Quality of Care for Hospitalized Heart Failure Patients
Quality of Care for Hospitalized Heart Failure Patients
Substantial efforts have been made to measure and improve the quality of care delivered to heart failure patients in both the inpatient and outpatient setting. Inpatient quality of care has focused primarily on patients with a diagnosis of acute heart failure, commonly identified by principal discharge diagnosis code. Our results suggest that quality improvement initiatives have had an effect on care delivery in a representative sample of 4 communities: we found that 2 commonly used measures of heart failure care, assessment of LV systolic function and prescription of an ACE inhibitor or ARB at time of discharge for patients with LV systolic dysfunction, were more likely to be achieved in patients with a principal diagnosis of heart failure as compared to those with another principal diagnosis. Conversely, β-blocker therapy for LV systolic dysfunction did not differ between groups. Of note, β-blocker therapy is not a CMS quality measure and became an ACCF/AHA/AMA-PCPI performance measure for patients with a principal diagnosis of heart failure only as of 2012, so there might not have been incentives to target this therapy specifically to patients with a principal diagnosis of heart failure during the study period.
We found that the majority of hospitalizations for individuals with heart failure had a principal diagnosis that was not heart failure, a finding consistent with previous studies. Although hospitalizations with a principal diagnosis other than heart failure generally are not subject to heart failure quality improvement measures, the metrics we evaluated are consistent with guideline-recommended care for all heart failure patients. Thus, these measures should have clinical value for heart failure patients hospitalized for other causes. We found that, as compared with individuals with a principal diagnosis of heart failure, heart failure patients hospitalized with a nonheart failure diagnosis had a 7% lower rates of LV functional assessment, a 10% lower rate of prescription for an ACE inhibitor or ARB at time of discharge, and lower rates of prescription for an aldosterone antagonist. These data suggest that heart failure patients admitted for other diagnoses may be receiving lower rates of guideline-concordant care as compared to patients whose primary reason for hospitalization is acute heart failure. These findings are notable as we found selected measures to have associations with mortality that provided comparable benefit for individuals both with and without a principal heart failure diagnosis in a real-world setting. These results suggest that improving compliance with processes of care such as LV assessment and, as appropriate, discharge prescriptions for ACE inhibitors/ARBs, beta-blockers, aldosterone antagonists, and anticoagulants, may result in improved survival among both individuals with a primary diagnosis of heart failure as well as those with a secondary diagnosis of heart failure. The potential for improved outcomes with quality care for individuals with a secondary heart failure diagnosis is particularly important, as these individuals are more commonly seen in the hospital and are less likely to receive heart failure-related therapies than individuals with a principal heart failure diagnosis.
The ACCF/AHA/AMA-PCPI recently updated their recommendations for performance measures for heart failure A number of the measures, including LV systolic assessment and ACE inhibitors or ARBs and β-blockers for LV systolic dysfunction, applied to both the inpatient and outpatient clinical encounters. In these recommendations, while outpatient measures are applicable to all patients with a diagnosis of heart failure, inpatient measures are specific to those patients for whom heart failure is the primary cause for hospitalization. In this paradigm, a hospitalization in which heart failure is either a secondary reason for hospitalization or a stable, chronic condition may be similarly subject to heart failure quality measures as an outpatient encounter. Our data suggest that there may be a missed opportunity to deliver these quality metrics to heart failure patients whose primary reason for hospitalization is a different cause.
Our study included only individuals with adjudicated acute or chronic heart failure, both of whom are appropriate for guideline concordant care such as ACE inhibitors for LV systolic dysfunction. One potential limitation of expanding performance measurement to heart failure patients who are hospitalized for any cause is a loss of specificity for heart failure. Indeed, a prior study from the ARIC study demonstrated that the ICD-9 code of 428 in any position carried a 23% false positive rate for acute or chronic heart failure as compared with only 3% for this code as the principal diagnosis. However, the imperfect specificity may represent an opportunity for coding improvement, particularly as increased coding for heart failure may be inappropriately driven by reimbursement incentives. More so, expanding quality measures to individuals with a heart failure diagnosis in any position will significantly increase the sensitivity for detection of heart failure; in the ARIC study, the sensitivity was 0.95 for ICD-9 code 428 in any position versus 0.36 in the primary position.
