Variation in hospital performance for heart failure management in the National Heart Failure Audit for England and Wales

Abstract

Objective: Investigation of variations in provider performance and its determinants may help inform strategies for improving patient outcomes. Methods:We used the National Heart Failure Audit comprising 68,772 patients with heart failure with reduced left ventricular ejection fraction (HFREF), admitted to 185 hospitals in England and Wales (2007-2013). We investigated hospital adherence to three recommended key performance measures (KPM) for in-hospital care (ACE-inhibitors or ARBs on discharge, beta-blockers on discharge, and referral to specialist follow-up) individually and as a composite performance score. Hierarchical regression models were used to investigate hospital-level variation.Results: Hospital-level variation in adherence to composite KPM ranged from 50% to 97% (median 79%), but after adjustments for patient characteristics and year of admission, only 8% (CI 7 % to 10%) of this variation was attributable to variations in hospital features. Similarly, hospital prescription rates for ACE-I/ARB and beta-blocker showed low adjusted hospital-attributable variations (7% CI 6% to 9% and 6% CI 5% to 8%, for ACE-I/ARB and beta-blocker, respectively). Referral to specialist follow-up, however, showed larger variations (median 81%; range; 20%, 100%,) with 26% of this being attributable to hospital-level differences (CI 22% to 31%). Conclusions:Only a small proportion of hospital variation in medication prescription after discharge was attributable to hospital-level features. This suggests that differences in hospital practices are not a major determinant of observed variations in prescription of investigated medications and outcomes. Future healthcare delivery efforts should consider evaluation and improvement of more ambitious KPM.

Towards global improvement in heart failure care

“…Quality of care for HF is publicly reported among the nation's hospitals and registries, such as the American Heart Association's Get With the Guidelines programme that provides feedback for process measures and outcomes to participating hospitals . Similar measures have been reported from the United Kingdom and other countries …”

Referral for Specialist Follow-up and Its Association With Post-discharge Mortality Among Patients With Systolic Heart Failure (from the National Heart Failure Audit for England and Wales)

“…As suggested in an earlier report, interventions to tackle the low referral rates after discharge could also contribute to reductions in between-hospital variation in quality of care. 6 …”

Impact of missed treatment opportunities on outcomes in hospitalised patients with heart failure

“…Emdin et al have previously examined the adherence to treatment guidelines for patients discharged from hospital following admission for HF using NHFA data. 8 As part of the current analysis, these data were reanalysed to establish the potential for improving uptake of ACEi, BBs and optimal therapy (one or both of ACEi and BBs if not contraindicated) for the years 2010–2013. Not all patients are clinically eligible to receive all these drugs as they may be contraindicated to one or more treatments.…”

“…7 The NHFA suggests that not all patients with HF are receiving treatment according to guidelines. 8 In particular, UK guidelines recommend that, following hospitalisation for HF, patients should receive ACE inhibitors (ACEi) and beta blockers (BB) as first-line therapy. 9 A recent study of the NHFA has shown that, while treatment with ACEi and BBs has been improving over time, many patients are still not receiving these therapies: in 2013, only 81.7% of patients who were eligible were receiving BBs and 83.7% were receiving ACEi.…”

“…9 A recent study of the NHFA has shown that, while treatment with ACEi and BBs has been improving over time, many patients are still not receiving these therapies: in 2013, only 81.7% of patients who were eligible were receiving BBs and 83.7% were receiving ACEi. 8 …”