Heart Failure Audit identifies serious gaps in specialist care, medication and discharge provision

Published: 19 Jul 2016

The National Heart Failure Audit has identified serious gaps in the management of heart failure (HF), across England Wales, including specialist care, correct medication prescription and coordinated specialist care post-discharge.

View full report here

Acute heart failure necessitating hospital admission is a life threatening condition. The quality of care including specialist involvement during an admission, determines the immediate and long-term outcomes including likelihood of survival. Yet the quality of care varies from one hospital to another, and within a hospital, between the specialist and other wards.

The audit, commissioned by the Health Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patients Outcomes Programme (NCAPOP), covers the year 1 April 2014 to 31 March 2015.

Key findings include:

  • Of the 56,915 heart failure admissions 9% went home not having had the key diagnostic investigation – an echocardiogram, without which effective treatment cannot be delivered. Rates are highest for those on the specialist ward (96%), 95% on wards where the patients are seen by a specialist but drop to 88% elsewhere
  • Prescription rates for all three key disease modifying medications, in patients with HF and a reduced ejection fraction, has increased from 35% to 50% for those admitted to Cardiology wards over the last five years and for those seen by the specialist elsewhere to 45%, but this figure is much lower for those who don’t receive any specialist input at just 20%
  • The individual prescribing rates of beta-blockers, and mineralocorticoid antagonists, treatments that are both life-saving and inexpensive have both increased since the last audit with the highest prescribing rates achieved on the specialist ward, whilst maintaining the high rates of angiotensin converting enzyme inhibitors, previously reported. Again the visiting specialist positively influences outcomes elsewhere but patients may be missed and to them the cost is high
  • Specialist input is most readily delivered on the cardiology ward but overall 80% of all HF admissions, irrespective of place of care, will receive input from one or more members of the specialist HF team, with 58% of patients being seen by a cardiologist, and an increase in HF specialist nurse care to 32% in the non-specialist ward. A worrying 20% of patients admitted with acute HF receive no specialist input with worrying consequences
  • In-hospital mortality overall was 9.6%, higher in the over 75yrs at 12% and 4.8% in those aged less 75. Mortality on the specialist cardiology ward was lowest at 7.1%, against 10.4% on general medical wards. Again the influence of the specialist is apparent in a reported 8.2% mortality for those who receive this input compared to 14.7% for those who do not
  • Thus patients managed on specialist cardiac wards, currently just under 50%, are more likely to survive to discharge, more likely to receive key disease modifying drugs, more likely to have timely specialist follow up and more likely to be alive at follow up – and these influences are still apparent from censoring at six years

Professor Theresa McDonagh, clinical lead for cardiology and heart failure at King’s College Hospital, London and the audit’s clinical lead said: “These results from our National Audit, once again should focus our attention on heart failure. Heart failure is increasing in prevalence due to our ageing population. Outcomes are still poor. Yet we know how to diagnose it, investigate it and (for the majority of patients with reduced ejection fraction), we have effective treatments. Specialist care in hospital matters. Getting onto the correct drugs matters and coordinated specialist care post discharge matters. The audit provides the data to allow health care providers to engineer change to deliver better care.”

Dr Suzanna Hardman, consultant cardiologist and Whittington Health HF lead, said:” The audit provides a wealth of hospital specific data alongside stark overall messages. Outcomes will only improve if this data is used by local teams including clinicians, commissioners and health providers to drive improvements in care. Of note a key priority for implementation of the NICE acute HF guidance is that all hospitals admitting people with suspected acute heart failure should provide a specialist team based on a cardiology ward and provides outreach services. Adequate provision within this team is essential, if hospitals are to comprehensively implement the latest NICE guidance and Quality Standards. It is of note that the most cost effective model is to deliver care to most HF patients in the specialist ward but less than 50% are looked after on cardiology wards. It is time to ensure heart failure patients have a higher priority in timely access to the specialist unit and all that follows.”

The National Heart Failure Audit monitors the treatment and care of people with an unscheduled admission to hospital who are discharged with a primary diagnosis of heart failure. This is the seventh audit cycle and reports data from 139 NHS Trusts in England and six Health Boards in Wales. Data from 56,915 heart failure admissions to hospitals in England and Wales between 1 April 2014 and 31 March 2015. This represents in England 73% of all emergency heart failure admissions to hospital and 81% in Wales.

The National Heart Failure Audit is managed by NICOR (National Institute for Cardiovascular Outcomes Research) and supported by the British Society of Heart Failure (BSH).