Heart Failure Performance Measures Research Articles

2024 Update to the 2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: A Report of the American Heart Association/American College of Cardiology Joint Committee on Performance Measures.

This document describes performance measures for heart failure that are appropriate for public reporting or pay-for-performance programs and is meant to serve as a focused update of the "2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures." The new performance measures are taken from the "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines" and are selected from the strongest recommendations (Class 1 or Class 3). In contrast, quality measures may not have as much evidence base and generally comprise metrics that might be useful for clinicians and health care organizations for quality improvement but are not yet appropriate for public reporting or pay-for-performance programs. New performance measures include optimal blood pressure control in patients with heart failure with preserved ejection fraction, the use of sodium-glucose cotransporter-2 inhibitors for patients with heart failure with reduced ejection fraction, and the use of guideline-directed medical therapy in hospitalized patients. New quality measures include the use of sodium-glucose cotransporter-2 inhibitors in patients with heart failure with mildly reduced and preserved ejection fraction, the optimization of guideline-directed medical therapy prior to intervention for chronic secondary severe mitral regurgitation, continuation of guideline-directed medical therapy for patients with heart failure with improved ejection fraction, identifying both known risks for cardiovascular disease and social determinants of health, patient-centered counseling regarding contraception and pregnancy risks for individuals with cardiomyopathy, and the need for a monoclonal protein screen to exclude light chain amyloidosis when interpreting a bone scintigraphy scan assessing for transthyretin cardiac amyloidosis.

Inpatient Quality-of-Care Measures for Heart Failure: Treatment Gaps and Opportunities in the Contemporary Era.

Quality of care measures are vital tools to assess processes of care within and between health care systems. The 2020 American College of Cardiology/AHA performance measures for heart failure provide a new set of such measures. We evaluated the achievement of these and other performance measures within the Veterans Affairs hospital system in a contemporary cohort of patients hospitalized for heart failure. Hospital discharges from January 2010 to February 2021 with a primary diagnosis of heart failure (n=289 810) were evaluated. Adherence to each measure was determined using the measure's stated definition and by site. Among patients with reduced ejection fraction (53.0%), beta blocker use was high (89.0%), ACE (angiotensin-converting enzyme) inhibitor, angiotensin receptor blocker, or angiotensin receptor-neprilysin inhibitor (ARNI) use decreased over time (75.3% in 2010, 55.8% in 2020), and hydralazine/nitrate use in eligible Black patients (19.3%) was low. While 68.1% were eligible for ARNI, only 6.0% received them, reaching 17.2% by 2020. Mineralocorticoid receptor antagonists were used in 49.3% of those eligible; laboratory testing 7 days after their initiation was 73.0%, detecting hyperkalemia in 2.2%, although it occurred in 13.7% by 90 days. Achievement of ≥50% target dose was low (beta blocker 45.9%, ACE inhibitor/angiotensin receptor blocker 31.6%, ARNI 19.0%) and for ACE inhibitor/angiotensin receptor blocker/ARNI, decreased over time. Discharge appointments were 56.2% at 7 days and 78.8% at 14 days. Cardiac rehabilitation referral was low (10.5%) but increased. There were significant site-level differences, particularly for hydralazine, ARNI, devices, and cardiac rehabilitation. Important inpatient quality of care measures can be readily measured across the Veterans Administration health care system from electronic health records. Treatment gaps and site-level differences persisted into the contemporary era and will likely be exacerbated as newer treatments are added to this complex baseline. These measures and methods also offer the opportunity to target global, local, and individual processes of care for innovative quality improvement initiatives.

Association of hospital performance measures with readmissions for patients with heart failure: A report from JROAD-DPC study

