The National Heart Failure Audit a Lever for Change Professor T A - PowerPoint PPT Presentation

The National Heart Failure Audit –a Lever for Change Professor T A McDonagh, King’s College Hospital, London. UK

The National Heart Failure Audit-8th Annual Report Established in 2007. Report the clinical practice and patient outcomes for acute patients discharged from hospital with a primary diagnosis of heart failure (also record I/P death) ICD-10 codes. Purpose is to use the data to improve the standard of care . Participation in the audit is mandated by the Department of Health’s NHS Standard Contracts for 2012/13 and by the NHS Health’s NHS Standard Contracts for 2012/13 and by the NHS Wales National Clinical Audit and Outcome Review Plan 2012/13 . Supported by BSH, managed by NICOR, commissioned by HQIP ICD-10 codes: I11.0 Hypertensive heart disease with (congestive) heart failure, I25.5 Ischaemic cardiomyopathy, I42.0 Dilated cardiomyopathy, I42.9 Cardiomyopathy, unspecified, I50.0 Congestive heart failure, I50.1 Left ventricular failure, I50.9 Heart failure, unspecified BSH, British Society for Heart Failure, NICOR, National Institute for Cardiovascular Outcomes research, HQIP, Healthcare Quality improvement Partnership

The Process Submit the data annually Annual report for National Data Compare your Hospital to the National Data KPIs published-case ascertainment, diagnostics, drug prescriptions rates, specialist care metrics Mortality only known by the hospital Use the data to change care locally Nationally-feeding into –NHS England-Best Practice Tariff NICE-data use for Guideline development (AHF latest) Quality standards-Audit is the way to collect the data and adapts to the standards

April 2013-March 2014 participation and case ascertainment 99 % NHS Trusts in England and 89 % Welsh Health Boards submitting data Reporting on 55,040 admissions 54,654. Post data cleaning 25% increase since last year! HES admission increased 85% of HF admissions in England and 76% in Wales Aggregate data presented >300,000 patient episodes since the beginning

Demographics 2013-14 Mean age=77.6 years Median age=80.2 years Mean age men=75.7 years Mean age women=80.1 years

Symptoms Total on Total on Symptoms/signs of heart failure admission (%) readmission (%) NYHA class I/II 18.6 16.1 NYHA class III 44.7 44.5 NYHA class IV NYHA class IV 36.6 36.6 39.4 39.4 No/mild peripheral oedema 49.1 45.3 Moderate peripheral oedema 32.4 32.9 Severe peripheral oedema 18.5 21.9 NYHA, New York Heart Association

Echo diagnosis Total (%) Normal echo 3.3 Left ventricular systolic dysfunction (LVSD) 70.3 Left ventricular hypertrophy (LVH) 7.1 Valve disease 27.8 Diastolic dysfunction 9.7 Other diagnosis 9.9

Aetiology and comorbidity HF-REF/HF-PEF LVSD No LVSD Medical history p value (%) (%) Ischaemic heart disease (IHD) 49.8 39.8 <0.001 Atrial fibrillation 38.8 47.2 <0.001 Acute myocardial infarction (AMI) 33.4 20.4 <0.001 Valve disease Valve disease 20.9 20.9 29.5 29.5 <0.001 <0.001 Hypertension 51 59.7 <0.001 Chronic renal impairment 23.4 27.4 0.074 Diabetes 31.2 32.5 0.008 Asthma 8.3 9.6 <0.001 Coronary obstructive pulmonary disease 17.2 18.9 <0.001

Place of care Index admissions (%) Readmission (%) Cardiology ward 49.1 50.6 General medical ward 39.7 37.8 Other ward 11.2 11.6 Men (%) Women (%) Cardiology ward 54.1 42.7 General medical ward 35.7 44.8 Other ward 10.2 12.5 <75 years (%) > 75 years (%) Cardiology ward 63 42 General medical ward 29.4 44.9 Other ward 7.6 13

Specialist input First admission Readmission (%) (%) Consultant cardiologist 60 62.7 Heart failure nurse specialist 18.5 17.9 Other consultant with interest in heart Other consultant with interest in heart 5.4 4.8 failure Any heart failure specialist 78.1 79.7 Other clinician 27 25.5 Input from heart failure MDT 65.6 68.3

Treatment Total Medication prescribed (%) ACEi 72.7 ARB 18.6 ACE and/or ARB 85 Beta-blocker 84.9 MRA 50.9 ACEi and/or ARB, 41.3 beta blocker and MRA Loop diuretic 90.8 Thiazide diuretic 5.3 Digoxin 21.7 ACE and ARB 0.9 ACEi, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; MRA, mineralocorticoid (aldosterone) receptor antagonist

Five year trends in prescribing for LVSD

Treatment and specialist input Cardiology ward General medical Other ward (%) (%) ward (%) ACEi 75.5 68.6 68.8 ARB 19 16.7 18.5 ACE and/or ARB 87.8 78.4 81.2 Beta blocker 88.4 77.5 79.8 MRA 56.7 47.4 43 ACEi and/or ARB, beta blocker and MRA 47.8 37.5 31.9 Loop diuretic 89.8 95.3 92.9 Thiazide diuretic 6.4 5.9 3.5 Digoxin 21.7 21.1 21.5 ACEi, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; MRA, mineralocorticoid (aldosterone) receptor antagonist 15

