Heart failure: mortality doubles when specialist care not provided
Published: 20 Oct 2015
Data from 56,654 heart failure admissions to hospitals in England and Wales between 1 April 2013 and 31 March 2014 shows variation in the quality of care and outcomes for patients. Data published today shows that the quality of heart failure care can vary widely from one hospital to another, as it does between specialist and non-specialist wards, within a given hospital. Key findings include:
- Only 41% of patients with a confirmed diagnosis of heart failure were discharged on all three of the recommended therapies for heart failure – ACE inhibitor/ARB, beta blocker and MRA. This is a small improvement (5%) from 2012 but more can be done to improve equitable access to care
- Inpatient mortality rates vary between place of care, ranging from 6.9% on cardiology wards to 11.4% on general medical wards and 13.7% on ‘other’ wards
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The National heart failure audit is commissioned by HQIP as part of NCAPOP and managed by NICOR, supported by the British Society of Heart Failure. The 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 7th National Heart Failure Audit cycle reports data from 100% of NHS Trusts in England and Local Health Boards in Wales, and, recording 85% of all emergency heart failure admissions to hospital, now describes care comprehensively across the NHS in England and Wales.
The overall inpatient mortality across the 56,654 heart failure admissions to hospital between 1 April 2013 and 31 March 2014 is high at 9.5% and remains stable from 2012/13. For those who survive to discharge, mortality rates are 27% 12 months later. Although, many of these patients are older and have other medical conditions only half the patients were looked after in the optimum place of care, on a cardiology ward. Yet 11.4% of inpatients died in hospital if their care was on a general medical ward and 13.7% if looked after on other wards, compared with only 6.9% if they were cared for on a cardiology ward. When analyses were adjusted for age and severity of disease, the added benefit of being treated on a cardiology ward remained.
However, it is the variation between hospitals in the numbers cared for on a cardiology ward that should be of interest to the hospital and local communities. Although heart failure teams also reached some of the patients cared for elsewhere, 22% of patients admitted to hospital with this life threatening condition received no specialist input.
The use of disease modifying drugs, including beta blockers and ACE inhibitors, is strongly associated with improved outcomes, and patients are far more likely to receive these drugs if they are treated by heart failure specialists, with recent NICE guidance suggesting the most cost effective way of delivering this is from a cardiology ward for the majority.
2013/14 data shows that prescription rates are increasing for recommended treatments although there are large group of patients who do not receive them, again with variations between hospitals and across hospitals. 85% of eligible patients were prescribed ACE inhibitor and beta blocker, with beta blocker prescribing increasing from less than 70% to 85% in 5 years. However the range of beta blocker prescribing between hospitals varies from less than 60% to over 90%. Only 41% of patients received the three key disease modifying drugs – the drugs that allow the heart to recover function and improve patient wellbeing with fewer deaths, fewer readmissions and a better quality of life.
A reliable diagnosis, specialist care—both ward-based or elsewhere—prescribing rates of disease modifying drugs for eligible patients, adequate discharge planning to include early cardiology and heart failure nurse follow up are the minimum requirements of hospital care for people admitted to hospital with heart failure. Yet the reported current practice shows enormous variation in every aspect of such care from one hospital to another. This report is a powerful tool for chief executives, clinicians and other health care providers to understand the effectiveness of their heart failure care, and to rectify poor practice. Similarly local communities including heart failure patients and GPs should not miss the opportunity to review the data for their local hospitals and ensure acute heart failure care is of an adequate standard.
Theresa McDonagh, the clinical lead for the audit, said: “The National Heart Failure Audit is giving us the consistent message that specialist care for Heart Failure matters. It is important that we continue to use this powerful data to improve patient care.”
Dr Suzanna Hardman, Consultant Cardiologist, Whittington Hospital, London said: “These data are like gold dust and should be used by us all to drive change, eliminate variations reflecting poor practice and ensure everyone admitted to hospital with heart failure receives excellent care.”