Incremental Survival Benefit With Adherence to Standardized Heart Failure Core Measures: A Performance Evaluation Study of 2958 Patients

doi:10.1016/j.cardfail.2007.10.011

Journal of Cardiac Failure

Volume 14, Issue 2, March 2008, Pages 95-102

https://doi.org/10.1016/j.cardfail.2007.10.011 Get rights and content

Abstract

Background

In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established four heart failure (HF) core measures to standardize and improve health care quality in the United States. Although adherence to these HF care processes may be improving, their collective impact on survival is not yet settled.

Methods

JCAHO HF measures were implemented within a 20-hospital health care system. Eligible patients had a principal discharge diagnosis of HF. Metrics representing compliance with these measures were derived and their relationship with 1-year survival was examined using an adjusted Cox proportional hazards regression.

Results

A total of 2958 patients met study criteria. The average age was 73 years, 50% were male, and 9.9% were smokers. One-year survival benefits were seen in an item-by-item evaluation of HF measures for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy (hazard ratio [HR] = 0.69), left ventricular function assessment (HR = 0.83), and patient education (HR = 0.79). When assessed collectively, improved survival was seen among patients eligible for two (HR = 0.53), three (HR = 0.36), or four HF measures (HR = 0.65). Further, we found a positive and incremental relationship between the degree of adherence and survival (P = .008).

Conclusion

Adherence to JCAHO HF core measures is associated with improved 1-year survival after HF hospitalization. This validates these simple and effective performance measures and justifies efforts to implement them in all eligible patients with HF.

Section snippets

Study Population and Selection

The study was conducted using data generated within Intermountain Healthcare (IHC), which serves patients in Utah, Idaho, Nevada, and Wyoming. IHC is a nonprofit, integrated health care system that includes 20 hospitals, a system of health plans, and both employed (∼400 mainly primary care) and affiliated (∼2500 mainly specialty) physicians. It is also an approved Joint Commission Performance Measurement System vendor for JCAHO core measure sets. This allowed us to link case-level information

Results

A population of 2958 patients with HF were identified for the study, with an average patient age of 73.5 ± 13.8 years and men composing 50.4% of the sample (Table 1). Smokers made up only 9.9% (n = 294) of the population, and 87.1% (2576) of patients were cared for in urban settings. Of our study population, 2.7% (n = 81) were eligible for only one HF core measure, 23% (n = 689) were eligible for two HF core measures, 66% (n = 1943) were eligible for three HF core measures, and 8.3% (n = 245)

Discussion

HF is widely recognized as a common, disabling, deadly, and costly disorder. More emphasis than ever is now being placed on optimizing care of patients with HF. The Institute of Medicine's report, Crossing the Quality Chasm, supports the national trend toward improving the quality of health care.¹³ Further, updated American College of Cardiology/American Heart Association and Heart Failure Society of America HF Management Guidelines recognize the importance of reducing HF morbidity and

Conclusions

This study shows that in patients hospitalized with HF, adherence to JCAHO HF core measures was associated with improved 1-year survival after discharge. It also demonstrates an association between these care processes and outcomes. Different performance assessments suggested that the HF core measures are weighted unequally, and that partial adherence to them was associated with partial survival benefit in an incremental fashion. These results underscore the importance of implementing these

Acknowledgments

The authors thank Jerod M. Loeb, PhD, Stephen P. Schmaltz, PhD, and Scott C. Williams, PsyD for valuable critique of the article and helpful suggestions on the data analysis. The authors also thank Ashley R. Renlund for technical and editorial assistance.

