JACC in a Flash | Reality Check: Recalibrating Performance Measures for All Cause Heart Failure

Given the significant morbidity and mortality associated with heart failure (HF), ensuring that HF patients receive guideline-endorsed care to improve their outcomes has become a major focus of HF research. The Centers for Medicare and Medicaid Services, the ACCF, and the Physician Consortium for Performance Improvement have all developed performance measures for patients hospitalized with HF. However, these typically target patients whose primary reason for admission is HF; in a study appearing in JACC, Saul Blecker, MD, MHS, and colleagues assessed the quality of care for patients with HF who were hospitalized for another cause.

To test their hypothesis—patients with all-cause HF would receive less optimal care than patients who were specifically hospitalized for HF—Blecker et al. compared the rates of compliance with care measures and outcomes in 4,345 hospitalizations of HF patients (39.6% of whom carried a principal diagnosis of HF).

Overall, compliance to quality and process care measures was higher in those patients with a principal HF diagnosis compared to those with secondary HF (TABLE).

Of the care measures assessed, LV assessment and angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) use were associated with reductions in 1-year post-discharge mortality: odds ratios of 0.66 and 0.72, respectively. This remained true regardless of the reason for hospitalization, suggesting that quality improvement initiatives have indeed had an effect on care delivery in this sample population.

“We found that the majority of hospitalizations for individuals with heart failure had a principal diagnosis that was not heart failure, a finding consistent with previous studies,” the authors wrote. Despite this statistic, HF patients admitted for other diagnoses may be receiving lower rates of guideline-concordant care. “Improving compliance with processes of care such as LV assessment and, as appropriate, discharge prescriptions for ACE inhibitors/ARBs, beta-blockers, aldosterone antagonists, and anticoagulants, may result in improved survival among both individuals with a primary diagnosis of heart failure as well as those with a secondary diagnosis of heart failure.”

“Despite evidence-based guidelines, performance measures, quality improvement programs, and public reporting of hospital-level performance data, the number of patients dying or readmitted to hospitals in the year after hospital discharge remains excessive,” Robert O. Bonow, MD, MS, and Mihai Gheorghiade, MD, wrote in an accompanying editorial. “There is evidence of an important gap in care affecting a large number of heart failure patients who are currently under the radar screen of public scrutiny, and hence there is an opportunity for substantial quality improvement.”

While the association between process measures and outcomes is a major concern, Drs. Bonow and Gheorgiades noted that there has been little research in the setting of HF hospitalization. Becker et al. provide evidence and real-world observations about this relationship, but they also reported, unfortunately, a “glaring under-use” of ACE inhibitors/ARBs in patients with LV systolic dysfunction—even in those with a primary HF diagnosis. “Given the significant link between ACE inhibitor/ARB therapy and improved survival in this study, consistent with multiple randomized clinical trials and guidelines recommendations, the under-performance on this measure represents an egregious gap in care that provides an unsettling wake-up call that ongoing monitoring of heart failure quality metrics and attention to all aspects of evaluation and treatment are necessary to achieve optimal outcomes,” the authors concluded.

TABLE: Compliance to Care Measures in Patients With Principal vs. Secondary HF Diagnosis
Care Measure
Patients Assessed for Measure (n)
Principal HF Diagnosis
Other Principal Diagnosis
p Value
Adjusted Prevalence Ratio, Principal HF
LV assessment
< 0.0001
1.07 (1.04–1.10)
ACE inhibitor/ARB for LV dysfunction
1.11 (1.03–1.20)
β-Blocker for LV dysfunction
1.03 (0.98–1.08)
Anticoagulation for atrial fibrillation
1.16 (0.89–1.52)
Aldosterone antagonist for LV dysfunction
1.35 (1.06-1.72)

Blecker S, Agarwal SK, Chang PP, et al. J Am Coll Cardiol. 2013 October 1. [Epub ahead of print]
Bonow RO, Gheorghiade M. J Am Coll Cardiol. 2013 October 1. [Epub ahead of print]

Keywords: Quality Improvement, Process Assessment, Health Care, Heart Failure, Centers for Medicare and Medicaid Services, U.S., Patient Discharge, Hospitalization

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