*For medical professionals only
Heart failure (HF) is a leading cause of hospitalization in adults worldwide, with a high rate of readmissions, high mortality, and a growing economic burden. In the management of HF, the medical quality control system has played a very important role. Establishing a sound medical quality management system can continuously improve medical quality, standardize clinical diagnosis and treatment behavior, and reduce the burden of HF.
Recently, the European Society of Cardiology (ESC) published the latest HF management and outcome quality indicators to assess the quality of HF management in adults. The purpose of this article is to introduce these management indicators, in order to provide some inspiration and thinking for the management of heart failure and the continuous improvement of the quality control system in China.
Overview
Guide-recommended HF treatment measures can improve the prognosis of HF patients, especially is an improved prognosis in patients with HF with reduced ejection fraction (HFrEF). However, observational data show that there are geographical differences in the application of guidelines in clinical practice. A situation where there is a disconnect between new medical technology and implementation (a “second translational gap”), needs to be improved by taking new initiatives.
Quality Indicators (QIs) are increasingly used to measure guidelines-recommended treatments in clinical practice. adherence to these treatments and associated outcomes. Given that QIs address different aspects of disease management, they allow for a more complete interpretation of real-world data. Several organizations such as the American College of Cardiology (ACC)/American Heart Association (AHA) and the National Institute for Excellence in Health Management (NICE) have gradually recognized this and have developed a series of QIs for HF management. It is imperative to develop sufficiently detailed QIs to be compatible with contemporary HF management practices and the application habits of cardiologists.
The European Society of Cardiology (ESC), in collaboration with the HF Association (HFA), established a working group on HF QIs to develop A set of QIs for the management of adult HF. This set of QIs is consistent with current recommendations for the management of adult HF and is designed to facilitate standardized assessment of guideline compliance and to identify areas for improvement in the quality of HF management, thereby reducing the burden of HF.
Methods
Quality indicators to measure cardiovascular management and prognostic outcomes, including:< /span>
(i) Construct a conceptual framework for HF management and identify key management areas for HF management;
(ii) review the literature Conduct a systematic review to develop candidate QIs;
(iii) use a modified Delphi method to select final QIs;
( iv) Assess the feasibility of the developed QIs.
This group of quality indicators can be divided intostructural indicators, process performance indicators and outcome indicators.
Structural indicators are measures to assess management quality at the level of medical institutions, and process indicators are measures to assess management at the level of individual patients quality. Outcome measures are used to record outcomes thought to be related to the condition itself (eg, complications of disease), treatment (eg, treatment adverse events), or patient-reported conditions (eg, health-related quality of life).
In addition, the quality indicators of ESC include primary and secondary indicators, where the primary indicator is considered to be more effective and feasible , and thus can be used for cross-regional and long-term quality assessment.
HF Management Area< /p>
The target population was defined as: patients with established diagnosis of HF of any type (including HF with preserved ejection fraction [HFpEF], HF with mildly reduced ejection fraction [HFmrEF], and Fractional reduced HF [HFrEF]). In addition, QIs that are only relevant to specific HF types are specifically defined. Key areas of HF management are established by constructing a multidimensional conceptual framework for the HF patient (Figure 1).
Figure 1 Conceptual framework for the management of HF patients
The numerator (patients under management assessment), denominator (patients eligible for management assessment) are defined for each procedural QI span>, the measurement period (the point at which the evaluation is made) and the measurement duration (sufficient cases need to be collected).
Results
Heart Failure Management Area
The working group identified five management areas for HF management, including:
(1) Structural framework;
(2) Patient evaluation;
(3) Initiate treatment;
(4) Optimization of treatment;
(5) Health-related quality of life assessment of patients (Figure 2).
Figure 2 Quality indicators for the management of ESC HFA HF patients
System review results
A total of 12 primary indicators and 4 secondary indicators were included in the final indicator set for ESC HFA HF in 2021 (Figure 2).
Quality Metrics p>
Domain 1: Structural Framework
Structural QIs may indirectly assess HF management quality , concerning the implementation of evidence-based interventions for HF and its association with prognosis. In addition, structural QIs primarily address aspects of HF management impacted by the healthcare facility and may be difficult to consider at the individual patient level.
Therefore two main QIs are proposed in this field:
< span>Is there a dedicated multidisciplinary team to manage patients with HF (major QIs 1.1);
Is there a dedicated healthcare professional providing HF-specific education to facilitate the patient self-management (main QIs 1.2).
These are key aspects of HF management and have been shown to be associated with improved outcomes (Table 1).
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Table 1 ESC HFA quality indicators in the management of HF patients
Multidisciplinary HF Management is defined as a holistic assessment of the patient with HF, not only focusing on HF treatment, but extending to HF risk factor control and lifestyle changes, as well as the patient’s overall physical and mental health. The multidisciplinary team in HF should include at least one cardiologist with research in the field of HF and one allied health professional trained in HF follow-up, with access to other services (including psychosocial support and palliative care).
Domain 2: Patient Assessment
The clinical type of HF determines the suitability of certain guideline-recommended interventions, such as novel drugs or devices.
Thus, the assessment and documentation of the clinical type of HF (including HFpEF, HFmrEF, HFrEF) (primary QIs 2.1) and the patient’s electrocardiographic findings (primary QIs 2.2) constitute HF patient management indicators of quality (Table 1). In addition, natriuretic peptide concentrations (primary QIs 2.3) can guide the diagnosis and prognosis of HF, and other relevant blood tests (primary QIs 2.4) are also important variables for a comprehensive assessment of patient health.