We observed that adherence to care measures such as LV evaluation and ACE inhibitors or ARBs for LV dysfunction was associated with reduced mortality among patients with heart failure. Prior studies have questioned whether inpatient care measures have direct clinical benefits. For instance, in a large registry of heart failure hospitalizations, performance measures were generally found to have no association with outcomes and other studies have been inconclusive. Nonetheless, care measures have been associated with improved outcomes in the outpatient setting. Further evaluation of the effect of current heart failure care measures on mortality and rehospitalization is needed.
Our findings must be interpreted with several caveats. First, the analysis was limited by the inability to assess physician exceptions for not adhering with measures. For instance, we were unable to determine if echocardiography was previously performed but not recorded in the chart or was planned for post-discharge and we could not detect if an ACE inhibitor was not prescribed because an individual had an allergy to this medication or had acute kidney injury. We partly addressed this issue through our sensitivity analyses and found that adherence to performance measures was similar for individuals with different levels of kidney disease and those with COPD. Second, residual measured and unmeasured confounding may account for some of the findings in this observational study. Third, due to limitations in the data, we were unable to assess the relationship of the selected performance measures with clinically important outcomes such as rehospitalizations, quality of life, and costs. Fourth, due to the design of the ARIC study, hospitalizations were fully abstracted only if there was evidence of worsening symptoms of heart failure. Therefore, hospitalizations adjudicated as chronic stable heart failure represented only a subsample of chronic stable heart failure hospitalizations in the ARIC study communities. The reduced number of chronic heart failure hospitalizations included in the study partly accounts for the finding of a high rate (70.9%) of acute decompensated heart failure among hospitalizations with a principal diagnosis other than heart failure. Nonetheless, this finding can be explained by the fact that heart failure decompensation is commonly precipitated by another condition that may result in hospitalization; in this context, a patient who is principally hospitalized for pneumonia or renal failure will also have concurrent acute heart failure. Fifth, we defined LV systolic dysfunction as an ejection fraction of <50%, based on the ARIC study abstraction definition. While this cutoff is commonly used in research, performance measures typically define LV systolic dysfunction as an ejection fraction of <40%. Sixth, the study was limited to patients with heart failure, so patient characteristics and outcomes may be different from other individuals in the ARIC study communities. Finally, while this study included a sample of hospitalizations from 4 U.S. communities, the results may not reflect practice patterns nationally.
Discussion
Substantial efforts have been made to measure and improve the quality of care delivered to heart failure patients in both the inpatient and outpatient setting. Inpatient quality of care has focused primarily on patients with a diagnosis of acute heart failure, commonly identified by principal discharge diagnosis code. Our results suggest that quality improvement initiatives have had an effect on care delivery in a representative sample of 4 communities: we found that 2 commonly used measures of heart failure care, assessment of LV systolic function and prescription of an ACE inhibitor or ARB at time of discharge for patients with LV systolic dysfunction, were more likely to be achieved in patients with a principal diagnosis of heart failure as compared to those with another principal diagnosis. Conversely, β-blocker therapy for LV systolic dysfunction did not differ between groups. Of note, β-blocker therapy is not a CMS quality measure and became an ACCF/AHA/AMA-PCPI performance measure for patients with a principal diagnosis of heart failure only as of 2012, so there might not have been incentives to target this therapy specifically to patients with a principal diagnosis of heart failure during the study period.
We found that the majority of hospitalizations for individuals with heart failure had a principal diagnosis that was not heart failure, a finding consistent with previous studies. Although hospitalizations with a principal diagnosis other than heart failure generally are not subject to heart failure quality improvement measures, the metrics we evaluated are consistent with guideline-recommended care for all heart failure patients. Thus, these measures should have clinical value for heart failure patients hospitalized for other causes. We found that, as compared with individuals with a principal diagnosis of heart failure, heart failure patients hospitalized with a nonheart failure diagnosis had a 7% lower rates of LV functional assessment, a 10% lower rate of prescription for an ACE inhibitor or ARB at time of discharge, and lower rates of prescription for an aldosterone antagonist. These data suggest that heart failure patients admitted for other diagnoses may be receiving lower rates of guideline-concordant care as compared to patients whose primary reason for hospitalization is acute heart failure. These findings are notable as we found selected measures to have associations with mortality that provided comparable benefit for individuals both with and without a principal heart failure diagnosis in a real-world setting. These results suggest that improving compliance with processes of care such as LV assessment and, as appropriate, discharge prescriptions for ACE inhibitors/ARBs, beta-blockers, aldosterone antagonists, and anticoagulants, may result in improved survival among both individuals with a primary diagnosis of heart failure as well as those with a secondary diagnosis of heart failure. The potential for improved outcomes with quality care for individuals with a secondary heart failure diagnosis is particularly important, as these individuals are more commonly seen in the hospital and are less likely to receive heart failure-related therapies than individuals with a principal heart failure diagnosis.
