Associations Between Outpatient Heart Failure Process-of-Care Measures and Mortality

Study Questions:

Does practitioner adherence to heart failure (HF) process measures improve patient outcomes?


This was an analysis of data collected from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF), a prospective cohort study of outpatients with chronic HF (left ventricular ejection fraction ≤35%). Adherence to four current HF process measures (angiotensin-converting enzyme [ACE] inhibitor/angiotensin-receptor blocker [ARB] use, beta-blocker use, anticoagulant therapy for atrial fibrillation, and HF education) and three emerging measures (aldosterone antagonist use, implantable cardioverter-defibrillator [ICD] implantation, cardiac resynchronization therapy [CRT]) was assessed in patients enrolled into 167 US cardiology practices. A composite score for adherence to the process measures was generated. Generalized estimating equation modeling (regression for binary outcomes with repeated measures) was used to examine mortality at 24 months based on HF quality of care.


There were 15,177 patients evaluated, of which 11,621 had documentation of vital status. Of these, 22% (n = 2,569) were dead by 24 months. Median [25th, 75th] patient age was 70 [60, 79], 71% were men, and 71% were New York Heart Association (NYHA) class I/II. Only 9% of patients were cared for at university-based practices. Compared with survivors, patients who died had lower conformity at baseline to beta-blocker, ACE inhibitor/ARB, ICD, and CRT use and anticoagulation for atrial fibrillation. After 24 months of follow-up, practitioner adherence to all HF but one process measure (aldosterone antagonist use) was associated with reduced odds of death. Every 10% improvement in composite care was associated with a 13% lower odds of death (adjusted odds ratio, 0.87 [0.84-0.90]).


The authors concluded that adherence to HF process care measures leads to improved HF survival.


Performance measures have been developed to assess practitioner and practice HF care, and are increasingly being used to guide practice/practitioner reimbursement. This study provides strong evidence (31-55% reduced odds) that practitioner adherence to HF process measures (with the exception of aldosterone antagonists) leads to improved patient outcomes, and may provide support for quality-based reimbursement practices. However, some important considerations must be taken into account. Such quality assessments assume that 1) practitioner adherence to process measures directly translates into patient adherence, which translates into the improved outcome (i.e., patients actually take the medications prescribed and follow HF education recommendations); 2) the cohort of patients and cardiology practices analyzed are reflective of the standard HF patient and practitioner in the United States; and 3) nonprescription without documentation of a contraindication is truly nonconformity to HF process measures and not just poor documentation (only 35% of patients were cared for at practices with an electronic medical record). Along these lines, practices that specialize in advanced HF care have an inherent referral bias, caring for patients referred from non-HF specialists who have failed best care attempts. Often, these patients have end-stage disease and multiple comorbidities that make them intolerant of evidenced-based therapies (few NYHA class IV patients in this study) or are ‘frequent fliers’ due to nonadherence. HF specialists may, therefore, be faced with severe underpayment if documentation is not pristine.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, Acute Heart Failure

Keywords: Survivors, Registries, Follow-Up Studies, Process Assessment (Health Care), Outpatients, Cardiology, Heart Failure, New York, Universities, United States, Cardiac Resynchronization Therapy

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