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Title

BRITISH SOCIETY FOR HEART FAILURE

NATIONAL HEART FAILURE AUDIT APRIL 2011 - MARCH 2012 National Heart Failure Audit April 2011-March 2012

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NICOR (National Institute for Cardiovascular Outcomes Research) is a partnership of clinicians, IT experts, statisticians, academics and managers which manages six cardiovascular clinical audits and three clinical registers. NICOR analyses and disseminates information about clinical practice in order to drive up the quality of care and outcomes for patients.

The British Society for Heart Failure (BSH) is a national organisation of healthcare professionals which aims to improve care and outcomes for patients with heart failure by increasing knowledge and promoting research about its diagnosis, causes and management.

The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact of clinical audit in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The programme comprises 40 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. Founded in 1826, UCL (University College London) was the first English university established after Oxford and Cambridge, the first to admit students regardless of race, class, religion or gender, and the first to provide systematic teaching of law, architecture and medicine. It is among the world’s top universities, as reflected by performance in a range of international rankings and tables. UCL currently has 24,000 students from almost 140 countries, and more than 9,500 employees. Its annual income is over £800 million.

Authors Report produced by John Cleland (University of Hull) Henry Dargie (University of Glasgow) Suzanna Hardman (Whittington NHS Trust) Theresa McDonagh (King’s College London) Polly Mitchell (NICOR)

Data cleaning and analysis Emmanuel Lazaridis (NICOR) Darragh O’Neill (NICOR)

Acknowledgments The National Heart Failure Audit is managed by the National Institute for Cardiovascular Outcomes Research (NICOR), which is part of the National Centre for Cardiovascular Prevention and Outcomes, based at University College London. The National Heart Failure Audit is funded and commissioned by the Healthcare Quality Improvement Partnership (HQIP). Specialist clinical knowledge and leadership is provided by the British Society for Heart Failure (BSH) and the audit’s clinical lead, Professor Theresa McDonagh. The strategic direction and development of the audit is determined by the audit Project Board. This includes major stakeholders in the audit, including cardiologists, the BSH, heart failure specialist nurses, clinical audit and effectiveness managers, cardiac networks, patients, NICOR managers and developers, and HQIP. This report was completed in close collaboration with the NICOR technical team, formerly known as the Central Cardiac Audit Database (CCAD). Marion Standing has again been especially involved. We would especially like to thank the contribution of all NHS Trusts, Welsh Heath Boards and the individual nurses, clinicians and audit teams who collect data and participate in the audit. Without this input the audit could not continue to produce credible analysis, or to effectively monitor and assess the standard of heart failure care in England and Wales. This report is available online at www.ucl.ac.uk/nicor/audits/heartfailure/additionalfiles National Heart Failure Audit National Institute for Cardiovascular Outcomes Research (NICOR) Institute of Cardiovascular Science, University College London 3rd floor, 170 Tottenham Court Road, London W1T 7HA

Tel: 0203 108 3927 Email: polly.mitchell@ucl.ac.uk

National Heart Failure Audit April 2011-March 2 Published 27th November 2012. The contents2012 of this report may not be published or used commercially without permission

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National Heart Failure Audit April 2011 - March 2012 The fifth annual report for the National Heart Failure Audit presents findings and recommendations based on patients discharged with a diagnosis of heart failure between 1 April 2011 and 31 March 2012, covering all NHS Trusts in England and Health Boards in Wales which admit acute heart failure patients. The report is aimed at those involved in collecting data for the National Heart Failure Audit, as well as clinicians, healthcare managers, clinical governance leads, and all those interested in improving the outcomes and well-being of patients with heart failure. The report includes clinical findings at national and local levels and patient outcomes for the audit year.

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Contents The Authors

2

Contents

4

List of figures

Readmission

15

Aetiology

16

5

Symptoms

16

Foreword

6

Aetiology

16

1. Executive summary

7

Diagnosis

16

Echocardiography

16

Diagnosis

17

Treatment on discharge for LVSD

17

ACE inhibitor and ARB

17

Beta blocker

17

MRA

17

Loop diuretics

17

Thiazide diuretics

17

Digoxin

17

Treatment on discharge by age

17

Monitoring heart failure patients

18

Follow-up services

18

Palliative care

18

Analysis by hospital

19

Participation and case ascertainment

19

Clinical practice

30

1.1

National Heart Failure Audit

7

1.2

Findings

7

Participation

7

Hospitalisation

7

Diagnosis

7

Treatment

7

Referrals on discharge

7

Hospital level analysis

7

In-hospital mortality

8

Mortality for survivors to discharge

8

Recommendations

8

1.3

2. Introduction

3.6

3.7

3.8

3.9

2.1

Heart Failure

10

2.2

The role of the audit

10

2.3

National use of audit data

10

2.4

Organisation of the audit

11

2011/12 in-hospital mortality

42

2.5

The scope of the audit

11

2011/12 post-discharge mortality

42

2.6

The database

11

2.7

Data collection and IT

11

2.8

Improving our IT platform

12

2.9

Improving analysis

12

3. Findings

13

3.1

Data cleaning and data quality

13

3.2

Participation

13

Number of Trusts

13

Number of patients

14

Case ascertainment

14

Demographics

14

Age

14

Age and sex

14

Age and Index of Multiple Deprivation

14

3.3

3.4

4

10

3.5

3.10 Mortality

3.11 Three-year trends

42

47

Three-year in-hospital mortality

47

Three-year post-discharge mortality

47

4. Case studies

51

4.1

Improving clinical practice and patient outcomes

51

4.2

Using data to drive improvement

51

4.3

An example of local practice in conducting the

51

national Heart Failure Audit 4.4

The national perspective

5. Research use of National Heart Failure

51

54

Audit data 6. Conclusions

Demographics

15

6.1

In-hospital care

15

6.2

Length of stay

15

55

Quality of care and patient outcomes

55

Data completeness and participation

55

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7. Appendices A1

National Heart Failure Audit Project Board

56 56

membership A2

HALO Group

56

A3

Data for 2011/12 mortality analysis

56

A4

Data for 2009-12 mortality analysis

58

A5

Glossary

59

8. References

61

List of figures and tables

Figure 14 Post-discharge survival by prescription of beta blockers on discharge for patients with LVSD

45

Figure 15 Post-discharge survival by prescription of beta blockers on discharge (all patients)

45

Figure 16 Post-discharge survival by prescription of loop diuretics on discharge for patients with LVSD

45

Figure 17 Post-discharge survival by prescription of loop diuretics on discharge (all patients)

46

Figure 18 Post-discharge survival by additive drug treatment on discharge for patients with a diagnosis of LVSD

46

Figure 19 Post-discharge survival by referral to cardiology follow-up services

46 46 48

Table 1

Records excluded from analysis in this report

13

Figure 20 Post-discharge survival by referral to heart failure liason follow-up services

Table 2

Records excluded from mortality analysis in

13

Table 9

this report Figure 1

Age at first admission by sex

Figure 2

The effect of deprivation on age of first admission 15

Figure 3

Mean length of stay by hospital

15

Figure 4

Median length of stay by hospital

15

Figure 5

Number of readmissions in 2011/12

16

Table 3

Previous medical history and diagnosis of LVSD

16

Figure 6

Treatment for LVSD on discharge by age

18

Table 4

Participation and case ascertainment in England 19

Table 5

Participation and case ascertainment in Wales

29

Table 6

Clinical practice in England (2011/12)

30

Table 7

Clinical practice in Wales (2011/12)

41

Table 8

Cox proportional hazards model for post-

43

14

discharge mortality (2011/12) Figure 7

Overall post-discharge survival

43

Figure 8

Post-discharge survival by sex

43

Figure 9

Post-discharge survival by age at admission

44

Figure 10 Post-discharge survival by place of care

44

Figure 11 Post-discharge survival by presence or

44

absence of LVSD Figure 12 Post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge for patients with LVSD

44

Figure 13 Post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge (all patients)

45

Cox proportional hazards model for post-discharge mortality (2009-12)

Figure 21 Three-year post-discharge survival (2009-12)

48

Figure 22 Three-year post-discharge survival by sex (2009-12)

48

Figure 23 Three-year post-discharge survival by age (2009-12)

48

Figure 24 Three-year post-discharge survival by place of care (2009-12)

49

Figure 25 Three-year post-discharge survival by presence 49 or absence of LVSD (2009-12) Figure 26 Three-year post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge in patients with LVSD (2009-12)

49

Figure 27 Three-year post-discharge survival by prescription of beta blockers on discharge in patients with LVSD (2009-12)

49

Figure 28 Three-year post-discharge survival by prescription of loop diuretics on discharge in patients with LVSD (2009-12)

50

Figure 29 Three-year post-discharge survival by additive drug treatment on discharge in patients with LVSD (2009-12)

50

Figure 30 Three-year post-discharge survival by referral to cardiology follow-up services (2009-12)

50

Figure 31 Three-year post-discharge survival by referral 50 to heart failure liason follow-up services (2009-12)

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Foreword The ability of high quality national audit data to improve clinical cardiovascular care and its role in delivering important outcome benefits has already been well demonstrated through initiatives such as MINAP (Myocardial Ischaemia National Audit Project). However, heart failure remains one of the biggest challenges for modern cardiovascular care and an area where robust audit data has major potential to inform change for the benefit of patients. The National Heart Failure Audit 2011/2012 highlights the importance of heart failure which affects around 900,000 individuals in the UK, accounts for 5% of all emergency hospital admissions and utilises 2% of all NHS hospital bed days. It is associated with a high annual mortality, especially if poorly treated, and the effect of heart failure on quality of life cannot be underestimated. Yet optimal management can result in a better prognosis with fewer symptoms and an increased life expectancy. The National Heart Failure Audit, now in its sixth year, has evolved to include data on acute heart failure admissions from 90% of the Trusts and Health Boards in England and Wales and now represents 59% of all heart failure admissions. It provides a valuable insight into the diversity of both management and outcomes, highlighting the importance of specialist care, optimising medical therapy and appropriate specialist follow-up as key indicators of improved mortality. Although in-hospital mortality remains high at 11.1% the differences between specialist and non-specialist care are striking, with 7.8% in-hospital mortality for patients managed under cardiology care versus 13.2% mortality under general medicine and 17.4% for those managed in other wards.

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The additional mortality benefits of specialist follow-up by cardiology and heart failure teams also highlight the importance of integrated care beyond hospital admission. These insights into the significant outcome gains possible through evidence based, specialist delivered management are a powerful vehicle for driving up quality, addressing variations in care, and for planning and commissioning of future heart failure services. The National Heart Failure Audit is managed by the National Institute for Cardiovascular Outcomes Research (NICOR), receiving clinical direction and leadership from the British Society for Heart Failure which, along with the clinical teams managing the patients and all those submitting the data, deserves enormous credit for its development and continued evolution. From April 2013, when hospitals will be required to submit data on all heart failure admissions, the increasing importance of this audit in driving up the quality of heart failure management will be further enhanced.

Dr Iain A Simpson President, British Cardiovascular SocietyChair, British

Cardiovascular Society

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1 Executive Summary Heart failure is a highly prevalent condition, often with poor outcomes: an estimated 900,000 people in the U.K. have heart failure and over a third will die within a year of diagnosis. Despite an elderly patient group, many of whom have extensive comorbidities contributing to or complicating their heart failure, good clinical management has been shown to substantially improve patient outcomes.

Overall mean length of stay was 13.1 days on first admission and 13.4 days on readmission. This is an increase from last year’s audit (11 days on admission and 13 days on readmission). In contrast to last year, when cardiology patients had longer lengths of stay than patients treated on other wards, in 2011/12 cardiology patients had shorter lengths of stay (12.7 days) than patients on general medical wards (13.1 days) and those on other wards (14.7 days).

1.2.3 Diagnosis

1.1 National Heart Failure Audit The National Heart Failure Audit was established in 2007 to monitor the care and treatment of patients admitted to hospital in England and Wales with heart failure. The audit reports on the clinical practice and patient outcomes of acute patients discharged from hospital with a primary diagnosis of heart failure. The audit collects data based on recommended clinical indicators with a view to driving up standards by encouraging the implementation of guideline recommendations and reporting on practice statistics and outcomes. Audit data is used by a number of national groups, including the NHS Information Centre, the Care Quality Commission and data.gov.uk. However improvements in standards of care depend on participating hospitals using and reviewing their own data to change and improve practice. The audit is strongly supported by the British Society for Heart Failure and is one of six cardiovascular audits managed by NICOR, part of the National Centre for Cardiovascular Prevention and Outcomes at UCL. The audits are funded and commissioned by HQIP.

1.2 Findings 1.2.1 Participation Between April 2011 and March 2012 142 out of 155 NHS Trusts in England and Health Boards in Wales (92%) submitted data to the audit. 12 NHS Trusts and one Health Board did not submit any data to the audit. After data cleaning, the total number of records in the 2011/12 audit was 37,076, made up of 32,906 index admissions and 4,170 readmissions within the audit period. Nationally the audit represents 59% of all heart failure patients in England and Wales. Case ascertainment was 62% for England and 12% for Wales.

1.2.2 Hospitalisation 48% of patients were treated in cardiology wards, with 41% treated on general medical wards and 11% on other wards. Men were far more likely to be treated on cardiology wards than women, as were younger patients.

The use of echocardiography remains high, with 86% receiving an echo during the admission.

1.2.4 Treatment Prescription rates of disease modifying treatments at discharge for patients with left ventricular systolic dysfunction (LVSD) remain broadly similar to those recorded in the 2010/11 audit. Prescription of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) remains high, with 84% of patients discharged on either of the therapies (81% in 2010/11). Prescription of some recommended therapies increased: 78% of patients were prescribed beta blockers on discharge, compared to 65% in 2010/11. 45% of patients were discharged on a mineralocorticoid receptor antagonist (MRA), an increase from 36% in 2010/11. Some of the apparent increase in prescribing between years may be accounted for by changes in analytical method. As observed in previous years, prescription rates for ACE inhibitors/ARBs, beta blockers and MRAs are all higher when patients are admitted to cardiology wards, as opposed to general medical or other wards.

1.2.5 Referral on discharge 54% of patients were referred to a heart failure liaison service on discharge, and 52% to cardiology follow-up. Referral rates were higher for patients who were younger, male and treated on a cardiology ward.

1.2.6 Hospital level analysis For the first time, the National Heart Failure Audit includes analysis on clinical practice at a hospital level, for all hospitals which submitted at least 100 patient records (or more than 70% of their Hospital Episode Statistics (HES) recorded heart failure admissions) to the audit. The findings show fairly wide variation in clinical practice between hospitals, but it is unclear how representative the patients in the audit are of the heart failure patient population at many hospitals, due to the small number of returns. As of April 2013, hospitals will be required to enter data on all of their heart failure patients, and this will hopefully give a more accurate picture of the variation in the treatment and management of heart failure at a hospital level. National Heart Failure Audit April 2011-March 2012

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1.2.7 In-hospital mortality In hospital mortality remains high, with 11.1% of patients discharged in 2011/12 dying during their admission, similar to the 11.6% recorded in 2010/11. These findings are higher than in-hospital mortality rates reported by other European registries,1 and this is likely to reflect the more comprehensive approach taken by the National Heart Failure Audit. In-hospital mortality rates were 7.8% for patients treated on cardiology wards, compared with 13.2% for those treated on general medical wards and 17.4% for those on other wards. The benefit of treatment in a cardiology ward persists when these findings are adjusted for confounding factors such as age and New York Heart Association (NYHA) class. These findings are similar to previous years’ results, and highlight the benefits of specialist treatment.

1.2.8 Mortality for survivors to discharge Of those patients who survived to discharge, 26% died within the follow-up period. Outcomes were significantly better for patients treated on cardiology wards (22%) compared to those treated on general medical wards (30%) and other wards (33%). Mortality rates with key medical treatment (ACEI/ ARBs, beta blockers, MRAs) were substantially lower than without such therapy. The benefits of disease modifying treatment were present in patients with diagnosed with non-systolic heart failure as well as patients with left ventricular systolic dysfunction when taken alone. Patients discharged from cardiology wards were more likely to be prescribed these drugs. The benefits of disease modifying therapies were additive. Patients discharged on all of ACEI/ARBs, beta blockers and MRAs had better survival outcomes than patients prescribed an ACEI/ARB and a beta blocker but no MRA, and patients prescribed an ACEI/ARB alone. All of these patients had substantially lower mortality than patients discharged on none of the three therapies. Patients referred to heart failure nurse and cardiology followup services also had better survival, only 20% of patients referred to cardiology follow-up services on discharge died, compared with 32% of patients not referred to follow-up with a cardiologist. 25% of patients referred to heart failure nurse liaison services within the audit year died, compared with 28% of those not referred to nurse led follow-up. Cox proportional hazards models appear to show that even with adjustment for age, severity of symptoms and history of acute myocardial infarction, for patients who survived to discharge, those not prescribed ACE inhibitors/ARBs and beta blockers on discharge had higher mortality rates. Patients prescribed loop diuretics on discharge had increased mortality

8

rates following adjustment for these confounding factors. After adjusting for possible differences in patient characteristics, patients who were not managed on cardiology wards and those who did not receive cardiology follow-up continued to have higher mortality rates. (The analysis was adjusted for the following covariates: age>75, NHYA class III/IV, previous AMI, no ACEI/ARB, no beta blocker, loop diuretic, no cardiology follow-up, not treated on cardiology ward). Mortality analyses for the three year period between April 2009 and March 2012 show similar findings. 42% of patients who survived to discharge died during this period, but optimal treatment and management in hospital had beneficial effects on patient outcomes, which continued long after discharge.

1.3 Recommendations The National Heart Failure Audit provides key information to improve outcomes in acute heart failure, one of the great unmet needs in the management of the condition. Considerable progress has been made in case ascertainment since the audit began. The aim now should be to strive for inclusion of all patients admitted to hospital with a primary diagnosis of heart failure to ensure a more representative dataset. The following recommendations are made based on the findings of the audit in this and previous years: This audit has consistently shown that specialist cardiology care and follow up is associated with better outcomes for patients with heart failure even after adjusting for age, severity and other observed differences in patient characteristics. Trusts should ensure that patients with a primary diagnosis of heart failure have specialist input to their care as proposed in NICE guidelines and are managed on cardiology or wards specialising in heart failure wherever feasible. Implementation of key evidence-based medicine i.e. the use of ACE inhibitors, beta blockers and MRAs for those with systolic dysfunction is associated with much improved patient outcomes. Trusts need to concentrate on getting these cornerstone therapies initiated in hospital, wherever possible. Robust arrangements for the optimisation of therapy for cardiac dysfunction via cardiology follow-up, heart failure liaison services and primary care need to be firmly in place prior to discharge. The next phase of the audit will address this discharge planning phase more specifically. As access to specialist medical and nursing care is the gatekeeper to optimal care for heart failure patients, Trusts should ensure that key personnel are in place to deliver this care. The audit also shows that outcome is poorer for patients without, compared to those with, left ventricular systolic dysfunction (LVSD). This likely reflects the greater age of

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patients who do not have LVSD but other possibilities will be explored by the audit group. The continuing increase in case ascertainment coupled with data already accrued from previous audits will provide a robust basis for these aims and should be a focus of interest for subsequent audit reports. In 2011 the National Institute for Health and Clinical Excellence produced a quality standard for chronic heart failure, comprising 13 statements summarising the optimal and recommended management of heart failure.2 Hospitals should adhere to these standards in the treatment and care of heart failure patients, with the following statements being particularly relevant: Statement 7: People with chronic heart failure due to left

ventricular systolic dysfunction are offered angiotensinconverting enzyme inhibitors (or angiotensin II receptor antagonists licensed for heart failure if there are intolerable side effects with angiotensin-converting enzyme inhibitors) and beta-blockers licensed for heart failure, which are gradually increased up to the optimal tolerated or target dose with monitoring after each increase.

Statement 10: People admitted to hospital because of heart failure have a personalised management plan that is shared with them, their carer(s) and their GP. Statement 11: People admitted to hospital because of heart failure receive input to their management plan from a multidisciplinary heart failure team. Statement 12: People admitted to hospital because of heart

failure are discharged only when stable and receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge. Statement 13: People with moderate to severe chronic heart failure, and their carer(s), have access to a specialist in heart failure and a palliative care service.

