Original article Inclusion into a heart failure critical pathway reduces the risk of death or readmission after hospital discharge Nicolas Garin a, b, ⁎, Sebastian Carballo a , Eric Gerstel a , René Lerch c , Philippe Meyer c , Maryam Zare a , Alexis Zawodnik d , Arnaud Perrier a a Division of Internal Medicine, Geneva University Hospitals, Switzerland b Division of Internal Medicine, Chablais Regional Hospital, Switzerland c Division of Cardiology, Geneva University Hospital, Switzerland d Division of Clinical Pharmacology, Geneva University Hospitals, Switzerland abstract article info Article history: Received 12 January 2012 Received in revised form 30 May 2012 Accepted 6 June 2012 Available online 2 July 2012 Keywords: Heart failure Disease management Critical pathway Background: Evidence-based therapies can lower the risk of death or hospital admission in heart failure (HF) patients, but are underprescribed. Critical pathways are one means of supporting systematic use of evidence- based recommendations. Methods: Patients admitted for HF in one hospital in 2009 and included in a critical pathway were compared with a control group of patients admitted in 2007. The primary endpoint was the risk of death or readmission within 90 days after discharge. The hazard ratio of death or readmission was evaluated in a multivariate Cox proportional hazard model adjusting for age, sex, co-morbidities, and length of stay. Results: Three hundred and sixty-three patients were evaluated (151 in the critical pathway and 212 in the control group). Adjusted hazard ratio for death or readmission at 90 days was 0.72 (95 CI 0.51–1.00, p = 0.049). Adhesion to guidelines was significantly better for patients included in the critical pathway (p = 0.004), with more frequent prescription of beta-blockers (70.9% (95% CI 62.9–78.0) vs. 56.6% (95% CI 49.6–63.4), p = 0.006), and evaluation of left ventricular ejection fraction (LVEF, 73.5% (95% CI 65.7–80.3) vs. 57.5% (95% CI 50.6–64.3), p = 0.002). Patients with reduced LVEF seem to have benefited the most from the inclusion in the critical pathway. Conclusions: Implementation of a critical pathway for patients hospitalized for HF was associated with a 28% reduction of the relative risk of death or readmission and improved adhesion to guidelines. © 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. 1. Introduction The prevalence of chronic heart failure (HF) is estimated at 1–2% in developed countries [1] and rises sharply with age, with 10 to 20% of people aged over 75 years being affected [2]. Mortality can reach 11% at 30 days and 37% at 1 year among elderly patients admit- ted for HF [3]. HF hospitalizations account for 5% of all hospital admis- sions [4]. The risk of readmission after a first hospitalization for HF can reach 20 to 25% at 30 days and 40 to 50% at 90 days [3,5,6]. Mul- tiple admissions do not only impact heavily on the quality of life of patients but are also associated with increased subsequent mortality [7,8]. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin- receptor blockers (ARBs) [9], beta-blockers [10], mineralocorticoid receptor antagonists (MRAs) [11,12], cardiac resynchronization ther- apy (CRT) in selected patients [13], and intensive case management for ambulatory patients [14] have all been shown to reduce the risk of hospital admission in chronic HF with reduced left ventricular ejec- tion fraction (LVEF). Even if these evidence-based therapies are wide- ly diffused in national and international guidelines [15–17], their underuse has been repeatedly documented, particularly for beta blockers and MRAs [18–20]. A critical (or clinical) pathway is an organizational tool for im- proving the quality of care delivery [21]. It is developed through a multidisciplinary analysis of the process of care, and based on the best available evidence. Its physical substrate is mainly document- based, consisting of medical records, operating procedures, and care plans [22]. Formal evaluations of critical pathways have suggested that they can be useful for decreasing length of stay, total costs, and mortality in chronic HF inpatients [23]. However, these benefits have not been replicated in all settings [24]. We aimed to test the abil- ity of a computer-based critical pathway to lower the risk of death and readmission and to improve the quality of care in a cohort of pa- tients admitted for HF. European Journal of Internal Medicine 23 (2012) 760–764 ⁎ Corresponding author at: Service de Médecine Interne Générale, Hôpitaux Universitaires de Genève, 4 rue Gabrielle-Perret-Gentil, 1211 Genève 14, Switzerland. Tel.: +41 24 473 14 32, +41 79 454 07 70(mobile); fax: +41 24 473 14 46. E-mail address: Nicolas.Garin@hcuge.ch (N. Garin). 0953-6205/$ – see front matter © 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2012.06.006 Contents lists available at SciVerse ScienceDirect European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim