Four of five hospital performance measures for heart failure do not appear to accurately reflect the quality of care provided, according to a study in the January 3 issue of JAMA.
Heart failure continues to be a serious public health concern in the United States: the overall prevalence of heart failure was 5 million individuals in 2003, with 550,000 new cases being reported each year. Heart failure is the leading cause of hospitalization in persons older than 65 years, with almost 3.6 million hospitalizations attributed to heart failure as the primary or a secondary discharge diagnosis each year, according to background information in the article. Because heart failure is a substantial cause of illness, death, and health care expenditures, it is important to use evidence-based therapies that have been shown to improve clinical outcomes.
The American College of Cardiology and the American Heart Association (ACC/AHA) have developed clinical practice guidelines outlining diagnostic and therapeutic interventions for patients with heart failure. Adherence to these suggested interventions may serve as a marker of quality of care and form a foundation for quality improvement. Heart failure performance measures have been developed to provide a mechanism through which the quality of medical care can be measured and improved. The recently released ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure includes: discharge instructions, evaluation of left ventricular systolic function, angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD), adult smoking cessation advice/counseling, and anticoagulant at discharge for patients with atrial fibrillation. Although it is expected that application of these carefully developed heart failure inpatient performance measures should result in substantial improvement in heart failure patient outcomes, available data validating these measures are limited.
Gregg C. Fonarow, M.D., of the University of California Los Angeles Medical Center, and colleagues analyzed data from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry to determine the relationship between current ACC/AHA performance measures and relevant patient clinical outcomes, including the risk of death at 60- to 90-days after discharge, and rehospitalization rates. Follow-up data were collected from 5,791 patients at 91 U.S. hospitals between March 2003 and December 2004. Average patient age was 72.0 years, 51 percent were male and 78 percent were white. The researchers also evaluated the potential performance measure for beta-blockers at discharge among eligible patients hospitalized with heart failure.
During follow-up, 8.6 percent of the patients had died and the total death or rehospitalization rate was 36.2 percent. None of the current ACC/AHA performance measures was a significant independent predictor of death in the first 60 to 90 days after hospital discharge. Prescription of a beta-blocker at the time of hospital discharge, currently not a heart failure performance measure, was highly predictive of improved postdischarge survival (52 percent reduced risk of death) and a 27 percent lower risk of death/rehospitalization.
“These findings may have significant clinical and public health implications and suggest that additional measures may be required to more effectively quantify the quality of care provided to heart failure patients in the hospital setting,” the authors write.
“For the ACC/AHA performance measure sets to achieve their stated goal of serving as a vehicle for more rapidly translating the strongest clinical evidence into practice, better methods for identifying and validating new performance measures may be needed. As this limited set of performance measures is being used to publicly report the quality of heart failure care delivery at the hospital level and is beginning to affect financial payments to medical centers and individual physicians, it is essential that measures be prioritized to include those that are proven to be closely associated with patient outcomes,” they write. “Although these findings require confirmation in other studies, they suggest that use of the ACC/AHA heart failure performance measures in their current form in Centers for Medicare & Medicaid Services pay-for-performance programs may not be the most efficacious way to assess quality of care, given the lack of a connection between the majority of performance measures and early heart failure patient outcomes.”