NICOR: National Institute for Cardiovascular Outcomes Research

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Background

Heart Failure

Heart failure is a condition in which the heart has lost the ability to pump enough blood to the body's tissues. With too little blood being delivered, the organs and other tissues do not receive enough oxygen and nutrients to function properly.

The most common causes of heart failure are:

• coronary artery disease and heart attack
  
• cardiomyopathy
• high blood pressure (hypertension)
• heart valve disease
• congenital heart disease
• excessive alcohol consumption

Why was the audit selected?

Heart failure is an extremely prevalent condition: Heart failure affects at least 1% of people the UK, increasing steeply with age to 16.4% in men over 75. The number of patients with heart failure is set to rise in the next twenty years. This is due to the combined effects of improved survival after a heart attack and an ageing population.

Heart failure has a significant impact on patients: Survival rates are worse than for breast and prostate cancer, with annual mortality ranging from 10 per cent to 50 per cent depending on severity, and a high risk of sudden death. Patients with heart failure experience a poor quality of life, with over a third experiencing severe and prolonged depressive illness.

Heart failure has a significant impact on NHS resources: Heart failure is one of the largest sources of emergency hospital admissions, readmission rates and occupied bed days, equating to almost 5 per cent of all emergency medical admissions.

The role of the audit

Progress in improving heart failure services has been slow compared to progress in other areas of heart disease, e.g. management of heart attacks and revascularisation. There is a lack of national data on heart failure services. There is also a lack of local data - one of the enduring findings of a Healthcare Commission review (2007) of heart failure services was that fewer than 20% of organisations were able to meet the CHD NSF criteria (2000) for auditing the delivery of heart failure services. This is despite a milestone of 2002 (hospitals) and 2003 (PCTs).

The National Heart Failure Audit provides aggregate data on the diagnostic tools, care, treatments and follow-up care that patients with heart failure receive, and can analyse morbidity and mortality in light of these indicators. Audit data can therefore inform guidelines for best practice and help hospitals to monitor their performance. There is good evidence that appropriate diagnosis, treatment and ongoing support can improve quality of life, help reduce morbidity and mortality and reduce hospital admission.

Annual reports are published online, and can be downloaded from the Annual Reports webpage.

Progress to date

Participation in the audit has improved substantially since 2009/10, with 85% of NHS Trusts and Welsh Health Boards now participating, and submitting data on 36504 patients: 54% of all patients discharged with heart failure as a primary diagnosis.

Key findings from the 2011 annual report (pdf) show that although access to NICE recommended diagnostic tests and key treatments is fairly good, variation in patient outcomes continue:

• Just under 12% of patients died during the hospital admission and almost one third died within 12 months of discharge.
• Outcomes for patients are strongly associated with certain key factors, including the prescription of beta blockers, ACE inhibitors and other clinically recommended drugs, and the use of follow up services in community and primary care services.
• Patients admitted to cardiology wards had in-hospital mortality rates of 8%, compared to 14% for patients admitted to general medicine and 17% for those admitted to other wards.
• Mortality rates after discharge are significantly better for those who received cardiology follow up (18% vs. 31%) and those referred to heart failure specialist nursing services (22% vs. 27%) compared to those who were not.

Despite this evidence base, access to the highest quality of care is mixed:

• The uptake of evidence-based guidance on diagnosis, treatment and therapy remains mixed.
• Under half of patients (45%) were admitted to cardiology wards.
• Only 65% were prescribed beta blockers on discharge, although this figure was significantly higher for those patients admitted to cardiology wards (78%) compared to those in in general medical wards (63%).
• Under half of patients (47%) with a confirmed diagnosis of heart failure were referred to heart failure liaison services on discharge.