Quality of Care for Hospitalized Heart Failure Patients
Quality of Care for Hospitalized Heart Failure Patients
Objectives The study sought to assess the quality of care for heart failure patients who are hospitalized for all causes.
Background Performance measures for heart failure target patients with a principal diagnosis of heart failure. However, patients with heart failure are commonly hospitalized for other causes and may benefit from treatments such as angiotensin-converting enzyme (ACE) inhibitors for left ventricular (LV) systolic dysfunction.
Methods We assessed rates of compliance with care measures for patients hospitalized with acute or chronic heart failure in the ARIC (Atherosclerosis Risk In Communities) study surveillance catchment area from 2005 to 2009. Rates of compliance were compared between patients with a principal discharge diagnosis of heart failure and those with another principal discharge diagnosis.
Results Of 4,345 hospitalizations of heart failure patients, 39.6% carried a principal diagnosis of heart failure. Patients with a principal heart failure diagnosis had higher rates of LV function assessment (89.1% vs. 82.5%; adjusted prevalence ratio [aPR]: 1.07; 95% confidence interval [CI]: 1.04 to 1.10) and discharge ACE inhibitor/angiotensin receptor blocker (ARB) in LV dysfunction (64.1% vs. 56.3%; aPR: 1.11; 95% CI: 1.03 to 1.20) as compared to patients hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with reductions in 1-year post-discharge mortality (adjusted odds ratio: 0.66, 95% CI: 0.51 to 0.85; adjusted odds ratio: 0.72, 95% CI: 0.54 to 0.96, respectively) that did not differ for patients with versus without a principal heart failure diagnosis.
Conclusions Compared with individuals hospitalized with a principal diagnosis of heart failure, heart failure patients hospitalized for other causes were less likely to receive guideline recommended care. Quality initiatives may improve care by targeting hospitalizations with either principal or secondary heart failure diagnoses.
Individuals with heart failure experience high rates of hospitalization and death. Given the significant morbidity and mortality associated with heart failure, a substantial effort has been placed on ensuring that heart failure patients receive guideline-endorsed care that is associated with improved outcomes. To encourage quality care, the Centers for Medicare and Medicaid Services (CMS) have developed performance measures for hospitalized patients. These measures currently include evaluation of left ventricular (LV) systolic function, prescription of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for individuals with LV systolic dysfunction at time of discharge, and discharge instructions. The American College of Cardiology Foundation, American Heart Association, and American Medical Association–Physician Consortium for Performance Improvement (ACCF/AHA/AMA-PCPI) have endorsed similar quality measures for adults with heart failure.
Both the CMS and ACCF/AHA/AMA-PCPI performance measures specifically target patients whose primary reason for admission is heart failure, based on the principal discharge diagnosis code. Thus, these measures do not apply to patients with heart failure with another principal discharge diagnosis. Similarly, current registries of heart failure hospitalizations, which were created to evaluate and improve inpatient care, focus on patients who are hospitalized with acute heart failure. Nonetheless, the majority of hospitalizations of heart failure patients are for reasons other than heart failure. While care measures for heart failure are reported only for those patients with a principal diagnosis of heart failure, some measures are beneficial to all patients with heart failure, including LV function assessment and ACE inhibitor or ARB use in LV systolic dysfunction.
The purpose of this study is to determine the quality of care for individuals hospitalized with a principal diagnosis of heart failure and individuals with heart failure who are admitted with a principal diagnosis other than heart failure. As quality improvement initiatives for heart failure have not been routinely targeting heart failure patients hospitalized for other reasons, we hypothesized that patients with heart failure admitted for other causes would receive less optimal care for heart failure as compared to individuals who are specifically hospitalized for heart failure. We further hypothesized that quality measures would be associated with improved outcomes in heart failure, regardless of the reason for hospitalization.
Abstract and Introduction
Abstract
Objectives The study sought to assess the quality of care for heart failure patients who are hospitalized for all causes.
Background Performance measures for heart failure target patients with a principal diagnosis of heart failure. However, patients with heart failure are commonly hospitalized for other causes and may benefit from treatments such as angiotensin-converting enzyme (ACE) inhibitors for left ventricular (LV) systolic dysfunction.
Methods We assessed rates of compliance with care measures for patients hospitalized with acute or chronic heart failure in the ARIC (Atherosclerosis Risk In Communities) study surveillance catchment area from 2005 to 2009. Rates of compliance were compared between patients with a principal discharge diagnosis of heart failure and those with another principal discharge diagnosis.
Results Of 4,345 hospitalizations of heart failure patients, 39.6% carried a principal diagnosis of heart failure. Patients with a principal heart failure diagnosis had higher rates of LV function assessment (89.1% vs. 82.5%; adjusted prevalence ratio [aPR]: 1.07; 95% confidence interval [CI]: 1.04 to 1.10) and discharge ACE inhibitor/angiotensin receptor blocker (ARB) in LV dysfunction (64.1% vs. 56.3%; aPR: 1.11; 95% CI: 1.03 to 1.20) as compared to patients hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with reductions in 1-year post-discharge mortality (adjusted odds ratio: 0.66, 95% CI: 0.51 to 0.85; adjusted odds ratio: 0.72, 95% CI: 0.54 to 0.96, respectively) that did not differ for patients with versus without a principal heart failure diagnosis.
Conclusions Compared with individuals hospitalized with a principal diagnosis of heart failure, heart failure patients hospitalized for other causes were less likely to receive guideline recommended care. Quality initiatives may improve care by targeting hospitalizations with either principal or secondary heart failure diagnoses.
Introduction
Individuals with heart failure experience high rates of hospitalization and death. Given the significant morbidity and mortality associated with heart failure, a substantial effort has been placed on ensuring that heart failure patients receive guideline-endorsed care that is associated with improved outcomes. To encourage quality care, the Centers for Medicare and Medicaid Services (CMS) have developed performance measures for hospitalized patients. These measures currently include evaluation of left ventricular (LV) systolic function, prescription of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for individuals with LV systolic dysfunction at time of discharge, and discharge instructions. The American College of Cardiology Foundation, American Heart Association, and American Medical Association–Physician Consortium for Performance Improvement (ACCF/AHA/AMA-PCPI) have endorsed similar quality measures for adults with heart failure.
Both the CMS and ACCF/AHA/AMA-PCPI performance measures specifically target patients whose primary reason for admission is heart failure, based on the principal discharge diagnosis code. Thus, these measures do not apply to patients with heart failure with another principal discharge diagnosis. Similarly, current registries of heart failure hospitalizations, which were created to evaluate and improve inpatient care, focus on patients who are hospitalized with acute heart failure. Nonetheless, the majority of hospitalizations of heart failure patients are for reasons other than heart failure. While care measures for heart failure are reported only for those patients with a principal diagnosis of heart failure, some measures are beneficial to all patients with heart failure, including LV function assessment and ACE inhibitor or ARB use in LV systolic dysfunction.
The purpose of this study is to determine the quality of care for individuals hospitalized with a principal diagnosis of heart failure and individuals with heart failure who are admitted with a principal diagnosis other than heart failure. As quality improvement initiatives for heart failure have not been routinely targeting heart failure patients hospitalized for other reasons, we hypothesized that patients with heart failure admitted for other causes would receive less optimal care for heart failure as compared to individuals who are specifically hospitalized for heart failure. We further hypothesized that quality measures would be associated with improved outcomes in heart failure, regardless of the reason for hospitalization.