BackgroundMeasuring quality of care is central to quality improvement. Improving outcomes for heart failure (HF) may relate to hospital care delivery. However, there is limited nationwide data on the relationship between hospital-level HF performance measures and clinical outcomes. MethodsFrom the Japanese Registry of All cardiac and vascular Diseases (JROAD-DPC) database, 83,567 HF patients hospitalised in 731 certificated hospitals in 2014 by the Japanese Circulation Society were analysed. Five performance measures were prescription rate of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, and mineralocorticoid receptor antagonist and measurement rate of echocardiography and B-type natriuretic peptide during hospitalisation. Relationships between these measures and 1-year readmission due to HF were analysed. Composite performance score (CPS) obtained from the five performance measures and outcomes were also analysed. We also investigated the relationships between CPS and hospital structural factors. ResultsFrom the cohort (mean age; 78.2 years, woman 48.4%), HF readmission rate at 1 year was 19.6% (n = 16,368). Readmission rate decreased with higher quartiles of prescription rate in each medication and diagnostic performance rates. The highest CPS group was associated with a 15% risk reduction in HF readmission compared with the lowest CPS group (hazard ratio, 0.85, 95% confidence interval [0.80–0.89], p < 0.001) after covariate adjustment. Several structural factors such as number of cardiology specialists, hospital case volume for HF, and presence of cardiac surgery division were associated with high CPS. ConclusionHigher hospital performance measures for HF were inversely associated with HF readmissions.

2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure

2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure

Validity of Performance and Outcome Measures for Heart Failure.

Background Numerous quality metrics for heart failure (HF) care now exist based on process and outcome. What remains unclear, however, is if the correct quality metrics are being emphasized. To determine the validity of certain measures, we compared correlations between measures and reliability over time. Measures assessed include guideline-recommended β-blocker (BB), any BB, angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker, mineralocorticoid receptor antagonist, and hydralazine/isosorbide dinitrate (in blacks) use among candidates, 30-day mortality, 1-year mortality, and 30-day readmission. Methods and Results This was an observational cohort analysis using chart review and electronic resources for 55 735 patients from 102 Veterans Affairs medical centers hospitalized with HF from 2008 to 2013. Assessments of convergent validity and reliability were performed. Significant correlations were found between in-hospital rates of ACE inhibitor use and the following measures: BB use, 30-day mortality, and 1-year mortality. Guideline-recommended BB use was also significantly correlated with mineralocorticoid receptor antagonists, 30-day mortality, and 1-year mortality. There was no correlation between 30-day readmission rates and any therapy or mortality. Measure reliability over time was seen for guideline-recommended BBs ( r=0.57), mineralocorticoid receptor antagonists ( r=0.50), 30-day mortality ( r=0.29), and 1-year mortality ( r=0.31). ACE inhibitor and readmission rates were not reliable measures over time. Conclusions BB use, ACE inhibitor use, mortality, and mineralocorticoid receptor antagonist use are valid measures of HF quality. Thirty-day readmission rate did not seem to be a valid measure of HF quality of care. If the goal is to identify high-quality HF care, the emphasis on decreasing readmission rates might be better directed towards improving usage of the recommended therapies.

Practitioner Gender and Quality of Care in Ambulatory Cardiology Practices: A Report From the National Cardiovascular Data Practice Innovation and Clinical Excellence (PINNACLE) Registry.

Some studies suggest that female practitioners are more likely to provide guideline-concordant care than male practitioners; however, little is known about the role of practitioner gender in cardiology. The aim of the study was to measure the association between practitioner gender and adherence to the cardiovascular performance measures in the American College of Cardiology's ambulatory Practice Innovation and Clinical Excellence Registry. Patients with at least 1 outpatient visit with a unique practitioner were included. Among eligible patients, adherence to 7 guideline-supported performance measures for coronary artery disease, heart failure, and atrial fibrillation over 12 months after registry entry was compared by practitioner gender using hierarchical models adjusting for practitioner type (physicians vs advance practice practitioners) and number of visits. The study cohort included 1493 individual practitioners who saw 769 139 patients; 80% of practitioners were men. Male practitioners were more often physicians compared with female practitioners (98.2% vs 43.7%, P < .01). Accounting for practitioner category and visit frequency, guideline adherence rates were similar by practitioner gender for all measures with the exception of marginally higher rates for coronary artery disease performance measures for male practitioners compared with female practitioners (antiplatelet: rate ratio [RR] = 1.06; 95% confidence interval [CI], 1.03-1.09; β-blockers: RR = 1.06; 95% CI, 1.01-1.10; and lipid-lowering drug: RR = 1.07; 95% CI, 1.04-1.10) and atrial fibrillation (oral anticoagulants: RR = 1.05; 95% CI, 1.01-1.09). Male practitioners marginally outperformed their female counterparts in ambulatory practices enrolled in a voluntary cardiovascular performance improvement registry program. Overall low adherence to some performance measures suggests room for improvement among all practitioners.