Given the importance of extended evaluation of patients after hospitalization for HF, post-discharge interventions [eg, cardiac rehabilitation (primary QIs 2.5) and early follow-up (secondary QIs 2.1) ] was associated with improved patient outcomes (Table 1).
Domain 3: Initiating Therapy
Drug therapy is the cornerstone of HF patient management. Especially for patients with HFrEF, some guideline-recommended therapies can improve outcomes, and recent studies both consolidate existing evidence for established therapies and provide additional considerations that should be considered. Choices:
(i) beta-blockers bisoprolol, carvedilol, metoprolol succinate extended-release or nebivolol (mainly QIs 3.1);
(ii) angiotensin-converting enzyme inhibitor, angiotensin receptor blocker (ARB), or angiotensin receptor-enkephalin Enzyme inhibitor (mainly 3.2);
(iii) Mineralocorticoid receptor antagonists (major QIs 3.3);
(iv) sodium-glucose cotransporter Inhibitor (SGLT2i) (major QIs 3.4) (Table 1).
QIs 3.5 primarily document the prescription of loop diuretics in HF patients with evidence of fluid retention (Table 1).
Domain 4: Optimizing Treatment
For sinus rhythm patients with left ventricular ejection fraction (LVEF) ≤35%, QRS duration ≥150 ms, and ECG showing left bundle branch block morphology, receive at least 3 Symptoms persist after months of optimal drug therapy, and clinical outcomes can be improved with cardiac resynchronization therapy (minor QIs 4. 1);
for LVEF≤35%, Primary prevention implantable cardioverter-defibrillator in patients with a history of ischemic heart disease, life expectancy well beyond 1 year, and symptomatic despite at least 3 months of optimal medical therapy (minor QIs 4.2) (Table 1).
Although the role of device therapy in HF is well established, the working group expressed doubts about the feasibility of delivering this therapy in different medical systems in Europe, and therefore developed a Quality indicators are used as secondary indicators.
Domain 5: Assessment of Patient Health-Related Quality of Life
Although methodologies for patient-reported outcome measures have been developed, their implementation in clinical practice has been limited due to the burden of data collection.
The International Consortium for Health Outcomes Measurement (ICHOM) recommends the use of the abbreviated Kansas City Cardiomyopathy Questionnaire (KCCQ-12) to assess patients’ health-related quality of life. However, common quality-of-life measures such as the EuroQoL Group Quality of Life Questionnaire have also been used in the literature. Therefore, the task force agreed to recommend the use of “valid tools” to assess patients’ health-related quality of life (secondary QIs 5.1).
In view of the concerns about the feasibility of obtaining health-related quality of life in clinical practice, this QI was designed as a process QI strong>, instead of a result evaluation. Therefore, the assessment of a patient’s health-related quality of life would form the completed part of this QIs without requiring certain scores to be targeted for treatment (Table 1).
Comprehensive Quality Indicators< /p>
A composite quality indicator is a combination of two or more indicators into a single score in order to combine some individual QIs into a comprehensive assessment of management quality. Compared with individual indicators, comprehensive quality indicators can provide more reliable baseline information.
Discussion and Summary
This article describes the first group of ESCs used to evaluate HF management quality indicators. These QIs are derived from clinical evidence, based on expert consensus, and provide the means for quality improvement initiatives, facilitating the development of the 2021 ESC HF Clinical Practice Guidelines Its seamless integration into the guideline document and provides some guideline recommendations that translate into specific and measurable metrics. A total of 12 major QIs and 4 minor QIs in the field of HF management were defined, (1) structural framework; (2) patient assessment; (3) initiation of treatment; (4) optimization of treatment; (5) patient health-related quality of life evaluation of. For each quality control measure, relevant specifications are described to enhance its use in practice. The quality indicators recommended in this paper can facilitate the implementation of clinical practice guidelines and assess adherence, enabling institutions to monitor, compare, and improve the quality of management of patients with HF.
Experts Introduction
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Professor Liu Tong
Capital Chief Physician, Doctor, Associate Professor, Postgraduate Supervisor, Heart Failure Ward, Department of Cardiology, Beijing Anzhen Hospital Affiliated to Medical University,
Working in the Emergency Rescue Center and Cardiology Department of Beijing Anzhen Hospital For more than 20 years, his main research directions are clinical treatment of severe heart failure and the pathogenesis and pathological research of myocardial fibrosis and left ventricular remodeling; Experiment design, analysis of cardiac imaging data, and data processing;
Currently serving as a member of the Heart Failure Group of the Cardiovascular Branch of the Chinese Medical Association,< /p>
Member of the Chinese Medical Doctor Association CCCP Cardiac Precision Medicine and Rare Diseases Group,
Chinese Journal of Cardiovascular Research, etc.;
In the past 5 years, he has published 20 SCI articles on clinical heart failure research as the first author, and participated in the compilation of many consensuses.
Source:
European Society of Cardiology quality indicators for the care and outcomes of adults with heart failure. Developed by the Working Group for Heart Failure Quality Indicators in collaboration with the Heart Failure Association of the European Society of Cardiology. European Journal of Heart Failure, 2022, Epub.doi:10.1002/ejhf.2371