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Senior Citizen Health & Medicine
Hospital Performance Guidelines for Heart Failure
are Failing Senior Citizens
Medicare & Medicaid pay-for-performance programs
may not work
 January 2, 2007 It sounds like a good idea.
Experts devise a set of performance standards for hospitals that, if
followed, are expected to assure better results in the treatment of the
3.6 million senior citizens hospitalized each year with heart failure.
Since this is the leading cause of hospitalization for senior citizens
covered by Medicare, it makes sense for Medicare to pay a little more
to the hospitals willing to use the standards. But, like many good
ideas, this one, too, has run into a problem - four of five hospital
performance measures for heart failure do not appear to accurately
reflect the quality of care provided.
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Health & Medicine |
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Heart failure continues to be a serious public
health concern in the United States: the overall prevalence of heart
failure was 5 million individuals in 2003, with 550,000 new cases being
reported each year.
Heart failure is the leading cause of
hospitalization in persons older than 65 years, with almost 3.6
million hospitalizations attributed to heart failure as the primary or a
secondary discharge diagnosis each year, according to background
information in the article in the January 3 issue of JAMA.
Because heart failure is a substantial cause of
illness, death, and health care expenditures, everyone agrees it is
important to use evidence-based therapies that have been shown to
improve clinical outcomes. The practice guidelines that specify the
diagnostic and therapeutic treatments for patients with heart failure
were developed by the elite American College of Cardiology and the
American Heart Association.
Adherence to these suggested interventions may
serve as a marker of quality of care and form a foundation for quality
improvement, is the theory leading to the heart failure performance
measures developed to provide a means by which the quality of medical
care can be measured and improved.
The recently released ACC/AHA Clinical Performance
Measures for Adults With Chronic Heart Failure includes:
● discharge instructions,
● evaluation of left ventricular systolic function,
● angiotensin-converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD),
● adult smoking cessation advice/counseling, and
● anticoagulant at discharge for patients with atrial fibrillation.
Although it is expected that application of these
carefully developed heart failure inpatient performance measures should
result in substantial improvement in heart failure patient outcomes,
available data supporting these measures are limited.
Gregg C. Fonarow, M.D., of the University of
California Los Angeles Medical Center, and colleagues analyzed data from
the Organized Program to Initiate Lifesaving Treatment in Hospitalized
Patients with Heart Failure (OPTIMIZE-HF) registry to determine the
relationship between current ACC/AHA performance measures and relevant
patient clinical outcomes, including the risk of death at 60- to 90-days
after discharge, and rehospitalization rates.
Follow-up data were collected from 5,791 patients
at 91 U.S. hospitals between March 2003 and December 2004.
Average patient age was 72.0 years, 51
percent were male and 78 percent were white. The researchers also
evaluated the potential performance measure for beta-blockers at
discharge among eligible patients hospitalized with heart failure.
During follow-up, 8.6 percent of the patients had
died and the total death or rehospitalization rate was 36.2 percent.
None of the current ACC/AHA performance measures was a significant
independent predictor of death in the first 60 to 90 days after hospital
discharge.
Prescription of a β-blocker at the time of hospital
discharge, currently not one of the heart failure performance measures,
was highly predictive of improved post-discharge survival (52 percent
reduced risk of death) and a 27 percent lower risk of
death/re-hospitalization.
These findings may have significant clinical and
public health implications and suggest that additional measures may be
required to more effectively quantify the quality of care provided to
heart failure patients in the hospital setting, the authors write.
For the ACC/AHA performance measure sets to
achieve their stated goal of serving as a vehicle for more rapidly
translating the strongest clinical evidence into practice, better
methods for identifying and validating new performance measures may be
needed.
"As this limited set of performance measures is
being used to publicly report the quality of heart failure care delivery
at the hospital level and is beginning to affect financial payments to
medical centers and individual physicians, it is essential that measures
be prioritized to include those that are proven to be closely associated
with patient outcomes, they write.
Although these findings require confirmation in
other studies, they suggest that use of the ACC/AHA heart failure
performance measures in their current form in Centers for Medicare &
Medicaid Services pay-for-performance programs may not be the most
efficacious way to assess quality of care, given the lack of a
connection between the majority of performance measures and early heart
failure patient outcomes.
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