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Physician practice patterns in the management of hospitalized acute decompensated heart failure (ADHF) patients may vary by specialty; comparative practice patterns in ADHF management and clinical outcomes as a function of provider type have not been well reported. We studied a total of 496 patients discharged with the principal diagnosis of ADHF to analyze practice patterns among 3 provider types (cardiologists, hospitalists, and nonhospitalists). We examined outcomes of death and rehospitalization for HF and adherence to the Joint Commission HF performance core measures. Cardiologists had the highest adherence in all 4 HF core measures compared with hospitalists and nonhospitalists. At 6 months, 6.0% of the patients cared by cardiologists died compared with 10.9% and 11.4% cared by hospitalist and nonhospitalists (p = 0.12). Patients cared for by cardiologists had a significantly lower 6-month ADHF readmission rate (16.2%) compared with hospitalists (40.1%) and nonhospitalists (34.9%, p <0.001). In multivariate analysis, both hospitalist and nonhospitalist provider types were an independent predictor for 6-month ADHF-related readmission (hospitalists vs cardiologists, hazard ratio_adjusted 3.01; 95% confidence interval 1.84 to 4.89, p <0.001; and nonhospitalists vs cardiologists, hazard ratio_adjusted 2.07; 95% confidence interval 1.24 to 3.46, p = 0.005). In conclusion, cardiologist-delivered ADHF care is associated with greater adherence to HF core measures and with significantly lower rates of adverse outcome compared with noncardiologists.
Heart failure performance measures: Eligibility and implementation in the community
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Citation Excerpt :
This would also guide future research in the development and implementation of performance measures. In our cohort, LV systolic function assessment was universal, higher than the previously reported range from 79% to 87%.20,21 This may reflect the practice of a large teaching hospital as Heidenreich et al have previously reported.25
The goal of heart failure (HF) performance measures is to improve quality of care by assessing the implementation of guidelines in eligible patients. Little is known about the proportion of eligible patients and how performance measures are implemented in the community.
We determined the eligibility for and adherence to performance measures and β-blocker therapy in a community-based cohort of hospitalized HF patients from January 2005 to June 2011.
All of the 465 HF inpatients (median age 76 years, 48% men) included in the study received an ejection fraction assessment. Only 164 had an ejection fraction <40% thus were candidates for β-blocker and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) therapy. Considering absolute contraindications, 99 patients were eligible to receive ACE inhibitors/ARB, and 162 to receive β-blockers. Among these, 85% received ACE inhibitors/ARBs and 91% received β-blockers. Among the 261 individuals with atrial fibrillation, 89 were eligible for warfarin and 54% received it. Of 52 current smokers, 69% received cessation counseling during hospitalization.
In the community, among eligible hospitalized HF patients, the implementation of performance measures can be improved. However, as most patients are not candidates for current performance measures, other approaches are needed to improve care and outcomes.
Clinical pharmacy services in heart failure: An opinion paper from the heart failure society of america and american college of clinical pharmacy cardiology practice and research network
2013, Journal of Cardiac Failure
Heart failure (HF) care takes place in multiple settings, with a variety of providers, and generally involves patients who have multiple comorbidities. This situation is a “perfect storm” of factors that predispose patients to medication errors.
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Positive outcomes associated with clinical pharmacist activities support the value of making this resource available to HF teams.
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Citation Excerpt :
Previous studies have demonstrated that specific interventions can improve the outcomes of patients hospitalized with HF, but the evidence has not been overwhelming. Kfoury et al7 were the first to show that adherence to quality measures, established by the Joint Commission on Accreditation of the Healthcare Organizations in 2002, was associated with lower 1-year mortality. In the OPTIMIZE-HF study, compliance with each of the 4 performance measures increased significantly between 2003 and 2004, with a trend toward lower mortality, rehospitalization, and length of stay.8
In 2005, the American College of Cardiology/American Heart Association published performance measures to provide a standard of care for hospitalized patients with heart failure (HF). Despite increasing compliance with these measures, hospital mortality and readmission rates remain stagnant. Whether compliance with HF performance measures improves patient outcomes at the hospital level is unclear.
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We found that socioeconomic factors and hospital volume were stronger predictors of mortality than compliance with HF performance measures. After adjusting for socioeconomic factors and hospital volume, only 1 of the 4 performance measures was associated with lower 30-day mortality and 2 were associated with lower readmissions.

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Clinical InvestigationIncremental Survival Benefit With Adherence to Standardized Heart Failure Core Measures: A Performance Evaluation Study of 2958 Patients

Abstract

Background

Methods

Results

Conclusion

Section snippets

Study Population and Selection

Results

Discussion

Conclusions

Acknowledgments

J Am Coll Cardiol

Am Heart J

Heart Failure Society of America. Executive summary: HFSA 2006 Comprehensive Heart Failure Practice Guidelines

J Card Fail

Quality the need for intelligent efforts

Arch Intern Med

Quality of care in U.S. hospitals as reflected by standardized measures

N Engl J Med

Association between performance measures and clinical outcomes for patients hospitalized with heart failure

JAMA

Voluntary Hospitals of America task force report on severity indexing systems

Clinical Investigation
Incremental Survival Benefit With Adherence to Standardized Heart Failure Core Measures: A Performance Evaluation Study of 2958 Patients