Abstract 080: Validity of Performance Measures for Heart Failure

Background: Numerous quality metrics for heart failure care now exist based on process (from clinical guidelines) or outcome (readmission and mortality). It is unclear, however, how valid these measures are at serving as indicators of hospital quality for patients with heart failure (HF). We sought to determine validity by comparing convergent validity (correlation among measures) and reliability (correlation over time). Methods: We gathered data on several HF performance measures from the Veterans Affairs Health Care System from 2008-2013. Process data are collected through chart review of a random sample of facilities. There are between 114 and 119 facilities that have at least one patient that is a treatment candidate each year. There are a mean 72 patients per facility per year included. For each facility and each year, we determined, among ideal candidates, use of ACE-inhibitor (ACEi), any beta-blocker (BB), recommended beta-blocker (rBB) (carvedilol, metoprolol succinate, bisoprolol), mineralocorticoid receptor antagonist (MRA), hydralazine/isosorbide dinitrate in African Americans, as well as rates of 30-day readmission, 30-day mortality, and 1-year mortality. We measured validity in 2 ways: determining correlations between measures, assuming that if a measure is associated with overall “quality” that it should be correlated with the other measures, and year-to-year reliability, assuming that if a measure has a good signal/noise ratio then there should be a strong correlation from one year to the next. Results: Data were available for 55,735 hospitalizations for HF from 2008-2013. In determining correlations between performance measures, we found a statistically significant correlation between ACEi and rBB (R=0.25, p&lt;0.001), ACE inhibitors and any BB (R=0.20, p&lt;0.001), ACEi and 30-day mortality (R=-0.08, p&lt;0.05), ACEi and 1-year mortality (R=-0.12, p&lt;0.01), rBB and MRA (R=0.12, p&lt;0.01), rBB and 30-day mortality (R=-0.11, p&lt;0.01), rBB and 1-year mortality (R=-0.18, p&lt;0.001), any BB and MRA (R=0.12, p&lt;0.01), any BB and 30-day mortality (-0.08, p&lt;0.05), and any BB and 1-year mortality (R=-0.13, p&lt;0.001). Additionally, both rBB and any BB showed statistically significant year-to-year reliability (R=0.57, p&lt;0.0001 and R=0.48, p&lt;0.0001 respectively). MRA, 30-day mortality, and 1-year mortality also had similar reliability (R=0.50, R=0.42, R=0.41, respectively, p&lt;0.0001), but not ACEi (R=0.04, p=0.71). Readmission within 30 days and hydralazine/nitrate were not reliable year-to-year nor did they correlate with any of the above performance measures. Conclusion: BB, ACEi and MRA use rates showed evidence of validity as measures of HF quality through correlation with each other, mortality and/or year to year reliability. In contrast, 30-day readmission was poorly correlated with process of care and mortality and had poor reliability.

Accreditation and improvement in process quality of care: a nationwide study.

To examine whether performance measures improve more in accredited hospitals than in non-accredited hospital. A historical follow-up study was performed using process of care data from all public Danish hospitals in order to examine the development over time in performance measures according to participation in accreditation programs. All patients admitted for acute stroke, heart failure or ulcer at Danish hospitals. Hospital accreditation by either The Joint Commission International or The Health Quality Service. The primary outcome was a change in opportunity-based composite score and the secondary outcome was a change in all-or-none scores, both measures were based on the individual processes of care. These processes included seven processes related to stroke, six processes to heart failure, four to bleeding ulcer and four to perforated ulcer. A total of 27 273 patients were included. The overall opportunity-based composite score improved for both non-accredited and accredited hospitals (13.7% [95% CI 10.6; 16.8] and 9.9% [95% 5.4; 14.4], respectively), but the improvements were significantly higher for non-accredited hospitals (absolute difference: 3.8% [95% 0.8; 8.3]). No significant differences were found at disease level. The overall all-or-none score increased significantly for non-accredited hospitals, but not for accredited hospitals. The absolute difference between improvements in the all-or-none score at non-accredited and accredited hospitals was not significant (3.2% [95% -3.6:9.9]). Participating in accreditation was not associated with larger improvement in performance measures for acute stroke, heart failure or ulcer.

