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

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

The National Heart Failure Audit-8th Annual Report

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

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

The Process

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

Mean age=77.6 years Median age=80.2 years Mean age men=75.7 years Mean age women=80.1 years

Demographics 2013-14

Symptoms

Symptoms/signs of heart failure Total on admission (%) Total on readmission (%) NYHA class I/II 18.6 16.1 NYHA class III 44.7 44.5 NYHA class IV 36.6 39.4 NYHA class IV 36.6 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

Total (%) Normal echo 3.3 Left ventricular systolic dysfunction (LVSD) 70.3

Echo diagnosis

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

Medical history LVSD (%) No LVSD (%) 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 20.9 29.5 <0.001 Valve disease 20.9 29.5 <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 failure 5.4 4.8 Any heart failure specialist 78.1 79.7 Other clinician 27 25.5 Input from heart failure MDT 65.6 68.3

Treatment

Medication Total prescribed (%) ACEi 72.7 ARB 18.6 ACE and/or ARB 85 Beta-blocker 84.9 MRA 50.9 ACEi and/or ARB, beta blocker and MRA 41.3 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 ward (%) Other 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

15

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

Treatment and specialist input (cont)

Seen by any HF specialist (%) No specialist input (%) 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

Median LOS by Hospital

Index admission Readmission

Mean LOS (days) 12.3+13.9 12.2+13.2 Median LOS (days) 8 (IQR 4-16) 8 (IQR 4-16)

Cardiology ward General medical ward Other ward Seen by any specialist No specialist input

Mean LOS (days) 13.1+14.1 9.5+12.5 Median LOS (days) 9 (IQR 5-17) 6 (IQR 2-12)

ward

Mean LOS (days) 12.7+13 11.5+14.1 13+15.8 Median LOS (days) 9 (IQR 5-16) 7 (IQR 3-15) 8 (IQR 3-17) LOS, length of stay

In Hospital 9.5% (same as last year) Was 11.1% in 2011/12 30-day 15%

Mortality data from the National Heart Failure Audit 2013-2014

15% 1 year (within the audit year) 34%

Outcome ADHERE N=751, 649 MEDICARE N=79, 508 I/P death 4.9% 4.4% 30 day day 12.2% 11.2%

US DATA

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

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

ACM following discharge

ACM post discharge in those with LVSD and disease modifying drugs

ACM for survivors by quality of care indicators

HF nurse Place of care 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

30 40 50 60 70

Clinical trials

Annual Mortality %

Real world

10 20

Residual mortality risk and recurrent CV hospitalisations 12-20% NHFA Audit 2012/13 www.ucl.ac.uk/nicor

Acute heart failure outcomes in England and Wales

Mortality fall for in-patients has been maintained through

• prescribing rates
• particularly beta-blockers and MRAs
• treatment in specialist wards and referral to heart failure follow-

up services up services

• trend to increasing age
• no difference comorbidities or disease severity of patients across the

last three years Mortality rates remain high still.

Integrated Heart Failure Service

• Heart failure cardiologist
• Heart failure specialist nurses
• GP/Geriatrician/pharmacist/GPwSIs

and others

In-patient decompensated CHF General Cardiology Clinics General Medical Clinics Primary care Open access echo

Elements of an Integrated Heart Failure Service (BSH/ESC Standards of Care)

Diagnosis Planning of management (Periodic Review)

Heart Failure Clinic follow up ± specialist nurse Advanced Heart Failure Service Primary care + specialist nurse Primary care Patient referred for device Rx Post-MI patients

McDonagh T et al European Journal of Heart Failure (2011) 13, 235–241

Please may I see a heart failure specialist !

Seeing a Cardiologist ??

Thank you 2013-14

Polly Mitchell Damian Marlee Julie Sanders Project Board