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Invited Commentary
January 8, 2020

Measuring and Improving the Quality of Heart Failure Care Globally

Author Affiliations
  • 1Division of Cardiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
  • 2University of California, Los Angeles (UCLA) Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California
  • 3Beijing Institute of Heart, Lung & Blood Vessel Diseases, Capital Medical University Beijing Anzhen Hospital, Beijing, China
JAMA Netw Open. 2020;3(1):e1918642. doi:10.1001/jamanetworkopen.2019.18642

In JAMA Network Open, Gupta and coauthors1 report their findings from a retrospective analysis of the China Patient-Centered Evaluative Assessment of Cardiac Events Retrospective Study of Heart Failure (China PEACE). Their analysis included 10 004 heart failure (HF) hospitalizations from 189 hospitals that were abstracted by 2 contracted vendors and reviewed at patient and hospital levels for adherence to 4 American Heart Association (AHA) Get With The Guidelines–Heart Failure (GWTG-HF) achievement measures: (1) assessment of left ventricular ejection fraction, (2) discharge therapy with β-blockers, (3) discharge with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and (4) scheduled follow-up appointment at discharge. A hospital-level composite performance score was also calculated. Hospitals were stratified into 5 economic-geographic regions in China. The study’s results showed low implementation of the 4 performance measures and an overall low score for the composite performance measure. Wide variation was found, with higher scores for tertiary, teaching, and medical university–affiliated hospitals. Scores were higher in the Eastern region and in urban hospitals. Patient-level adherence to measures was lower for women and elderly patients. The factor most strongly associated with a higher composite performance score was a hospital with an independent cardiology department. Gupta et al1 concluded that the quality of HF care in China is suboptimal at the patient and hospital levels, with wide variation among hospitals across China. They suggest a national strategy in China to reduce this heterogeneity in quality care.

Heart failure is among the most common reasons for hospital admission of adult patients in the United States and China, as well as worldwide.2 Most patients hospitalized with HF have worsening of chronic HF. Despite often rapid, significant improvement in presenting signs and symptoms with diuretics, the postdischarge outcomes for patients with HF remain poor. The early postdischarge period carries a particularly high risk for poor outcomes. Approximately one-quarter of patients hospitalized with HF are rehospitalized within 30 days of discharge, and mortality rates within the first year after hospital discharge approach 30%.3 With at least 26 million patients with HF worldwide, there is a critical need for global attention, research efforts, and quality improvement initiatives to improve the quality of care and clinical outcomes for this high-risk population. In China, an estimated 4.2 million people have HF, with an estimated prevalence of 1.3%.2 Hypertension and coronary heart disease are the leading causes of HF in older Chinese patients, with coronary heart disease being increasingly common and the major cause of HF in patients aged 80 years or older.

In the United States, efforts have focused over the past 2 decades on measuring, analyzing, and improving the quality of care for patients hospitalized with HF. The Acute Decompensated HF National Registry (ADHERE)4 evaluated demographic characteristics, clinical characteristics, treatments, quality-of-care indicators, and in-hospital outcomes among 159 168 HF hospitalization episodes among 285 participating hospitals from 2002 to 2004. Substantial gaps, hospital-level variation, and disparities in adherence to performance measures and use of other guideline-directed medical therapies for HF among eligible patients were demonstrated in a series of ADHERE registry analyses. Performance improvement registries were developed to move beyond passive data collection and to deploy tools and strategies for facilitating improvements in care and clinical outcomes. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure3 included 48 612 patients hospitalized with HF from 2003 to 2004 at 259 hospitals using a multidimensional performance improvement intervention. Participation was associated with increased use of evidence-based HF therapies, adherence to HF performance measures, and improved in-hospital mortality and 60- to 90-day postdischarge mortality and rehospitalization. Participating centers with greater use of clinical decision support tools had greater improvements in quality of care, and their patients with HF experienced improved clinical outcomes.

In 2005, the AHA launched the GWTG-HF program with a systems-of-care platform to improve quality of care, reduce disparities, and improve outcomes for patients hospitalized with HF. The program provides clinical decision support tools, webinars, conferences focused on quality improvement, and other educational materials.5 In addition, the program provides expert AHA field staff to assist hospitals and physicians in developing sophisticated quality improvement programs. The program facilitates real-time hospital and individual physician access to benchmarked performance data. Clinicians can compare their performance against other hospitals based on a large selection of variables. More than 800 US hospitals and more than 1 million patients hospitalized with HF have participated. Hospitals in the GWTG-HF program have been able to achieve and sustain rates of ACEI, ARB, or angiotensin receptor neprilysin inhibitor use at hospital discharge exceeding 94%, guideline-recommended β-blocker use of 95%, and a high level of conformity with the full spectrum of guideline-directed medications and device therapy along with provision of HF patient education.5 With GWTG-HF, improvements in care quality have been attained in hospitals large and small, rural and urban, teaching and nonteaching, and from all regions in the United States.5 Variations in care between hospitals have been reduced over time, and age, sex, and racial/ethnic disparities in HF care quality have been reduced or entirely eliminated with GWTG-HF participation. Better quality-of-care and clinical outcomes have been reported for participating hospitals compared with US hospitals not participating.