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2 Introduction 2.1 Heart Failure Heart Failure is a complex clinical syndrome characterised by the reduced ability of the heart to pump blood around the body. It is caused by structural or functional cardiac abnormalities, including previous myocardial infarction, cardiomyopathies, valvular heart disease and hypertension. It is thought that around 70% of all heart failure cases are caused by coronary heart disease. Atrial fibrillation and renal dysfunction are common precipitating factors and complications of heart failure, and the condition is characterised by symptoms such as shortness of breath and fatigue, and signs such as fluid retention. Around 900,000 people in the U.K. suffer from heart failure, and this number is set to rise due to an ageing population, improved post-infarction survival rates, and more effective treatments3. In 2007 it was estimated that 1.81% of the population aged 45 years or older suffered from heart failure4. The prevalence of heart failure rises steeply with age, with the British Heart Foundation Statistics Database estimating in 2009 that 13.7% of men and 12.5% of women aged over 75 years in England suffer from the condition5. Heart failure constitutes a large burden on the NHS, accounting for one million inpatient bed-days – 2% of the NHS total – and 5% of all emergency hospital admissions6. Survival rates for heart failure patients who receive suboptimal care are poor. 40% of newly diagnosed patients die within a year,7 and total annual mortality ranges from 10-50%, depending on severity. These figures are supported by the mortality rates reported by the National Heart Failure Audit, which has consistently recorded one-year mortality of around 30% since 2008.8 Heart failure patients can also experience poor quality of life, experiencing pain, dyspnoea (shortness of breath) and fatigue. Heart failure patients also often suffer from mental health problems, with studies showing that over half report low mood, and more than a third suffer from major depression.9 10 These outcomes reflect considerable variation in standards of care: optimal treatment and management of heart failure results in significantly improved prognosis, with fewer symptoms and increased life expectancy.

2.2 The role of the audit National clinical audit is designed to monitor clinical practice and patient outcomes with a view to evaluating hospital performance and driving up standards of care. The National Heart Failure Audit was established in 2007 with the aim of helping clinicians improve the quality of heart failure services and to achieve better outcomes for patients. The audit aims to capture data on clinical indicators which have a proven link to improved outcomes, and to encourage the increased use of clinically recommended diagnostic tools, disease modifying treatments and referral pathways. 10

A series of clinical care standards for heart failure have been developed, including the National Service Framework for Coronary Heart Disease (2000),11 NICE Clinical Guidance for Chronic Heart Failure (2010),12 NICE chronic heart failure quality standards (2011)13 and a standard for delivering heart failure care produced by the European Society of Cardiology Heart Failure Association (2011).14 The audit dataset corresponds to these standards, in order to evaluate the implementation of these existing evidence-based recommendations by hospitals in England and Wales. The audit dataset is regularly reviewed and updated to ensure it is in line with contemporary guidance.

2.3 National use of audit data In addition to this publicly available annual report, the analysis produced by the National Heart Failure Audit are used by national groups with a legitimate interest in the analysis. The NHS Information Centre’s Indicators for Quality Improvement (IQI), a set of indicators developed to describe the quality of NHS service, include participation in the National Heart Failure Audit,15 and the NHS Choices website includes details of participation in the audit in its ‘scorecard’ for Trust performance. Furthermore, the audit currently provides participation rates to the Care Quality Commission’s (CQC) ‘Quality and Risk Profiles’ (QRP),16 a tool used for gathering together key information about NHS organisations, which allows the CQC to monitor compliance with the essential standards of quality and safety. The QRP enable compliance inspectors to assess where risks lie and may prompt front line regulatory activity, such as further enquiries. Clinical audit was one of six key areas raised under the heading ‘NHS’ in the Prime Minister’s Letter to Cabinet Ministers on transparency and open data which stated: Clinical audit data, detailing the performance of publicly funded clinical teams in treating key healthcare conditions, will be published from April 2012. This service will be piloted in December 2011 using data from the latest National Lung Cancer Audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP).17 National Heart Failure Audit data will be published on data.gov. uk following the publication of this report in November 2012. There are future plans to provide anonymised National Heart Failure Audit data, at a hospital level, to Cardiac Networks and Clinical Commissioning Groups. An archive of annual audit reports, containing national aggregate data, is also available for download on NICOR’s publicly accessible website. The National Heart Failure Audit had also been published in Heart journal.18

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2.4 Organisation of the audit The National Heart Failure Audit is managed by the National Institute for Cardiovascular Outcomes Research (NICOR), and receives clinical direction and leadership from the British Society for Heart Failure. It is overseen by a Project Board which represents key stakeholders, including cardiologists, heart failure nurses, Cardiac Networks and heart failure patients.i The audit is one of six national clinical audits managed by NICOR, part of the National Centre for Cardiovascular Prevention and Outcomes at University College London. These audits are funded by HQIP, which holds commissioning and funding responsibility for 40 national clinical audits in the NACPOP.19

2.5 The scope of the audit The National Heart Failure Audit collects data on acute patients discharged from hospitals in England and Wales with a primary diagnosis of heart failure on discharge, designated by any of the following ICD-10 codes: I11.0 Hypertensive heart disease with (congestive) heart failure I25.5 Ischaemic cardiomyopathy I42.0 Dilated cardiomyopathy I42.9 Cardiomyopathy, unspecified I50.0 Congestive heart failure I50.1 Left ventricular failure I50.9 Heart failure, unspecified Only acute patients should be included in the National Heart Failure Audit, so those patients admitted for elective procedures, for example elective pacemaker implantation or angiography, ought not to be included. Large numbers of these patients being included in the audit has led to several thousand records being deleted from the dataset in the data cleaning process (this is detailed in section 3.1). Participation is currently defined as an NHS Trust or Welsh Health Board submitting a minimum of 20 cases to the audit database each calendar month, or the full number of cases if fewer than 20 patients with heart failure are discharged from the Trust in a month. Participation in the audit has been mandated in the Department of Health’s standard terms and conditions for acute hospital services in 2011/12, covering all acute hospitals in England.20 Participation in the audit has been mandatory for Welsh Local Health Boards since April 2012.21 Although a large proportion of the treatment of chronic heart failure occurs in the community, the National Heart Failure Audit currently only covers acute heart failure admissions to hospital, partly due to IT limitations. The development of a web-based platform for the database in 2013 will make

it feasible for community hospitals and other primary care institutions to participate in the audit.

2.6 The database In 2011/12 the dataset contained 38 core fields, covering patient details and demographics, medical history, symptoms, diagnosis, treatment on discharge, referral to follow-up services and place of care in hospital. In March 2011 a revision of the dataset increased the number of core fields to 59. New fields have been added to bring the audit in line with latest NICE guidance,22 23 as well as to ensure that mortality analysis can be adequately risk adjusted to account for known confounding factors. The new fields include input from a multidisciplinary heart failure team, discharge planning, as well as increasing the data collected on medical history, diagnostic tests and follow-up services. These new fields will be included in the analysis in the 2012/13 annual report.

2.7 Data collection and IT User roles vary between hospitals, but the personnel involved in collecting and inputting data tend to be Heart Failure Specialist Nurses, clinical audit leads, and clinical effectiveness managers. Some of the more effective systems of data collection and data entry use nurses or other clinical staff to interpret medical notes and collect data, and clerical staff or clinical audit facilitators to enter it onto the database. This ensures that the data is clinically accurate whilst making optimal use of clinicians’ time. Hospitals are responsible for ensuring that data is entered accurately but the database contains a series of validation checks to ensure that contradictory and clinically improbable data are not entered into the audit. A pro forma, designed to aid data collection, can be downloaded from the NICOR website, along with a set of application notes which defines and explains core data items.24 The application notes will be regularly reviewed to ensure they are clinically accurate and will be amended in response to comments and questions from users to cover frequently asked questions and points of contention. All data are submitted electronically by hospital into a secure central database. To ensure patient confidentiality the database uses advanced data encryption technology and access control through a secure key system. Data can be inputted manually or imported from locally developed systems or third party commercial databases.

i. See Appendix 1 for details of project board membership.

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2.8 Improving our IT platform

2.9 Improving analysis

Earlier this year NICOR began a major project to upgrade its data collection and management systems. The current Lotus Notes software has become increasingly unwieldy as the NICOR databases have grown in size and complexity. A new platform will substantially improve NICOR’s ability to derive high-quality analyses from the National Heart Failure Audit to inform hospitals, Cardiac Networks and patients regarding the provision of cardiac care.

The processes that NICOR uses for analysing National Heart Failure Audit data have also undergone substantial changes this year. Until recently NICOR data were analysed using software and ad hoc analytic codes that were neither consistent nor easy to manage. In preparation for the incorporation of analytic technologies into the new NICOR system, code that was written in SPSS and Excel spreadsheets (for analyses presented in this annual report) was migrated to a standard cross-audit analytic platform based on the R statistical processing language - precise details are available from NICOR.

The first step in this project involved a transfer of all data from the NHS Information Centre for Health and Social Care onto secure NICOR servers. This involved re-issuing a new user ID to every database user. The migration was not easy, and it led to some delays in accessing the National Heart Failure Audit. Despite these difficulties, participating hospitals submitted their data on time, making possible the timely publication of this report. We would like to thank everyone for their effort and patience during the migration. The second phase involves the development of a new IT platform which will be rolled out in stages throughout 2013, with the National Heart Failure Audit being the first to be transferred in April.

12

Migration of the National Heart Failure Audit to the new platform for statistical analysis began in August 2012 and continues, with an intended completion date of June 2013. The results presented in this annual report were generated using some, but not all, elements of the new platform. Because the new analytic platform is still under development, with incremental improvements expected over the next few months, the results presented in this report should be considered preliminary and subject to change. Any substantive differences that follow improvements in filtering and more sophisticated statistical modelling of the data will be highlighted in next year’s annual report.

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3 Findings 3.1 Data cleaning and data quality

3.2 Participation

As of 31st June 2012, the total number of records submitted to the National Heart Failure Audit database since 2007 was 137,637. Of these, 41,635 were patients discharged from hospital between 1st April 2011 and 31st March 2012.

3.2.1 Number of Trusts

Table 1: Records excluded from analysis in this report Number excluded from full dataset (number excluded from 2011/12 dataset)

Admission/ readmission dataset

Reason

16 (3)

Admission

Missing or invalid hospital identifier

8 (5)

Readmission

Missing or invalid hospital identifier

14 (2)

Admission

Identical duplicate of another row

67 (2)

Readmission

Identical duplicate of another row

6 (6)

Admission

Non-identical rows with duplicate ‘unique’ ID

4268 (299)

Admission/ Readmission

Time to discharge <0

14204 (3952)

Admission/ Readmission

Time to discharge 0 or 1 day, and survived to discharge*

1174 (286)

Admission/ Readmission

Time to discharge 0 or 1 day, and no MRIS life status*

149 NHS Acute Trusts in England and six Health Boards in Wales discharged patients with a coded diagnosis of heart failure in 2011/12, according to HES and PEDW data.iii Out of these 137 NHS Trusts (91.9%) and five Health Boards (83.3%) submitted data to the audit – a total of 91.6% of all eligible institutions. In England 88 of the eligible institutions (64.2%) met the National Heart Failure Audit participation requirements of 20 cases per calendar month, or submitted more than 70% of their HES-recorded heart failure discharges. 70% was chosen as the cut-off point because this was the overall case ascertainment rate aimed for in the 2011/12 audit. A further 37 Trusts (27.0%) submitted less than 70% of their HES figures, but still between 10 and 20 cases per month. In Wales no Health Boards met the participation requirements, and three (50.0%) submitted between 10 and 20 cases per month. The audit has therefore met its participation target of at least 90% of NHS Trusts in England and Health Boards in Wales submitting data to the audit in 2011/12. This marks a significant improvement on the 85% of Trusts taking part in 2010/11. Participation analysis, by Trust, can be found in the hospital level analysis in section 3.7 of this report. No data were submitted by 12 Trusts in England and one Health Board in Wales (those marked with a * have not registered to participate at time of publication): Non-submitting Trusts in England

*0 and 1 day admissions who survived to discharge were determined to be outside of the scope of the audit. The National Heart Failure Audit measures acute admissions to hospital, and these patients were deemed very likely to be elective admissions for pacemaker implantation or angiography, and so were excluded from the audit. Patients who had a length of stay of 0 or 1 days and died in hospital were not excluded.

Airedale NHS Foundation Trust

Table 2: Records excluded from mortality analysis in this report

The Royal Bournemouth and Christchurch Hospitals NHS

Number secluded from 200912 survival analysis (number excluded from 2001/12 dataset)

Reason

4370 (2019)

No MRISii life status

708 (303)

Time from discharge to follow-up either < 0 or > longest possible interval

East Kent Hospitals University NHS Foundation Trust Medway NHS Foundation Trust* Papworth Hospital NHS Foundation Trust* Plymouth Hospitals NHS Trust* Royal United Hospital Bath NHS Trust South Warwickshire NHS Foundation Trust The Princess Alexandra Hospital NHS Trust* Foundation Trust Trafford Healthcare NHS Trust* University Hospitals of Leicester NHS Trust University Hospitals of Morecambe Bay NHS Foundation Trust*

ii. The life status of all patients in the National Heart Failure Audit is provided by the Data Linkage Service of the NHS Information Centre (NHS IC). The audit data is linked to death registration data from the Office of National Statistics (ONS). iii. Hospital Episode Statistics (HES) and Patient Episode Database for Wales (PEDW) are the national statistical data warehouses for England and Wales respectively, recording details of all patient admissions to NHS hospitals.

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Non-submitting Health Boards in Wales

Cardiff & Vale University Health Board From April 2013 Trusts will be required to submit all of the patients discharged with a coded diagnosis of heart failure, and this number will be measured against the number of heart failure coded discharges recorded by HES in England and PEDW in Wales. Collecting data on all heart failure discharges will prevent any selection bias in the patient records submitted to the audit, and will thus ensure the representativeness of the National Heart Failure Audit. It will also significantly augment the research value of the dataset.

3.2.2 Number of patients

Although Welsh case ascertainment has improved, it remains unsatisfactorily low. However as of April 2012 participation in the National Heart Failure Audit has been mandated by the Welsh Government, and as a result of this all Welsh Health Boards and the majority of hospitals have registered with the audit.

3.3 Demographics 3.3.1 Age The mean age of patients on their first admission in 2011/12 was 77.7, and on readmission 77.2; the median age was 80.1 on admission and 79.6 on readmission. 66.6% of patients were over 75 at their first admission, and 64.9% of readmitted patients were over 75.

The total number of records submitted to the National Heart Failure Audit in 2011/12 was 41,635. After data cleaning and exclusion of invalid records (detailed above in section 3.1), the total number of records was 37,076. This was made up of 32,906 index admissions and 4,170 readmissions within the audit period.

3.3.2 Age and sex

Of the index admissions, 24649 (74.9%) were recorded as having a confirmed diagnosis of heart failure, defined as a diagnosis of heart failure that has been confirmed by imaging or brain natriuretic peptide (BNP) measurement either during this admission or at a previous time. It is acknowledged that in some cases a clinician may justifiably diagnose heart failure in the absence of tests.

Overall there were more men recorded in the audit than women, with men comprising 55.2% of the patient group at index admission and 58.2% at readmission.

The mean age at first admission for men was 75.5 years, and 80.3 years for women. As in previous reports, the majority of patients up to the age of 85 were men (61.1%); in those over the age of 85 there were more women (57.9%).

Fig 1: Age at first admission by sex 8000

3.2.3 Case ascertainment

In England records were submitted on a total of 36,559 heart failure admissions, 61.9% of the 59,083 patients with heart failure recorded by HES in 2010/11; in Wales 517 records were submitted, 11.9% of the 4,348 total reported by PEDW in 2011/12. Overall this does not constitute a large increase compared to the number of patients recorded in the audit in 2010/11 (36,504 records, case ascertainment 54%). However if case ascertainment were judged against the 41,635 records counted prior to the data cleaning process, it would stand at 70.5% of all heart failure admissions. The lower-than-anticipated case ascertainment reflects the large number of 0 and 1 day admissions which were deleted as part of an extensive data cleaning process detailed in section 3.1 above. This has highlighted the need to remind participating hospitals not to include elective patients in the audit.

14

5836

6000 Number of patients

The total number of cases where a patient was discharged with a primary diagnosis of heart failure recorded by HES and PEDW is 63,431, so the National Heart Failure audit currently represents 58.5% of all heart failure discharges in England and Wales.

6505

5304 4243

4051

4000

2127

2072

2000 862 433

0

219

18-44

862 371

45-54

55-64

65-74

75-84

85+

Age group Men Women

3.3.3 Age and Index of Multiple Deprivation As recorded in previous years, age at admission was related to Index of Multiple Deprivation. Index of Multiple Deprivation was assigned to each patient based on their postcode of residence. Indices of Multiple Deprivation are allocated to 34,378

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areas in England and Wales, each with an average of 1,500 and a minimum of 1,000 residents. There are seven factors considered: income deprivation; employment deprivation; health deprivation and disability; education, skills and training deprivation; barriers to housing and services; crime; and living environment deprivation. Mean age of admission for patients in the most deprived quintile, with a deprivation score of 5, was 74.5 years, compared with a mean age at admission of 79.6 years for patients in the least deprived quintile, with a deprivation score of 1 (figure 2). This is similar to the average age difference recorded last year (4.9 years). The National Heart Failure Audit intends to carry out further analysis on the variation in the treatment and management of heart failure in patients based on their Index of Multiple Deprivation.

3.4.2 Length of stay The overall mean length of stay was 13.1 days on index admission and 13.4 days on readmission, and the median length of stay was 9.0 days for both index admissions and readmissions. Mean length of stay was 12.7 days for those patients treated in a cardiology ward, 13.1 days for those treated in a general medical wards, and 14.7 days for patients in other wards. Median length of stay was 9 days for patients treated on cardiology wards, 8 days for patients treated on general medical wards, and 10 days for patients on other wards. Both mean and median length of stay varied significantly between hospitals, although the very high and very low mean figures may in many cases be explained by low numbers of

Fig 3: Mean length of stay by hospital

Fig 2: The effect of deprivation on age of first admission 80

79.6

79.1 78.3

78 76.9

77 76 75

74.5

Hospitals

Mean age at first admission in audit period 2011/12

79

74 73 72 71 70

1

2

3

4

5

Index of multiple deprivation

0

5

10

15

20

25

Length of stay (mean) in days

1= least deprived 5= most deprived

Fig 4: Median length of stay by hospital

3.4 Hospitalisation 47.6% of heart failure patients in the audit were treated in cardiology wards, with 41.3% being treated on general medical wards, and 10.8% on other wards. These findings do not show much change from 2010/11, when 45% of patients were treated on both cardiology wards and general medical wards, and the demographic characteristics of these patients also reflect last yearâ&#x20AC;&#x2122;s findings. 54.1% of men were treated on cardiology wards, compared with only 39.5% of women. Women were more likely to be treated on general medical wards (47.9% vs. 36.0%) and other wards (12.4% vs. 9.5%). The likelihood of being treated on a cardiology ward decreased with age: 76.3% of patients who were 16-44 were treated on cardiology wards, compared with 47.1% of patients in the 7484 age group, and 32.1% of patients over 85.

Hospitals

3.4.1 In-hospital care

0

5

10

15

Length of stay (median) in days

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patients submitted, with abnormally long or short admission spells (figure 3, figure 4).

3.4.3 Readmission Readmission data are incomplete since only readmission with a primary diagnosis of heart failure will be identified and not all cases even with a primary diagnosis have been recorded. The audit group is planning to identify readmissions from HES data in future years. This should provide robust data on readmission. There were 4,170 readmissions to hospital recorded in 2011/12. The analysis for this report defines an admission as the index admission within the audit period. There are some records of patients who were admitted to hospital with heart failure in 2011/12 who had been previously admitted in an earlier audit year. Such a record is treated as an admission for the purpose of this analysis, because it is the first admission for a patient within the audit period, although it is not the patientâ&#x20AC;&#x2122;s first admission to hospital with heart failure. 7,357 (19.8%) of the 37,076 records submitted to the National Heart Failure Audit in 2011/12 were readmissions, although only 4,170 (11.2%) were readmissions within the audit period. Most of these patients were only readmitted once, but some were readmitted two times or more (figure 5). The highest number of readmissions for a single patient was 10.

Unsurprisingly, these symptoms were worse for readmissions to hospital, with 78% of readmitted patients in NYHA class III or IV, and 52% with moderate or severe oedema.