Abstract 375: Influence Of Intensification Of Pharmacology Therapy In Preventing Hospital Readmissions

Background: A Gap remains between evidence-based guidelines in the treatment of heart failure and current pharmacologic and device therapy. Current performance measures for Heart Failure are designed to assess medication prescription but fail to address the need to achieve optimal pharmacology dosing. Methods: We examined 405 patients’ charts who were admitted with a diagnosis of acute systolic heart failure or acute on chronic systolic heart failure with a left ventricular ejection fraction ≤ 40%. Twenty-one data elements related to heart failure were abstracted based on Seattle Heart Failure Model. Results: The mean age of the population examined was 77 ± 9 years. The cohort was comprised of 72 % males, mean weight 89 ± 22.5kg, with NYHA class 2.4 ± 0.6 symptoms. Ischemic etiology was identified in 86% with a mean left ventricular EF of 29.8 ± 9 %. The one year all-cause mortality rate was 19.5 %, reflecting an advanced heart failure population. There were 97 (23.9%) patients who were not readmitted in 1 year and were considered as optimal medical therapy. The readmission group was compared against this group (Tables). Up titration of medication or addition happened only in 27 % of patients. In 61.5 % of patients there were no dose adjustments made in follow up visits. There was statistically significant difference (P &lt; 0.05) between both the groups in terms of pharmacology and device therapy. Conclusion: Up titration of heart failure medications to guideline recommended therapeutic doses reduces heart failure readmissions.

Associations Between Use of the Hospitalist Model and Quality of Care and Outcomes of Older Patients Hospitalized for Heart Failure

This study sought to examine the associations of hospitalist and cardiologist care of patients with heart failure with outcomes and adherence to quality measures. The hospitalist model of inpatient care has grown nationally, but its associations with quality of care and outcomes of patients hospitalized with heart failure are not known. We analyzed data from the Get With the Guidelines-Heart Failure registry linked to Medicare claims for 2005 through 2008. For each hospital, we calculated the percentage of heart failure hospitalizations for which a hospitalist was the attending physician. We examined outcomes and care quality for patients stratified by rates of hospitalist use. Using multivariable models, we estimated associations between hospital-level use of hospitalists and cardiologists and 30-day risk-adjusted outcomes and adherence to measures of quality care. The analysis included 31,505 Medicare beneficiaries in 166 hospitals. Across hospitals, the use of hospitalists varied from 0% to 83%. After multivariable adjustment, a 10% increase in the use of hospitalists was associated with a slight increase in mortality (risk ratio: 1.03; 95% confidence interval [CI]: 1.00 to 1.06) and decrease in length of stay (0.09 days; 95% CI: 0.02 to 0.16). There was no association with 30-day readmission. Increased use of hospitalists in hospitals with high use of cardiologists was associated with improved defect-free adherence to a composite of heart failure performance measures (risk ratio: 1.03; 95% CI: 1.01 to 1.06). Hospitalist care varied significantly across hospitals for heart failure admissions and was not associated with improved 30-day outcomes. Comanagement by hospitalists and cardiologists may help to improve adherence to some quality measures, but it remains unclear what care model improves 30-day clinical outcomes.

Heart failure performance measures: Eligibility and implementation in the community

The goal of heart failure (HF) performance measures is to improve quality of care by assessing the implementation of guidelines in eligible patients. Little is known about the proportion of eligible patients and how performance measures are implemented in the community. We determined the eligibility for and adherence to performance measures and β-blocker therapy in a community-based cohort of hospitalized HF patients from January 2005 to June 2011. All of the 465 HF inpatients (median age 76 years, 48% men) included in the study received an ejection fraction assessment. Only 164 had an ejection fraction <40% thus were candidates for β-blocker and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) therapy. Considering absolute contraindications, 99 patients were eligible to receive ACE inhibitors/ARB, and 162 to receive β-blockers. Among these, 85% received ACE inhibitors/ARBs and 91% received β-blockers. Among the 261 individuals with atrial fibrillation, 89 were eligible for warfarin and 54% received it. Of 52 current smokers, 69% received cessation counseling during hospitalization. In the community, among eligible hospitalized HF patients, the implementation of performance measures can be improved. However, as most patients are not candidates for current performance measures, other approaches are needed to improve care and outcomes.

