Physicians’ guideline adherence is associated with long-term heart failure mortality in outpatients with heart failure with reduced ejection fraction: The QUALIFY international registry

M Komajda,J Schöpe,S Wagenpfeil,L Tavazzi,M Böhm,P Ponikowski,S Anker,G Filippatos,M Cowie

doi:10.1016/j.acvdsp.2019.09.070

Abstract

Physicians’ adherence to guideline-recommended therapy is associated with short-term clinical outcomes in heart failure (HF) with reduced ejection fraction (HFrEF). However, its impact on longer-term outcomes is poorly documented. In this analysis we assessed the longer-term association of physicians’ adherence with clinical outcomes, including mortality and unplanned hospitalisations, at 18-month follow-up of the QUALIFY registry (Clinical trial registration ISRCTN87465420) Data at 18 months were available for 6118 ambulatory HFrEF patients from this international prospective observational survey. Adherence was measured as a continuous variable, ranging from 0 to 1, and was assessed with regard to five classes of recommended HF medications and dosages. Most deaths were cardiovascular (CV) (228/394) and HF-related (191/394) and the same was true for unplanned hospitalisations (1175 CV and 861 HF-related hospitalisations, out of a total of 1541). According to univariable analysis, CV and HF deaths were significantly associated with physician adherence to guidelines. In multivariable analysis, HF death was associated with adherence level [subdistribution hazard ratio (SHR) 0.93, 95% confidence interval (CI) 0.87–0.99 per 0.1 unit adherence level increase; P = 0.034] as was composite of HF hospitalisation or CV death (SHR 0.97, 95% CI 0.94–0.99 per 0.1 unit adherence level increase; P = 0.043), whereas unplanned all-cause, CV or HF hospitalisations were not (all-cause: SHR 0.99, 95% CI 0.9–1.02; CV: SHR 0.98, 95% CI 0.96–1.01; and HF: SHR 0.99, 95% CI 0.96–1.02 per 0.1 unit change in adherence score; P = 0.52, P = 0.2, and P = 0.4, respectively). These results suggest that physicians’ adherence to guideline-recommended HF therapies is associated with improved outcomes in HFrEF. Practical strategies should be established to improve physicians’ adherence to guidelines.

Highlights

Heart failure (HF) is a major cause of mortality, morbidity and impaired quality of life (QoL) and places a substantial financial burden on healthcare systems worldwide. [1,2,3,4] International guidelines make clear recommendations as to which evidence-based drugs should be prescribed for patients with heart failure (HF) with reduced ejection fraction (HFrEF). [5,6] observational studies have repeatedly shown that patients are missing out on potentially life-saving therapies. [7,8][9,10] Even when prescription rates of guideline-based HF medication are high, patients frequently fail to reach target doses [11] and some, but not all, randomised studies have shown that sub-optimal dosing may adversely influence outcomes. [12,13]
Recommended medications were often under-dosed since 27.3% of patients treated with angiotensin converting enzyme inhibitors (ACEI), 49.9% of those on angiotensin receptor blocker (ARB) and 48.5% of those on beta blockers (BBs) received at least half of the dose recommended by the international guidelines
The data from the recent prospective European BIOSTAT-chronic heart failure (CHF) study in 2516 HF patients showed that those with HFrEF who were treated with less than 50% of recommended doses of ACEIs/ARBs and BBs seemed to have a greater risk of death and/or HF hospitalization than patients reaching at least 100% of recommended doses.[27]

Summary

Introduction

Heart failure (HF) is a major cause of mortality, morbidity and impaired quality of life (QoL) and places a substantial financial burden on healthcare systems worldwide. [1,2,3,4] International guidelines make clear recommendations as to which evidence-based drugs should be prescribed for patients with HF with reduced ejection fraction (HFrEF). [5,6] observational studies have repeatedly shown that patients are missing out on potentially life-saving therapies. [7,8][9,10] Even when prescription rates of guideline-based HF medication are high, patients frequently fail to reach target doses [11] and some, but not all, randomised studies have shown that sub-optimal dosing may adversely influence outcomes. [12,13] there is evidence that good adherence to HF treatment guidelines is associated with better short-term cardiovascular (CV) mortality[14] and hospitalization, [14,15] international data on the longer-term association of adherence to guidelines with clinical outcomes are scarce. To address the need for a longer-term, global perspective, the QUALIFY study (QUality of Adherence to guideline recommendations for LIFe-saving treatment in heart failure surveY) was established. Previous reports have presented baseline characteristics and guideline adherence scores (good, moderate, poor) for the study population at enrolment,[19] and shown the beneficial impact of physicians’ adherence to these five guideline-recommended classes of HF medication, including prescription of recommended doses, on clinical outcomes at 6-month follow-up. [20] In the current paper, we assessed the longer-term association of physicians’ adherence with clinical outcomes, including mortality and unplanned hospitalizations, at 18-month follow-up. Physicians’ adherence to guideline-recommended therapy is associated with short-term clinical outcomes in heart failure (HF) with reduced ejection fraction (HFrEF). Conclusion: These results suggest that physicians’ adherence to guideline-recommended HF therapies is associated with improved outcomes in HFrEF.

Methods

Results

Conclusion