3.5.2 Aetiology The aetiology of heart failure reported by the audit is very similar to that reported in previous years. Hypertension (54%) and ischaemic heart disease (IHD) (46%) were the most common contributory causes of heart failure; 26% of patients had a history of both. 31% of patients in the audit had suffered a previous acute myocardial infarction (AMI), and 36% had a history of arrhythmia. Diabetes (31%) and valve disease (22%) were also very common. Patients with a history of IHD, atrial fibrillation, AMI and renal impairment were more likely to be diagnosed with LVSD, whereas patients with a history of valve disease or hypertension were more likely to be diagnosed with heart failure without LVSD (table 3).

Table 3: Previous medical history and diagnosis of LVSD Medical History

LVSD (%)

Non-LVSD (%)

Ischaemic Heart Disease

51

39

Atrial Fibrillation

41

30

2 readmissions

Acute Myocardial Infarction

37

22

3 readmissions

Valvular Heart Disease

19

28

Hypertension

52

58

Renal Impairment

26

17

Fig 5: Number of readmissions in 2011/12 81.2%

to be in NYHA class IV, with breathlessness at rest. 29% of patients were admitted with moderate peripheral oedema, and 16% with severe peripheral oedema.

1 readmission

4+ readmissions

p-value â&#x2030;¤0.001 in all cases

3.6 Diagnosis 3.6.1 Echocardiography 14.4%

3% 1.4%

3.5 Aetiology 3.5.1 Symptoms 40% of patients were in NYHA class III at first admission, with breathlessness on minimal activity, and 32% were deemed

16

86.0% of the patients recorded in the audit had an echocardiogram (echo) or other NICE-recommended imaging test, for example radionuclide imaging, computerised tomography (CT) scan or cardiac magnetic resonance imaging (MRI). Echocardiography rates continue to be commendably high, with 2011/12 findings representing an increase on the 82% recorded in 2010/11. However access to echocardiography was dependent on several factors: Patients were more likely to receive a diagnostic imaging test if they were men, with 88.8% of men having an echo compared to 82.6% of women. Patients

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aged less than 75 years were also more likely to have an echo (91.4% vs. 83.3%) as were those admitted to a cardiology ward (92.9% vs. 80.1% of those admitted to general medical wards, and 77.8% of patients admitted to other wards).

3.6.2 Diagnosis Of those patients who had an echo, 65.0% were diagnosed with LVSD. 13.8% of patients were diagnosed with valve disease following an echo, but only 3.8% were reported to have leftventricular hypertrophy (LVH) and 4.3% diastolic dysfunction. It is likely that low rates of LVH and diastolic dysfunction reflect under-reporting. Men were more likely to be diagnosed with LVSD, as were younger patients. 53.1% of patients over 75 were diagnosed with LVSD, compared with 70.7% of patients aged under 75 years. 67.6% of men and 48.3% of women had an echo diagnosis of LVSD, but women were more likely to be diagnosed with diastolic dysfunction (5.0% vs. 3.1%), LVH (4.0% vs. 3.0%) and valve disease (15.7% vs. 9.9%).

3.7 Treatment on discharge for LVSD All analyses on prescription rates for disease modifying treatments were performed on a denominator of those patients with a diagnosis of LVSD who survived to discharge.

3.7.1 ACE inhibitor and ARB 72% of patients were discharged on an angiotensin-converting enzyme (ACE) inhibitor, and 84% were discharged on either an ACE inhibitor or an angiotensin receptor blocker (ARB), or both. 1% were prescribed both an ACE inhibitor and an ARB. 87% of patients treated in a cardiology ward were discharged on an ACE inhibitor and/or an ARB, compared to 80% of those treated in a general medical ward and 76% of patients treated in other wards. Men were more likely to receive an ACE inhibitor and/or ARB than women, as were younger patients. Prescription rates of ACEI/ARB were 85% for men and 83% for women, and 89% of patients under 75 were discharged on either of the treatments, compared with 80% of patients over 75.

3.7.2 Beta blocker 78% of patients were prescribed a beta blocker on discharge. This is considerably higher than the 65% recorded in the 2010/11 audit, which was considered unsatisfactorily low. This is consistent with NICE guidance on prescription of beta blockers, which recommends that they are given to all patients with a diagnosis of LVSD, including older patients and patients with chronic obstructive pulmonary disease (COPD) without reversibility.25

discharged on a beta blocker. 83% of patients treated on a cardiology ward were given beta blockers, compared with 71% for both general medical patients and those on other wards. 79% of men were discharged on beta blockers, compared with 76% of women, and 84% of patients under 75 received the treatment versus 74% of those over 75.

3.7.3 MRA 45% of patients with LVSD were discharged on a mineralocorticoid receptor antagonist (MRA). Patients treated on cardiology wards were more likely to be prescribed an MRA (51%) compared with those on a general medical ward (37%) and patients on other wards (33%). Men were more likely to be discharged on an MRA than women (48% vs. 40%) as were patients under 75, compared with those over 75 (53% vs. 39%).

3.7.4 Loop diuretics 89% of patients in the audit were discharged on loop diuretics. 87% of patients on cardiology wards were prescribed a loop diuretic on discharge, slightly lower than the 93% of patients on general medical wards, and 90% of patients on other wards. Rates of prescription were similar in women and men (90% vs. 89%). Patients who were aged over 75 years on admission were more likely to be discharged on loop diuretics than younger patients (92% vs. 86%).

3.7.5 Thiazide diuretics 4% of patients were prescribed thiazide diuretics on discharge. Prescription rates were a little higher for those patients treated on a cardiology ward (5%) than for those treated on a general medical ward (3%) and on other wards (3%). Men were more likely to be prescribed thiazide diuretics than women (5% vs. 3%), as were patients over 75 compared with those under 75 (6% vs. 3%).

3.7.6 Digoxin 23% of patients were prescribed digoxin on discharge. Rates of prescription were similar in women and men (24% vs. 22%) and amongst patients aged above or below 75 years. Prescription rates were similar for patients on general medical (23%), cardiology (22%) and other wards (23%).

3.7.7 Treatment on discharge by age The prescription of ACE inhibitors, beta blockers and MRAs decreased with age. Only prescription of loop diuretics was higher amongst older patients (figure 6).

As with ACEI/ARB prescription, patients treated in a cardiology ward, men, and younger patients were all more likely to be

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Fig 6: Treatment for LVSD on discharge by age 100 % of patients key heart failure drugs

90 80 70 60 50 40 30

76.5% of patients were referred onwards to their GP for followup, and 13.5% were referred to care of the elderly follow-up services.

20 10 0

51.7% of patients were referred to cardiology follow-up, that is, any follow-up involving a consultant cardiologist. As with heart failure liaison follow-up, cardiology patients were far more likely to be referred to cardiology follow-up, with 69.6% receiving onwards referral, compared with 34.4% of general medical patients and 31.7% of patients on other wards. Men were more likely to be referred to cardiology follow-up than women (57.6% vs. 44.2%), as were those under 75, of whom 67.2% received cardiology follow-up, compared to only 43.3% of patients over 75.

18-44

45-54

55-64

65-74

75-84

85+

Age group

ACEI

Loop diuretic

Beta blocker

MRA

3.8 Monitoring heart failure patients 3.8.1 Follow-up services

3.8.2 Palliative care Only 3.1% of patients were referred to palliative care services following the first admission, and 7.3% following a readmission. This does not constitute a significant improvement on 2010/11 data, which recorded referral levels of 4% on admission and 6% on readmission. These numbers are surprisingly low considering the age of the patient population, and the high mortality rates in the year following discharge.

53.7% of patients were referred to a heart failure liaison service, which is defined as a nurse led heart failure clinic. Patients treated in a cardiology ward were more likely to be referred to heart failure liaison services: 64.1% compared to only 43.3% for those on general medical wards and 42.9% for those on other wards. 59.0% of men and 47.1% of women were referred to nurse-led follow-up, and 60.8% of those under 75, compared with 49.9% of patients over 75.

18

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iv. HES data is from 2010/11, and PEDW data from 2011/12, due to availability.

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8

903

Blackpool Teaching Hospitals NHS Foundation Trust

Bolton NHS Foundation Trust

220

35

1.9%

243.4%

75.6%

9.7%

39.9%

155

Bedford Hospital NHS Trust

Basildon and Thurrock University Hospitals NHS Foundation Trust

Barts and the London

106.1% 72.6%

519

Barnet and Chase Farm Hospitals NHS Trust

113.1%

90.2%

0.0%

110.9%

61.9%

% HES submitted

201

719

Barking, Havering and Redbridge University Hospitals NHS Trust

Barnsley Hospital NHS Foundation Trust

296

0

296

36559

Trust records submitted

Ashford and St Peter's Hospitals NHS Trust

Airedale NHS Foundation Trust

Aintree University Hospital NHS Foundation Trust

England

Trust name

Table 4: Participation and case ascertainment in England

Partial

Yes

Yes

Partial

Partial

Yes

Yes

Yes

Yes

No

Yes

Participation status

423

371

291

362

388

277

489

636

328

245

267

59083

Primary HES heart failure discharges

327

363

229

339

478

256

391

492

305

242

221

52471

Secondary HES heart failure discharges

261

375

244

480

613

211

406

500

299

172

218

50315

Tertiary HES heart failure discharges

King George Hospital Barnet General Hospital Chase Farm Hospital

KGG BNT CHS

BOL

VIC

BED

BAS

BAL

Royal Bolton Hospital

Blackpool Victoria Hospital

Bedford Hospital

Basildon University Hospital

The London Chest Hospital/The Royal London Hospital

Barnsley Hospital

Queen's Hospital (Romford)

OLD

BAR

St Peter's Hospital

Airedale General Hospital

University Hospital Aintree

Hospital name

SPH

AIR

FAZ

NICOR hospital code

8

903

220

35

155

201

225

294

295

424

296

0

296

36559

Hospital records submitted

Tables 4 and 5 compare the number of patient records submitted to the audit (after data cleaning) to the number of inpatients discharged with a primary diagnosis of heart failure, as recorded by HES for English Trusts and PEDW for Welsh Health Boards.iiivThe number of patients with a secondary and tertiary diagnosis of heart failure are also included. Participation is defined as a Trust or Health Board submitting either 20 cases per calendar month, or greater than 70% of their HES/PEDW recorded figures.

3.9.1 Participation and case ascertainment

For the first time since it was established, the National Heart Failure Audit is publishing a series of analyses at a hospital level. All hospitals are included that submitted over 100 records or over 70% of their HES/PEDW figures. There is significant variation across hospitals, but this is to some extent down to hospitals including unrepresentative patient populations in the audit.

3.9 Analysis by hospital


20

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239

367

Burton Hospitals NHS Foundation Trust

Calderdale and Huddersfield NHS Foundation Trust

223

341

Countess of Chester Hospital NHS Foundation Trust

Croydon Health Services NHS Trust

381

Colchester Hospital University NHS Foundation Trust

325

245

City Hospitals Sunderland NHS Foundation Trust

County Durham and Darlington NHS Foundation Trust

178

84

Chelsea and Westminster Hospital NHS Foundation Trust

Chesterfield Royal Hospital NHS Foundation Trust

221

Central Manchester University Hospitals NHS Foundation Trust

22

220

Buckinghamshire Healthcare NHS Trust

Cambridge University Hospitals NHS Foundation Trust

628

170

Trust records submitted

Brighton and Sussex University Hospitals NHS Trust

Bradford Teaching Hospitals NHS Foundation Trust

Trust name

75.6%

58.9%

132.2%

86.8%

67.7%

63.1%

46.4%

71.1%

4.7%

71.7%

91.6%

94.0%

114.8%

32.3%

% HES submitted

Yes

Yes

Yes

Yes

Yes

Partial

Partial

Yes

Partial

Yes

Yes

Yes

Yes

Partial

Participation status

295

552

258

439

362

282

181

311

467

512

261

234

547

527

Primary HES heart failure discharges

232

529

215

362

436

269

107

327

362

444

234

205

513

429

Secondary HES heart failure discharges

205

558

208

310

475

257

112

436

304

452

166

161

447

403

Tertiary HES heart failure discharges

Stoke Mandeville Hospital

SMV

Darlington Memorial Hospital

DAR

Croydon University Hospital

University Hospital of North Durham

DRY

MAY

Countess of Chester Hospital

Colchester General Hospital

Sunderland Royal Hospital

Chesterfield Royal Hospital

Chelsea and Westminster Hospital

Manchester Royal Infirmary

Addenbrooke's Hospital

Huddersfield Royal Infirmary

COC

COL

SUN

CHE

WES

MRI

ADD

HUD

Calderdale Royal Hospital

Wycombe General Hospital

AMG

RHI

Princess Royal Hospital (Haywards Heath)

PRH

Queen's Hospital (Burton)

Royal Sussex County Hospital

RSC

BRT

Bradford Royal Infirmary

Hospital name

BRD

NICOR hospital code

223

145

180

341

381

245

178

84

221

22

182

185

239

0

220

222

406

170

Hospital records submitted


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481

167

East and North Hertfordshire NHS Trust

East Cheshire NHS Trust

210 287 128 261

121

Epsom and St Helier University Hospitals NHS Trust

Frimley Park Hospital NHS Foundation Trust

Gateshead Health NHS Foundation Trust

George Eliot Hospital NHS Trust

Gloucestershire Hospitals NHS Foundation Trust

212

424

East Sussex Healthcare NHS Trust

Great Western Hospitals NHS Foundation Trust

234

East Lancashire Hospitals NHS Trust

0

262

Ealing Hospital NHS Trust

East Kent Hospitals University NHS Foundation Trust

176

197

Doncaster and Bassetlaw Hospitals NHS Foundation Trust

Dorset County Hospital NHS Foundation Trust

196

73

Derby Hospitals NHS Foundation Trust

Dartford and Gravesham NHS Trust

83.8%

23.9%

133.2%

56.6%

121.6%

57.9%

69.3%

47.4%

0.0%

64.0%

134.7%

118.0%

89.8%

37.4%

38.4%

23.7%

Yes

Partial

Yes

Partial

Yes

Partial

Yes

Partial

No

Partial

Yes

Yes

Yes

Partial

Partial

Partial

253

507

196

226

236

363

612

494

833

261

357

222

196

527

510

308

275

467

217

262

236

349

476

515

661

152

305

158

201

446

418

228

276

412

191

249

257

319

338

536

636

171

253

181

179

441

380

191

Bassetlaw Hospital

BSL

Cheltenham General Hospital

CHG

The Great Western Hospital

Gloucestershire Royal Hospital

GLO

PMS

George Eliot Hospital

Queen Elizabeth Hospital (Gateshead)

Frimley Park Hospital

NUN

QEG

FRM

Epsom Hospital

St Helier Hospital

SHC EPS

Eastbourne District General Hospital

Conquest Hospital

CGH DGE

Royal Blackburn Hospital

William Harvey Hospital

WHH BLA

Queen Elizabeth The Queen Mother Hospital

Kent and Canterbury Hospital

KCC QEQ

Macclesfield District General Hospital

MAC

Queen Elizabeth II Hospital

Lister Hospital

LIS QEW

Ealing Hospital

EAL

Dorset County Hospital

Doncaster Royal Infirmary

DID

WDH

Royal Derby Hospital

Darent Valley Hospital

DER

DVH

212

54

67

261

128

287

100

110

206

218

234

0

0

0

167

214

267

262

176

69

128

196

73


22

National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 22

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309

94.5%

Yes

Yes

327

397

264

332

230

204

362

252

KTH

KCH

KGH

JPH

Kingston Hospital NHS Trust

61.7%

302

310

245

Yes

292

King's College Hospital NHS Foundation Trust

79.1%

329

239

Partial

118

Kettering General Hospital NHS Foundation Trust

34.7%

148

114

196

James Paget University Hospitals NHS Foundation Trust

Yes

IOW

88.3%

173

Isle of Wight NHS PCT

621

CCH

594

CHH

Imperial College Healthcare NHS Trust

621

464

HOM

HIN

Kingston Hospital

King's College Hospital

Kettering General Hospital

James Paget University Hospital

St Mary's Hospital, Newport

Charing Cross Hospital

Hammersmith Hospital

St Mary's Hospital Paddington

Hull Royal Infirmary

Castle Hill Hospital

Homerton University Hospital

Hinchingbrooke Hospital

Wexham Park Hospital

Good Hope Hospital

GHS WEX

Solihull Hospital

SOL

Birmingham Heartlands Hospital

EBH

Royal Hampshire County Hospital

RHC

Harrogate District Hospital

Basingstoke and North Hampshire Hospital

NHH

HAR

St Thomas' Hospital

Hospital name

STH

NICOR hospital code

HAM

Yes

411

154

111

279

757

162

295

351

Tertiary HES heart failure discharges

Imperial College Healthcare NHS Trust

79.1%

431

144

151

292

740

153

265

368

Secondary HES heart failure discharges

STM

491

Yes

245

169

388

1122

215

333

406

Primary HES heart failure discharges

Imperial College Healthcare NHS Trust

171.0%

Yes

Partial

Partial

Yes

Partial

Partial

Partial

Participation status

HRI

737

Hull and East Yorkshire Hospitals NHS Trust

86.5%

22.5%

18.3%

32.8%

60.5%

38.4%

56.4%

% HES submitted

Hull and East Yorkshire Hospitals NHS Trust

212

Homerton University Hospital NHS Foundation Trust

38

368

Heart of England NHS Foundation Trust

Hinchingbrooke Health Care NHS Trust

130

Harrogate and District NHS Foundation Trust

71

128

Hampshire Hospitals NHS Foundation Trust

Heatherwood and Wexham Park Hospitals NHS Foundation Trust

229

Trust records submitted

Guy's and St Thomas' NHS Foundation Trust

Trust name

309

245

239

114

173

99

151

241

110

627

212

38

71

0

161

207

130

0

128

229

Hospital records submitted


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117 136 346 404

Lewisham Healthcare NHS Trust

Liverpool Heart and Chest Hospital NHS Foundation Trust

Luton and Dunstable Hospital NHS Foundation Trust

Maidstone and Tunbridge Wells NHS Trust

North Middlesex University Hospital NHS Trust

171

78

484

North Bristol NHS Trust

North Cumbria University Hospitals NHS Trust

374

2

Norfolk and Norwich University Hospitals NHS Foundation Trust

Newham University Hospital NHS Trust

154

Milton Keynes Hospital NHS Foundation Trust

74

Mid Staffordshire NHS Foundation Trust

420

136

Mid Essex Hospital Services NHS Trust

Mid Yorkshire Hospitals NHS Trust

263

Mid Cheshire Hospitals NHS Foundation Trust

0

248

Leeds Teaching Hospitals NHS Trust

Medway NHS Foundation Trust

566

Lancashire Teaching Hospitals NHS Foundation Trust

55.3%

22.3%

126.7%

51.4%

0.8%

75.9%

64.9%

25.2%

34.7%

126.4%

0.0%

90.2%

121.8%

64.5%

40.5%

30.4%

123.3%

Partial

Partial

Yes

Yes

Partial

Yes

Yes

Partial

Partial

Yes

No

Yes

Yes

Partial

Partial

Yes

Yes

309

350

382

728

242

203

647

294

392

208

300

448

284

211

289

815

459

176

372

373

696

169

164

491

227

211

228

241

448

271

118

181

719

581

156

310

324

746

169

129

393

187

201

216

256

336

255

150

175

704

469

Southmead Hospital Cumberland Infirmary

BSM CMI

NMH

North Middlesex University Hospital

West Cumberland Hospital

Frenchay Hospital

FRY

WCI

Norfolk and Norwich University Hospital

Newham University Hospital

Milton Keynes General Hospital

NOR

NWG

MKH

Dewsbury and District Hospital

Pinderfields Hospital

PIN DEW

Stafford Hospital

Broomfield Hospital

Leighton Hospital

SDG

BFH

LGH

Medway Maritime Hospital

Tunbridge Wells Hospital

KSX MDW

Maidstone Hospital

Luton and Dunstable Hospital

Liverpool Heart and Chest Hospital

University Hospital Lewisham

Leeds General Infirmary

Chorley and South Ribble Hospital

Royal Preston Hospital

MAI

LDH

BHL

LEW

LGI

CHO

RPH

171

32

46

205

279

374

2

154

119

301

74

136

263

0

178

226

346

136

117

248

232

334


24

National Heart Failure Audit April 2011-March 2012

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212

256

400

203

736

Northern Devon Healthcare NHS Trust

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

Northumbria Healthcare NHS Foundation Trust

Nottingham University Hospitals NHS Trust

Oxford Radcliffe Hospitals NHS Trust

Poole Hospital NHS Foundation Trust

307

0

296

Peterborough and Stamford Hospitals NHS Foundation Trust

Plymouth Hospitals NHS Trust

645

Pennine Acute Hospitals NHS Trust

0

217

Northampton General Hospital NHS Trust

Papworth Hospital NHS Foundation Trust

383

Trust records submitted

North Tees and Hartlepool NHS Foundation Trust

Trust name

146.2%

0.0%

89.4%

88.5%

0.0%

102.5%

25.5%

60.6%

75.5%

74.9%

77.0%

140.3%

% HES submitted

Yes

No

Yes

Yes

No

Yes

Partial

Yes

Yes

Yes

Yes

Yes

Participation status

210

635

331

729

274

718

797

660

339

283

282

273

Primary HES heart failure discharges

237

525

280

929

282

615

722

530

278

231

290

329

Secondary HES heart failure discharges

198

498

251

881

227

534

719

503

311

219

227

316

Tertiary HES heart failure discharges

Queen's Medical Centre Nottingham City Hospital John Radcliffe Hospital Horton General Hospital

