Variation in hospital performance for heart failure management in the National Heart Failure Audit for England and Wales

Journal article

Objective: Investigation of variations in provider performance and its determinants may help inform strategies for improving patient outcomes.

Methods: We used the National Heart Failure Audit comprising 68,772 patients with heart failure with reduced left ventricular ejection fraction (HFREF), admitted to 185 hospitals in England and Wales (2007-2013). We investigated hospital adherence to three recommended key performance measures (KPM) for in-hospital care (ACE-inhibitors or ARBs on discharge, beta-blockers on discharge, and referral to specialist follow-up) individually and as a composite performance score. Hierarchical regression models were used to investigate hospital-level variation.

Results: Hospital-level variation in adherence to composite KPM ranged from 50% to 97% (median 79%), but after adjustments for patient characteristics and year of admission, only 8% (CI 7 % to 10%) of this variation was attributable to variations in hospital features. Similarly, hospital prescription rates for ACE-I/ARB and beta-blocker showed low adjusted hospital-attributable variations (7% CI 6% to 9% and 6% CI 5% to 8%, for ACE-I/ARB and beta-blocker, respectively). Referral to specialist follow-up, however, showed larger variations (median 81%; range; 20%, 100%,) with 26% of this being attributable to hospital-level differences (CI 22% to 31%).

Conclusions: Only a small proportion of hospital variation in medication prescription after discharge was attributable to hospital-level features. This suggests that differences in hospital practices are not a major determinant of observed variations in prescription of investigated medications and outcomes. Future healthcare delivery efforts should consider evaluation and improvement of more ambitious KPM.

Authors: Emdin, C; Conrad, N; Kiran, A; Khorshidi, G; Woodward, M

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: BMJ Publishing Group
• Journal: Heart
• Publication date: 2016-08-01
• Acceptance date: 2016-07-05
• DOI: 10.1136/heartjnl-2016-309706
• EISSN: 1468-201X
• ISSN: 1355-6037
• Keywords: health services; heart failure; quality and outcomes of care