The results from Gupta et al1 are similar to those in a smaller number of patients from the Bridging the Gap on Coronary Heart Disease Secondary Prevention in China Project published in 2013,6 which found low discharge implementation of guideline-recommended therapies in patients admitted with HF associated with acute coronary syndromes. That study, which was a collaborative project with the World Heart Federation and included 65 hospitals with representation from all provinces in China, concluded that the quality of care for patients with HF and acute coronary syndromes in China needed to be improved. The authors found important regional differences in adherence to guideline-recommended strategies. Implementation rates for discharge instruction and evaluation of left ventricular function were lowest in central South China. Discharge prescription rates of ACEI or ARB and β-blockers were lowest in South China and East China. Overall treatment rates were lower for women and elderly patients. Importantly, the present study by Gupta et al1 is larger and excludes patients with an admission diagnosis of acute myocardial infarction. Therefore, it provides vital new information on patients who are hospitalized primarily for HF. This information is essential to the understanding and development of programs to effectively treat this major health issue in China and other countries with similar demographics and health care systems.

A major quality improvement program for patients with acute coronary syndromes, the Improving Care for Cardiovascular Disease in China (CCC Project), was launched in 2014 as a collaborative effort of the Chinese Society of Cardiology and the AHA, with data management by the Beijing Heart Lung Institute and in consultation with the National Health Commission of the People’s Republic of China.7 The CCC has expanded to include atrial fibrillation and increased from 75 tertiary hospitals to 240 hospitals, of which roughly one-third are secondary hospitals implementing these quality improvement programs. More than 150 000 patients with acute coronary syndrome and atrial fibrillation have now been enrolled in CCC, with performance measures adapted from AHA GWTG Programs. The reported use of β-blockers was 67% overall for patients with acute coronary syndrome in the CCC progam,8 which was much higher than the rate of use among patients with HF reported by Gupta et al.1 This difference may be related to the varying patient populations; Gupta et al1 excluded patients with acute myocardial infarction, whereas CCC included patients with acute coronary syndromes. Similar to findings in the present study, in the CCC program, women were less likely than men to receive evidence-based therapy.8

Recently, the AHA has initiated a pilot study in collaboration with the Chinese Nurse Association to explore the benefits of specialized nurses collaborating with cardiologists to improve implementation of guideline-based therapy after hospital discharge. If successful, these efforts may be combined with ongoing quality improvement in the CCC project. There is great opportunity to improve the use of guideline-directed therapies for patients with cardiovascular disease. At a time when cardiovascular disease is the leading cause of mortality worldwide, the findings of the present study by Gupta et al1 and other ongoing projects noted herein represent for China a challenge as well as an opportunity to move beyond registries and set an example on a global basis for the true benefit of quality improvement programs.

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Article Information

Published: January 8, 2020. doi:10.1001/jamanetworkopen.2019.18642

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Smith SC Jr et al. JAMA Network Open.

Corresponding Author: Sidney C. Smith Jr, MD, Division of Cardiology, Department of Medicine, University of North Carolina, Burnett-Womack Bldg, CB 7075, 130 Dental Circle, Chapel Hill, NC 27599-7075 (scs@med.unc.edu).

Conflict of Interest Disclosures: Dr Fonarow reported receiving grants from the National Institutes of Health and personal fees from Abbott, Amgen, CHF Solutions, Janssen, Medtronic, Merck, and Novartis outside the submitted work. No other disclosures were reported.

Gupta  A, Yu  Y, Tan  Q,  et al.  Quality of care for patients hospitalized for heart failure in China.  JAMA Netw Open. 2020;3(1):e1918619. doi:10.1001/jamanetworkopen.2019.18619Google Scholar
Savarese  G, Lund  LH.  Global public health burden of heart failure.  Card Fail Rev. 2017;3(1):7-11. doi:10.15420/cfr.2016:25:2PubMedGoogle ScholarCrossref
Fonarow  GC, Abraham  WT, Albert  NM,  et al; OPTIMIZE-HF Investigators and Hospitals.  Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF).  Arch Intern Med. 2007;167(14):1493-1502. doi:10.1001/archinte.167.14.1493PubMedGoogle ScholarCrossref
Fonarow  GC, Yancy  CW, Heywood  JT; ADHERE Scientific Advisory Committee, Study Group, and Investigators.  Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry.  Arch Intern Med. 2005;165(13):1469-1477. doi:10.1001/archinte.165.13.1469PubMedGoogle ScholarCrossref
Ellrodt  AG, Fonarow  GC, Schwamm  LH,  et al.  Synthesizing lessons learned from Get With The Guidelines: the value of disease-based registries in improving quality and outcomes.  Circulation. 2013;128(22):2447-2460. doi:10.1161/01.cir.0000435779.48007.5cPubMedGoogle ScholarCrossref
Wang  N, Zhao  D, Liu  J,  et al; BRIG project.  Performance measures for management of chronic heart failure patients with acute coronary syndrome in China: results from the Bridging the Gap on Coronary Heart Disease Secondary Prevention in China (BRIG) Project.  Chin Med J (Engl). 2013;126(14):2625-2631. https://insights.ovid.com/pubmed?pmid=23876884. Accessed November 21, 2019.PubMedGoogle Scholar
Hao  Y, Liu  J, Liu  J,  et al; CCC-ACS Investigators.  Rationale and design of the Improving Care for Cardiovascular Disease in China (CCC) project: a national effort to prompt quality enhancement for acute coronary syndrome.  Am Heart J. 2016;179:107-115. doi:10.1016/j.ahj.2016.06.005PubMedGoogle ScholarCrossref
Hao  Y, Liu  J, Liu  J,  et al.  Sex differences in in-hospital management and outcomes of patients with acute coronary syndrome.  Circulation. 2019;139(15):1776-1785. doi:10.1161/CIRCULATIONAHA.118.037655PubMedGoogle ScholarCrossref
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