UHN CHN RAD HOR

PGH

PLY

Poole General Hospital

Derriford Hospital

Peterborough City Hospital

Rochdale Infirmary

BHH PET

North Manchester General Hospital

NMG

Royal Oldham Hospital

Hexham General Hospital

HEX

OHM

Wansbeck General Hospital

ASH

Fairfield General Hospital

North Tyneside Hospital

NTY

BRY

Scunthorpe General Hospital

SCU

Papworth Hospital

Diana Princess of Wales Hospital

GGH

PAP

North Devon District Hospital

NDD

Northampton General Hospital

University Hospital of Hartlepool

HGH NTH

University Hospital of North Tees

Hospital name

NTG

NICOR hospital code

307

0

296

53

183

204

205

0

112

624

44

159

56

125

219

95

161

212

217

149

234

Hospital records submitted


National Heart Failure Audit April 2011-March 2012

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449 234 155 225 223 330 144

Royal Berkshire NHS Foundation Trust

Royal Brompton and Harefield NHS Foundation Trust

Royal Cornwall Hospitals NHS Trust

Royal Devon and Exeter NHS Foundation Trust

Royal Free London NHS Trust

Royal Liverpool and Broadgreen University Hospitals NHS Trust

Royal Surrey County Hospital NHS Foundation Trust

345

Sandwell and West Birmingham Hospitals NHS Trust

85

Shrewsbury and Telford Hospitals NHS Trust

359

315

Sherwood Forest Hospitals NHS Foundation Trust

South Devon Healthcare NHS Foundation Trust

452

Sheffield Teaching Hospitals NHS Foundation Trust

7

342

Salisbury NHS Foundation Trust

Scarborough and North East Yorkshire NHS Trust

241

Salford Royal NHS Foundation Trust

0

227

Rotherham NHS Foundation Trust

Royal United Hospital Bath NHS Trust

319

Portsmouth Hospitals NHS Trust

87.1%

19.5%

72.2%

51.3%

2.7%

48.8%

209.8%

94.1%

0.0%

81.8%

148.6%

84.8%

71.9%

32.2%

46.7%

111.4%

78.8%

59.5%

Yes

Partial

Yes

Yes

Partial

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Partial

Partial

Yes

Yes

Yes

412

437

436

881

258

707

163

256

455

176

222

263

313

481

501

403

288

536

236

331

269

905

256

614

139

331

395

141

237

229

389

428

512

305

323

543

243

304

221

736

212

608

150

301

434

144

272

224

620

395

375

261

250

509

Harefield Hospital

HH

Royal Hallamshire Hospital King's Mill Hospital Newark Hospital Princess Royal Hospital (Telford) Royal Shrewsbury Hospital

RHA KMH NHN TLF RSS

Torbay Hospital

Northern General Hospital

NGS

TOR

Scarborough General Hospital

SCA

Sandwell General Hospital

Birmingham City Hospital

DUD SAN

Salisbury District Hospital

Salford Royal

Royal United Hospital Bath

Royal Surrey County Hospital

Royal Liverpool University Hospital

Royal Free Hospital

Royal Devon & Exeter Hospital

SAL

SLF

BAT

RSU

RLU

RFH

RDE

Royal Cornwall Hospital

Royal Brompton Hospital

NHB

RCH

Royal Berkshire Hospital

Rotherham Hospital

Queen Alexandra Hospital

BHR

ROT

QAP

359

37

48

13

302

10

442

7

155

190

342

241

0

144

330

223

225

155

24

210

449

227

319


26

National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 26

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267

South Tyneside NHS Foundation Trust

555 203 229 226 175 302 178 300 180 197 203 170

Southend University Hospital NHS Foundation Trust

Southport and Ormskirk Hospital NHS Trust

St George's Healthcare NHS Trust

St Helens and Knowsley Teaching Hospitals NHS Trust

Stockport NHS Foundation Trust

Surrey and Sussex Healthcare NHS Trust

Tameside Hospital NHS Foundation Trust

Taunton and Somerset NHS Foundation Trust

The Dudley Group NHS Foundation Trust

The Hillingdon Hospitals NHS Foundation Trust

The Ipswich Hospital NHS Trust

The Newcastle Upon Tyne Hospitals NHS Foundation Trust

0

209

South Tees Hospitals NHS Foundation Trust

South Warwickshire NHS Foundation Trust

262

Trust records submitted

South London Healthcare NHS Trust

Trust name

24.1%

53.0%

86.8%

38.7%

87.2%

73.0%

90.7%

50.0%

68.5%

43.3%

74.6%

165.2%

0.0%

147.5%

43.1%

34.7%

% HES submitted

Partial

Partial

Yes

Partial

Yes

Yes

Yes

Partial

Partial

Partial

Yes

Yes

No

Yes

Partial

Yes

Participation status

704

383

227

465

344

244

333

350

330

529

272

336

126

181

485

756

Primary HES heart failure discharges

680

418

171

375

343

286

302

399

390

506

224

241

232

140

563

550

Secondary HES heart failure discharges

559

429

155

379

292

223

242

358

354

608

191

268

180

112

817

526

Tertiary HES heart failure discharges

Queen Mary's Hospital (Sidcup) James Cook University Hospital Friarage Hospital

QMH SCM FRH

The Ipswich Hospital Freeman Hospital Royal Victoria Infirmary

FRE RVN

Hillingdon Hospital

Russells Hall Hospital

Musgrove Park Hospital

Tameside General Hospital

East Surrey Hospital

Stepping Hill Hospital

Whiston Hospital

St George's Hospital

Southport and Formby District General Hospital

Southend Hospital

Warwick Hospital

IPS

HIL

RUS

MPH

TGA

ESU

SHH

WHI

GEO

SOU

SEH

WAR

South Tyneside District Hospital

Princess Royal University Hospital (Bromley)

BRO

STD

Queen Elizabeth Hospital (Woolwich)

Hospital name

GWH

NICOR hospital code

0

170

203

197

180

300

178

302

175

226

229

203

555

0

267

0

209

1

24

237

Hospital records submitted


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181 137

The Royal Wolverhampton Hospitals NHS Trust

The Whittington Hospital NHS Trust

209 304 142 292 384

University Hospital of North Staffordshire NHS Trust

University Hospital of South Manchester NHS Foundation Trust

University Hospital Southampton NHS Trust

University Hospitals Birmingham NHS Foundation Trust

University Hospitals Bristol NHS Foundation Trust

0

0

University Hospitals of Leicester NHS Trust

University Hospitals of Morecambe Bay NHS Foundation Trust

309

335

University College London Hospitals NHS Foundation Trust

University Hospitals Coventry and Warwickshire NHS Trust

253

United Lincolnshire Hospitals NHS Trust

0

0

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Trafford Healthcare NHS Trust

201

0

The Princess Alexandra Hospital NHS Trust

The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust

360

The North West London Hospitals NHS Trust

0.0%

0.0%

60.7%

94.6%

44.0%

27.3%

88.6%

28.1%

129.3%

32.0%

0.0%

53.9%

41.0%

0.0%

66.3%

0.0%

77.9%

No

No

Yes

Yes

Yes

Partial

Yes

Partial

Yes

Yes

No

Partial

Partial

No

Partial

No

Yes

449

1169

509

406

663

521

343

743

259

790

96

254

442

584

303

290

462

351

741

577

423

382

464

473

483

272

748

104

160

317

662

291

218

361

281

658

671

458

357

443

444

461

298

693

83

165

304

615

316

238

335

Lincoln County Hospital Grantham and District Hospital

LIN GRA

Hospital of St Cross Glenfield Hospital Leicester Royal Infirmary Furness General Hospital

RUG GRL LER FGH

Royal Lancaster Infirmary

University Hospital Coventry

WAL

RLI

Bristol Royal Infirmary

Queen Elizabeth Hospital (Edgbaston)

Southampton General Hospital

Wythenshawe Hospital

University Hospital of North Staffordshire

BRI

QEB

SGH

WYT

STO

University College Hospital

Pilgrim Hospital

PIL

UCL

Trafford General Hospital

Whittington Hospital

New Cross Hospital

Royal Bournemouth General Hospital

Queen Elizabeth Hospital (King's Lynn)

Princess Alexandra Hospital

Central Middlesex Hospital

Northwick Park Hospital

TRA

WHT

NCR

BOU

QKL

PAH

CMH

NPH

0

0

0

0

28

281

384

292

142

304

209

335

46

101

106

0

137

181

0

201

0

14

346


28

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74.7% 101.0%

245 212 218 639 116 206 219

392

513 188 253 220

West Hertfordshire Hospitals NHS Trust

West Middlesex University Hospital NHS Trust

West Suffolk NHS Foundation Trust

Western Sussex Hospitals NHS Trust

Weston Area Health NHS Trust

Whipps Cross University Hospital NHS Trust

Wirral University Teaching Hospital NHS Foundation Trust

Worcestershire Acute Hospitals NHS Trust

Wrightington, Wigan and Leigh NHS Foundation Trust

Wye Valley NHS Trust

Yeovil District Hospital NHS Foundation Trust

York Teaching Hospital NHS Foundation Trust

85.3%

128.4%

92.6%

181.3%

71.9%

44.2%

66.9%

59.2%

86.8%

84.5%

66.8%

145

Warrington and Halton Hospitals NHS Foundation Trust

72.4%

% HES submitted

241

Trust records submitted

Walsall Healthcare NHS Trust

Trust name

Yes

Yes

Yes

Yes

Yes

Partial

Partial

Partial

Yes

Yes

Yes

Yes

Partial

Yes

Participation status

258

197

203

283

545

496

308

196

736

258

210

328

217

333

Primary HES heart failure discharges

276

163

180

334

454

383

268

144

561

229

181

287

265

345

Secondary HES heart failure discharges

226

132

181

348

500

303

266

133

495

225

216

220

218

297

Tertiary HES heart failure discharges

St Richard's Hospital

STR

YDH

YEO

HCH

AEI

York District Hospital

Yeovil District Hospital

County Hospital Hereford

Royal Albert Edward Infirmary

Worcestershire Royal Hospital

Alexandra Hospital

RED WRC

Arrowe Park Hospital

Whipps Cross University Hospital WIR

WHC

Weston General Hospital

Worthing Hospital

WRG

WGH

West Suffolk Hospital

West Middlesex University Hospital

Watford General Hospital

Warrington Hospital

Manor Hospital

Hospital name

WSH

WMU

WAT

WDG

WMH

NICOR hospital code

220

253

188

513

165

227

219

206

116

276

363

218

212

245

145

241

Hospital records submitted


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28/11/2012 14:19

Hywel Dda Health Board

Cwm Taf Health Board

161

2

0

172

Betsi Cadwaladr University Health Board

Cardiff & Vale University Health Board

175

7

517

Trust records submitted

Aneurin Bevan Health Board

Abertawe Bro Morgannwg University Health Board

Wales

Trust name

23.4%

0.4%

0.0%

18.5%

19.4%

0.9%

11.9%

% PEDW submitted

Table 5: Participation and case ascertainment in Wales

Partial

Partial

No

Partial

Partial

Partial

Participation status

688

467

541

928

901

823

4348

Primary PEDW heart failure discharges

479

332

497

478

713

804

3303

Secondary PEDW heart failure discharges

417

236

432

719

647

929

3380

Tertiary PEDW heart failure discharges

Ysbyty Gwynedd

GWY

University Hospital of Wales Prince Charles Hospital Royal Glamorgan Bronglais General Hospital Prince Philip Hospital West Wales General Withybush General Hospital

UHW PCH RGH BRG PPH WWG WYB

Llandough Hospital

Glan Clwyd Hospital

CLW

LLD

Caerphilly District Miners Hospital/Ysbyty Ystrad Fawr

YYF

Wrexham Maelor Hospital

Nevill Hall Hospital

NEV

WRX

Royal Gwent Hospital

GWE

Llandudno General Hospital

Singleton Hospital

SIN

LLA

Princess Of Wales Hospital

Neath Port Talbot Hospital

NGH POW

Morriston Hospital

Hospital name

MOR

NICOR hospital code

4

5

6

146

1

1

0

0

172

0

0

0

0

175

0

0

7

0

0

517

Hospital records submitted


30

National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 30

SPH

KGG OLD

BNT

CHS

Ashford and St Peter's Hospitals NHS Trust

Barking, Havering and Redbridge University Hospitals NHS Trust

Barking, Havering and Redbridge University Hospitals NHS Trust

Barnet and Chase Farm Hospitals NHS Trust

Barnet and Chase Farm Hospitals NHS Trust

BAR

AIR

Airedale NHS Foundation Trust

Barnsley Hospital NHS Foundation Trust

FAZ

Aintree University Hospital NHS Foundation Trust

Barnsley Hospital

Chase Farm Hospital

Barnet General Hospital

Queen's Hospital (Romford)

King George Hospital

St Peter's Hospital

Airedale General Hospital

University Hospital Aintree

201

225

294

424

295

296

0

296

36559

Records submitted

England

Hospital name

37076

NICOR hospital code

England and Wales

Trust name

• % referred to cardiology follow-up: all records where patient survived to discharge.

• % referred to HF liaison service: all records where patient had LVSD and survived to discharge.

• % beta blocker on discharge: all records where patient had LVSD and survived to discharge.

• % ACEI/ARB on discharge: all records where patient had LVSD and survived to discharge.

• % cardiology inpatient: all records.

• % received echo: all records.

Denominators for tables 6 and 7 as follows:

Table 6: Clinical practice in England (2011/12)

84.1%

86.2%

91.8%

98.6%

98.6%

84.8%

98.3%

85.9%

85.9%

% received echo

20.4%

37.8%

59.5%

19.6%

21.0%

49.3%

83.4%

47.0%

47.1%

% cardiology inpatient

92.9%

81.5%

97.2%

79.0%

72.0%

59.0%

65.6%

82.7%

82.7%

% ACEI/ARB on discharge

82.1%

80.6%

86.2%

78.3%

70.8%

56.4%

75.1%

76.3%

76.4%

% beta blocker on discharge

24.6%

71.9%

63.4%

82.0%

73.1%

51.4%

97.7%

63.2%

63.2%

% referred to HF liaison service

43.2%

58.3%

50.6%

55.5%

55.5%

50.6%

91.2%

51.5%

51.1%

% referred to cardiology follow-up

Please note that these outputs have not been risk adjusted, but the denominators used for each analysis have been chosen to ensure that the outcomes are as representative as possible. The audit Project Board has decided to refrain from publishing outcomes data (e.g. readmission and mortality rates) at a hospital level until a satisfactory risk adjustment model has been developed. However, since April 2012 the National Heart Failure Audit has included a series of new mandatory data items, which will enable a sophisticated risk adjustment of the data to account for known confounders. This will enable the audit to publish outcome data at a hospital level in the near future.

Tables 6 and 7 show the percentages of cases at each hospital receiving key diagnostic tests, therapies and referral to follow-up services at hospitals in England and Wales. Hospitallevel data on clinical practice has only been published if a hospital submitted more than 100 records to the audit, or greater than 70% of their HES recorded figures. An asterisk (*) in a cell indicates that too few records were submitted for a percentage to be published.

harge.

3.9.2 Clinical practice

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BAL BAS

BED VIC BOL

BRD

PRH RSC

SMV

AMG BRT RHI

HUD

ADD MRI

WES

CHE

SUN COL

COC

Barts and the London

Basildon and Thurrock University Hospitals NHS Foundation Trust

Bedford Hospital NHS Trust

Blackpool Teaching Hospitals NHS Foundation Trust

Bolton NHS Foundation Trust

Bradford Teaching Hospitals NHS Foundation Trust

Brighton and Sussex University Hospitals NHS Trust

Brighton and Sussex University Hospitals NHS Trust

Buckinghamshire Healthcare NHS Trust

Buckinghamshire Healthcare NHS Trust

Burton Hospitals NHS Foundation Trust

Calderdale and Huddersfield NHS Foundation Trust

Calderdale and Huddersfield NHS Foundation Trust

Cambridge University Hospitals NHS Foundation Trust

Central Manchester University Hospitals NHS Foundation Trust

Chelsea and Westminster Hospital NHS Foundation Trust

Chesterfield Royal Hospital NHS Foundation Trust

City Hospitals Sunderland NHS Foundation Trust

Colchester Hospital University NHS Foundation Trust

Countess of Chester Hospital NHS Foundation Trust

Countess of Chester Hospital

Colchester General Hospital

Sunderland Royal Hospital

Chesterfield Royal Hospital

Chelsea and Westminster Hospital

Manchester Royal Infirmary

Addenbrooke's Hospital

Huddersfield Royal Infirmary

Calderdale Royal Hospital

Queen's Hospital (Burton)

Wycombe General Hospital

Stoke Mandeville Hospital

Royal Sussex County Hospital

Princess Royal Hospital (Haywards Heath)

