Patient and hospital characteristics associated with traditional measures of inpatient quality of care for patients with heart failure

doi:10.1016/j.ahj.2011.10.008

American Heart Journal

Volume 163, Issue 2, February 2012, Pages 239-245.e3

https://doi.org/10.1016/j.ahj.2011.10.008 Get rights and content

Background

The purpose of this study was to determine patient and hospital characteristics associated with 4 measures of quality of inpatient heart failure care used by both the primary payer of heart failure care in the United States (Center for Medicare and Medicaid Services) and the main hospital accrediting organization (The Joint Commission).

Methods

We used data from Get With The Guidelines Program for patients hospitalized with heart failure. Eligibility for receiving care based on the Center for Medicare and Medicaid Services performance measures was determined for assessment of left ventricular ejection fraction (LVEF; n = 60,601), use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) if LVEF<40% and no contraindications (24,130), discharge instructions (49,383), and smoking cessation counseling (10,152). Patient and hospital characteristics that were significantly associated with performance measures in univariate analyses were entered into multivariate logistic regression models.

Results

Overall, documentation for LVEF assessment was noted in 95%, ACEi/ARB use in 87%, discharge instruction in 82%, and smoking cessation counseling in 91% of eligible patients. In adjusted analyses, older patients and those with evidence of renal failure were significantly less likely to receive each care measure except for discharge instructions (no age effect). Patients with higher body mass index were more likely to receive ACEi/ARB and discharge instructions but less likely to have LVEF documented or to receive smoking cessation counseling. Small hospitals (<200 beds) were less likely to provide each of the performance measures compared with larger hospitals.

Conclusion

Recommended heart failure care is less likely in patients with certain characteristics (older age and abnormal renal function) and those cared for in smaller hospitals. Programs to improve evidence-based care for heart failure should consider interventions specifically targeting and tailored to smaller facilities and patients who are older with comorbidities.

Section snippets

Get With The Guidelines program

The details of the GWTG program have been previously published.8, 9 In brief, the American Heart Association launched the GWTG initiative with the goal of improving the quality of care of patients with coronary artery disease, heart failure, and stroke. The GWTG program uses a Web-based patient management tool (PMT; Outcome, Cambridge, MA) to collect clinical data, provide decision support, and provide real-time reports. Data collected by the program include patient demographics, prior medical

Patient characteristics

There were 60,601 patients eligible for documentation of the LVEF, 49,383 for discharge instructions, 24,130 for ACEi or ARB treatment at discharge, and 10,152 for smoking cessation. A detailed list of the patient and hospital characteristics for the largest cohort (those eligible for LVEF) is displayed in the online Appendix. The mean age of the patients was 72 ± 14 years (median 75 years), half were women, and close to 70% were white. Common comorbidities included coronary artery disease

Discussion

This study examined patient- and hospital-related characteristics to identify those associated with the 4 quality measures of inpatient heart failure care reported by CMS. Recommended heart failure care was more likely in patients with certain characteristics (younger age and normal renal function) and those cared for in larger hospitals. Quality of heart failure care was not, in general, significantly associated with patients' race/ethnicity or sex. Other hospital characteristics were, with

Disclosures

Paul A. Heidenreich, MD, MS: There are no relationships to disclose.

Xin Zhao, MS: Employee of Duke Clinical Research Institute.

Adrian Hernandez, MD: Reported receiving research support from Johnson & Johnson, Medtronic, and Merck & Co; (significant), serving on the speakers' bureau for Novartis; and receiving honoraria from AstraZeneca (modest) and Medtronic (modest).

Clyde Yancy, MD: There are no relationships to disclose.

