Towards Global Improvement in Heart Failure Care

This article refers to ‘Assessing the evidence–practice gap for heart failure in China: the Heart Failure Registry of Patient Outcomes (HERO) study design and baseline characteristics’ by L. Li et al., published in this issue on pages 646–660. Heart failure (HF) is an increasingly prevalent cause of morbidity and mortality worldwide, with an estimated 26 million people affected.1 Care for patients with HF is estimated to cost $108 billion annually worldwide.2 In the United States (US), measures to improve care of patients with HF have been introduced from more than a decade ago that target not only quality of healthcare delivery, but also cost reduction for patients with HF. Quality of care for HF is publicly reported among the nation's hospitals and registries, such as the American Heart Association's Get With the Guidelines programme that provides feedback for process measures and outcomes to participating hospitals.3 Similar measures have been reported from the United Kingdom and other countries.4 Heart failure has now also been widely recognized as an epidemic afflicting developing countries like China. More than 4 million individuals in China are reported to have HF, and 500 000 new cases are diagnosed every year.5, 6 In the face of this growing epidemic, the Chinese government has emphasized improvement in HF care as a priority in the past decade. The Chinese Hospital Association included HF as one of the target diseases for quality improvement and established a panel of HF-specific quality measures to characterize hospital performance.7 Moreover, the State Council in China has initiated extensive healthcare reform leading to much improved access to care with near universal health coverage for inpatient treatment in recent years. Despite these efforts, information pertaining to adherence to guideline-recommended therapy and outcomes for patients hospitalized with HF in China has been scarce. In this issue of the Journal, Li et al.8 describe the methods and baseline characteristics of HERO, a Heart Failure Registry of Patient Outcomes study, designed to address the lack of clinical data to support HF population research in China. The researchers prospectively and longitudinally recruited 5620 patients from November 2017 to November 2018 from a sample of 73 provincial, municipal, and county-level hospitals. Data collection was performed by centrally trained staff to maximize accuracy. Consecutive cases seen during random seasonal surveillance periods throughout the year were reported to the registry. The mean patient age was 72 years, 50% were women, and 75% of patients came from county/rural areas of China. While the authors did not sample patients from across the country, inclusion of a high proportion of rural centres from the Henan province would likely allow for extrapolating results of this study to the rest of the country given its diverse patient population. Importantly, the study team administered the Chinese version of the Minnesota Living with Heart Failure Questionnaire in an effort to assess patient-reported outcomes. Longitudinal outcomes will be assessed through scheduled telephone encounters by trained personnel. This study finds some notable differences in characteristics of patients hospitalized with HF in China compared with other parts of the world. First, the prevalence of co-morbidities like coronary artery disease, hypertension and diabetes was lower among patients with HF in the HERO registry as compared with reports in HF registries from other countries including the US and Europe.9-11 In contrast, the burden of valvular heart disease was high likely secondary to higher prevalence of rheumatic heart disease in China. This may have important clinical implications with regard to treatment given that majority of the evidence base for medical treatment of HF pertains to non-valvular or ischaemic cardiomyopathies. Second, more than 70% of patients in the HERO registry who received an echocardiogram had an ejection fraction (EF) >40%. This is much higher than the prevalence for HF with preserved EF (HFpEF) noted in inpatient registries from the US and other countries.10-12 While this is in accordance with the global trend of increasing HFpEF prevalence secondary to increasing recognition and the changing epidemiology of HF, higher prevalence of valvular HF may be particularly responsible in China. Moreover, non-specific and non-standardized diagnostic criteria for HFpEF also render it prone to misdiagnosis.13 Third, diuretic use for patients hospitalized with acute decompensated HF was observed in only 58% of patients, in contrast to much higher proportions (>90%) reported from HF registries from other countries. This may be related to lower acuity of hospitalization in the HERO registry. It is plausible that the threshold for hospitalization in China is lower than other countries given the wide gap in inpatient (>90%) vs. outpatient (<50%) insurance coverage.14, 15 Fourth, this study elucidates important HF treatment gaps that may be targets for performance improvement initiatives. Only 57% of the study population received an echocardiogram for evaluation of EF, even though this is a Class 1 American College of Cardiology/American Heart Association recommendation for HF care.16 Further, of 668 patients with elevated B-type natriuretic peptide and EF <40%, only 52.2% received angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, or angiotensin–receptor neprilysin inhibitor therapy on discharge, and only 61.0% of patients received beta-blocker therapy on discharge. This is markedly lower than the reported adherence to these measures of HF care quality metrics in the US and highlight potential areas for care improvement.10 There were also some notable observations made in this study with regard to the short-term clinical outcome of patients hospitalized with HF. The in-hospital mortality was ∼3.5% (inclusive of 3 days post-discharge to account for patients preference to die at home instead of in the hospital), comparable with or even better than Western countries.1 This is despite much lower adherence to guideline-recommended medical therapies, providing further insight into the possibility of hospitalization of low-acuity patients. It is also noteworthy that the median length of stay of patients hospitalized for acute decompensated HF was more than double compared with that in the US (9 days vs. 4 days).9 Relatively low rates of in-hospital mortality despite a much longer median length of stay in China suggest greater utilization of in-hospital healthcare resources, providing opportunities for optimizing efficiency of healthcare delivery for HF in China. The HERO registry improves upon previous registries from China that were either retrospective (ADHERE International-Asia Pacific)17 or had low percentages of female patients (TSOC-HFrEF),18 or did not provide long-term follow-up (China PEACE 5r-HF and China-HF).19, 20 Moreover, although not reported in the current study, the authors plan to collect quality-of-life endpoints that will be highly informative to evaluate the association of quality of care with patient-centred outcomes. However, despite the rigorous data collection, there are some limitations to the study. Given that only 57% of patients hospitalized with HF received an echocardiogram, it is possible that missingness was not randomly distributed across different EF subgroups, precluding further epidemiologic descriptions of HF subtypes. Moreover, while this registry will provide valuable insights into HF practice patterns and gaps in treatment, the authors do not describe how information gained from this study would inform further quality improvement initiatives for HF care, a model typically followed by registry-based studies. The Get With the Guidelines–Heart Failure registry in the US, for example, provides ongoing feedback to participating hospitals, and has been associated with improvement in process of care metrics and outcomes for HF care.3 Although describing baseline treatment patterns and outcomes may stimulate improvement, it will likely not suffice by itself. Findings from this study highlight the need for broad-based initiatives for improved adoption of evidence-based care, including launch of national hospital quality monitoring systems, policies incentivizing high-performing providers and hospitals, and quality improvement initiatives tailored for poor-performing hospitals. Elements of such initiatives could include standardized best practices algorithms for HF care that are easily accessible to providers, standardized orders for both electronic and paper medical records, discharge checklists, pocket cards or chart stickers. Extrapolation of knowledge generated from this study may also lay the groundwork for quality improvement initiatives in other developing countries in Southeast Asia, South America, and Africa, that may share cultural, socio-economic or demographic characteristics with China and are also faced with the HF epidemic common to aging populations across the world. Conflict of interest: none declared.