Bradford Royal Infirmary

Royal Bolton Hospital

Blackpool Victoria Hospital

Bedford Hospital

Basildon University Hospital

The London Chest Hospital/The Royal London Hospital

341

381

245

178

84

221

22

182

185

239

220

0

406

222

170

8

903

220

35

155

99.1%

99.5%

85.7%

75.3%

*

88.2%

*

91.8%

94.1%

72.4%

97.7%

82.3%

68.0%

82.4%

*

91.4%

90.0%

*

89.7%

68.0%

50.5%

24.5%

44.9%

*

47.0%

*

50.5%

62.2%

43.9%

70.5%

50.0%

6.8%

46.5%

*

60.3%

38.6%

*

69.7%

95.7%

81.4%

81.8%

91.5%

*

89.0%

*

95.6%

93.0%

90.4%

90.9%

86.5%

89.4%

79.5%

*

85.1%

64.3%

*

78.8%

92.0%

80.0%

77.4%

86.4%

*

90.6%

*

73.2%

69.6%

92.2%

81.3%

74.5%

84.6%

70.5%

*

83.8%

74.1%

*

83.5%

90.6%

94.6%

31.3%

48.8%

*

77.8%

*

53.2%

58.2%

43.2%

62.7%

75.0%

34.2%

59.0%

*

70.9%

29.1%

*

86.4%

51.9%

39.5%

50.7%

28.6%

*

72.9%

*

42.7%

55.2%

51.5%

79.1%

55.4%

33.5%

63.2%

*

21.8%

55.1%

*

85.7%


32

National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 32

28/11/2012 14:19

QEW MAC KCC QEQ

WHH BLA CGH DGE EPS

East and North Hertfordshire NHS Trust

East Cheshire NHS Trust

East Kent Hospitals University NHS Foundation Trust

East Kent Hospitals University NHS Foundation Trust

East Kent Hospitals University NHS Foundation Trust

East Lancashire Hospitals NHS Trust

East Sussex Healthcare NHS Trust

East Sussex Healthcare NHS Trust

Epsom and St Helier University Hospitals NHS Trust

DID

Doncaster and Bassetlaw Hospitals NHS Foundation Trust

LIS

BSL

Doncaster and Bassetlaw Hospitals NHS Foundation Trust

East and North Hertfordshire NHS Trust

DER

Derby Hospitals NHS Foundation Trust

EAL

DVH

Dartford and Gravesham NHS Trust

Ealing Hospital NHS Trust

MAY

Croydon Health Services NHS Trust

WDH

DRY

County Durham and Darlington NHS Foundation Trust

Dorset County Hospital NHS Foundation Trust

DAR

NICOR hospital code

County Durham and Darlington NHS Foundation Trust

Trust name

Epsom Hospital

Eastbourne District General Hospital

Conquest Hospital

Royal Blackburn Hospital

William Harvey Hospital

Queen Elizabeth The Queen Mother Hospital

Kent and Canterbury Hospital

Macclesfield District General Hospital

Queen Elizabeth II Hospital

Lister Hospital

Ealing Hospital

Dorset County Hospital

Doncaster Royal Infirmary

Bassetlaw Hospital

Royal Derby Hospital

Darent Valley Hospital

Croydon University Hospital

University Hospital of North Durham

Darlington Memorial Hospital

Hospital name

100

206

218

234

0

0

0

167

214

267

262

176

128

69

196

73

223

180

145

Records submitted

49.0%

89.3%

88.1%

76.1%

75.4%

84.6%

62.9%

93.9%

71.0%

85.9%

*

89.80%

*

79.8%

97.8%

93.1%

% received echo

43.0%

56.3%

53.2%

61.5%

56.3%

16.4%

57.7%

37.0%

21.0%

17.3%

*

51.03%

*

30.5%

53.9%

47.6%

% cardiology inpatient

80.0%

73.2%

64.0%

82.0%

89.7%

62.6%

87.0%

72.5%

68.9%

95.0%

*

81.11%

*

63.3%

69.4%

86.5%

% ACEI/ARB on discharge

40.0%

62.6%

57.0%

85.7%

86.5%

66.1%

82.4%

90.8%

80.5%

75.6%

*

67.78%

*

67.2%

71.7%

73.7%

% beta blocker on discharge

63.6%

70.3%

63.2%

89.5%

50.0%

25.2%

78.4%

11.5%

47.3%

52.2%

*

98.94%

*

31.8%

46.6%

50.8%

% referred to HF liaison service

35.6%

53.6%

44.9%

75.9%

62.9%

30.1%

74.2%

82.0%

29.5%

53.6%

*

76.74%

*

33.9%

48.5%

42.0%

% referred to cardiology follow-up


National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 33

33

28/11/2012 14:19

GHS

Heart of England NHS Foundation Trust

HRI

EBH

Heart of England NHS Foundation Trust

Hull and East Yorkshire Hospitals NHS Trust

HAR

Harrogate and District NHS Foundation Trust

CHH

RHC

Hampshire Hospitals NHS Foundation Trust

Hull and East Yorkshire Hospitals NHS Trust

NHH

Hampshire Hospitals NHS Foundation Trust

HOM

STH

Guy's and St Thomas' NHS Foundation Trust

Homerton University Hospital NHS Foundation Trust

PMS

Great Western Hospitals NHS Foundation Trust

HIN

GLO

Gloucestershire Hospitals NHS Foundation Trust

Hinchingbrooke Health Care NHS Trust

CHG

Gloucestershire Hospitals NHS Foundation Trust

WEX

NUN

George Eliot Hospital NHS Trust

Heatherwood and Wexham Park Hospitals NHS Foundation Trust

QEG

Gateshead Health NHS Foundation Trust

SOL

FRM

Frimley Park Hospital NHS Foundation Trust

Heart of England NHS Foundation Trust

SHC

Epsom and St Helier University Hospitals NHS Trust

Hull Royal Infirmary

Castle Hill Hospital

Homerton University Hospital

Hinchingbrooke Hospital

Wexham Park Hospital

Solihull Hospital

Good Hope Hospital

Birmingham Heartlands Hospital

Harrogate District Hospital

Royal Hampshire County Hospital

Basingstoke and North Hampshire Hospital

St Thomas' Hospital

The Great Western Hospital

Gloucestershire Royal Hospital

Cheltenham General Hospital

George Eliot Hospital

Queen Elizabeth Hospital (Gateshead)

Frimley Park Hospital

St Helier Hospital

110

627

212

38

71

161

0

207

130

0

128

229

212

67

54

261

128

287

110

64.5%

89.0%

84.0%

*

*

97.5%

97.1%

81.5%

85.9%

98.7%

85.4%

*

*

87.4%

78.1%

87.5%

69.1%

0.9%

75.8%

50.0%

*

*

78.0%

50.0%

51.5%

69.5%

60.3%

55.9%

*

*

34.1%

30.8%

72.1%

40.9%

77.3%

86.8%

82.7%

*

*

88.2%

84.5%

90.0%

92.6%

82.2%

95.4%

*

*

77.3%

65.1%

84.8%

83.3%

68.2%

83.8%

89.6%

*

*

75.6%

66.1%

90.2%

63.0%

77.8%

84.8%

*

*

85.0%

55.5%

65.2%

81.8%

60.9%

66.8%

72.6%

*

*

82.1%

68.3%

66.7%

83.3%

92.3%

89.1%

*

*

0.0%

65.1%

84.8%

70.3%

39.0%

84.6%

60.5%

*

*

40.1%

55.6%

44.4%

19.5%

80.3%

70.1%

*

*

50.7%

46.8%

60.2%

37.8%


34

National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 34

28/11/2012 14:19

LDH MAI KSX

MDW LGH

Maidstone and Tunbridge Wells NHS Trust

Maidstone and Tunbridge Wells NHS Trust

Medway NHS Foundation Trust

Mid Cheshire Hospitals NHS Foundation Trust

RPH

Lancashire Teaching Hospitals NHS Foundation Trust

Luton and Dunstable Hospital NHS Foundation Trust

CHO

Lancashire Teaching Hospitals NHS Foundation Trust

BHL

KTH

Kingston Hospital NHS Trust

Liverpool Heart and Chest Hospital NHS Foundation Trust

KCH

King's College Hospital NHS Foundation Trust

LEW

KGH

Kettering General Hospital NHS Foundation Trust

Lewisham Healthcare NHS Trust

JPH

James Paget University Hospitals NHS Foundation Trust

LGI

IOW

Isle of Wight NHS PCT

Leeds Teaching Hospitals NHS Trust

St Mary's Hospital Paddington

STM

Imperial College Healthcare NHS Trust

Leighton Hospital

Medway Maritime Hospital

Tunbridge Wells Hospital

Maidstone Hospital

Luton and Dunstable Hospital

Liverpool Heart and Chest Hospital

University Hospital Lewisham

Leeds General Infirmary

Royal Preston Hospital

Chorley and South Ribble Hospital

Kingston Hospital

King's College Hospital

Kettering General Hospital

James Paget University Hospital

St Mary's Hospital, Newport

Hammersmith Hospital

HAM

Imperial College Healthcare NHS Trust

Charing Cross Hospital

Hospital name

CCH

NICOR hospital code

Imperial College Healthcare NHS Trust

Trust name

263

0

178

226

346

136

117

248

334

232

309

245

239

114

173

241

151

99

Records submitted

100.0%

82.0%

93.8%

90.5%

95.6%

99.1%

98.8%

98.8%

100.0%

60.2%

95.1%

87.0%

83.3%

73.4%

99.2%

85.4%

91.9%

% received echo

82.9%

43.8%

64.4%

26.3%

97.8%

45.3%

94.4%

37.7%

50.4%

34.6%

44.0%

74.9%

40.4%

26.0%

26.1%

47.0%

43.4%

% cardiology inpatient

90.4%

97.7%

90.9%

92.3%

72.9%

86.7%

81.5%

80.0%

97.1%

80.0%

89.0%

83.0%

89.6%

71.4%

88.2%

89.4%

100.0%

% ACEI/ARB on discharge

89.2%

55.7%

78.0%

71.4%

79.8%

92.9%

82.6%

81.6%

84.7%

48.5%

85.6%

85.7%

82.2%

42.0%

81.0%

86.5%

64.0%

% beta blocker on discharge

69.7%

80.9%

89.2%

69.0%

76.2%

88.6%

98.7%

98.8%

96.6%

0.0%

49.2%

93.3%

12.8%

93.5%

30.3%

48.2%

60.7%

% referred to HF liaison service

46.5%

60.7%

74.7%

47.1%

99.1%

96.7%

88.6%

86.4%

78.4%

44.7%

36.2%

53.3%

27.1%

48.3%

53.9%

76.2%

35.8%

% referred to cardiology follow-up


National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 35

35

28/11/2012 14:19

HEX NTY

Northumbria Healthcare NHS Foundation Trust

Northumbria Healthcare NHS Foundation Trust

NTG

North Tees and Hartlepool NHS Foundation Trust

SCU

HGH

North Tees and Hartlepool NHS Foundation Trust

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

NMH

North Middlesex University Hospital NHS Trust

GGH

WCI

North Cumbria University Hospitals NHS Trust

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

CMI

North Cumbria University Hospitals NHS Trust

NDD

BSM

North Bristol NHS Trust

Northern Devon Healthcare NHS Trust

FRY

North Bristol NHS Trust

NTH

NOR

Norfolk and Norwich University Hospitals NHS Foundation Trust

Northampton General Hospital NHS Trust

NWG

PIN

Mid Yorkshire Hospitals NHS Trust

Newham University Hospital NHS Trust

DEW

Mid Yorkshire Hospitals NHS Trust

MKH

SDG

Mid Staffordshire NHS Foundation Trust

Milton Keynes Hospital NHS Foundation Trust

BFH

Mid Essex Hospital Services NHS Trust

North Tyneside Hospital

Hexham General Hospital

Scunthorpe General Hospital

Diana Princess of Wales Hospital

North Devon District Hospital

Northampton General Hospital

University Hospital of North Tees

University Hospital of Hartlepool

North Middlesex University Hospital

West Cumberland Hospital

Cumberland Infirmary

Southmead Hospital

Frenchay Hospital

Norfolk and Norwich University Hospital

Newham University Hospital

Milton Keynes General Hospital

Pinderfields Hospital

Dewsbury and District Hospital

Stafford Hospital

Broomfield Hospital

219

56

95

161

212

217

234

149

171

32

46

205

279

374

2

154

301

119

74

136

90.9%

*

*

22.4%

84.9%

86.6%

78.2%

96.0%

83.0%

*

*

94.6%

93.2%

80.5%

*

76.6%

94.0%

79.8%

*

99.3%

45.7%

*

*

31.7%

50.2%

49.3%

58.5%

64.4%

7.6%

*

*

55.1%

34.4%

100.0%

*

48.7%

53.5%

31.1%

*

30.1%

60.5%

*

*

78.3%

74.0%

100.0%

97.7%

100.0%

92.9%

*

*

58.5%

80.2%

84.0%

*

76.0%

84.9%

90.4%

*

97.0%

79.3%

*

*

69.6%

54.3%

98.7%

93.2%

98.0%

79.3%

*

*

71.8%

72.4%

79.0%

*

68.0%

87.6%

77.1%

*

95.9%

47.1%

*

*

0.0%

71.3%

99.0%

75.6%

63.6%

86.2%

*

*

13.7%

1.9%

33.2%

*

75.9%

69.7%

92.7%

*

78.0%

29.6%

*

*

43.5%

30.1%

29.0%

30.4%

32.8%

36.0%

*

*

45.6%

21.0%

68.5%

*

46.2%

60.4%

61.3%

*

63.8%


36

National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 36

28/11/2012 14:19

BHH

OHM PET PLY PGH QAP ROT

BHR

Pennine Acute Hospitals NHS Trust

Pennine Acute Hospitals NHS Trust

Peterborough and Stamford Hospitals NHS Foundation Trust

Plymouth Hospitals NHS Trust

Poole Hospital NHS Foundation Trust

Portsmouth Hospitals NHS Trust

Rotherham NHS Foundation Trust

Royal Berkshire NHS Foundation Trust

RDE

NMG

Pennine Acute Hospitals NHS Trust

Royal Devon and Exeter NHS Foundation Trust

BRY

Pennine Acute Hospitals NHS Trust

RCH

PAP

Papworth Hospital NHS Foundation Trust

Royal Cornwall Hospitals NHS Trust

RAD

Oxford Radcliffe Hospitals NHS Trust

NHB

HOR

Oxford Radcliffe Hospitals NHS Trust

Royal Brompton and Harefield NHS Foundation Trust

UHN

Nottingham University Hospitals NHS Trust

HH

CHN

Nottingham University Hospitals NHS Trust

Royal Brompton and Harefield NHS Foundation Trust

ASH

NICOR hospital code

Northumbria Healthcare NHS Foundation Trust

Trust name

Royal Devon & Exeter Hospital

Royal Cornwall Hospital

Royal Brompton Hospital

Harefield Hospital

Royal Berkshire Hospital

Rotherham Hospital

Queen Alexandra Hospital

Poole General Hospital

Derriford Hospital

Peterborough City Hospital

Royal Oldham Hospital

Rochdale Infirmary

North Manchester General Hospital

Fairfield General Hospital

Papworth Hospital

John Radcliffe Hospital

Horton General Hospital

Queen's Medical Centre

Nottingham City Hospital

Wansbeck General Hospital

Hospital name

225

155

210

24

449

227

319

307

0

296

204

53

183

205

0

624

112

159

44

125

Records submitted

77.78%

84.52%

100.00%

*

88.2%

83.3%

96.6%

70.7%

87.5%

90.7%

*

95.1%

80.0%

95.7%

96.4%

88.7%

*

93.6%

% received echo

52.89%

43.23%

98.50%

*

46.1%

32.6%

94.0%

23.1%

71.6%

4.4%

*

40.4%

63.4%

22.8%

17.9%

18.9%

*

49.6%

% cardiology inpatient

100.00%

81.08%

92.00%

*

83.3%

80.4%

79.9%

70.5%

75.4%

87.8%

*

83.0%

86.0%

99.6%

100.0%

75.8%

*

81.1%

% ACEI/ARB on discharge

100.00%

70.54%

87.84%

*

83.4%

81.9%

74.8%

67.0%

65.7%

63.4%

*

82.5%

80.4%

98.7%

97.1%

67.4%

*

67.6%

% beta blocker on discharge

75.00%

61.86%

52.27%

*

72.9%

69.5%

77.9%

20.0%

51.7%

97.1%

*

91.2%

93.9%

91.7%

93.0%

70.0%

*

69.3%

% referred to HF liaison service

40.21%

37.14%

97.52%

*

28.2%

37.1%

43.7%

28.0%

59.6%

83.3%

*

55.3%

31.9%

54.1%

17.3%

31.9%

*

12.0%

% referred to cardiology follow-up


National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 37

37

28/11/2012 14:19

NHN TLF

Sherwood Forest Hospitals NHS Foundation Trust

Shrewsbury and Telford Hospitals NHS Trust

FRH

KMH

Sherwood Forest Hospitals NHS Foundation Trust

South Tees Hospitals NHS Foundation Trust

RHA

Sheffield Teaching Hospitals NHS Foundation Trust

QMH

NGS

Sheffield Teaching Hospitals NHS Foundation Trust

South London Healthcare NHS Trust

SCA

Scarborough and North East Yorkshire NHS Trust

GWH

SAN

Sandwell and West Birmingham Hospitals NHS Trust

South London Healthcare NHS Trust

DUD

Sandwell and West Birmingham Hospitals NHS Trust

BRO

SAL

Salisbury NHS Foundation Trust

South London Healthcare NHS Trust

SLF

Salford Royal NHS Foundation Trust

TOR

BAT

Royal United Hospital Bath NHS Trust

South Devon Healthcare NHS Foundation Trust

RSU

Royal Surrey County Hospital NHS Foundation Trust

RSS

RLU

Royal Liverpool and Broadgreen University Hospitals NHS Trust

Shrewsbury and Telford Hospitals NHS Trust

RFH

Royal Free London NHS Trust

Friarage Hospital

Queen Mary's Hospital (Sidcup)

Queen Elizabeth Hospital (Woolwich)

Princess Royal University Hospital (Bromley)

Torbay Hospital

Royal Shrewsbury Hospital

Princess Royal Hospital (Telford)

Newark Hospital

King's Mill Hospital

Royal Hallamshire Hospital

Northern General Hospital

Scarborough General Hospital

Sandwell General Hospital

Birmingham City Hospital

Salisbury District Hospital

Salford Royal

Royal United Hospital Bath

Royal Surrey County Hospital

Royal Liverpool University Hospital

Royal Free Hospital

0

1

237

24

359

37

48

13

302

10

442

7

155

190

342

241

0

144

330

223

*

92.4%

*

63.0%

*

*

*

78.1%

*

100.0%

*

94.2%

88.4%

95.0%

90.0%

72.9%

83.3%

93.27%

*

61.2%

*

31.8%

*

*

*

49.3%

*

26.9%

*

69.0%

56.3%

61.7%

30.7%

26.4%

56.4%

45.29%

*

89.2%

*

60.0%

*

*

*

79.8%

*

78.6%

*

88.6%

67.7%

87.2%

65.0%

86.7%

75.5%

97.47%

*

93.8%

*

47.0%

*

*

*

81.4%

*

72.3%

*

62.4%

54.0%

76.1%

74.3%

65.2%

87.6%

95.18%

*

82.9%

*

20.2%

*

*

*

65.0%

*

0.0%

*

98.9%

64.9%

31.3%

91.8%

8.9%

92.0%

64.55%

*

63.6%

*

33.1%

*

*

*

51.5%

*

29.0%

*

84.3%

76.7%

46.8%

46.3%

38.9%

42.8%

58.51%


38

National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 38

28/11/2012 14:19

SCM STD

WAR SEH

SOU GEO WHI

SHH ESU TGA

MPH

RUS HIL IPS FRE

RVN

CMH

NPH

South Tyneside NHS Foundation Trust

South Warwickshire NHS Foundation Trust

Southend University Hospital NHS Foundation Trust

Southport and Ormskirk Hospital NHS Trust

St George's Healthcare NHS Trust

St Helens and Knowsley Teaching Hospitals NHS Trust

Stockport NHS Foundation Trust

Surrey and Sussex Healthcare NHS Trust

Tameside Hospital NHS Foundation Trust

Taunton and Somerset NHS Foundation Trust

The Dudley Group NHS Foundation Trust

The Hillingdon Hospitals NHS Foundation Trust

The Ipswich Hospital NHS Trust

The Newcastle Upon Tyne Hospitals NHS Foundation Trust

The Newcastle Upon Tyne Hospitals NHS Foundation Trust

The North West London Hospitals NHS Trust

The North West London Hospitals NHS Trust

NICOR hospital code

South Tees Hospitals NHS Foundation Trust

Trust name

Northwick Park Hospital

Central Middlesex Hospital

Royal Victoria Infirmary

Freeman Hospital

The Ipswich Hospital

Hillingdon Hospital

Russells Hall Hospital

Musgrove Park Hospital

Tameside General Hospital

East Surrey Hospital

Stepping Hill Hospital

Whiston Hospital

St George's Hospital

Southport and Formby District General Hospital

Southend Hospital

Warwick Hospital

South Tyneside District Hospital

James Cook University Hospital

Hospital name

346

14

0

170

203

197

180

300

178

302

175

226

229

203

555

0

267

209

Records submitted

96.5%

*

58.2%

63.5%

91.9%

96.1%

80.3%

71.9%

76.2%

95.4%

92.5%

99.1%

96.1%

87.2%

91.8%

95.7%

% received echo

84.7%

*

68.8%

25.6%

52.8%

65.6%

52.7%

34.8%

54.4%

16.6%

77.0%

13.1%

18.3%

39.1%

64.0%

87.1%

% cardiology inpatient

77.0%

*

85.7%

86.8%

80.2%

77.8%

83.7%

80.8%

81.5%

92.7%

78.7%

87.3%

67.5%

70.8%

94.4%

90.1%

% ACEI/ARB on discharge

71.9%

*

72.3%

81.3%

60.2%

74.7%

73.1%

76.7%

63.7%

87.5%

72.1%

84.9%

42.7%

77.4%

80.3%

77.5%

% beta blocker on discharge

72.4%

*

52.8%

46.1%

70.5%

72.5%

0.0%

72.6%

57.7%

32.2%

95.6%

94.9%

70.9%

85.3%

93.8%

93.3%

% referred to HF liaison service

47.7%

*

93.1%

22.3%

29.0%

68.6%

37.2%

50.4%

52.5%

42.2%

34.6%

48.7%

70.8%

38.7%

73.7%

63.6%

% referred to cardiology follow-up


National Heart Failure Audit April 2011-March 2012

HF Report 2012 Design B.indd 39

39

28/11/2012 14:19

SGH

University Hospital Southampton NHS Trust

LER

WYT

University Hospital of South Manchester NHS Foundation Trust

University Hospitals of Leicester NHS Trust

STO

University Hospital of North Staffordshire NHS Trust

GRL

UCL

University College London Hospitals NHS Foundation Trust

University Hospitals of Leicester NHS Trust

PIL

United Lincolnshire Hospitals NHS Trust

WAL

LIN

United Lincolnshire Hospitals NHS Trust

University Hospitals Coventry and Warwickshire NHS Trust

GRA

United Lincolnshire Hospitals NHS Trust

RUG

TRA

Trafford Healthcare NHS Trust

University Hospitals Coventry and Warwickshire NHS Trust

WHT

The Whittington Hospital NHS Trust

BRI

NCR

The Royal Wolverhampton Hospitals NHS Trust

University Hospitals Bristol NHS Foundation Trust

BOU

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

QEB

QKL

The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust

University Hospitals Birmingham NHS Foundation Trust

PAH

The Princess Alexandra Hospital NHS Trust

Leicester Royal Infirmary

Glenfield Hospital

University Hospital Coventry

Hospital of St Cross

Bristol Royal Infirmary

Queen Elizabeth Hospital (Edgbaston)