Abstract 107: Quality Of Care In Heart Failure Patients Hospitalized For Any Cause

Background: Hospital quality performance measures for heart failure (HF) target patients with a principal discharge diagnosis of HF. However, patients with chronic HF are commonly admitted for other causes and are recommended treatments such as angiotensin converting enzyme (ACE) inhibitors for left ventricular (LV) systolic dysfunction. The purpose of this study was to assess the quality of care for HF patients who are hospitalized for all causes. Methods: We conducted a community-wide surveillance of hospitalized patients with acute or chronic HF as part of the Atherosclerosis Risk in Communities (ARIC) Study from 2005-2009. HF diagnosis was validated by chart abstraction and adjudication by physician committee. We assessed rates of compliance for two available Centers for Medicare &amp; Medicaid Services (CMS) inpatient quality measures: LV function assessment and discharge prescription for an ACE inhibitor or angiotensin receptor blocker (ARB) for patient with LV systolic dysfunction; rates were compared for HF patients with a principal ICD-9 discharge diagnosis of HF and those with another principal discharge diagnosis. Cox proportional hazard models were used to assess the association of quality measures with post-discharge mortality. Results: Of 4,345 hospitalizations of HF patients, 39.6% carried a principal discharge diagnosis of HF. Individuals with a principal discharge diagnosis of HF had higher rates of LV function assessment (89.1% versus 82.5%, p&lt;0.0001; adjusted prevalence ratio (aPR) 1.07, 95% CI 1.04-1.10) and ACE inhibitor/ARB use in LV dysfunction (64.1% versus 56.3%, p&lt;0.01; aPR 1.11, 95% CI 1.03-1.20) as compared to individuals hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with significant or near significant reductions in post-discharge mortality (adjusted hazard ratios 0.69, 95% CI 0.50-0.90 and 0.73, 95% CI 0.52-1.03, respectively). The associations between quality measures and post-discharge mortality did not differ for patients with versus without a primary discharge diagnosis of HF (p-interaction=0.8 for LV assessment; p-interaction=0.6 for ACE inhibitor/ARB use). Conclusions: Compared to individuals hospitalized with a principal diagnosis of heart failure, heart failure patients hospitalized for other causes are less likely to receive aspects of guideline recommended care. Quality initiatives may improve care and outcomes by targeting hospitalizations with both a principal and secondary HF diagnosis.

Are we targeting the right metric for heart failure? Comparison of hospital 30-day readmission rates and total episode of care inpatient days

Hospitals are challenged to reduce length of stay (LOS), yet simultaneously reduce readmissions for patients with heart failure (HF). This study investigates whether 30-day rehospitalization or an alternative measure of total inpatient days over an episode of care (EOC) is the best indicator of resource use, HF quality, and outcomes. Using data from the American Heart Association's Get With The Guidelines-Heart Failure Registry linked to Medicare claims, we ranked and compared hospitals by LOS, 30-day readmission rate, and overall EOC metric, defined as all hospital days for an HF admission and any subsequent admissions within 30 days. We divided hospitals into quartiles by 30-day EOC and 30-day readmission rates. We compared performance by EOC and readmission rate quartiles with respect to quality of care indicators and 30-day postdischarge mortality. The population had a mean age of 80 ± 7.95 years, 45% were male, and 82% were white. Hospital-level unadjusted median index LOS and overall EOC were 4.9 (4.2-5.6) and 6.2 (5.3-7.4) days, respectively. Median 30-day readmission rate was 23.2%. Hospital HF readmission rate was not associated with initial hospital LOS, only slightly associated with total EOC rank (r = 0.26, P = .001), and inversely related to HF performance measures. After adjustment, there was no association between 30-day readmission and decreased 30-day mortality. In contrast, better performance on the EOC metric was associated with decreased odds of 30-day mortality. Although hospital 30-day readmission rate was poorly correlated with LOS, quality measures, and 30-day mortality, better performance on the EOC metric was associated with better 30-day survival. Total inpatient days during a 30-day EOC may more accurately reflect overall resource use and better serve as a target for quality improvement efforts.

Does Systematic Adherence to Joint Commission and AHA Heart Failure Performance Measures Improve Patient Outcomes?

