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News of the Day ... In Perspective


Performance measures poorly related to outcome in heart failure

Adherence to “evidence-based” interventions is being used to assess quality of care and eventually is to be the basis of “pay for performance” (P4P). The performance measures are supposed to be backed by evidence so strong that the failure to perform them reduces the likelihood of an optimal patient outcome.

Four of the five measures suggested for hospital performance in patients with heart failure had little relationship to mortality or to combined mortality or rehospitalization within 60 to 90 days.

The measures were: discharge instructions, evaluation of left ventricular systolic function, angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blockade (ARB) for left ventricular systolic dysfunction, adult smoking cessation advice, and anticoagulation in patients with atrial fibrillation.

The percentage of eligible patients who received ACE inhibitors or ARB was about 84%. The risk-adjusted hazard rate for mortality was 0.61 in patients who received this intervention compared with those who did not (P = .08), and the risk-adjusted hazard rate for mortality/readmission was 0.51 (P = .002).

The prescription of beta blockade at discharge, not one of the chosen measures, was also significantly associated with lower mortality or rehospitalization. About 84% of patients received this intervention.

The authors noted that eligibility for an intervention was based on documentation in the medical record. Failure to document intolerances or contraindications may have led to an overestimation of the number of eligible patients.

The authors concluded: “To more accurately identify practitioners and medical care facilities providing the care that is most closely associated with optimal early postdischarge outcomes, additional measures, as well as better methods for identifying and validating heart failure performance measures, may be needed.” (JAMA 2007:297:61-70).

The article required nearly two pages of fine print to list all the investigators and financial disclosures. The OPTIMIZE-HF registry was funded by GlaxoSmithKline, which manufactures an ARB (telmisartan) and a third-generation beta blocker (carvedilol).

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