Southampton General Hospital

Wythenshawe Hospital

University Hospital of North Staffordshire

University College Hospital

Pilgrim Hospital

Lincoln County Hospital

Grantham and District Hospital

Trafford General Hospital

Whittington Hospital

New Cross Hospital

Royal Bournemouth General Hospital

Queen Elizabeth Hospital (King's Lynn)

Princess Alexandra Hospital

0

0

281

28

384

292

142

304

209

335

106

101

46

0

137

181

0

201

0

95.0%

*

93.8%

55.7%

100.0%

75.0%

81.6%

99.1%

59.4%

62.4%

*

99.3%

75.1%

94.5%

74.6%

*

89.3%

17.4%

39.4%

49.3%

31.1%

55.8%

27.4%

30.7%

*

61.3%

11.6%

67.2%

86.1%

*

80.8%

91.1%

0.0%

94.9%

71.9%

99.4%

73.7%

60.7%

*

97.0%

78.5%

93.9%

76.3%

*

78.7%

82.9%

0.0%

90.4%

56.1%

95.0%

76.3%

69.0%

*

93.7%

67.2%

87.1%

94.2%

*

64.4%

30.8%

0.0%

57.4%

82.9%

83.3%

28.2%

47.1%

*

85.3%

65.1%

84.6%

51.7%

*

80.4%

32.2%

49.2%

38.3%

60.1%

90.2%

50.0%

53.8%

*

78.3%

30.7%

31.8%


40

National Heart Failure Audit April 2011-March 2012

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WAT

WMU

WSH STR

WRG

WGH

WHC WIR RED

WRC

West Hertfordshire Hospitals NHS Trust

West Middlesex University Hospital NHS Trust

West Suffolk NHS Foundation Trust

Western Sussex Hospitals NHS Trust

Western Sussex Hospitals NHS Trust

Weston Area Health NHS Trust

Whipps Cross University Hospital NHS Trust

Wirral University Teaching Hospital NHS Foundation Trust

Worcestershire Acute Hospitals NHS Trust

Worcestershire Acute Hospitals NHS Trust

HCH YEO YDH

Wye Valley NHS Trust

Yeovil District Hospital NHS Foundation Trust

York Teaching Hospital NHS Foundation Trust

AEI

WDG

Warrington and Halton Hospitals NHS Foundation Trust

Wrightington, Wigan and Leigh NHS Foundation Trust

WMH

RLI

University Hospitals of Morecambe Bay NHS Foundation Trust

Walsall Healthcare NHS Trust

FGH

NICOR hospital code

University Hospitals of Morecambe Bay NHS Foundation Trust

Trust name

York District Hospital

Yeovil District Hospital

County Hospital Hereford

Royal Albert Edward Infirmary

Worcestershire Royal Hospital

Alexandra Hospital

Arrowe Park Hospital

Whipps Cross University Hospital

Weston General Hospital

Worthing Hospital

St Richard's Hospital

West Suffolk Hospital

West Middlesex University Hospital

Watford General Hospital

Warrington Hospital

Manor Hospital

Royal Lancaster Infirmary

Furness General Hospital

Hospital name

220

253

188

513

165

227

219

206

116

363

276

218

212

245

145

241

0

0

Records submitted

72.3%

92.1%

80.9%

97.3%

44.8%

87.7%

95.0%

83.0%

78.4%

75.5%

84.8%

69.3%

83.5%

94.7%

100.0%

100.0%

% received echo

9.5%

55.6%

25.0%

62.0%

53.9%

35.9%

43.8%

33.0%

25.9%

40.5%

48.9%

33.0%

23.1%

50.6%

67.6%

52.3%

% cardiology inpatient

84.0%

92.3%

77.4%

88.0%

83.0%

71.1%

98.7%

84.8%

69.8%

75.9%

76.8%

83.6%

71.8%

100.0%

94.1%

100.0%

% ACEI/ARB on discharge

80.0%

85.3%

58.1%

87.7%

61.5%

79.8%

85.9%

77.3%

65.1%

72.4%

72.5%

68.0%

77.9%

99.1%

85.7%

100.0%

% beta blocker on discharge

28.6%

100.0%

58.1%

68.2%

18.2%

42.2%

97.4%

75.0%

0.0%

59.0%

53.7%

12.8%

76.8%

81.6%

98.9%

90.4%

% referred to HF liaison service

32.2%

40.5%

30.4%

66.0%

39.6%

53.3%

40.9%

47.4%

20.6%

47.1%

46.1%

34.2%

30.7%

92.1%

69.7%

78.0%

% referred to cardiology follow-up


HF Report 2012 Design B.indd 41

RGH

BRG

PPH

WWG

WYB

Hywel Dda Health Board

Hywel Dda Health Board

Hywel Dda Health Board

Hywel Dda Health Board

WRX

Betsi Cadwaladr University Health Board

Cwm Taf Health Board

LLA

Betsi Cadwaladr University Health Board

PCH

CLW

Betsi Cadwaladr University Health Board

Cwm Taf Health Board

GWE

Aneurin Bevan Health Board

UHW

NEV

Aneurin Bevan Health Board

Cardiff & Vale University Health Board

YYF

Aneurin Bevan Health Board

LLD

SIN

Abertawe Bro Morgannwg University Health Board

Cardiff & Vale University Health Board

POW

Abertawe Bro Morgannwg University Health Board

GWY

NGH

Abertawe Bro Morgannwg University Health Board

Betsi Cadwaladr University Health Board

MOR

NICOR hospital code

Abertawe Bro Morgannwg University Health Board

Wales

England and Wales

Health Board name

Singleton Hospital

Princess of Wales Hospital

Neath Port Talbot Hospital

Morriston Hospital

Hospital name

Withybush General Hospital

West Wales General

Prince Philip Hospital

Bronglais General Hospital

Royal Glamorgan

Prince Charles Hospital

University Hospital of Wales

Llandough Hospital

Ysbyty Gwynedd

Wrexham Maelor Hospital

Llandudno General Hospital

Glan Clwyd Hospital

Royal Gwent Hospital

Nevill Hall Hospital

Caerphilly District Miners Hospital/Ysbyty Ystrad Fawr

Table 7: Clinical practice in Wales (2011/12)

National Heart Failure Audit April 2011-March 2012

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4

5

6

146

1

1

0

0

0

172

0

0

0

175

0

0

7

0

0

517

37076

Records submitted

*

*

*

94.5%

*

*

79.1%

87.4%

*

87.0%

85.9%

% received echo

*

*

*

82.2%

*

*

37.2%

39.4%

*

52.9%

47.1%

% cardiology inpatient

*

*

*

88.2%

*

*

64.2%

92.3%

*

81.6%

82.7%

% ACEI/ARB on discharge

*

*

*

70.2%

*

*

74.7%

92.9%

*

79.3%

76.4%

% beta blocker on discharge

*

*

*

66.2%

*

*

78.9%

48.4%

*

64.5%

63.2%

% referred to HF liaison service

*

*

*

34.2%

*

*

33.9%

19.5%

*

29.2%

51.1%

% referred to cardiology follow-up


3.10 Mortality Mortality in the National Heart Failure Audit database is determined by linking audit data with mortality data from the Office of National Statistics (ONS) via NHS number, and other patient identifiable data collected by the audit. The total number of patients in the audit database who could be assigned a mortality status by MRIS was 24,744. The followup period refers to the period from date of discharge to date of death for those patients who died, and date of discharge to date of census for those who survived. Currently the audit uses all-cause mortality as the basis for all mortality analysis, but NICOR has now been granted permission by the National Information Governance Board (NIGB) to obtain cause of death for patients included in its audits and registers.v This will allow for a more accurate representation of the number of deaths caused by heart failure, as an elderly patient group with high levels of comorbidity is guaranteed to register a significant number of non-cardiovascular deaths.

3.10.1 2011/12 in-hospital mortalityvi Overall 11.1% of patients died in hospital but in-hospital mortality rates varied depending on the ward on which the patient was treated: 7.8% of those on cardiology ward died in hospital, compared with 13.2% of patients treated on general medicine and 17.4% of those on other wards. In-hospital mortality stood at 10.2% for men and 12.1% for women, and, predictably, was much higher for older patients: only 2.5% of patients in the 16-44 age group died in hospital, compared with 10.9% of patients who were aged 75-84 at admission, and 16.8% of patients over 85 years of age. Following adjustment for confounding factors (age >75 years; NYHA class III/IV; previous AMI), a significant association remained between not being treated on a cardiology ward and worse survival outcomes (HR=1.66, 95% CI 1.52 to 1.81, p<0.001.

3.10.2 2011/12 post-discharge mortality Overall mortality for those patients who survived to discharge stood at 26.2% for the audit year. Median follow-up was 211 days for all patients, 281 days for those who survived to the end of the follow-up period and 39 days for patients who deceased (figure 7). Sex: Mortality rates were similar for men and women who survived to discharge, with 26.6% of women and 25.9% of men dying within the follow-up period (median follow-up of 231 days for both men and women) (figure 8). v. The NIGB monitors NHS and health-related information governance. vi. Data for the 2011/2012 mortality analysis can be found in appendix 3 at the end of this report.

42

Age: Predictably, mortality increased significantly with age,

7.4% of those aged 16-44 died (301 days median follow-up), compared with 26.9% of patients the 75-84 age group (229 days median follow-up) and 37.2% of those over 85 years (median follow-up of 200 days) (figure 9). Place of care: Patients treated on a cardiology ward had better outcomes than those treated on general medical or other wards, with 21.8% of patients treated on cardiology wards dying (242 day median follow-up), compared with 29.8% on general medicine (225 day median follow-up), and 33.4% on other wards (215 day median follow-up) (figure 10). Diagnosis of LVSD: Of patients without LVSD 28.3% died during the follow-up period, compared to 24.8% of those with LVSD (median follow-up time of 227 days for those without LVSD and 236 days for those with LVSD) (figure 11). ACE inhibitor and/or ARB on discharge: For those patients with an echo diagnosis of LVSD, 38.8% of those who were not discharged on an ACE inhibitor and/or ARB died, with a median follow-up of 201 days. Only 20.2% of patients with LVSD who were discharged on ACE inhibitor and/or ARB died within the follow-up period (median follow-up of 249 days) (figure 12).

Mortality rates by ACEI/ARB prescription showed similar patterns when all patients were considered, rather than just those with a diagnosis of LVSD: 36.7% of patients who were discharged without ACE inhibitors and/or ARBs died, with a median follow-up period of 207 days, compared with 21.0% of patients discharged on the drugs (median follow-up of 247 days) (figure 13). Beta blocker on discharge: 33.0% of patients with LVSD who

were not discharged on beta blockers died within the follow-up period (median 220 day follow-up), compared with only 21.1% of patients who were prescribed the treatment on discharge (median follow-up of 245 days) (figure 14). Irrespective of echo diagnosis, 32.1% of those discharged on no beta blocker died (227 median follow-up), compared with 22.2% of patients discharged on beta blockers (242 day median follow-up) (figure 15). Loop diuretic on discharge: 17.0% of patients with a diagnosis of LVSD who were discharged in 2011/12 without a prescription of loop diuretics died within the follow-up period, with a median 262 day follow-up, compared with 25.6% of patients who were discharged on loop diuretics (median follow-up period of 235 days) (figure 16).

For all patients, including those without LVSD, 20.6% of patients discharged without loop diuretics died within the follow-up period (median 250 days), compared with 26.5% of patients discharged on a loop (231 day median follow-up) (figure 17).

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modifying drugs a patient was prescribed on discharge had a significant impact on survival: 45.8% of patients with LVSD discharged without a prescription for an ACEI/ARB, beta blocker or MRA died (median follow-up of 183 days), compared with 27.1% of those discharged on ACEI/ARB only (median follow-up 242 days) and 18.4% of patients discharged on an ACEI/ARB and a beta blocker (median follow-up 251 days). Mortality was 16.8% for patients discharged on ACEI/ARB, beta blocker and an MRA (257 days median follow-up) (figure 18). Referral to follow-up services: 20.1% of patients who were

referred to cardiology follow-up in 2011/12 died (median follow-up 249 days), compared to 32.1% of patients who did not receive a cardiology referral (median follow-up of 216 days) (figure 19).

Fig 7: Overall post-discharge survival 100 90 80 70 % survived

Additive drug treatment: The number of recommended disease

Table 8: Cox proportional hazards model for postdischarge mortality (2011/12) Predictor

Hazard ratio

Lower .95

Upper .95

p-value

Previous AMI

1.28

1.20

1.36

< 0.001

Age > 75

1.77

1.65

1.90

< 0.001

NYHA class III/IV

1.22

1.13

1.31

< 0.001

No ACEI/ARB on discharge

1.69

1.59

1.81

< 0.001

No beta blocker on discharge

1.26

1.19

1.35

< 0.001

Loop diuretic on discharge

1.16

1.04

1.29

0.006

No cardiology follow-up

1.36

1.28

1.45

< 0.001

Not a cardiology inpatient

1.10

1.03

1.17

0.003

40

20 10 0 0

100

200

300

400

Days after discharge

Fig 8: Post-discharge survival by sex 100 90 80 70 % survived

A Cox proportional hazards model appears to show that for patients who survived to discharge, even with adjustment for age, severity of symptoms and history of AMI, those not prescribed ACE inhibitors/ARBs and beta blockers on discharge had higher mortality rates. Patients prescribed loop diuretics on discharge also had increased mortality rates following adjustment for these confounding factors. Patients who were not cardiology inpatients and those who did not receive cardiology follow-up also had increased mortality rates when the confounding patient characteristics were taken into account (table 8).

50

30

Mortality was 24.8% for patients who were referred to a heart failure liaison service on discharge (median follow-up 232 days), compared to 27.9% for patients not referred to heart failure nurse led follow-up (median follow-up period of 231 days) (figure 20).

Predictors of mortality for survivors to discharge

60

60 50 40 30 20 10 0 0

100

200

300

400

Days after discharge

Women Men

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Fig 9: Post-discharge survival by age at admission

Fig 11: Post-discharge survival by presence or absence of LVSD

100 100

90

90

80

80

70

70

% Survived

60 % Survived

50 40 30

60 50 40 30

20

20

10

10

0 0

100

200

300

0

400

0

Days after discharge

100

200

300

400

Days after discharge

16-44

55-64

75-84

45-54

65-74

85+

Fig 10: Post-discharge survival by place of care

Diagnosis of LVSD No diagnosis of LVSD

Fig 12: Post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge for patients with LVSD

100 100

90

90

80

80 70

60 % Survived

% Survived

70

50 40 30

50 40 30

20

20

10

10

0 0

100

200

300

Days after discharge

Cardiology

Other

General Medicine

44

60

400

0 0

100

200

300

400

Days after discharge

ACE inhibitor/ARB No ACE inhibitor/ARB

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Fig 13: Post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge (all patients)

Fig 15: Post-discharge survival by prescription of beta blockers on discharge (all patients)

90

90

80

80

70

70

60

60

% Survived

100

% Survived

100

50 40

50 40

30

30

20

20

10

10

0

0

0

100

200

300

0

400

100

Days after discharge

ACE inhibitor/ARB

Beta blocker

No ACE inhibitor/ARB

No beta blocker

90

90

80

80

70

70

60

60

% Survived

% Survived

100

50 40

50 40

30

30

20

20

10

10

0

0 200

300

400

0

100

Days after discharge

Beta blocker No beta blocker

400

Fig 16: Post-discharge survival by prescription of loop diuretics on discharge for patients with LVSD

100

100

300

Days after discharge

Fig 14: Post-discharge survival by prescription of beta blockers on discharge for patients with LVSD

0

200

200

300

400

Days after discharge

No loop diuretic Loop diuretic

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Fig 19: Post-discharge survival by referral to cardiology follow-up services

100

100

90

90

80

80

70

70

60

60

% Survived

% Survived

Fig 17: Post-discharge survival by prescription of loop diuretics on discharge (all patients)

50 40

50 40

30

30

20

20

10

10

0

0 0

100

200

300

400

0

100

Days after discharge

300

400

Days after discharge

No loop diuretic

Referred to cardiology follow-up

Loop diuretic

Not referred to cardiology follow-up

Fig 18: Post-discharge survival by additive drug treatment on discharge for patients with a diagnosis of LVSD

Fig 20: Post-discharge survival by referral to heart failure liason follow-up services 100

100

90

90

80

80

70

70 60

% Survived

% Survived

200

50 40

60 50 40 30

30

20

20

10

10

0

0 0

100

200

300

400

Days after discharge

0

100

200

300

400

Days after discharge

ACEI inhibitor/ARB, beta blocker and MRA

Referred to heart failure liaison follow-up

ACEI inhibitor/ARB and beta blocker

Not referred to heart failure liaison follow-up

ACE inhibitor/ARB No ACEI inhibitor/ARB, beta blocker or MRA 46

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3.11 Three-year trends 3.11.1 Three-year in-hospital mortalityvii Over the three years from April 2009 to March 2012, 12.1% of patients died in hospital. Only 8.2% of patients treated on a cardiology ward died, compared with 14.7% of patient treated on general medical wards, and 18.5% of patients on other wards. 11.2% of men died in hospital, compared with 13.1% of women, in the three-year period.

3.11.2 Three-year post-discharge mortality Over the three years from 2009-2012, out of 66,249 patients, 24,590 (37.1%) died, with a median follow-up period between discharge and death/censoring of 331 days. Median followup was 504 days for patients who survived, and 89 days for patients who died (figure 21). The audit is not yet in a position to report place or cause of death for the majority of patients but hopes to do so in future reports. Sex: Long term mortality was broadly similar for men and

women: 37.8% of women discharged alive within the three years died, with a 375 day follow-up period, compared to 36.6% of men (median follow-up 376 days) (figure 22). Age: Unsurprisingly age had a major impact on mortality, with

52.0% of patients over the age of 85 (median follow-up of 281 days) and 38.4% of patients between 75 and 84 (median followup of 369 days), dying within the follow-up period, compared with only 10.8% of the youngest patients, aged 16-44 (538 day median follow-up period) (figure 23). Place of care: Heart failure patientsâ&#x20AC;&#x2122; main place of care

continued to have an impact on mortality long after discharge, with 31.1% of cardiology patients dying (404 day follow-up), compared with 42.4% of general medical patients (355 day follow-up) and 45.0% of patients on other wards (323 day follow-up) (figure 24). Diagnosis of LVSD: 40.7% of patients diagnosed with heart

failure without LVSD admitted between 2009 and 2012 died, compared with 34.7% of patients diagnosed with LVSD (Median follow-up period of 362 days for no LVSD and 384 days for LVSD) (figure 25). ACE inhibitor and/or ARB on discharge: Of those patients discharged in 2009-12 diagnosed with LVSD, 50.1% of those who did not receive an ACE inhibitor or ARB on discharge died (median follow-up of 285 days), whereas only 30.2% of those who were prescribed an ACE inhibitor and/or ARB died (median follow-up of 417 days) (figure 26).

