Heart Failure Measures Don't Measure Up

By Steven Reinberg
HealthDay Reporter
Tuesday, January 2, 2007 12:00 AM

TUESDAY, Jan. 2 (HealthDay News) -- The measures U.S. hospitals use to gauge how well they care for heart failure patients may be faulty, new research shows.

Those measures include guidelines developed by the American College of Cardiology and the American Heart Association. These recommendations describe the proper diagnosis and treatment of patients with heart failure. Adherence to the guidelines is used as a marker of quality of care and a means of pointing to areas needing improvement.

But in the study, these performance measures "did not perform well as far as predicting clinical outcomes" for patients, said lead researcher Dr. Gregg C. Fonarow, a professor of clinical medicine at the University of California Los Angeles Medical Center.

"However, we were able to identify an additional measure that's not currently being utilized -- that of [prescribing] beta blockers at hospital discharge -- which did perform extremely well," he added.

The report appears in the Jan. 3 issue of theJournal of the American Medical Association.

In the study, Fonarow's team analyzed data from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure registry. They used this data to determine the relationship between performance measures and patient outcomes, including the risk of patient death at 60 to 90 days after hospital discharge and the rate of rehospitalization.

The researchers collected data on almost 5,800 patients, average age 72, treated at 91 U.S. hospitals between March 2003 and December 2004. During follow-up, 8.6 percent of the patients had died, and the total death or rehospitalization rate was 36.2 percent.

Fonarow's group found that none of the standard performance measures significantly predicted a patient's risk of death in the first 60 to 90 days after hospital discharge.

Those performance measures included discharge instructions; evaluation of the heart's left ventricular function; prescribing angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs); giving smoking cessation advice or counseling; and prescribing anticoagulant medication for patients with atrial fibrillation, a kind of irregular heartbeat.

However, prescribing a beta blocker at the time of hospital discharge -- a step that is currently not factored into heart failure performance evaluation -- was highly predictive of improved post-discharge survival. For example, patients who received a beta blocker were at 52 percent reduced risk of death and 27 percent lower risk of death/rehospitalization, the researchers report, compared to patients who did not receive such a drug.

Fonarow believes that because these drugs arenotcurrently part of hospital performance measures, they are being under-prescribed for heart failure patients. "Beta blockers are the single most important life-prolonging therapy for patients with heart failure," he said.

"Current performance measures for patients with heart failure could be improved if they were augmented with beta blockers at discharge," Fonarow said. "There also needs to be additional research to identify additional performance measures."

"We would expect if a beta-blocker performance measure was adopted and being publicly reported, it would improve treatment rates and, as a result, would markedly lower the risk of rehospitalization and death in a large number of patients that are hospitalized each year with heart failure," Fonarow added.

One expert agreed with the findings.

"This paper underscores what many people in health care already know: that measuring the quality of health care is very difficult," said Dr. Byron Lee, an assistant professor of medicine at the University of California San Francisco.

Rating hospitals and physicians on how often they prescribe certain drugs oversimplifies a complex issue, Lee added. "Unfortunately, this type of rating system has been adopted by Medicare to 'assure quality.' However, the result is that many health-care providers spend time making the numbers look good, rather then truly taking care of the patients," he said.

More information

There's more on heart failure at the American Heart Association.

SOURCES: Gregg C. Fonarow, M.D., professor, clinical medicine, University of California Los Angeles Medical Center; Byron Lee, M.D., assistant professor, medicine, University of California San Francisco; Jan. 3, 2007,Journal of the American Medical Association

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