Treatment and specialist input (cont) Seen by any HF No specialist input (%) specialist (%) ACEi 74.2 63.6 ARB 18.7 18.1 ACE and/or ARB 86.5 75.4 Beta blocker 86.7 74 MRA 53.8 33.8 ACEi and/or ARB, beta blocker and MRA 44.5 21.3 Loop diuretic 90.3 93.8 Thiazide diuretic 5.7 2.6 Digoxin 21.6 22.7 ACEi, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; MRA, mineralocorticoid (aldosterone) receptor antagonist

Length of stay Index Median LOS by Hospital Readmission admission Mean LOS (days) 12.3+13.9 12.2+13.2 Median LOS (days) 8 (IQR 4-16) 8 (IQR 4-16) General Cardiology medical Other ward ward ward ward Mean LOS 12.7+13 11.5+14.1 13+15.8 (days) Median 9 (IQR 5-16) 7 (IQR 3-15) 8 (IQR 3-17) LOS (days) Seen by any No specialist specialist input Mean LOS (days) 13.1+14.1 9.5+12.5 Median LOS (days) 9 (IQR 5-17) 6 (IQR 2-12) LOS, length of stay

Mortality data from the National Heart Failure Audit 2013-2014 In Hospital 9.5% (same as last year) Was 11.1% in 2011/12 30-day 15% 15% 1 year (within the audit year) 34%

US DATA Outcome ADHERE MEDICARE N=751, 649 N=79, 508 I/P death 4.9% 4.4% 30 day day 12.2% 11.2% 1-year death 38.3% 36% 1-year readmission 67.9% 65.8% 1-year CV readmission 43.4% 42.6% Koicol et al : Am Heart J 2010;160:885-92

In patient death 2013/14 Cox Proportional Hazards Model N=17272 HR Lower CI Upper CI p value Age (>75 years) 1.81 1.57 2.10 <0.001 Not cardiology patient 1.76 1.57 1.97 <0.001 NYHA III/IV 1.19 1.02 1.39 0.026 Systolic BP (10mmHg decrease) 1.14 1.12 1.17 <0.001 Female 1.13 1.01 1.26 0.031 Urea (5mEg/dL increase) 1.12 1.10 1.14 <0.001 COPD 1.07 0.94 1.22 0.280 Heart rate (5bpm increase) 1.06 1.04 1.07 <0,001 Ischaemic heart disease 1.05 0.95 1.17 0.350 Valve disease 1.05 0.93 1.18 0.400 Haemoglobin (g/dL increase) 1.04 1.01 1.06 0.011 Sodium (5mEq/L decrease) 1.02 0.97 1.07 0.440 Creatinine (10umol/L increase) 1.02 1.02 1.03 <0.001 Potassium <3.5 (mEq/L) 1.35 1.12 1.62 0.002 Potassium 3.5-4.5 (mEq/L) 1 Potassium 4.5-5.5 (mEq/L) 1.37 1.22 1.54 <0.001 Potassium >5.5 (mEq/L) 2.21 1.83 2.66 <0.001

5 year trends in in-patient and 30 day mortality

ACM following discharge 24.7% at end of Follow-up (median 180 days)

ACM post discharge in those with LVSD and disease modifying drugs

ACM for survivors by quality of care indicators Place of care HF nurse Cardiology follow-up

Cox Proportional Hazards Model for ACM N=12690 HR Lower CI Upper CI p value Age (>75 years) 1.86 1.70 2.04 <0.001 No cardiology follow-up 1.50 1.38 1.62 <0.001 No ACEi and/or ARB 1.46 1.35 1.58 <0.001 COPD 1.22 1.11 1.33 <0.001 Ischaemic heart disease 1.22 1.13 1.31 <0.001 Valve disease 1.22 1.13 1.32 <0.001 Not cardiology in patient 1.13 1.05 1.22 0.002 No beta blocker 1.12 1.03 1.21 0.01 Sodium (5mEq/L decrease) 1.11 1.07 1.15 <0.001 Systolic BP (10mmHg decrease) 1.09 1.07 1.11 <0.001 Urea (5mEg/dL increase) 1.07 1.05 1.09 <0.001 Haemoglobin (g/dL increase) 1.06 1.04 1.08 <0.001 Male 1.05 0.98 1.14 0.167 NYHA III/IV 1.05 0.96 1.15 0.312 Creatinine (10umol/L increase) 1.02 1.01 1.02 <0.001 Potassium <3.5 (mEq/L) 1.24 1.09 1.41 0.001 Potassium 3.5-4.5 (mEq/L) 1

Cox Proportional Hazards Model for ACM (Cont) N=12690 HR Lower CI Upper CI p value Potassium 4.5-5.5 (mEq/L) 1.07 0.98 1.16 0.124 Potassium >5.5 (mEq/L) 1.41 1.17 1.70 <0.001 Length of stay 0-4 days 1 Length of stay 5-8 days 1.14 1.03 1.28 0.016 Length of stay 9-15 days 1.28 1.15 1.42 <0.001 Length of stay >16 days 1.81 1.63 2 <0.001

All-cause mortality for survivors to discharge by additive drug treatment on discharge, place of care and cardiology follow up (2009-14)

Can we do better? Mortality in CHF REF Trials and the real world Clinical trials Real world 70 60 50 40 30 Annual Mortality % 20 10 0 Residual mortality risk and NHFA Audit 2012/13 recurrent CV www.ucl.ac.uk/nicor hospitalisations 12-20%