Enhancing quality of heart failure care in managed Medicare and Medicaid in North Carolina: results of the North Carolina Achieving Cardiac Excellence (NC ACE) Project

Am Heart J. 2005 Oct;150(4):717-24. doi: 10.1016/j.ahj.2004.12.025.


Objectives: To evaluate an intervention to improve the quality of care of patients with heart failure in managed Medicare and Medicaid plans in North Carolina.

Background: Utilization of angiotensin-converting enzyme inhibitors (ACE-I) and beta-adrenergic receptor blockers (BB) in heart failure (HF) patients remains suboptimal despite evidence-based guidelines supporting their use.

Methods: Managed care plans identified adult patients with HF during 2000 (preintervention) and from July 1, 2001, through June 30, 2002 (postintervention). Outpatient medical records were reviewed to obtain data regarding type of heart failure, demographics, comorbidities, and therapies. The intervention consisted of guideline summary dissemination, performance audit with feedback, patient-specific chart reminders, and patient activation mailings.

Results: We sampled 1613 patients from 5 plans during the preintervention period and 1528 patients during the postintervention period. Assessment of left ventricular function (LVF) increased from 88.2% to 92.5% of patients (P < .0001). Among patients with moderate to severe left ventricular systolic dysfunction, there was no substantive change in treatment with ACE-I or vasodilators, whereas, appropriate treatment with BB increased from 48.3% (with another 11.9% with documented contraindications) to 67.9% (with another 7.5% with documented contraindications). The quality gap decreased from 39.8% to 24.6% (P < .0001).

Conclusion: LVF assessment improved despite high preintervention rates. Treatment rates with ACE-I and vasodilators remained high, but did not improve. Treatment rates with BB improved substantially translating into a significant public health benefit. Health-care payers should consider development of financial incentives to encourage collaborative quality improvement programs.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use*
  • Adult
  • Aged
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Drug Utilization Review*
  • Female
  • Guideline Adherence
  • Heart Failure / drug therapy*
  • Humans
  • Male
  • Managed Care Programs / standards*
  • Medicaid / standards*
  • Medical Audit
  • Medicare / standards*
  • Middle Aged
  • North Carolina
  • Quality Assurance, Health Care / methods*


  • Adrenergic beta-Antagonists
  • Angiotensin-Converting Enzyme Inhibitors