Association of hospital performance measures with readmissions for patients with heart failure: A report from JROAD-DPC study

https://doi.org/10.1016/j.ijcard.2021.08.019Get rights and content

Highlights

  • Hospital-based performance measures for HF including prescription (ACEI/ARB, BB, and MRA) and examination (Echo and BNP) were associated with HF.

  • Composite performance of hospitals was associated positively with several hospital structural factors.

  • Nation-wide evaluation and improvement of hospital-level performance may be significant to reduce HF readmissions in ageing societies like Japan.

Abstract

Background

Measuring quality of care is central to quality improvement. Improving outcomes for heart failure (HF) may relate to hospital care delivery. However, there is limited nationwide data on the relationship between hospital-level HF performance measures and clinical outcomes.

Methods

From the Japanese Registry of All cardiac and vascular Diseases (JROAD-DPC) database, 83,567 HF patients hospitalised in 731 certificated hospitals in 2014 by the Japanese Circulation Society were analysed. Five performance measures were prescription rate of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, and mineralocorticoid receptor antagonist and measurement rate of echocardiography and B-type natriuretic peptide during hospitalisation. Relationships between these measures and 1-year readmission due to HF were analysed. Composite performance score (CPS) obtained from the five performance measures and outcomes were also analysed. We also investigated the relationships between CPS and hospital structural factors.

Results

From the cohort (mean age; 78.2 years, woman 48.4%), HF readmission rate at 1 year was 19.6% (n = 16,368). Readmission rate decreased with higher quartiles of prescription rate in each medication and diagnostic performance rates. The highest CPS group was associated with a 15% risk reduction in HF readmission compared with the lowest CPS group (hazard ratio, 0.85, 95% confidence interval [0.80–0.89], p < 0.001) after covariate adjustment. Several structural factors such as number of cardiology specialists, hospital case volume for HF, and presence of cardiac surgery division were associated with high CPS.

Conclusion

Higher hospital performance measures for HF were inversely associated with HF readmissions.

Introduction

Heart failure (HF) pandemic is rapidly developing and is a critical problem not only in Japan but also in many developed countries. The Global Burden of Disease study in 2015 estimated that approximately 40 million people worldwide have HF [1]. The prevalence of HF is expected to increase further due to the ageing general population [2]. HF readmissions lead to high healthcare resource utilisation and increase healthcare costs [3]. HF readmission is associated with poorer quality of life and increase mortality risk [4]. Improving quality of care for HF and preventing readmission is an important issue.

Evaluating HF stages and providing appropriate treatment, as recommended by the guidelines, is expected to reduce readmission rates and improve patient symptoms and prognosis [5,6]. However, there exist significant variations in the delivery of care for HF and its outcomes worldwide [7,8], suggesting that the potential to reduce cardiovascular disease burden has not been fully realised. Measuring and standardising the quality of medical care is expected to improve healthcare for patients with HF. When there are data to show that adherence to guidelines improves clinical outcomes, variations from set standards in healthcare delivery serve as indirect evidence for the potential to improve outcomes. In several countries such as the UK and USA, assessing the process of patient care has an important role in managing HF and is a target of hospital quality improvement initiatives (e.g., National Heart Failure Audit [NHFA] and American Heart Association's Get With The Guidelines [GWTG] programme) [9]. However, there are limited number of studies examining the relationship between hospital-level process of care for HF and outcomes at the nationwide level.

The Japanese Registry Of All cardiac and vascular Diseases (JROAD)-Diagnosis Procedure Combination (DPC) launched by the Japanese Circulation Society (JCS) is a nationwide claim database containing data from the Japanese DPC/Per Diem Payment System (DPC/PDPS) [2,10]. In this study, we investigated hospital-level performance measures related to the prescription rate of guideline-directed medication and diagnostic examination and their relationships with readmission due to HF using a nationwide database in Japan. We also evaluated the association between composite performance score (CPS) for process of care and structural factors of hospitals.

Section snippets

Study cohort

The JROAD-DPC database was created by combining JROAD data derived from a JCS national survey to assess the clinical activity of each Japanese institution with cardiovascular beds and to provide adequate feedback to teaching hospitals for improving patient care database [11] and the DPC, which is a mixed case patient classification system launched in 2002 by the Ministry of Health, Labour and Welfare of Japan [12]. The DPC database contains the following data for each patient: patient

Baseline characteristics of HF patients

Among 111,503 patients hospitalised due to HF in 2014, we excluded those who died during hospitalisation (n = 11,790), who underwent dialysis during hospitalisation (n = 6429), who were aged <20 years (n = 312), who were without an NYHA class (n = 9307), and who were without prescription information (n = 63). We also excluded hospitals with <10 HF hospitalisations annually (10 hospitals, 35 subjects). Finally, a total of 83,567 patients from 731 hospitals were included in the present analysis

Discussion

We used a nationwide cohort to explore the possible association between performance measures of HF patient care and readmission with HF among patients who survived after hospitalisation for HF. We found that 1) among hospital performance measures, there were wide variations, especially in terms of prescription rates of guideline-directed medications, 2) hospital performance measures were inversely associated with HF readmission even after adjusting for variables, 3) HR for HF hospitalisation

Limitations

Our study has a few key limitations. First, our dataset was not linked to death record after discharge. However, this would rather underestimate our results because hospitals with low indicators are expected to have more deaths. Second, our dataset could not capture readmissions outside the same hospital. However, since most patients are usually admitted to the same hospital, the effect on the analysis results is considered to be limited. Third, although this research was conducted using

Conclusions

There were wide variations in hospital-level performance measures for the treatment of HF patients in Japanese hospitals. The prescription rate of guideline-directed medication and diagnostic examination in each hospital was inversely associated with readmission due to HF following discharge. Reducing the variability in performance measures between hospitals may help reduce post-HF readmissions.

Author statement/Contribution of authors

KN (corresponding author): study conception and design; funding acquisition; analysis and interpretation of data; conducted the statistical analyses; writing - original draft; review and approval of the manuscript.

SY: study conception and design; funding acquisition; analysis and interpretation of data; writing - editing; review and approval of the manuscript.

TN: study conception and design; analysis and interpretation of data; review and approval of the manuscript.

YS: dataset construction;

Declaration of Competing Interest

Dr. Yasuda reports grants and personal fees from Takeda, grants and personal fees from Daiichi-Sankyo, personal fees from Bristol-Z, grants and personal fees from Bristol-Myers, grants from Abbot, outside the submitted work. Dr. Tsutsui reports Grants from Daiichi Sankyo, Mitsubishi Tanabe Pharma, Nippon Boehringer Ingelheim, IQVIA Services Japan, Omron Healthcare, MEDINET, Medical Innovation Kyushu, and personal fees from AstraZeneca, Ono Pharmaceutical, Otsuka Pharmaceutical, Daiichi Sankyo,

Acknowledgements

The present work was supported in part by a grant from the Ministry of Health, Labour and Welfare of Japan [H29–31201709018A] (SY). This work was also supported by Japan Society for the Promotion of Sience KAKENHI Grant Number 17 K09548 (KN) and 20 K08483 (KN), grant from Japanese Cardiovascular Research Foundation: The Bayer Scholarship for Cardiovascular Research (KN) and research grant from The Japan Research Foundation for Healthy Ageing (KN). The funders had no role in the design and

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