361 days for those discharged on no beta blocker and 403 days for patients discharged on a beta blocker) (figure 27). Loop diuretic on discharge: Of patients diagnosed with LVSD discharged between 2009 and 2012, 25.0% died within the follow-up period if they were not discharged on loop diuretics, compared with 35.8% of patients discharged on loop diuretics (follow-up 423 days for patients without loop diuretics, and 384 days for patients with loop diuretics) (figure 28). Additive drug treatment: Patients with a diagnosis of LVSD

discharged on all three of ACEI/ARBs, beta blockers and MRAs had mortality rates of 25.0% over three years (median followup of 419 days). 26.9% of patients discharged on ACEI/ARBs and beta blockers in 2009-12 died (427 days median follow-up), compared with 40.6% for those discharged on an ACEI/ARB alone (412 days median follow-up). 56.7% of patients who left hospital on none of the three NICE recommended treatments in 2009-12 died (median follow-up of 257 days) (figure 29). Referral to follow-up services on discharge: Patients referred

for cardiology follow-up had far better outcomes than those not referred for follow-up with a cardiologist, with mortality of 29.3% (422 days median follow-up) for the former, compared with 44.6% for the latter (327 days median follow-up) (figure 30). Those referred to heart failure liaison follow-up services had lower mortality (34.7%) than those not referred to nurse led follow-up (39.4%) across the three year audit period (median follow-up of 363 for those not referred to HF liaison service follow-up, and 384 days for patients referred to nurse led services on discharge) (figure 31).

Three-year predictors of mortality for survivors to discharge Similar to the findings of the 2011/12 survival analyses, a Cox proportional hazards model shows that in 2009-12, even when accounting for age, severity of symptoms on admission and previous AMI, those patients who were not prescribed an ACE inhibitor/ARB and those not prescribed a beta blocker on discharge were more likely to die during the follow-up period than those given these therapies on discharge. The mortality rate also remained higher for patients discharged on a loop diuretic, those not referred to cardiology follow-up, and those who were not treated on a cardiology ward (table 9).

Beta blocker on discharge: Of those patients discharged with

a diagnosis of LVSD between 2009 and 2012, 45.9% of those not discharged on beta blockers died, compared with 29.4% of patients prescribed a beta blocker (median follow-up period of

vii. Data for the 2009-12 mortality analysis can be found in appendix 4 at the end of this report.

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Table 9: Cox proportional hazards model for postdischarge mortality (2009-12)

Fig 22: Three-year post-discharge survival by sex (2009-12)

Predictor

Hazard ratio

Lower .95

Upper .95

p value

Previous AMI

1.26

1.22

1.31

< 0.001

Age > 75

1.82

1.75

1.89

< 0.001

NYHA class III/IV

1.15

1.11

1.19

< 0.001

No ACEI/ARB on discharge

1.58

1.52

1.63

< 0.001

No beta blocker on discharge

1.29

1.25

1.33

< 0.001

Loop diuretic on discharge

1.21

1.14

1.28

< 0.001

No cardiology follow-up

1.34

1.30

1.39

< 0.001

Not a cardiology inpatient

1.11

100 90 80 70

% Survived

60 50 40 30 20

1.08

1.15

< 0.001

10 0 0

Fig 21: Three-year post-discharge survival (2009-12)

200

400

600

800

1000

1200

Days after discharge

100

Women Men

90 80

Fig 23: Three-year post-discharge survival by age (2009-12)

% Survived

70 60

100

50

90

40

80

30

70 % Survived

20 10 0 0

200

400

600

800

Days after discharge

1000

1200

60 50 40 30 20 10 0 0

200

400

600

800

1000

1200

Days after discharge

48

16-44

55-64

75-84

45-54

65-74

85+

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Fig 24: Three-year post-discharge survival by place of care (2009-12)

Fig 26: Three-year post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge in patients with LVSD (2009-12)

100 100

90

90

80

80 % Survival post-discharge

% Survived

70 60 50 40 30 20 10

70 60 50 40 30 20 10

0 0

200

400

600

800

1000

0

1200

0

200

400

600

Days after discharge

1000

1200

Days

Other

Cardiology

800

ACE inhibitor/ARB

General Medicine

No ACE inhibitor/ARB

Fig 27: Three-year post-discharge survival by prescription of beta blockers on discharge in patients with LVSD (2009-12)

Fig 25: Three-year post-discharge survival by presence or absence of LVSD (2009-12) 100

100

90

90

80

80 70

60 % Survived

% Survived

70

50 40 30

60 50 40 30

20

20

10

10

0 0

200

400

600

800

Days after discharge

1000

1200

0 0

200

400

800

1000

1200

Days after discharge

Diagnosis of LVSD No diagnosis of LVSD

600

Beta blocker No beta blocker

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Fig 28: Three-year post-discharge survival by prescription of loop diuretics on discharge in patients with LVSD (2009-12)

Fig 30: Three-year post-discharge survival by referral to cardiology follow-up services (2009-12) 100

100

90

90

80

80

70 % Survived

70 % Survived

60 50 40

60 50 40 30

30

20

20

10

10

0

0 0

200

400

600

800

1000

0

1200

200

400

600

800

1000

1200

Days after discharge

Days after discharge

Beta blocker

Referred to cardiology follow-up

No beta blocker

Not referred to cardiology follow-up

Fig 29: Three-year post-discharge survival by additive drug treatment on discharge in patients with LVSD (2009-12)

Fig 31: Three-year post-discharge survival by referral to heart failure liaison follow-up services (2009-12) 100

100

90

90

80

80

70 60 % Survived

% Survived

70 60 50 40

50 40 30

30

20

20

10

10

0

0

0

0

200

400

600

800

1000

1200

200

400

600

800

1000

1200

Days after discharge

Days after discharge

ACEI inhibitor/ARB, beta blocker and MRA ACEI inhibitor/ARB and beta blocker

Referred to heart failure liaison services Not referred to heart failure liaison services

ACE inhibitor/ARB No ACEI inhibitor/ARB, beta blocker or MRA 50

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4 Case studies 4.1 Improving clinical practice and patient outcomes Lee Taaffe, North Central London Cardiovascular and Stroke Network In North Central London, data from the National Heart Failure Audit is used to measure and improve the heart failure services across the six hospitals in the North Central London Cardiovascular and Stroke Network. The North Central London Heart Failure Task Group, which is hosted by the Network, devised a suite of local measures covering activity, admissions, diagnostics, prescribing, length of stay, and mortality. The data from the National Heart Failure Audit, along with HES data, is analysed quarterly and presented at the Heart Failure Task Group for discussion and learning. At the end of the financial year an annual report is produced that details the outcomes for each hospital across the year and benchmarks performance against local and national report findings. Furthermore, the report benchmarks against previous years’ findings to show how each hospital is progressing in its delivery of services to patients.

4.2 Using data to drive improvement Pauline Wortman, Enhancing Quality & Recovery Enhancing Quality & Recovery (EQ&R) is an innovative and award winning clinician-led quality improvement programme across Kent, Surrey and Sussex. The programme works with teams in 10 Acute Trusts, six Community Providers and three Mental Health Trusts and spans 10 clinical pathways. Clinicians identify between four and seven evidence-based measures, aligned wherever possible to NICE guidance, in order to benchmark performance and drive forward quality improvement focussed on improving patient outcomes and reducing variation in care.

Quality improvement that is clinically-led, data driven and focussed on patient outcomes is a very, very potent cocktail.

EQ&R has recognised that when clinicians take ownership of their data and believe and trust it, this provides a very strong motivation to improve against it. Making this happen requires a clear focus on data quality: the need for a tightly defined population and clinical criteria so that ”apples are being compared with apples” and for a high level of data completeness (all patients, not just patients on the cardiology ward, for example). Improvement builds on clinicians “knowing where they are”, not just “where they think they are”. It also depends on clinical leadership and the development of wider teams, including coders and data analysts, for example, and truly collaborative working focussed on sharing of best practice and using the skills and knowledge of multi-disciplinary teams. At the core of the EQ&R approach is a focus on producing transparent measurement which is hard to ignore for accountability and improvement, rather than judgement. Collecting timely and relevant data on every patient, every time can appear to be a chore especially before the value of the information being produced is realised. EQ&R has found engagement needs to encompass all those involved in the audit loop with active sharing of results within teams. Action against the data is more likely if analysis is available as soon as is practicable. In this way quality data can be reflected upon and action taken harnessing and maintaining the momentum and enthusiasm for improvement in patient care. This immediacy and impetus for service improvement can be lost where data is not fed back in a timely and consistent way. Collaboration between EQ&R and MINAP and the National Heart Failure Audit is securing advantages for all parties. By sharing data, the duplication of data input is avoided. By capturing the full population rather than a sample population, data completeness is improved and the discipline of a monthly rather than yearly data deadline feeds into a faster service improvement cycle. Data collection and reporting provides the canvas on which to build service improvements, outcome improvements and variation reductions. The data collected within the EQ programme is specifically designed to monitor: • That every heart failure patient in hospital has appropriate

Professor Sir Bruce Keogh, NHS Medical Director, EQ&R What a difference a year makes conference, Gatwick 25th January 2012.

EQ&R is the inaugural winner of the Cardiac care category of the Health Service Journal & Nursing Times 2012 Integration Award. This achievement reflects the success of clinical teams across the region in introducing quality improvement metrics for the full heart failure pathway as well as collaborative working that has led to action to improve quality of patient care with reduced variation and improved patient outcomes across the region.

diagnosis, management and appropriate information provided to them about their condition prior to discharge. • That every patient has a continuing plan. • That the ‘transfer of care’ between sectors contains

minimum information. • Personalised care plans and patient held records meet

‘best practice’ standards and are completed with the patient within two weeks of discharge. • That medical management is optimised in the community.

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• That end-of-life care is planned.

Process

• That there is a reduction in variations in clinical practice

and outcomes. • That the patient experience is improved.

Quality data provides the evidence that services are making improvements to reach the ultimate goal of delivering the care that each and every patient can expect: A quality of care delivered to every patient, every time, regardless of their local hospital or community provider, where they live, or who their GP is.

4.3 An example of local practice in conducting the National Heart Failure Audit Rachel Kindred, Denise Hockey and Lynne Thomas, Aneurin Bevan Health Board, South Wales

Cases are identified monthly by the Information Department based on discharge codes

Q&PS Improvement & Measurement Assistant obtains notes

Heart Failure Specialist Nurse team analyses notes and completes audit pro forma

Q&PS Improvement & Measurement Co-ordinator inputs data to the NICOR database, then exports data for analysis and feedback to Heart Failure clinical team meeting every two months.

Challenges

Left to right: Lynne Thomas (Quality and Patient Safety Improvement and Measurement Assistant), Denise Hockey (Heart Failure Nurse Specialist), Rachel Kindred (Quality and Patient Safety Improvement & Measurement Co-ordinator)

Background Participation in the National Heart Failure Audit began at Nevill Hall Hospital in 2008 with a small patient group, namely those patients referred to the Heart Failure Specialist Nurse team. In 2009 the Clinical Audit Department (now the Quality & Patient Safety Improvement & Measurement Department), became involved with the data input, also using the data for the All Wales 1000 Lives Campaign. The patient group was widened in 2010 to include all those with a coded diagnosis of heart failure on discharge. In 2012 data collection began at Royal Gwent Hospital, the Health Board’s other main acute hospital.

52

The biggest challenge has been to achieve collaboration between the three departments (Information, Quality & Patient Safety and the Heart Failure Specialist Nurse team). This has involved regular communication to refine the identification of cases and the obtaining of case notes for the audit. Obtaining case notes has proved time consuming and requires close communication to ensure the notes are available at the right time to be viewed by a busy clinical team, before being removed when required by other departments of the hospital.

Benefits The biggest benefit to participation has been the ability to export and review the data regularly as a team, allowing the comparison of data over time in order to resolve areas of lower compliance.

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4.4 The national perspective Hugh F McIntyre, Chair NICE Heart Failure Quality Standard and Heart Failure Commissioning Outcome Framework/Quality Outcome Framework The central purpose of improving the quality of care is to reduce variation and improve outcome. Improving the quality of care requires defined standards and the systematic measurement of care against those standards. These measurements must then be made available to those accountable for delivering care to allow them both to benchmark and where necessary improve care. Based upon the heart failure guideline update (2010), measurable indicators of care - the heart failure quality standards - were published in 2011. These define the components of high quality care which services for patients with heart failure should seek to deliver and which commissioners will increasingly expect from any provider. Consistent delivery of improved standards of care should lead to better outcome. It is the role of the National Commissioning Board to deliver such improvement in outcomes - to do so will require a set of integrated indicators (currently under development) which will be delivered through the Commissioning Outcome Framework/Quality Outcome Framework process and will be used by the National Commissioning Board to hold Clinical Commissioning Groups to account.

With standards established, the second component of quality improvement - consistent reliable local data - is fundamental to enable clinical teams to understand the quality of local care they deliver. Now in its sixth year, the National Heart Failure Audit, which covers nearly all of England and Wales, provides a dataset that not only addresses the majority of the hospitalbased quality standards but already indicates the potential link between better quality of care (for example place of care and optimal therapy) and better outcome. For the first time the introduction of hospital-level reporting provides specialist teams with measures of the inclusiveness and quality of the care which they deliver, and allows teams to compare their performance with that of local and national peers. Looking to the future, two areas are likely to become increasingly important. The National Commissioning Board sets five domains of outcome, which can be summarised as enhanced survival; quality of life; recovery (including both hospital admission and long term conditions); patient experience and safety. These move beyond the traditional â&#x20AC;&#x2DC;medicalâ&#x20AC;&#x2122; outcomes of death and readmission and are particularly relevant to heart failure - especially in older populations. Secondly the local mechanisms that deliver comparative data reporting (which are under development) will need to address not only the organised delivery of comparative data through networks, but also the mechanisms whereby local variations in quality of care can be targeted and reduced.

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5 Research use of National Heart Failure Audit data Professor Henry Dargie, HALO Chair The National Heart Failure Audit is in its sixth year of activity, and is now collecting data on 60% of all patients discharged from hospital with heart failure in England and Wales. With over 130,000 records in the database, the audit has become a valuable research resource, and as the size and representativeness of the audit increases, so too will its significance for research projects. In 2011 HALO â&#x20AC;&#x201C; the Heart failure Audit anaLysis and Outcomes group - was established to handle applications for the use of National Heart Failure Audit data from external groups, and to manage internal research projects. The National Heart Failure Audit has recently revised its dataset to include a series of new fields that will allow credible risk adjusted data to be produced. This data can be used for comparisons of outcomes among centres, and will allow the audit to start answering more sophisticated questions about variation in outcomes and to investigate the correlation between treatment and management, and outcomes for patients. We hope to start publishing risk adjusted data at a hospital level by 2013. Of particular interest to HALO is the prospect of investigating the very high mortality recorded by the audit, which is highly variable between centres. In 2011/12 overall mortality during admission stood at 11.1%, with much lower mortality in cardiology wards (7.8%) compared to General Medical wards (13.2%) and other wards (17.4%). The one-year mortality for those surviving to discharge was also very high (26.2%) and it is quite possible that recorded mortality rates will continue to rise as a result of increasing representativeness of the audit. Much higher than reported from Europe and the US, these high mortality rates probably reflect the relatively unselective nature of the data. The data seem to suggest that managing heart failure patients in a specialist setting has benefits beyond those conferred by higher prescription rates and optimal titration of evidence based drugs. This was shown dramatically for AMI when coronary care units (CCUs) were introduced by Desmond Julian in 1960s to provide early cardiopulmonary resuscitation (CPR), and mortality rates fell dramatically within a couple of years. Our hypothesis is that this was not due to CPR alone but to better management by cardiologists of the most common cause of death in CCUs which was then, and still remains, heart failure. However the extent to which the myriad factors affecting the outcomes for heart failure patients are managed better by specialists remains an unanswered and key research question, and one which HALO hopes to address.

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Current HALO projects include a collaborative application for funding to the NIHR Health Technology Assessment (HTA) programme with Professor Barnaby Reeves of the University of Bristol and his team. The study has been commissioned by the HTA to determine the effect of BNP and NT-proBNP testing on outcomes for chronic heart failure patients, and to assess the cost-effectiveness of the technology. The HALO/University of Bristol application proposes to use audit data to supplement this systematic review, and to evaluate the efficacy of BNP testing in reducing mortality and readmission rates in heart failure patients. HALO is also involved in a collaborative project with Professor Kazem Rahimi from the George Centre for Healthcare Innovation at the University of Oxford, which will investigate the diverse factors affecting outcomes for heart failure patients. The project, funded by an NIHR grant, will look into various aspects of the delivery of heart failure care, in an attempt to determine the percentage of variation in outcomes that is determined by hospital related factors. This project ties in closely with the ambition of the National Heart Failure Audit to deliver risk adjusted data, and will be extremely valuable towards the goal of generating and publishing risk adjusted, hospital level analysis. Adam Timmis, Chair of MAG (MINAP academic group), has recently joined the group in order to develop a programme of research between MAG and HALO, looking at the incidence of heart failure and outcomes in post-infarction patients. This would involve linkage of MINAP and National Heart Failure Audit data, and tracking patients across multiple cardiovascular admissions to hospital. In addition to this, HALO is working with the European Society of Cardiology Heart Failure Association to produce an educational tool which incorporates the ESC guideline for the treatment and care of heart failure patients into the audit application. This will provide guidance on best practice and clinical standards alongside the data entry application, and will turn the audit database into a powerful tool for promoting and implementing optimal heart failure care. As HALO moves from strength to strength, we welcome applications for use of National Heart Failure Audit data from hospitals, universities and research groups.

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6 Conclusions This audit confirms that patients admitted to hospital with a primary diagnosis of heart failure have a poor outcome despite contemporary pharmacological therapy, but that optimal treatment and management, which follows recommended clinical guidelines, is associated with improved outcomes. Patients are much more likely to receive this treatment if they are treated on a cardiology ward, and these patients consequently have lower mortality, both within hospital and following discharge. Improving the outcome of patients with heart failure requires four major approaches: • Improved case-ascertainment • Better treatments • Better implementation of existing treatment and

management pathways • Better recognition and management of the end of life

This cannot be achieved without better coordination and organisation of care across the spectrum of health and social care. Future audits will provide more detailed information on risk factors and devices. Increased access to other datasets will provide comprehensive data on the rate, duration and reasons for re-hospitalisation, and information on the cause of death will allow for more sophisticated mortality analyses. The audit group would like to thank all of the nurses, clinicians, clinical audit facilitators and all others involved in collecting and submitting data to the audit over the last five years. As the audit continues to grow it becomes more useful as a tool for monitoring the treatment and management of heart failure in England and Wales, both at a local and national level. The continued support and participation of hospitals, Trusts and Health Boards is essential for the success and development of the audit, and all of the work and input from individuals and hospitals across the U.K. is greatly appreciated.

6.1 Quality of care and patient outcomes The 2011/12 report supports the findings of previous years in emphasising the benefits of specialist cardiology input in the management of acute heart failure patients. The National Heart Failure Audit strongly supports the NICE guidance relating to heart failure, and continues to encourage its implementation. NICE has produced both a clinical guideline (2010) and a quality standard (2011) for chronic heart failure, which outline evidence based clinical guidance as to the most effective treatment and management of heart failure patients.26 On the basis of the findings in this report, the National Heart Failure Audit group recommends that Trusts and Health Boards ensure that patients with heart failure have specialist input to their care and are managed on cardiology wards wherever

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feasible. Access to specialist medical and nursing care is essential to optimal care for heart failure patients, so Trusts should ensure that key personnel are in place to deliver this care. Key, evidence-based therapies should be initiated during a patient’s hospital admission. The use of ACE inhibitors/ARBs, beta blockers and MRAs for patients with left ventricular systolic dysfunction is associated with improved patient outcomes, and these treatments should be implemented wherever possible. Furthermore, audit findings suggest that robust arrangements for optimisation of therapy for cardiac dysfunction via cardiology follow-up, nurse-led heart failure liaison services and primary care need to be firmly in place prior to discharge. The next phase of the audit will address this discharge planning phase more specifically, but 2011/12 findings clearly show that referral to specialist follow-up services on discharge has beneficial effects on outcomes for heart failure patients. The audit showed in 2011/12 that outcomes for patients with heart failure without LVSD are poorer than for those with LVSD. This likely reflects the greater age of patients who do not have LVSD, but this aspect of heart failure care requires greater attention to identify other possible reasons for this difference and to determine improved management strategies. The continuing increase in case ascertainment coupled with data already accrued from previous audits will provide a robust basis for these aims and should be a focus of interest for subsequent audit reports.

