Clinical Investigations
Congestive Heart Failure
Relationships between emerging measures of heart failure processes of care and clinical outcomes

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Background

Previous studies have not confirmed associations between some current performance measures for inpatient heart failure processes of care and postdischarge outcomes. It is unknown if alternative measures are associated with outcomes.

Methods

Using data for 20,441 Medicare beneficiaries in OPTIMIZE-HF from March 2003 through December 2004, which we linked to Medicare claims data, we examined associations between hospital-level processes of care and patient outcomes. Performance measures included any β-blocker for patients with left ventricular systolic dysfunction (LVSD); evidence-based β-blocker for patients with LVSD; warfarin for patients with atrial fibrillation; aldosterone antagonist for patients with LVSD; implantable cardioverter-defibrillator for patients with ejection fraction ≤35%; and referral to disease management. Outcome measures were unadjusted and adjusted associations of each process measure with 60-day and 1-year mortality and cardiovascular readmission at the hospital level.

Results

Adjusted hazard ratios for 1-year mortality with a 10% increase in hospital- level adherence were 0.94 for any β-blocker (95% CI, 0.90-0.98; P = .004), 0.95 for evidence-based β-blocker (95% CI, 0.92-0.98; P = .004); 0.97 for warfarin (95% CI, 0.92-1.03; P = .33); 0.94 for aldosterone antagonists (95% CI, 0.91-0.98; P = .006); 0.92 for implantable cardioverter-defibrillator (95% CI, 0.87-0.98; P = .007); and 1.01 for referral to disease management (95% CI, 0.99-1.03; P = .21).

Conclusions

Several evidence-based processes of care are associated with improved outcomes, can discriminate hospital-level quality of care, and could be considered as clinical performance measures.

Section snippets

Data sources

The study population was from the OPTIMIZE-HF registry, which contains data on processes of care for patients hospitalized with heart failure.10 Participating US hospitals (n = 259) enrolled 48 612 patients from March 1, 2003, through December 31, 2004, using a case-ascertainment approach similar to that used by the Joint Commission.11 Eligible patients were those who presented with heart failure symptoms during a hospitalization for which heart failure was the primary discharge diagnosis and

Results

The mean age of the study population was 79 years (SD, 7.7); 45% of the patients were men, and 82% were white. Approximately half of the patients had ischemic heart disease and a mean ejection fraction of 39.9% (SD, 15.4%). The most common comorbid conditions were diabetes mellitus (39%), atrial arrhythmias (39%), chronic obstructive pulmonary disease (28%), and chronic kidney disease (19%) (Table I). The overall unadjusted mortality and cardiovascular readmission rates were 30.9% and 46.0%,

Discussion

This study is the first to examine associations between emerging measures of processes of care for patients hospitalized with heart failure with early and long-term postdischarge clinical outcomes. The principal findings are threefold. First, hospital-level performance measures for any β-blocker, evidence-based β-blocker, aldosterone antagonist, and ICD were significantly associated with 1-year patient-level mortality. Second, fewer hospital-level performance measures were associated with early

Conclusion

Adherence to heart failure process measures for any β-blocker, evidence-based β-blockers, aldosterone antagonists, and ICDs are significantly associated with postdischarge clinical outcomes and can be used to effectively discriminate quality of care at the hospital level. These measures could be considered for inclusion in heart failure performance measure sets. Given the moderate associations between individual process measures and clinical outcomes, it may be appropriate to include multiple

Disclosures

This study was supported by grant U18HS10548 from the Agency for Healthcare Research and Quality and by a research agreement between GlaxoSmithKline and Duke University. Dr Hernandez is a recipient of an American Heart Association Pharmaceutical Roundtable grant (0675060N). Drs Curtis and Schulman were supported in part by grants U01HL066461 from the National Heart, Lung, and Blood Institute and R01AG026038 from the National Institute on Aging. Dr Fonarow is supported by the Ahmanson Foundation

Acknowledgements

We thank Damon M. Seils, MA, Duke University, for editorial assistance and manuscript preparation.

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