Guideline‐based audit of the hospital management of heart failure with reduced ejection fraction

Douglas Drak; Jordan Fulcher; Jens Kilian; James J.H. Chong; Rominder Grover; Andrew Sindone; Mark Adams; Jo‐Dee Lattimore; Anthony Keech

doi:10.1111/imj.15830

June 6, 2022Internal Medicine Journal

Guideline‐based audit of the hospital management of heart failure with reduced ejection fraction

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Why the study?

Multiple evidence-based therapies are recommended for HFrEF, but data on physician adherence to therapy guidelines are limited.

Structured PICO

P

Population

989 patients admitted with a principal diagnosis of heart failure with reduced ejection fraction (HFrEF) across six metropolitan hospitals in Sydney, Australia (excluding 39 patients managed with palliative intent).

I

Intervention

Actual hospital management and prescription of HFrEF medical and device therapies (beta-blockers, diuretics, ACEI/ARB, aldosterone antagonists, ivabradine, AICD, CRT).

C

Comparator

Guideline-recommended use of therapies based on individual patient indications and contraindications.

O

Outcome

Proportion of eligible patients receiving guideline-recommended medical and device therapies for HFrEF.

There are substantial evidence-practice gaps in the hospital prescription of guideline-directed medical and device therapies for HFrEF, representing a major opportunity for quality improvement.

Implication

High beta-blocker/diuretic use in Australian HFrEF inpatients supports guideline alignment; leaves open gaps in full GDMT implementation.

Abstract

BACKGROUND: Heart failure is a major burden in Australia in terms of morbidity, mortality and healthcare expenditure. Multiple evidence-based therapies are recommended for heart failure with reduced ejection fraction (HFrEF), but data on physician adherence to therapy guidelines are limited. AIM: To compare use of HFrEF therapies against current evidence-based guidelines in an Australian hospital inpatient population. METHODS: A retrospective review of patients admitted with a principal diagnosis of HFrEF across six metropolitan hospitals in Sydney, Australia, between January 2015 and June 2016. Use of medical and device therapies was compared with guideline recommendations using individual patient indications/contraindications. Readmission and mortality data were collected for a 1-year period following the admission. RESULTS: Of the 1028 HFrEF patients identified, 39 were being managed with palliative intent, leaving 989 patients for the primary analysis. Use of beta-blockers (87.7% actual use/93.6% recommended use) and diuretics (88.4%/99.3%) was high among eligible patients. There were large evidence-practice gaps for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB; 66.4%/89.0%) and aldosterone antagonists (41.0%/77.1%). In absolute terms, use of these therapies each increased by over 11% from admission. Ivabradine (11.5%/21.2%), automated internal cardiac defibrillators (29.5%/66.1%) and cardiac resynchronisation therapy (13.1%/28.7%) were used in a minority of eligible patients. Over the 1-year follow-up period, the mortality rate was 14.8%, and 44.2% of patients were readmitted to hospital at least once. CONCLUSION: Hospitalisation is a key mechanism for initiation of HFrEF therapies. The large evidence-practice gaps for ACEI/ARB and aldosterone antagonists represent potential avenues for improved HFrEF management.