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Original Investigation
July 27, 2021

Effect of a Hospital and Postdischarge Quality Improvement Intervention on Clinical Outcomes and Quality of Care for Patients With Heart Failure With Reduced Ejection Fraction: The CONNECT-HF Randomized Clinical Trial

Author Affiliations
  • 1Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
  • 2Department of Medicine, Duke University School of Medicine, Durham, North Carolina
  • 3Duke University School of Nursing, Durham, North Carolina
  • 4Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
  • 5Associate Section Editor, JAMA Cardiology
  • 6Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
  • 7Division of Cardiovascular Medicine, Stanford University, Palo Alto, California
  • 8Department of Medicine, University of Mississippi Medical Center, Jackson
  • 9Wayne State University and Detroit Medical Center, Detroit, Michigan
  • 10Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
  • 11Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 12Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia
  • 13Centennial Heart, Nashville, Tennessee
  • 14Henry Ford Heart and Vascular Institute, Department of Medicine, Cardiovascular Division, Henry Ford Hospital, Detroit, Michigan
  • 15American College of Cardiology, Washington, DC
  • 16Center for Advanced Hindsight, Duke University, Durham, North Carolina
JAMA. 2021;326(4):314-323. doi:10.1001/jama.2021.8844
Key Points

Question  Can a hospital and postdischarge intervention focused on education on heart failure care as well as audit and feedback on care processes improve postdischarge outcomes and quality of care for patients with heart failure with reduced ejection fraction?

Findings  In this cluster randomized trial that included 5647 patients and 161 hospitals, patients in hospitals randomized to the quality improvement intervention compared with usual care had a rate of rehospitalization or death of 38.6% vs 39.2% and change in quality-of-care scores of 2.3% vs −1.0%, respectively; neither comparison was statistically significant.

Meaning  A hospital and postdischarge quality improvement intervention did not result in better clinical outcomes or measure of quality of care for patients with heart failure with reduced ejection fraction.

Abstract

Importance  Adoption of guideline-directed medical therapy for patients with heart failure is variable. Interventions to improve guideline-directed medical therapy have failed to consistently achieve target metrics, and limited data exist to inform efforts to improve heart failure quality of care.

Objective  To evaluate the effect of a hospital and postdischarge quality improvement intervention compared with usual care on heart failure outcomes and care.

Design, Setting, and Participants  This cluster randomized clinical trial was conducted at 161 US hospitals and included 5647 patients (2675 intervention vs 2972 usual care) followed up after a hospital discharge for acute heart failure with reduced ejection fraction (HFrEF). The trial was performed from 2017 to 2020, and the date of final follow-up was August 31, 2020.

Interventions  Hospitals (n = 82) randomized to a hospital and postdischarge quality improvement intervention received regular education of clinicians by a trained group of heart failure and quality improvement experts and audit and feedback on heart failure process measures (eg, use of guideline-directed medical therapy for HFrEF) and outcomes. Hospitals (n = 79) randomized to usual care received access to a generalized heart failure education website.

Main Outcomes and Measures  The coprimary outcomes were a composite of first heart failure rehospitalization or all-cause mortality and change in an opportunity-based composite score for heart failure quality (percentage of recommendations followed).

Results  Among 5647 patients (mean age, 63 years; 33% women; 38% Black; 87% chronic heart failure; 49% recent heart failure hospitalization), vital status was known for 5636 (99.8%). Heart failure rehospitalization or all-cause mortality occurred in 38.6% in the intervention group vs 39.2% in usual care (adjusted hazard ratio, 0.92 [95% CI, 0.81 to 1.05). The baseline quality-of-care score was 42.1% vs 45.5%, respectively, and the change from baseline to follow-up was 2.3% vs −1.0% (difference, 3.3% [95% CI, −0.8% to 7.3%]), with no significant difference between the 2 groups in the odds of achieving a higher composite quality score at last follow-up (adjusted odds ratio, 1.06 [95% CI, 0.93 to 1.21]).

Conclusions and Relevance  Among patients with HFrEF in hospitals randomized to a hospital and postdischarge quality improvement intervention vs usual care, there was no significant difference in time to first heart failure rehospitalization or death, or in change in a composite heart failure quality-of-care score.

Trial Registration  ClinicalTrials.gov Identifier: NCT03035474

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