Hospital Quality Program for Heart Failure Patients Fails to Improve Outcomes

An effort to boost quality for hospitalized patients with heart failure did not reduce deaths or heart failure readmissions in a randomized controlled trial presented Monday during the American College of Cardiology’s 70th Scientific Session.

The study, called CONNECT-HF, called for one group of hospitals to receive special audits and guidance aimed at improving care of patients with heart failure, who are among the sickest patients in the health system and whose care is a major cost driver, especially in Medicare.

Heart failure is a leading cause of hospitalization for those over age 65, with costs projected to reach $70 billion by 2030. The Affordable Care Act targeted readmissions for heart failure within 30 days among Medicare patients as an area for improvement, but results have been mixed at best. One challenge in heart failure is that it’s often not the only thing going on with the patient—comorbid diabetes is common, for example—and other high-profile efforts to target the complex patient have famously fallen short, including the initiative by the Camden Coalition.

“We were disappointed to find no difference,” said Adam DeVore, MD, a cardiologist at Duke University Medical Center and the study’s lead author. “These principles of audit and feedback don’t seem to improve upon what already exists in terms of quality improvement for heart failure. This strategy doesn’t work above what we are already doing; we need to find other ones that do, and we have a lot of work ahead of us.”

While the Camden Coalition targeted the patient, CONNECT-HF approached the challenge from the other end: seeking to bolster existing quality efforts with added feedback and analysis. For hospitals randomIzed to receive the quality improvement intervention, researchers worked with in-house quality improvement teams to scrutinize existing programs to reinforce evidence-based practices.

In a press conference, DeVore said prescribing practices drew particular scrutiny. If too many patients with heart failure were not taking their prescribed medicines, the quality improvement team might work with pharmacists to make sure patients started taking new medications before discharge.

But in response to a question, DeVore said the findings presented now are only data based on what patients were prescribed, as well as outcomes. Factors such as patient adherence or whether out-of-pocket costs were a barrier to staying on a medication will be addressed, DeVore said, but “we’ll discuss those down the road.”

The Findings

Over a 3-year period, 5647 patients were treated for heart failure with reduced ejection fraction at 161 hospitals, with some hospitals receiving additional intervention on top of existing quality and evidence-based care programs.

Enrollment took place between March 2017 and May 2020, and DeVore said enrollment was cut off early due to COVID-19 and they did not enroll as many patients as planned but that they study was still adequately powered. The patients’ median age was 63 years, 67% were male, 38% were Black, and 87% had an existing heart failure diagnosis. About half (49%) had a heart failure admission within the prior 12 months at the time of enrollment.

Results showed:

• Heart failure hospitalization and all-cause mortality occurred in 38.1% in the usual care group and 37.8% in the intervention group, for an adjusted HR of 0.95 (95% CI, 0.79-1.14)
• Neither arm showed a significant change in the composite quality score. A positive change indicates an improvement from baseline; the change from baseline was –0.97% in usual care vs 2.32 in the intervention group, for a double-delta of 3.29 (95% CI, –0.75 to 7.33).
• There was no difference in the odds of achieving a higher opportunity-based [heart failure] quality score at last follow-up (adjusted odds ratio 1.06, 95% CI, 0.93-1.21), according to the abstract authors

DeVore said it may turn out the hospital is not the place where most heart failure care should take place and digital health tools and remote monitoring need more attention. The team even involved a patient panel to design the study, but that still did not improve outcomes.

“Based on our findings, I don’t think we’re going to move the needle if we continue focusing our attention on the hospital if there is already a quality improvement program there,” he said.

Reference

DeVore A, Granger B, Fonarow G, et al. Care optimization through patient and hospital engagement clinical trial for heart failure: primary results of the CONNECT-HF randomized clinical trial. Presented at: the 70th Scientific Session of the American College of Cardiology; May 17, 2021; Virtual. Abstract 21-LB-20781-ACC.