Are Guidelines Followed Less When Treating Secondary Diagnosis of HF?

The quality of care for hospitalized heart failure (HF) patients could be dramatically improved with one change — extending the same standard of care to patients with HF as a secondary diagnosis that is currently recommended for patients with HF as a primary diagnosis, according to a study published in the Journal of the American College of Cardiology.

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An analysis of 4,345 HF patients hospitalized with acute or chronic HF in the Atherosclerosis Risk in Communities (ARIC) study found that only 39.6 percent of patients hospitalized with HF had a primary diagnosis of HF. The remaining 59.1 percent of HF patients had some other primary diagnosis. Results also showed that patients with a primary diagnosis of HF had higher rates of guideline care, including left ventricular systolic function evaluation (89.1 percent versus 82.5 percent) and higher rates of angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) discharge prescriptions (64.1 percent versus 56.3 percent) compared to HF patients hospitalized for some other primary indication. HF patients who were assessed for left ventricular systolic function had a 34 percent lower mortality rate in the 12 months following discharge compared to patients who did not receive evaluation as indicated by Centers for Medicare and Medicaid Services (CMS) performance measures. Prescription of an ACE inhibitor or ARB at discharge for patients with left ventricular systolic dysfunction was associated with a 28 percent reduced risk of mortality in the year following discharge.

HF performance measures from the CMS include the evaluation of left ventricular systolic function evaluation and a discharge prescription for either an ACE inhibitor or angiotensin receptor blocker (ARB). The ACC, American Heart Association and the American Medical Association-Physician Consortium for Performance Improvement have endorsed similar guidelines for adult HF care.

"The majority of hospitalizations for individuals with HF had a principal diagnosis that was not HF," said lead author Saul Blecker, MD, MHS, New York University School of Medicine, NY. "HF patients being admitted for other diagnoses may be receiving lower rates of guideline-concordant care. The potential for improved outcomes with quality care for individuals with a secondary HF diagnosis is particularly important as these individuals are more commonly seen in hospitals and are less likely to receive HF-related therapies than individuals with a principal HF diagnosis."

An accompanying editorial supported the call for improved care for all HF patients. "Adherence to HF quality measures is significantly less rigorous among patients with a secondary diagnosis of HF," said Robert Bonow, MD, MS, MACC, Center for Cardiovascular Innovation at the Northwestern University Feinberg School of Medicine in Chicago. "Whether the diagnosis of HF was primary or secondary, the lack of either assessment of left ventricle function or appropriate use of ACE inhibitors/ARBs was associated with significantly higher post-discharge mortality rates. The overall utilization of ACE inhibitors/ARBs was remarkable low. Under-performance on this measure represents an egregious gap in care."

Keywords: Atherosclerosis, Standard of Care, Heart Failure, Centers for Medicare and Medicaid Services, U.S., Hospitalization, Systole

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