Author(s): Bender, M; Jaski, BE; Glaser, D; Thomas, V; Cary, DS; Smith, SC | Abstract: Introduction It is unclear whether inpatient heart failure (HF) performance measures reduce post-discharge adverse events. This exploratory study examined the association between systematic adherence to a set of performance measures and outcomes. Measures included all four Joint Commission (JC) HF core measures and AHA recommended beta blockade prescription on discharge. Methods A retrospective review of a 3-hospital system was performed for all patients discharged with a primary diagnosis of HF in 2008-2009. Patients were included if they met eligibility criteria for one or more measures (n=1270). ‘Perfect care’ was defined as compliance with all eligible measures. Subsequent all-cause 30-day readmission and 1-year mortality was determined via electronic records and social security national database. Results ‘Perfect care’ significantly reduced 30-day readmissions (19.2% vs. 24.9%, p=.045; OR=.72, 95% CI 0.52-0.99). ‘Perfect care’ did not influence 1-year mortality. Conclusions Adherence to this set of composite performance measures positively influenced short-term patient outcomes. Benefit of adherence was found despite the longer LOS and higher severity of illness on index admission for patients receiving ‘perfect care’. The data support the clinical value of a systematic approach towards HF care on patient care quality. ‘Perfect care’ did not influence long term outcomes, which may be because inpatient processes do not extend to long term outpatient medical management.

11. Heart failure core measure analysis project and it's impact on transitional discharge plans and 30 day readmissions

Heart Failure is among the top five most prevalent diagnoses. The 30 day readmissions of HF patients are costly and a burden the health care system. Nursing staff‘s knowledge base increased thorough understanding of Heart Failure Performance Measures, Outcomes and need for transitional plans and it impact on reimbursement to the organization.Despite the focused on discharge instructions for heart failure with systolic dysfunction, the condition continues to cause readmission hospitalization in the elderly populations.

Hospital compliance with performance measures and 30-day outcomes in patients with heart failure

In 2005, the American College of Cardiology/American Heart Association published performance measures to provide a standard of care for hospitalized patients with heart failure (HF). Despite increasing compliance with these measures, hospital mortality and readmission rates remain stagnant. Whether compliance with HF performance measures improves patient outcomes at the hospital level is unclear. We evaluated compliance with HF performance measures at 3,655 US hospitals. Patients admitted with a diagnosis of HF in 2008 were identified using the US Department of Health and Human Services Hospital Compare database. Compliance with 4 specific performance measures was examined: evaluation of left ventricular systolic function, administration of angiotensin-converting enzyme inhibitor I or angiotensin-receptor blocker for left ventricular systolic dysfunction, offering smoking cessation advice and counseling, and providing discharge instructions. Thirty-day mortality and readmission rate were recorded. Hospitals reporting greater compliance with the 4 performance measures had significantly lower 30-day mortality rates. However, these hospitals were also located in areas of higher socioeconomic status and treated higher volumes of patients with HF. After adjusting for socioeconomic and hospital factors, only evaluation of left ventricular systolic function was associated with lower 30-day mortality, and evaluation of left ventricular systolic function and smoking cessation counseling were associated with lower readmission rates. We found that socioeconomic factors and hospital volume were stronger predictors of mortality than compliance with HF performance measures. After adjusting for socioeconomic factors and hospital volume, only 1 of the 4 performance measures was associated with lower 30-day mortality and 2 were associated with lower readmissions.

The Relationship between Hospital Market Competition, Evidence-Based Performance Measures, and Mortality for Chronic Heart Failure

Using data from the Joint Commission's ORYX initiative and the Medicare Provider Analysis and Review file from 2003 to 2006, this study employed a fixed-effects approach to examine the relationship between hospital market competition, evidence-based performance measures, and short-term mortality at seven days, 30 days, 90 days, and one year for patients with chronic heart failure. We found that, on average, higher adherence with most of the Joint Commission's heart failure performance measures was not associated with lower mortality; the level of market competition also was not associated with any differences in mortality. However, higher adherence with the discharge instructions and left ventricular function assessment indicators at the 80th and 90th percentiles of the mortality distribution was associated with incrementally lower mortality rates. These findings suggest that targeting evidence-based processes of care might have a stronger impact in improving patient outcomes.