Gregg C. Fonarow, MD: Novartis consulting significant; Medtronic

References (19)

R.O. Bonow et al.
ACC/AHA clinical performance measures for adults with chronic heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart Failure Clinical Performance Measures) endorsed by the Heart Failure Society of America
J Am Coll Cardiol
(2005)
H.M. Krumholz et al.
Regional variation in the treatment and outcomes of myocardial infarction: investigating New England's advantage
Am Heart J
(2003)
K.A. LaBresh et al.
Using “get with the guidelines” to improve cardiovascular secondary prevention
Jt Comm J Qual Saf
(2003)
L.A. Smaha
The American Heart Association Get With The Guidelines program
Am Heart J
(2004)
G.C. Fonarow et al.
Age- and gender-related differences in quality of care and outcomes of patients hospitalized with heart failure (from OPTIMIZE-HF)
Am J Cardiol
(2009)
P.A. Heidenreich et al.
Hospital performance recognition with the Get With The Guidelines Program and mortality for acute myocardial infarction and heart failure
Am Heart J
(2009)
R.M. Werner et al.
Relationship between Medicare's hospital compare performance measures and mortality rates
JAMA
(2006)
G.C. Fonarow et al.
Association between performance measures and clinical outcomes for patients hospitalized with heart failure
JAMA
(2007)
Landis NT. JCAHO selects core performance measures. Joint Commission on Accreditation of Healthcare Organizations. Am J...

There are more references available in the full text version of this article.

Cited by (21)

