ensure the translation of valuable knowledge and high-quality evidence into practice.

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