Quality improvement intervention fails to improve care for patients with heart failure

A quality improvement intervention initiative designed to provide clinician education and feedback to enhance the quality of care failed to meaningfully improve outcomes for patients with heart failure (HF) over usual quality improvement processes in the CONNECT-HF trial [1].

Outcomes in patients with heart failure with reduced ejection fraction (HFrEF) are suboptimal; patients with HFrEF experience a high symptom burden and high rates of rehospitalisation and death. These poor outcomes are due in part to poor implementation of guideline-directed medical therapy (GDMT).

In an attempt to provide data to inform best practices in hospitals and post-discharge quality improvement initiatives, a pragmatic, prospective, cluster-randomised trial was designed to compare the effectiveness of a customised, multifaceted, health system-level quality improvement programme with usual care on HF outcomes. The CONNECT-HF trial (NCT03035474), presented by Prof. Adam DeVore (Duke University School of Medicine, NC, USA) enrolled 161 hospitals across the USA who treated ≥50 patients with acute HF annually to either participate in a quality improvement programme (n=82) or proceed as per usual care pathways. These hospitals had treated a total of 5,647 patients for HF; after hospital randomisation, 2,675 of these patients were in the intervention arm while 2,972 were in the usual care arm.

The intervention consisted of 2 components: audit and feedback to hospitals with pre-existing quality improvement teams directed towards care pathways and outcomes, and education and mentorship to hospitals by the CONNECT-HF Academy, a team of experts on quality improvement and HF. The primary outcome measure was time to first HF rehospitalisation or death during the 12-month follow-up, and the co-primary endpoints were a composite of HF rehospitalisation or death and a change in an opportunity-based composite score for quality of HF care.

At the 12-month follow-up, there was no statistically significant difference in the primary outcome between the 2 groups (adjusted HR 0.92; 95% CI 0.81–1.05; P=0.21) (see Figure).

Figure: CONNECT-HF results for the primary outcome of heart failure rehospitalisation or death [1]



Similarly, no statistically significant difference was observed in the composite score for quality of HF care between the groups. Prof. DeVore highlighted some of the individual quality measures of this composite score, noting that the use of medical therapy did not improve beyond baseline measures following 12 months of intervention. Specifically, the use of ACE inhibitors, ARBs, ARNIs, β-blockers, and MRAs lagged well below target doses.

The researchers concluded that the quality improvement intervention of the CONNECT-HF based on clinician education, audit, and feedback failed to improve outcomes in patients with HFrEF above current quality improvement processes. Major gaps in GDMT remain, and new approaches are required to improve care.

1. 
   
   1. DeVore A. Care optimization through patient and hospital engagement clinical trial for heart failure: primary results of the CONNECT-HF randomised clinical trial. ACC 2021 Scientific Session, 15–17 May.

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Posted on 9 July 202129 July 2021