Current use of guideline-based medical therapy in elderly patients admitted with acute heart failure with reduced ejection fraction and its impact on event-free survival
2017, International Journal of Cardiology
Citation Excerpt :
Clinical trials have established that GBMT improves the prognosis in HFrEF patients [6–12], which has led to its widespread use worldwide [4,5]. However, these findings were derived from HF patients who were younger with less comorbidities compared to the real-world patients; thus, optimal therapy, especially for the elderly, is less understood [13,14]. With better management of various cardiac conditions such as coronary artery disease, the prevalence of HF among the elderly has increased over the last decade [15,16].
Acute heart failure (HF) is a frequently encountered cardiac condition. Its prevalence increases exponentially with age. In spite of this, elderly patients are underrepresented in clinical trials and the implementation of guideline-based medical therapy (GBMT) in them is not well established. We investigated the current use of GBMT and its effects on mortality and HF rehospitalization among elderly patients with acute HF with reduced ejection fraction (HFrEF) using data obtained from a contemporary multi-center registry.
We analyzed data from 1,441 consecutive acute HF patients registered in the West Tokyo Heart Failure (WET-HF) registry (mean age 73.2 ± 13.6 years). Reduced ejection fraction (< 45%) was noted in 803 patients (55.7%), of which 237 were aged ≥ 80 years (elderly group). The prescription rate of GBMT (use of renin-angiotensin system inhibitors and β-blockers at discharge) was significantly lower in the elderly than in the younger (aged < 80 years) group (46.8% vs. 66.9%, p < 0.001). Although GBMT at discharge was associated with reductions in HF readmission or the composite endpoint of cardiac death and HF readmission (HR 0.49, 95% CI 0.30–0.80; and HR 0.53, 95% CI 0.32–0.89, respectively) in the younger group, this association was not observed in the elderly group (HR 1.41, 95% CI 0.68–2.92; and HR 1.54, 95% CI 0.76–3.13, respectively)
GBMT implementation in elderly patients with HFrEF was found to be suboptimal. However, the underuse of GBMT did not appear to be responsible for poorer outcomes in elderly HFrEF patients. Further research is required to establish an ideal therapeutic approach for this population.
URL: http://www.umin.ac.jp/icdr/index-j.html. Unique identifier: UMIN000001171.
Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure
2016, American Heart Journal
Citation Excerpt :
First, dual use may be systematically associated with greater variation in care quality leading to overtreatment or undertreatment of HF patients. Higher HF care quality, as measured by Centers for Medicare and Medicaid Services core measures compliance at the hospital level, has been associated with modestly but significantly lower 30-day hospital admission rates for HF patients.38 Second, dual use may be a marker for poorer actual or perceived access to HF care either in the primary care setting or in a cardiology clinic.
Heart failure (HF) frequently causes hospital admission and readmission. Patients receiving care from multiple providers and facilities (dual users) may risk higher health care utilization and worse health outcomes.
To determine rates of emergency department (ED) visits, hospitalizations, and hospital readmissions relative to dual use among HF patients, we analyzed a retrospective cohort of 13,977 veterans with HF hospitalized at the Veterans Affairs (VA) or non-VA facilities from 2007 to 2011; we analyzed rates of acute health care utilization using zero-inflated negative binomial regression.
Compared to VA-only users and dual users, individuals receiving all of their ED and hospital care outside the VA tended to be older, more likely to be non-Hispanic white and married, and less likely to have high levels of service connected disability. Compared to VA-only users, dual users had significantly higher rates of ED visits for HF as a primary diagnosis (adjusted rate ratio 1.15, 95% CI 1.04-1.27), hospitalization for HF (adjusted rate ratio 1.4, 95% CI 1.26-1.56), hospital readmission after HF hospitalization (all cause) (1.46, 95% CI 1.30-1.65), and HF-specific hospital readmission after HF hospitalization (1.46, 95% CI 1.31-1.63). With the exception of hospitalization for any primary diagnosis, non–VA-only users had significantly lower rates of ED visits, hospitalization, and readmission compared to VA-only users.
Dual use is associated with higher rates of health care utilization among patients with HF. Interventions should be devised to encourage continuity of care where possible and to improve the effectiveness and safety of dual use in instances where it is necessary or desired.
Management of chronic heart failure: Biomarkers, monitors, and disease management programs
2014, Annals of Global Health
Citation Excerpt :
Heart failure is a complex syndrome, and both diagnosis and treatment therefore can be challenging. Furthermore, although several evidence-based therapies exist, achieving an appropriate regimen and target doses of medications can be difficult, resulting in significant variability in treatment practices especially in older patients and patients with renal dysfunction.3 Use of guideline-recommended therapies has been linked to an improvement in survival that only starts to plateau after 4 to 5 therapies have been initiated.4
The management of patients with heart failure has been evolving given the complex nature of the disease and the increasing number of patients.
Biomarkers, and in particular the natriuretic peptides, have been studied to assist with diagnosis, chronic management, and prognosis in patients with heart failure. Several new biomarkers are emerging and may be used individually or in combination with the natriuretic peptides. The use of cardiac monitoring devices and disease management programs is being established to assist in the care of patients with chronic heart failure. Interventions using phone calls, telemedicine devices, intracardiac pressure monitors, and implantable cardioverter defibrillators have been investigated.
The combination of biomarkers, monitoring devices, and disease management programs shows promise for improving care in this challenging patient population.
Heart failure performance measures: Eligibility and implementation in the community
2013, American Heart Journal
Citation Excerpt :
This may reflect the practice of a large teaching hospital as Heidenreich et al have previously reported.25 We found 85% adherence to ACE inhibitors or ARBs in our study, in line with reports from prospective registries.20,21,25 However, β-blockers were prescribed to a higher number of patients in our population than in OPTIMIZE-HF registry, reflecting the different time period and the widespread clinical adoption of β-blockers in HF.20
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.
Association between performance measures and clinical outcomes in patients with heart failure in China: Results from the HERO study
2024, Clinical Cardiology
Association between Performance Measures and Clinical Outcomes in Patients with Heart Failure in China
2023, SSRN

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: Pamela N. Peterson, MD, MSPH served as guest editor for this article.

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Clinical InvestigationOutcomes, Health Policy, and Managed CarePatient and hospital characteristics associated with traditional measures of inpatient quality of care for patients with heart failure

Background

Methods

Results

Conclusion

Section snippets

Get With The Guidelines program

Patient characteristics

Discussion

Disclosures

J Am Coll Cardiol

Am Heart J

Jt Comm J Qual Saf

Am Heart J

Am J Cardiol

Am Heart J

Relationship between Medicare's hospital compare performance measures and mortality rates

JAMA

Association between performance measures and clinical outcomes for patients hospitalized with heart failure

JAMA

Clinical Investigation
Outcomes, Health Policy, and Managed Care
Patient and hospital characteristics associated with traditional measures of inpatient quality of care for patients with heart failure