6.2 Data completeness and participation The National Heart Failure Audit is a key tool for gathering information to improve outcomes in acute heart failure. Even though considerable progress has been made in case ascertainment since the audit began, the data is still not fully representative of the population of heart failure patients in England and Wales. The aim now should be to strive for inclusion of all patients admitted to hospital with a primary diagnosis of heart failure to ensure a more representative dataset. As of April 2013 hospitals will be required to submit data pertaining to all acute admissions with a primary discharge diagnosis of heart failure. By 2012/13, the audit aims to enrol 95% of eligible Trusts in England and Health Boards in Wales, and to capture 70% of all acute patients admitted to hospital with heart failure in England and Wales. Following the deletion of several thousand 0 and 1 day admissions from the 2011/12 data, which were believed to be elective admissions for patients with heart failure, hospitals are reminded that only acute heart failure patients should be included in the National Heart Failure Audit. The inclusion of elective admissions has the potential to skew survival analysis and misrepresent the treatment and management of heart failure in England and Wales. National Heart Failure Audit April 2011-March 2012

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7 Appendices Appendix 1: National Heart Failure Audit Project Board membership Name

Representation

Jackie Austin

Nurse Consultant (Aneurin Bevan Health Board) and Lead Nurse (South Wales Cardiac Network)

Gemma Baldock-Apps

Cardiology Audit and Data Manager (East Sussex Healthcare NHS Trust)

Lailaa Carr

Contract and Project Officer (HQIP)

John Cleland

Professor of Cardiology (U. of Hull)

Henry Dargie

Professor of Cardiology and Consultant Cardiologist (U. of Glasgow); Chair of the Heart Failure Academic Group

Nadeem Fazal

National Clinical Audit Services Manager (NICOR)

Jules Grange

Heart Failure Specialist Nurse (East Sussex Healthcare NHS Trust)

Suzanna Hardman

Consultant Cardiologist (Whittington) and Chair of British Society for Heart Failure

Candy Jeffries

Interim Director (Beds and Herts Heart and Stroke Network)

Helen Laing

National Clinical Audit Lead (HQIP)

Theresa McDonagh (Chair)

National Heart Failure Audit Clinical Lead; Consultant Cardiologist and Professor of Heart Failure (KCH/KCL)

Richard Mindham

Heart failure patient representative

Polly Mitchell

National Heart Failure Audit Project Manager (NICOR)

Marion Standing

Developer (NICOR)

Lynne Walker

NICOR Programme Manager (NICOR)

Appendix 2: HALO membership Name

Representation

John Cleland

Professor of Cardiology (U. of Hull)

Henry Dargie (Chair)

Professor of Cardiology and Consultant Cardiologist (U. of Glasgow)

Suzanna Hardman

Consultant Cardiologist (Whittington) and Chair of BSH

Theresa McDonagh

National Heart Failure Audit Clinical Lead; Consultant Cardiologist and Professor of Heart Failure (KCL)

Polly Mitchell

National Heart Failure Audit Project Manager (NICOR)

Appendix 3: Data for 2011/12 mortality analysis In-hospital mortality Analysis

Variable

Deaths

Denominator

Mortality (%)

Overall

In hospital deaths

3420

30886

11.1%

Sex

Men

1730

16969

10.2%

Sex

Women

1690

13910

12.1%

Place of care

Cardiology ward

1141

14635

7.8%

Place of care

General medical ward

1691

12833

13.2%

Place of care

Other ward

578

3316

17.4%

Age

16-44

15

594

2.5%

Age

45-54

29

1119

2.6%

Age

55-64

136

2704

5.0%

Age

65-74

416

5757

7.2%

Age

75-84

1207

11102

10.9%

Age

â&#x2030;Ľ85

1617

9609

16.8%

56

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Mortality for survivors to discharge Analysis

Variable

Deaths

Denominator

Mortality (%)

Overall

All discharges

7182

27386

26.2%

Sex

Men

3937

15186

25.9%

Sex

Women

3244

12193

26.6%

Place of care

Cardiology ward

2944

13463

21.9%

Place of care

General medical ward

3308

11100

29.8%

Place of care

Other ward

914

2734

33.4%

Age

16-44

43

576

7.5%

Age

45-54

99

1086

9.1%

Age

55-64

346

2561

13.5%

Age

65-74

1068

5320

20.1%

Age

75-84

2654

9864

26.9%

Age

â&#x2030;Ľ85

2972

7978

37.3%

Diagnosis LVSD

Dx LVSD

4087

16460

24.8%

Diagnosis LVSD

No Dx LVSD

3095

10926

28.3%

ACEI/ARB on discharge (LVSD)

ACEI/ARB

2527

12470

20.2%

ACEI/ARB on discharge (LVSD)

No ACEI/ARB

915

2361

38.8%

ACEI/ARB on discharge (all)

ACEI/ARB

3977

18895

21.0%

ACEI/ARB on discharge (all)

No ACEI/ARB

1995

5444

36.7%

Beta blocker on discharge (LVSD)

Beta blocker

2447

11592

21.1%

Beta blocker on discharge (LVSD)

No beta blocker

1079

3270

33.0%

Beta blocker on discharge (all)

Beta blocker

3806

17134

22.2%

Beta blocker on discharge (all)

No beta blocker

2350

7329

32.1%

Loop diuretic on discharge (LVSD)

Loop diuretic

3603

14075

25.6%

Loop diuretic on discharge (LVSD)

No loop diuretic

281

1658

17.0%

Loop diuretic on discharge (all)

Loop diuretic

6300

23798

26.5%

Loop diuretic on discharge (all)

No loop diuretic

521

2524

20.6%

Additive drug treatment (LVSD)

ACEI/ARB, beta blocker and MRA on discharge

734

4367

16.8%

Additive drug treatment (LVSD)

ACEI/ARB & beta blocker on discharge

809

4408

18.4%

Additive drug treatment (LVSD)

ACEI/ARB on discharge

357

1316

27.1%

Additive drug treatment (LVSD)

No ACEI/ARB, beta blocker or MRA on discharge

299

653

45.8%

Referral to cardiology follow-up

Cardiology follow-up

2745

13615

20.2%

Referral to cardiology follow-up

No cardiology follow-up

4082

12724

32.1%

Referral to nurse-led follow-up

HF liaison follow-up

3453

13922

24.8%

Referral to nurse-led follow-up

No HF liaison follow-up

3352

12000

27.9%

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Appendix 4: Data for 2009-12 mortality analysis Three-year in-hospital mortality (2009-12) Analysis

Variable

Deaths

Denominator

Mortality (%)

Overall

In hospital deaths

9082

75331

12.1%

Sex

Men

4605

41040

11.2%

Sex

Women

4472

34263

13.1%

Place of care

Cardiology ward

2872

34984

8.2%

Place of care

General medical ward

4742

32351

14.7%

Place of care

Other ward

1457

7888

18.5%

Age

16-44

15

594

2.5%

Age

45-54

29

1119

2.6%

Age

55-64

136

2704

5.0%

Age

65-74

416

5757

7.2%

Age

75-84

1207

11102

10.9%

Age

≥85

1617

9609

16.8%

Three-year mortality for survivors to discharge (2009-12) Analysis

Variable

Deaths

Denominator

Mortality (%)

Overall

All discharges

24572

66167

37.1%

Sex

Men

13319

36380

36.6%

Sex

Women

11247

29764

37.8%

Place of care

Cardiology ward

9971

32074

31.1%

Place of care

General medical ward

11692

27572

42.4%

Place of care

Other ward

2889

6427

45.0%

Age

16-44

159

1469

10.8%

Age

45-54

384

2742

14.0%

Age

55-64

1276

6247

20.4%

Age

65-74

3868

13201

29.3%

Age

75-84

9083

23652

38.4%

Age

≥85

9799

18851

52.0%

Diagnosis LVSD

Diagnosis of LVSD

13534

39028

34.7%

Diagnosis LVSD

No Diagnosis of LVSD

11038

27139

40.7%

ACEI/ARB on discharge (LVSD)

ACEI/ARB on discharge (LVSD)

9124

30166

30.32 %

ACEI/ARB on discharge (LVSD)

No ACEI/ARB on discharge (LVSD)

2810

5604

50.1%

Beta blocker on discharge (LVSD)

Beta blocker on discharge (LVSD)

7658

26054

29.4%

Beta blocker on discharge (LVSD)

No beta blocker on discharge (LVSD)

4275

9317

45.9%

Loop diuretic on discharge (LVSD)

Loop diuretic on discharge (LVSD)

12002

33525

35.8%

Loop diuretic on discharge (LVSD)

No loop diuretic on discharge (LVSD)

1003

4005

25.0%

58

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Additive drug treatment (LVSD)

ACEI/ARB, beta blocker and MRA on discharge

2389

9577

25.0%

Additive drug treatment (LVSD)

ACEI/ARB & beta blocker on discharge

2814

10470

26.9%

Additive drug treatment (LVSD)

ACEI/ARB on discharge

1606

3959

40.6%

Additive drug treatment (LVSD)

No ACEI/ARB, beta blocker or MRA on discharge

1013

1788

56.7%

Referral to cardiology follow-up

Cardiology follow-up

9581

32714

29.3%

Referral to cardiology follow-up

No cardiology follow-up

13652

30585

44.6%

Referral to nurse-led follow-up

HF liaison follow-up

11164

32175

34.7%

Referral to nurse-led follow-up

No HF liaison follow-up

11655

29575

39.4%

Appendix 5: Glossary Term

Acronym

Acute Myocardial Infarction

AMI

Commonly known as a heart attack, a myocardial infarction results from the interruption of blood supply to part of the heart, which causes heart muscle cells to die. The damage to the heart muscle carries a risk of sudden death, but those who survive often go on to suffer from heart failure.

Angiotensin II receptor antagonist/ angiotensin receptor blocker

ARB

A group of drugs usually prescribed for those patients who are intolerant of ACE inhibitors. Rather than lowering levels of angiotensin II, they instead prevent the chemical from having any effect on blood vessels.

Angiotensinconverting enzyme inhibitor

ACE inhibitor/ ACEI

A group of drugs used primarily for the treatment of high blood pressure and heart failure. They stop the bodyâ&#x20AC;&#x2122;s ability to produce angiotensin II, a hormone which causes blood vessels to contract, thus dilating blood vessels and increasing the supply of blood and oxygen to the heart.

Beta blocker

A group of drugs which slow the heart rate, decrease cardiac output and lessen the force of heart muscle and blood vessel contractions. Used to treat abnormal or irregular heart rhythms, and abnormally fast heart rates.

British Society for Heart Failure

BSH

The professional society for healthcare professionals involved in the care of heart failure patients. The BSH aims to improve care and outcomes for heart failure patients by increasing knowledge and promoting research about the diagnosis, causes and management of heart failure.

Cardiac resynchronisation therapy

CRT

CRT, also known as biventricular pacing, aims to improve the heartâ&#x20AC;&#x2122;s pumping efficiency by making the chambers of the heart pump together. 25-50% of all heart failure patients have hearts whose walls do not contract simultaneously. CRT involves implanting a CRT pacemaker or ICD (implantable cardioverter-defibrillator) that has a lead positioned in each ventricle. Most devices also include a third lead which is positioned in the right atrium to ensure that the atria and ventricles contract together.

Chronic obstructive pulmonary disease

COPD

The co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing lung diseases in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs, causing shortness of breath (dyspnoea). In contrast to asthma, this limitation is poorly reversible and usually gets progressively worse over time.

Contraindication

A factor serving as a reason to withhold medical treatment, due to its unsuitability.

Diuretic

A group of drugs which help to remove extra fluid from the body by increasing the amount of water passed through the kidneys. Loop diuretic

Echocardiography

Echo

A diagnostic test which uses ultrasound to create two-dimensional images of the heart. This allows clinicians to examine the size of the chambers of the heart and its pumping function in detail.

Electrocardiography

ECG

A diagnostic test which interprets the electrical activity of the heart, detected by electrode attached to the arms, legs and chest.

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Heart failure

A syndrome characterised by the reduced ability of the heart to pump blood around the body, caused by structural or functional cardiac abnormalities. The condition is characterised by symptoms such as shortness of breath and fatigue, and signs such as fluid retention. Acute heart failure refers to the rapid onset of the symptoms and signs of heart failure, often resulting in a hospitalisation, whereas in chronic heart failure the symptoms develop more slowly.

Hospital Episode Statistics

HES

The national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere. HES is the data source for a wide range of healthcare analysis for the NHS, government and many other organisations. The National Heart Failure Audit uses HES data to calculate case ascertainment.

Left ventricular dysfunction

LVD

Any functional impairment of the left ventricle of the heart.

Left ventricular ejection fraction

LVEF

A measurement of how much blood is pumped out of the left ventricle with each heartbeat. An ejection fraction of below 40% may be an indication of heart failure.

Left ventricular systolic dysfunction

LVSD

A failure of the pumping function of the heart, characterized by a decreased ejection fraction and inadequate ventricular contraction. It is often caused by damage to the heart muscle, for example following a myocardial infarction (heart attack).

Medical Research Information Service

MRIS

An NHS Information Centre service which links datasets at the level of individual patient records for medical research projects. NICOR uses MRIS to determine the life status of patients included in the audit, so as to calculate mortality rates.

Mineralocorticoid receptor antagonist

MRA

A group of diuretic drugs, whose main action is to block the response to the hormone aldosterone, which promotes the retention of salt and the loss of potassium and magnesium. MRAs increase urination, reduce water and salt, and retain potassium. They help to lower blood pressure and increase the pumping ability of the heart.

National Clinical Audit and Patient Outcomes Programme

NCAPOP

A group of 30 national clinical audits, funded by the Department of Health and overseen by HQIP that collect data on the implementation of evidence based clinical standard in U.K. Trusts, and report on patient outcomes.

National Institute for Cardiovascular Outcomes Research

NICOR

Part of the National Centre for Cardiovascular Prevention and Outcomes, based in the Institute of Cardiovascular Science at University College London. NICOR manages six national clinical audits and three new technology registries.

National Institute for Health and Clinical Excellence

NICE

A special health authority in England which provides guidance, sets quality standards and manages a national database to improve peopleâ&#x20AC;&#x2122;s health and prevent and treat ill health. NICE makes recommendations to the NHS on new and existing medicines, treatments and procedures, and on treating and caring for people with specific diseases and conditions.

New York Heart Association class

NYHA class

NYHA classification is used to describe degrees of heart failure by placing patients in one of four categories based on how much they are limited during physical activity: Class I (Mild): No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea (shortness of breath). Class II (Mild): Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea. Class III (Moderate): Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnoea. Class IV (Severe): Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Oedema

Patient Episode Database of Wales

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An excess build-up of fluid in the body, causing tissue to become swollen. Heart failure patients often suffer from peripheral oedema, affecting the feet and ankles, and pulmonary oedema, in which fluid collects around the lungs. PEDW

The national statistics database for Wales, collecting data on all inpatient and outpatient activity undertaken in NHS hospitals in Wales, and on Welsh patients treated in English NHS Trusts.

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8 References 1.

For example: EuroHeart Failure Survey II reports in-

6.

National Institute for Health and Clinical Excellence (2010),

hospital mortality rates of 6.7%, but has a patient group

CG108 Chronic heart failure: Management of chronic heart

of only 3580 (see Nieminen MS et al (2006), ‘EuroHeart

failure in adults in primary and secondary care, http://

Failure Survey II (EHFS II): a survey on hospitalized acute

publications.nice.org.uk/chronic-heart-failure-cg108.

heart failure patients: description of population’, European Heart Journal 27(22):2725:36. http://www.ncbi.nlm.nih.

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gov/pubmed/17000631), and the ESC Heart Failure Pilot

Wislon P, Sutton G (2000), ‘Survival of patients with a new

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Scarborough P, Bhatnagar P, Wickramasinghe K, Smolina K, Mitchell C, Rayner M (2010), Coronary heart disease statistics: 2010 edition, British Heart Foundation Statistics Database, p.54, www.bhf.org. uk/idoc.ashx?docid=9ef69170-3edf-4fbb-a202a93955c1283d&version=-1.

See National Heart Failure Audit annual reports from 2008/9, 2009/10 and 2010/11, www.ucl.ac.uk/nicor/audits/

European Journal of Heart Failure 12(10):1076-84. http://

2.

Cowie M, Woods D, Coats A, Thomson S, Suresh V, Poole-

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Gibbs JSR, McCoy ASM, Gibbs LME, Rogers AE, AddingtonHall JM (2002), ‘Living with and dying from heart failure: the role of palliative care’, Heart 88, 36-39, http://heart.bmj. com/content/88/suppl_2/ii36.full.

10. Jiang W, Alexander J et al (2001), ‘Relationship of Depression to Increased Risk of Mortality and Rehospitalization in Patients with Congestive Heart Failure’, Archives of Internal Medicine 161(15), 1849-1856, http://www.ncbi.nlm.nih.gov/ pubmed/11493126. 11. NHS (2010), National Service Framework for Coronary Heart Disease (Standard eleven: Heart failure), http://www. dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@ dh/@en/documents/digitalasset/dh_4057526.pdf. 12. National Institute for Health and Clinical Excellence (2010), CG108 Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care, http:// publications.nice.org.uk/chronic-heart-failure-cg108. 13. National Institute for Health and Clinical Excellence (2011), Chronic heart failure quality standard, http://www.nice. org.uk/guidance/qualitystandards/chronicheartfailure/ home.jsp. 14. Mcdonagh TA, Blue, L, Clark AL, Dahlström U, Ekman I, Lainscak M, McDonald K, Ryder M, Strömberg A, Jaarsma T (2011), ‘European Society of Cardiology Heart Failure Association Standards for Delivering Heart Failure Care’, European Journal of Heart Failure 13(3), 235-241, http:// eurjhf.oxfordjournals.org/content/13/3/235.full.

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15. The NHS Information Centre, Participation Rates in the

22. National Institute for Health and Clinical Excellence (2010),

Heart Failure Audit (CV37), http://mqi.ic.nhs.uk/Search.as

CG108 Chronic heart failure: Management of chronic heart

px?query=heart%25failure&ref=1.05.27.

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16. Care Quality Commission, Quality and Risk Profiles, http:// www.cqc.org.uk/organisations-we-regulate/registeredservices/quality-and-risk-profiles-qrps.

23. National Institute for Health and Clinical Excellence (2011), Chronic heart failure quality standard, http://www.nice. org.uk/guidance/qualitystandards/chronicheartfailure/

17. Number 10, Letter to Cabinet Ministers on transparency and

home.jsp.

open data, http://www.number10.gov.uk/news/letter-tocabinet-ministers-on-transparency-and-open-data/. 18. Cleland JGF, Mcdonagh TA, Rigby AS, et al (2011), â&#x20AC;&#x2DC;The

24. See www.ucl.ac.uk/nicor/audits/heartfailure/dataset. 25. National Institute for Health and Clinical Excellence (2010),

national heart failure audit for England and Wales 2008-

CG108 Chronic heart failure: Management of chronic heart

2009â&#x20AC;&#x2122;, Heart 97 (11), 876-86, http://www.ncbi.nlm.nih.gov/

failure in adults in primary and secondary care, http://

pubmed/21173198.

publications.nice.org.uk/chronic-heart-failure-cg108, clause 1.2.2.7.

19. HQIP, National Clinical Audits, http://www.hqip.org.uk/ national-clinical-audits-including-ncapop-and-corp/.

26. National Institute for Health and Clinical Excellence (2010), CG108 Chronic heart failure: Management of chronic heart

20. Department of Health, 2011/12 Standard terms and

failure in adults in primary and secondary care, http://

conditions for acute hospital services (Gateway reference

publications.nice.org.uk/chronic-heart-failure-cg108;

15458), http://www.dh.gov.uk/prod_consum_dh/groups/

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dh_digitalassets/documents/digitalasset/dh_124518.pdf.

Chronic heart failure quality standard, http://www.nice.

21. Welsh Government, NHS Wales National Clinical Audit and Outcomes Review Plan 2012/13, http://www.hqip.org.uk/

org.uk/guidance/qualitystandards/chronicheartfailure/ home.jsp

assets/Core-Team/NHS-Wales-NCAOR-Plan-2012-13.pdf.

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This work remains the sole and exclusive property of UCL and may only be reproduced where there is explicit reference to the ownership of UCL. This work may be re-used by NHS and government organisations without permission. Commercial re-use of this work must be granted by UCL.

Copyright Š 2012 UCL, NICOR National Heart Failure Audit. All rights reserved.

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National Heart Failure Audit  

Professor Dargie said figures showed that those on an ACE inhibitor and betablockers had better survival rates, as did those receiving immed...

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