The ACCF/AHA/AMA-PCPI recently updated their recommendations for performance measures for heart failure A number of the measures, including LV systolic assessment and ACE inhibitors or ARBs and β-blockers for LV systolic dysfunction, applied to both the inpatient and outpatient clinical encounters. In these recommendations, while outpatient measures are applicable to all patients with a diagnosis of heart failure, inpatient measures are specific to those patients for whom heart failure is the primary cause for hospitalization. In this paradigm, a hospitalization in which heart failure is either a secondary reason for hospitalization or a stable, chronic condition may be similarly subject to heart failure quality measures as an outpatient encounter. Our data suggest that there may be a missed opportunity to deliver these quality metrics to heart failure patients whose primary reason for hospitalization is a different cause.
Our study included only individuals with adjudicated acute or chronic heart failure, both of whom are appropriate for guideline concordant care such as ACE inhibitors for LV systolic dysfunction. One potential limitation of expanding performance measurement to heart failure patients who are hospitalized for any cause is a loss of specificity for heart failure. Indeed, a prior study from the ARIC study demonstrated that the ICD-9 code of 428 in any position carried a 23% false positive rate for acute or chronic heart failure as compared with only 3% for this code as the principal diagnosis. However, the imperfect specificity may represent an opportunity for coding improvement, particularly as increased coding for heart failure may be inappropriately driven by reimbursement incentives. More so, expanding quality measures to individuals with a heart failure diagnosis in any position will significantly increase the sensitivity for detection of heart failure; in the ARIC study, the sensitivity was 0.95 for ICD-9 code 428 in any position versus 0.36 in the primary position.
We observed that adherence to care measures such as LV evaluation and ACE inhibitors or ARBs for LV dysfunction was associated with reduced mortality among patients with heart failure. Prior studies have questioned whether inpatient care measures have direct clinical benefits. For instance, in a large registry of heart failure hospitalizations, performance measures were generally found to have no association with outcomes and other studies have been inconclusive. Nonetheless, care measures have been associated with improved outcomes in the outpatient setting. Further evaluation of the effect of current heart failure care measures on mortality and rehospitalization is needed.
Study Limitations
Our findings must be interpreted with several caveats. First, the analysis was limited by the inability to assess physician exceptions for not adhering with measures. For instance, we were unable to determine if echocardiography was previously performed but not recorded in the chart or was planned for post-discharge and we could not detect if an ACE inhibitor was not prescribed because an individual had an allergy to this medication or had acute kidney injury. We partly addressed this issue through our sensitivity analyses and found that adherence to performance measures was similar for individuals with different levels of kidney disease and those with COPD. Second, residual measured and unmeasured confounding may account for some of the findings in this observational study. Third, due to limitations in the data, we were unable to assess the relationship of the selected performance measures with clinically important outcomes such as rehospitalizations, quality of life, and costs. Fourth, due to the design of the ARIC study, hospitalizations were fully abstracted only if there was evidence of worsening symptoms of heart failure. Therefore, hospitalizations adjudicated as chronic stable heart failure represented only a subsample of chronic stable heart failure hospitalizations in the ARIC study communities. The reduced number of chronic heart failure hospitalizations included in the study partly accounts for the finding of a high rate (70.9%) of acute decompensated heart failure among hospitalizations with a principal diagnosis other than heart failure. Nonetheless, this finding can be explained by the fact that heart failure decompensation is commonly precipitated by another condition that may result in hospitalization; in this context, a patient who is principally hospitalized for pneumonia or renal failure will also have concurrent acute heart failure. Fifth, we defined LV systolic dysfunction as an ejection fraction of <50%, based on the ARIC study abstraction definition. While this cutoff is commonly used in research, performance measures typically define LV systolic dysfunction as an ejection fraction of <40%. Sixth, the study was limited to patients with heart failure, so patient characteristics and outcomes may be different from other individuals in the ARIC study communities. Finally, while this study included a sample of hospitalizations from 4 U.S. communities, the results may not reflect practice patterns nationally.
