Heart Failure Performance Measures Trivial For Survival

LOS ANGELES, Jan. 2 -- Performance measures adopted by the government to gauge hospital quality of care for heart failure have little impact on survival during the critical early post-discharge period, researchers here reported.

None of the heart failure performance measures used by Medicare and Medicaid, plus the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), significantly predicted 60- or 90-day mortality, found Gregg C. Fonarow, M.D., of the UCLA Medical Center, and colleagues in an analysis of a large registry.

When the combined outcome of post-discharge mortality or re-hospitalization was assessed, only ACE inhibitor or angiotensin receptor blocker use at discharge was a strong influence, they reported in the Jan. 3 issue of the Journal of the American Medical Association.

"These findings may have significant clinical and public health implications," they wrote, "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 American College of Cardiology and American Heart Association (ACC/AHA) performance measures currently used include discharge instructions, evaluation of left ventricular systolic function, ACE inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction, advice or counseling on smoking cessation, and anticoagulant at discharge for patients with atrial fibrillation.

The researchers looked at these measures in a subgroup of 5,791 patients followed for 60 to 90 days at 91 U.S. hospitals in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry.

Patients in the registry were adults hospitalized primarily for worsening heart failure or who developed significant heart failure symptoms during hospitalization for which the disease was the primary discharge diagnosis. The average patient age was 72.0, 51% were male, 78% were white, and 18% were African American. During follow-up, 8.6% of patients died and 29.6% were rehospitalized.

Among these patients, the risk-adjusted findings for 60- or 90-day mortality were:

• Discharge instructions had no significant effect (hazard ratio 0.90, 95% confidence interval 0.66 to 1.23, P=0.51),
• Evaluation of left ventricular systolic function did not have a significant impact (HR 0.91, 95% CI 0.65 to 1.28, P=0.59),
• ACE inhibitor or ARB for left-ventricular systolic dysfunction tended to improve survival but not significantly (HR 0.61, 95% CI 0.35 to 1.06, P=0.08),
• Smoking cessation counseling had no impact (HR 0.75, 95% CI 0.41 to 1.37, P=0.35), and
• Warfarin for atrial fibrillation did not significantly improve mortality (HR 0.74, 95% CI 0.50 to 1.09, P=0.13).

For combined mortality and rehospitalization at 60 or 90 days, the risk-adjusted results were:

• Discharge instructions had no significant effect (HR 1.07, 95% CI 0.89 to 1.28, P=0.46).
• Evaluation of left-ventricular systolic function did not have a significant impact (HR 1.06, 95% CI 0.81 to 1.38, P=0.67).
• ACE inhibitor or ARB use for left ventricular systolic dysfunction significantly improved survival (HR 0.51, 95% CI 0.34 to 0.78, P=0.002).
• Smoking cessation counseling had no impact (HR 0.74, 95% CI 0.50 to 1.09, P=0. 12).
• Coumadin (warfarin) for atrial fibrillation did not significantly improve outcomes (HR 0.83, 95% CI 0.64 to 1.09, P=0.19).

However, Dr. Fonarow and colleagues found a potential performance measure that would be related to outcomes.

Prescription of a beta-blocker at the time of hospital discharge for eligible patients reduced risk of death by 52% and lowered risk of death or rehospitalization by 27%. It was more predictive of improved postdischarge survival than any of the currently used measures. The risk-adjusted hazard ratios were:

• 0.48 for 60- or 90-day mortality (95% CI 0.30 to 0.79, P=0.004), and
• 0.73 for death or rehospitalization at 60 or 90 days (95% CI 0.55 to 0.96, P=0.02).

Because the registry included only self-selected hospitals and a subset of patients, the researchers cautioned that the results may not be entirely representative of national patterns of care and clinical outcomes.

Also, the data extended only to 60 to 90 days after discharge, which may not have been long enough to show an effect from some interventions. However, "the first 60 to 90 days after discharge comprise the period of highest risk for mortality and rehospitalization and are most likely to reflect the processes of hospital-based care," Dr. Fonarow and colleagues wrote.

They concluded:

"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 CMS [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."

"Additional measures with stronger process-outcome links in the first 60 to 90 days after hospital discharge, such as use of beta-blockers in eligible patients, should be considered," they added.