Major heart failure quality of care variations found in US hospitals

UCLA investigators found large gaps and marked variation in U.S. hospitals’ heart failure treatment based on adherence to four standard quality measures. The study points to the need for hospitals to establish education programs and systems to improve quality of care for this patient population.

Published in the July 11 issue of the Archives of Internal Medicine, researchers compared four standard measures for heart failure treatment used by the Joint Commission of Accreditation of Healthcare Organizations, the national agency that accredits hospitals.

“We found that the quality of care for heart failure treatment really depends to a very large extent on which hospital patients are admitted to. This is one of the first studies to take a scientific look at the variation in performance measures in hospitals across the country,” said Dr. Gregg C. Fonarow, lead study author, The Eliot Corday Chair in Cardiovascular Medicine and Science, professor of cardiology, David Geffen School of Medicine at UCLA.

Using a national registry of heart failure patients called the Acute Decompensated Heart Failure National Registry (ADHERE®), researchers analyzed admissions data from 223 U.S. hospitals and assessed whether hospitals performed four standard measures in heart failure treatment:

1) Supplying the patient or caregiver with written instructions and guidance on post-discharge care. Researchers found that only 24 percent of patients hospitalized received complete discharge instructions.

2) Adequate assessment of left heart ventricular function, which is the area of the heart most compromised in heart failure. Researchers found 86.2 percent of patients hospitalized had their heart function assessed.

3) Prescription of an angiotensin-converting enzyme (ACE) inhibitor drug upon discharge in appropriate patients. This is one of the most important therapies to prolong life and reduce the risk of re-hospitalization in patients with heart failure. Investigators found that only 72 percent of eligible patients were prescribed this therapy.

4) Counseling on smoking cessation for appropriate patients. UCLA researchers found only 43.2 percent of patients who were current or recent smokers were counseled regarding smoking cessation.

“Gaps in care were seen in hospitals large and small, teaching and non-teaching, and all regions of the country. There is a definite opportunity for hospitals to improve in all these quality areas, especially since performance on these measures is closely linked to heart failure patients’ risk of rehospitalization and death,” said Fonarow, director, Ahmanson-UCLA Cardiomyopathy Center.

In the poorest performing hospitals, less than one percent of patients received discharge information. In the best performing hospitals for this measure, 70 percent of patients were given the information. Fonarow notes that that is a 100-fold difference in conformity.

Fonarow adds that the study compared variation in clinical outcomes as well, including length of stay mortality rates. “Whether a patient makes it out of the hospital alive or not after being hospitalized with heart failure varies by the hospital they go to,” said Fonarow.

The difference in mortality rates between hospitals was fourfold, with variations from only 1.4 percent of patients dying at the best performing hospitals to as high as 6.1 percent of patients at the worse performing institutions. “We encourage facilities to institute new education programs and systems to help meet these national requirements and to minimize variations between hospitals,” said Fonarow.

There are a number of programs which hospitals can participate in to improve the quality of heart failure care and reduce variation, including the American Heart Association’s Get With the GuidelinesSM – Heart Failure. This initiative provides physicians, nurses and other hospital staff with effective tools to help ensure patients receive evidence-based treatment and care that is consistent with the national guidelines.

Fonarow adds that the U.S. Department of Health and Human Services now provides a website called “Hospital Compare” where patients can check each hospital for their performance on quality measures for heart failure and other conditions: http://www.hospitalcompare.hhs.gov/

Heart failure is a condition that affects five million Americans and is the leading cause of hospitalization for those over age 65.