Abstract P246: Heart Failure Performance Measures: Eligibility and Implementation In the Community

Background: The goal of heart failure (HF) performance measures is to improve the quality of care by enabling the practice implementation of guidelines. The guidelines define the population eligible for each measure. Little is known about the proportion of eligible patients to which these measures are applicable in the community. Methods: We determined the eligibility for and the adherence to performance measures and beta-blocker therapy in a community-based cohort of hospitalized patients diagnosed with incident HF from January 2005 to April 2011. Results: Of 294 inpatients with first ever HF (mean age 72 ± 15 years, 48% men), ejection fraction was measured in 292 (99%) patients during hospitalization. Of these, 97 (33%) had an ejection fraction &lt;40% and were thus candidates for beta-blocker and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) therapy. After excluding individuals with absolute contraindications, 71 patients were eligible to receive ACE inhibitors or ARB, and 86 were eligible to receive beta-blockers (figure). Among those eligible, 83% received ACEI/ARB and 91% received beta-blockers. Excluding those with relative contraindications, 70 patients were eligible for beta-blockers and 90% of them received it. Among the 139 (47%) individuals with HF and atrial fibrillation, 35 were eligible for warfarin and 49% received it. Of the 36 current smokers, 22 (61%) received cessation counseling during hospitalization. Conclusions: In the community, among patients hospitalized with HF eligible for performance measures, the implementation of performance measures varies by measure and can be improved for some. However, most community HF patients are not eligible for performance measures and other approaches should be identified to improve their care and outcomes.

Get With The Guidelines Program Participation, Process of Care, and Outcome for Medicare Patients Hospitalized With Heart Failure

Hospitals enrolled in the American Heart Association's Get With The Guidelines Program for heart failure (GWTG-HF) have improved their process of care. However, it is unclear if process of care and outcomes are better in the GWTG-HF hospitals compared with hospitals not enrolled. We compared hospitals enrolled in GWTG-HF from 2006 to 2007 with other hospitals using data on 4 process of heart failure care measures, 5 noncardiac process measures, risk-adjusted 30-day mortality, and 30-day all-cause readmission after a heart failure hospitalization, as reported by the Center for Medicare and Medicaid Services (CMS). Among the 4460 hospitals reporting data to CMS, 215 (5%) were enrolled in GWTG-HF. Of the 4 CMS heart failure performance measures, GWTG-HF hospitals had significantly higher documentation of the left ventricular ejection fraction (93.4% versus 88.8%), use of angiotensin-converting enzyme inhibitor or angiotensin receptor antagonist (88.3% versus 86.6%), and discharge instructions (74.9% versus 70.5%) (P<0.005 for all). Smoking cessation counseling rates were similar (94.1% versus 94.0%; P=0.51). There was no significant difference in compliance with noncardiac process of care. After heart failure discharge, all-cause readmission at 30 days was 24.5% and mortality at 30 days after admission was 11.1%. After adjustment for hospital characteristics, 30-day mortality rates were no different (P=0.45). However, 30-day readmission was lower for GWTG hospitals (-0.33%; 95% CI, -0.53% to -0.12%; P=0.002). Although there was evidence that hospitals enrolled in the GTWG-HF program demonstrated better processes of care than other hospitals, there were few clinically important differences in outcomes. Further identification of opportunities to improve outcomes, and inclusion of these metrics in GTWG-HF, may further support the value of GTWG-HF in improving care for patients with HF.

Treatment Performance Measures Affect Clinical Outcomes in Patients With Acute Systolic Heart Failure

There is a paucity of data on the effects of adherence to treatment on outcomes for patients with acute heart failure (HF) in Korea. We used HF performance measures to evaluate overall adherence and whether this affects clinical outcomes. Among 3,466 patients in the Korean Heart Failure Registry, 1,527 patients with left ventricular systolic dysfunction (LVSD) who survived hospitalization were evaluated. Modified validated performance measures were defined as follows: use at discharge of angiotensin-converting enzyme inhibitor (ACEI), angiotensin-receptor II blocker (ARB), β-blocker or aldosterone receptor antagonist. Adherence to performance measures were as follows: ACEI or ARB at discharge, 68.0%; β-blocker at discharge, 40.9%; aldosterone receptor antagonist at discharge, 37.5%. On multivariate analysis, adherence to the measure of ACEI or ARB use at discharge was significantly associated with mortality (odds ratio (OR), 0.344; 95% confidence interval (CI), 0.123-0.964), readmission (OR, 0.180; 95%CI, 0.062-0.522) and mortality/readmission (OR, 0.297; 95%CI, 0.125-0.707) at 60 days and that for β-blocker with mortality (OR, 0.337; 95%CI, 0.147-0.774) at 1 year. For patients with LVSD in Korea, adherence to treatment performance measures, including prescription of an ACEI/ARB and β-blocker use at discharge, is associated with improved clinical outcomes.