Monday, November 24, 2014

Heart failure performance and outcomes

Here's a recent paper in JACC with some interesting findings:

Methods We assessed rates of compliance with care measures for patients hospitalized with acute or chronic heart failure in the ARIC (Atherosclerosis Risk In Communities) study surveillance catchment area from 2005 to 2009. Rates of compliance were compared between patients with a principal discharge diagnosis of heart failure and those with another principal discharge diagnosis.

I interject here to point out this important distinction. If the primary diagnosis is heart failure the hospital is under the “report card” and financial incentive of the heart failure performance measures. If the heart failure patient is discharged under a different primary diagnosis (with heart failure as a secondary) the hospital is not under the incentive. Keep that in mind in reading the results:

Results Of 4,345 hospitalizations of heart failure patients, 39.6% carried a principal diagnosis of heart failure. Patients with a principal heart failure diagnosis had higher rates of LV function assessment (89.1% vs. 82.5%; adjusted prevalence ratio [aPR]: 1.07; 95% confidence interval [CI]: 1.04 to 1.10) and discharge ACE inhibitor/angiotensin receptor blocker (ARB) in LV dysfunction (64.1% vs. 56.3%; aPR: 1.11; 95% CI: 1.03 to 1.20) as compared to patients hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with reductions in 1-year post-discharge mortality (adjusted odds ratio: 0.66, 95% CI: 0.51 to 0.85; adjusted odds ratio: 0.72, 95% CI: 0.54 to 0.96, respectively) that did not differ for patients with versus without a principal heart failure diagnosis.

So if heart failure is the principal diagnosis and the performance game is in play, participants adhere at a higher rate. That isn't surprising. What surprised me is that the differences were not greater. More interesting to me, though, was the improvement in outcomes associated with following the measures. On the one hand the finding is intuitive; after all, the administration of neurohumeral antagonists guided by assessment of ventricular function is evidence based and would be expected to help patients. On the other hand it is a new finding, in disagreement with prior research, which failed to show that such inherently beneficial and evidence based therapies made a difference in outcomes when associated with performance incentives.

As expressed many times here on the blog, I have a contrarian view of performance measures. This study doesn't change that view much. ACEIs and ARBs seemed to help patients whether their prescription was performance driven or not. The performance driven population (those with a primary diagnosis of heart failure) reflected slightly higher utilization than the comparison group and one could therefore infer that the incentive drove a modest reduction in mortality. Moreover, the idea is plausible. However, as cited in an accompanying editorial, the finding is in contrast to the prior body of research, not only for heart failure but across the whole range of performance measures.

Therein lies the conundrum: take an evidence based treatment (one proven in clinical trials to be beneficial), put it in a public incentive package and it no longer seems to work. The reason is that the way performance is structured, providers are incented to game the system mainly through coding and charting. That, they have discovered, is where the low hanging fruit is for reimbursement and favorable public reporting. Thus performance is not a valid surrogate for quality, either as a driver of patient care or a way to measure it.

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