Heart failure performance measures and outcomes: real or illusory gains.

HEART FAILURE IS ONE OF THE MOST DEADLY AND costly conditions in the United States. Among Medicare beneficiaries, heart failure is the most frequent cause of hospitalization and death, with 1-year readmission and mortality rates of 65% and 35%, respectively. While a number of therapies and interventions have been demonstrated to improve heart failure outcomes, studies have consistently shown gaps, variations, and disparities in the application of these therapies in routine clinical practice. In 1996, the Centers for Medicare & Medicaid Services (CMS) first implemented a program to track and improve the quality of heart failure care in hospitals. The CMS subsequently aligned with The Joint Commission to create a national standardized “core” set of 4 heart failure performance metrics: measuring left ventricular function; using angiotensin-converting enzyme inhibitors in patients with left ventricular systolic dysfunction; providing complete heart failure discharge instructions; and providing smoking cessation counseling in current or recent smokers. The original heart failure process measures have been modified only once since then by adding use of angiotensin II receptor blockers as an alternative to angiotensin-converting enzyme inhibitors. Under the Medicare Prescription Drug, Improvement and Modernization Act, all hospitals were required to submit these performance metrics to receive full CMS reimbursement for services provided. Further incentives to improve these measures were later provided when the CMS began publicly releasing hospital-specific performance data and linking hospital performance with financial rewards via the pay-for-performance demonstration project. Hospitals must devote significant resources to document, abstract, and report these mandated performance measures. It is conservatively estimated that centers spend 22.2 minutes per heart failure case to abstract the data, which in aggregate amounts to more than 400 000 person-hours spent each year by US hospitals. Hospitals spend millions more dollars to purchase and maintain ORYX-certified systems needed to transmit the required data. In addition to these required resources, centers that wish to excel on the evaluation metrics often make huge additional investments in care redesign, implementing multisource data integration systems and hiring quality improvement staff to verify that patients receive these measured elements or have documented reasons not to. Clinicians, hospitals, payers, health care reformers, patients, and the public have been led to believe that committing these resources was highly worthy and that improvement in these measures would be closely linked to improved outcomes. Quality improvement campaigns have promoted the idea that increased conformity with process measures would improve the efficiency of heart failure care and reduce longitudinal costs. Furthermore, the public and patients have been told to use these publicly reported measures to make informed decisions about their health care. Data to date, however, call these assumptions into question. On the positive, from 2002 to 2007, provision of discharge instructions improved from 31% to 78%, left ventricular function measures improved from 82% to 95%, use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers for left ventricular systolic dysfunction improved from 74% to 90%, and provision of smoking cessation advice improved from 42% to 96% (FIGURE). This improved process performance led many to conclude that these national campaigns were a resounding success at improving care, saving lives, and reducing health care expenditures. Yet it is critical to close the loop and verify that changes in care processes were actually associated with improved patient outcomes, because prior cross-sectional studies had called this into question. From a longitudinal perspective, huge temporal shifts in these 4 heart failure process performance measures