Limitations in Quality-of-Care Indicators for Heart Failure Patients
Care for Heart Failure Patients
Academic researchers reported that all five standard hospital-based performance measures used to gauge quality of care for hospitalized heart failure patients may not be the best benchmarks, since none were significant predictors of patient mortality during the critical 60 to 90 days immediately following hospital discharge.
Published in the Jan. 3 issue of the Journal of the American Medical Association, the study found that none of the current measures used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which accredits hospitals, and by the federal government through the Center for Medicare and Medicaid Services (CMS) to assess hospital performance were associated with a lower risk of mortality during the days immediately following hospital discharge, when adverse events are most likely to occur.
Only one of the standard measures modestly influenced mortality and rehospitalization rates. Researchers also reported that the use of beta-blocker medications in eligible heart failure patients at the time of hospital discharge - which is not a current JCAHO/CMS performance measure - was associated with the most significant improvements in heart failure patient outcomes, predictive of a 52 percent reduction in mortality during the first 60 to 90 day period after hospital discharge.
Professional societies, health care accrediting organizations, the government and major insurers use performance measures to rank and accredit hospitals, rate quality of care, and develop hospital and physician pay-for-performance initiatives. According to researchers, performance measures should reflect the strongest clinical evidence in practice, and failure to perform these key treatments should reduce the likelihood of optimal patient outcomes.
"The study's findings are quite surprising, since it has been commonly held that existing performance measures could be used to distinguish hospitals that provide higher quality heart failure care and that these indicators were strongly linked to clinical outcomes," said principal investigator Dr. Gregg C. Fonarow, the Eliot Corday Chair in Cardiovascular Medicine and Science, director of the Ahmanson - UCLA Cardiomyopathy Center, and professor of medicine in the UCLA Division of Cardiology.
Fonarow added that the findings do not lessen the importance of providing the recommended elements of heart failure care covered by the existing performance measures, nor do they preclude these measures from influencing patient quality of life or long-term survival.
However, Fonarow noted that the study does demonstrate that the factors influencing mortality and rehospitalization after discharge may be driven by a different set of care processes and that better methods for identifying and validating new performance measures are needed.
Researchers utilized data on 5,791 patients at 91 hospitals, taken from a large heart failure patient registry and performance improvement program called the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF).
Researchers statistically analyzed the relationship between the five standard performance measures and clinical outcomes within the 60 to 90 days after patient discharge. Four of these heart failure measures are currently used by JCAHO/CMS and are publicly reported on the Hospital Compare website: www.hospitalcompare.hhs.gov
The five measures, developed by the American College of Cardiology and the American Heart Association, include: (1) Giving complete medical instructions to patients upon hospital discharge; (2) evaluating the heart's left ventricle systolic function; (3) prescribing patients an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) drugs; (4) smoking cessation counseling; and (5) prescribing anticoagulation for atrial fibrillation.
Researchers also evaluated the prescribing of a beta-blocker at hospital discharge, another key medication for heart failure that currently is not assessed with a performance measure.
The study determined that none of the five standard measures were significantly associated with reduced early mortality risk and that ACE inhibitor or ARB use only modestly affected mortality or rehospitalization outcomes. Prescribing a beta-blocker in eligible patients, however, was strongly associated with lower mortality risk and lower death or rehospitalization risk.
"This study has identified and validated a new performance measure that could be used to augment existing measures and more effectively quantify the quality of care provided to heart failure patients in the hospital setting," said Fonarow. "If this beta-blocker measure was adopted by JCAHO/CMS, and the levels of performance achieved by OPTIMIZE-HF hospitals in providing beta-blockers were achieved by hospitals nationwide, we estimate that an additional 19,000 lives a year could be saved."
The investigators noted that while performance measures for heart attack have a strong association with mortality outcomes, the connection for heart failure measures have not been as well studied.
"While the current performance measures for heart failure have some rationale for their continued use, in determining which measures should be publicly reported and used for pay-for-performance programs, there should be better selection of measures that significantly influence patient outcomes early after hospital discharge," Fonarow said.
Fonarow added that it may be helpful to require hospitals to report actual patient outcomes such as mortality, or mortality and rehospitalization, rates in the first 30 to 90 days post-discharge to help track and identify which hospitals are providing better care. Currently, hospitals only report in-hospital process of care data.
Only the American Heart Association's Get With the Guidelines - Heart Failure program, one of the national quality improvement programs for heart failure, routinely collects and reports on a beta-blocker performance measure for patients hospitalized with heart failure.
Heart failure is the leading cause of hospitalization in those over 65 - almost 3.6 million hospitalizations are attributed to heart failure as the primary or secondary discharge diagnosis each year. The estimated direct and indirect costs of heart failure in 2006 are expected to be $29.6 billion. Heart failure occurs when the heart cannot pump enough blood to the body's other organs. The heart keeps working but not as efficiently as it should. This condition is caused by narrowed arteries, heart attack, high blood pressure, heart defects, infection, or disease of the heart muscle or valves.
GlaxoSmithKline sponsored the OPTIMIZE-HF registry and funded the study. Dr. Fonarow has received research grants, honoraria and served as a consultant for GlaxoSmithKline. Additional author financial disclosure is available in the full Journal of the American Medical Association paper, on page 8.