Performance Measures and Outcomes for Patients Hospitalized With Heart Failure

Abstract

To the Editor: Dr Fonarow and colleagues studied the association between heart failure performance measures and mortality and rehospitalization. While adherence to guidelines is important and could affect hard clinical end points, neither this study nor the American College of Cardiology/American HeartAssociation(ACC/AHA)clinicalperformancemeasures for adults with chronic heart failure addresses patient medication adherence, an important aspect of this complex issue. There is evidence that 15% to 30% of patients discontinue guideline-recommended medications within 1 year, and, in some cases, do so as early as 30 days. Therefore, assessing quality of care based on performance measures at discharge without also considering patient medication adherence introduces potential for significant bias. Using such measures to judge the quality of efforts at facilities or by physicians who serve population subgroups less likely to adhere to medications is akin to ignoring case mix—an approach that would be judged unfair. While we agree with Fonarow et al that additional measures and better methods are needed to accurately assess and improve the care of patients with heart failure, such measures must consider all factors with significant influence on patient outcomes. Developing a “multilevel” performance measure that captures both physicians’ adherence to evidence-based guidelines and patients’ adherence to these regimens would better reflect quality in heart failure care and enable a more accurate assessment of performance in the delivery of health care for this and other chronic diseases.