Protected: Qi04 – Heart failure v0.2

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Operationalisation

Denominator

All patients who survived a hospitalisation for heart failure (ICD-10 I50.0, I50.1, I50.9, I42.0, I42.6, I42.7, I25.5, I11.0, I13.0, I13.2 (1)) requiring hospital-level care during the year.

Numerator

All defined in the denominator who were dispensed within 6 months of the end of the hospital care episode:

  • ACE-I or ARB (ATC C09A-D, C10BX04/06/07/10-21) or ARNi (valsartan and sacubitril, C09DX04),
  • Beta-blocker (C07, C09BX02/04–07, C09DX05)
  • Sodium-glucose co-transporter 2 (SGLT2)-inhibitor (A10BK, A10BD15/16/19-21/23-25/27/29)

Exclusions (Numerator, denominator)

  • Patients aged below 18 at the end of the year of hospital discharge.
  • Patients who die or emigrate within 6 months (180 days) of the discharge.

Notes

  • If a patient has had multiple qualifying events during the year, the first one is included.

Sources of Data

  • Population register
  • Secondary care patient registers
  • Outpatient medication dispensations register

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Clinical guidelines

2021 European Society of Cardiology (ESC) Guidelines for the diagnosis and treatment of acute and chronic heart failure (3):

  • pharmacotherapy is the cornerstone of treatment for HFrEF.
  • The triad of an ACEI/ARNI, a beta-blocker, and an MRA (spironolactone or eplerenone) is recommended in patients with HFrEF (evidence on improved survival, reduced the risk of HF hospitalizations, and reduced symptoms).
  • ARNI may be considered as a first-line therapy instead of an ACEI, and ARBs are an option to those who are intolerant to ACEI or ARNI.
  • SGLT2 inhibitors (dapagliflozin and empagliflozin) added to the tritherapy reduce the risk of CV death and worsening HF and are recommended for all patients with HFrEF regardless of whether they have diabetes or not. In the 2023 ESC update (11), a SGLT2 inhibitor (dapagliflozin and empagliflozin) is recommended to patients with HFmEF or HFpEF to reduce the risk of hospitalisation and CV death.
  • Diuretics are recommended in congested patients with HfpEF or HFmrEF to alleviate symptoms.
  • ACE-I/ARB/ARNI, beta-blockers, and/or MRAs may be considered for patients with HfmrEF to reduce the risk of hospitalisation and death.
  • The vast majority of HFpEF patients are treated with ACE-I/ARB, beta-blockers, or MRAs due to underlying hypertension and/or CAD.

 

The Finnish 2023 Current Care guideline on heart failure (12):

  • ACEI/ARB, SGLT2-inhibitor, beta blocker, and MRA to all patients with symptomatic heart failure. The benefits of beta blockers and MRAs are most evident in patients with HFrEF. Beta blocker commonly indicated for treatment of comorbidity atrial fibrillation. Renal insufficiency or hyperkalaemia may limit the use of MRAs.
  • ACEI/ARB and SGLT2-inhibitor is recommended for all heart failure patients.
  • ARNI may be used instead of ACEI/ARB in patients with symptoms despite other evidence-based treatments.

Similar or related indicators in Nordic or European quality assessment

European Society of Cardiology (ESC) HFA quality indicators (13)

  • Proportion of patients with HFrEF who are prescribed the beta-blocker bisoprolol, carvedilol, sustained-release metoprolol succinate, or nebivolol in the absence of any contraindications
  • Proportion of patients with HFrEF who are prescribed an ACE inhibitor, ARB or ARNI in the absence of any contraindications
  • Proportion of patients with HFrEF who are prescribed an MRA in the absence of any contraindications
  • Proportion of patients with HFrEF who are prescribed a SGLT2 inhibitor in the absence of any contraindications
  • Proportion of patients with HF who are prescribed loop diuretic therapy if they have evidence of fluid retention

Swedish heart failure registry SwedeHF quality indicators (14)

  • Prescribed quadruple therapy in patients with HFrEF
  • Prescribed ACEI/ARB/ARNI in patients with HFrEF
  • Prescribed ARNI in patients with HFrEF
  • Prescribed beta-blocker in patients with HFrEF
  • Prescribed MRA in patients with HFrEF
  • Prescribed SGLT2 inhibitor in patients with HFrEF
  • Prescribed SGLT2 inhibitor in patients with HFmrEF
  • Prescribed SGLT2 inhibitor in patients with HFpEF
  • Trends in prescribed ACEI/ARB/ARNI in patients with HFrEF
  • Trends in prescribed ARNI in patients with HFrEF
  • Trends in prescribed beta-blocker in patients with HFrEF
  • Trends in prescribed MRA in patients with HfrEF

Swedish Association of Local Authorities and Regions quality indicators (Vården i siffror)

  • % of patients hospitalised for heart failure who were dispensed ACEI/ARB and beta blockers within six months after hospital discharge, discontinued indicator (15)
  • % of patients hospitalised for heart failure who were dispensed ACEI/ARB and beta blockers within 12-18 months after hospital discharge, discontinued indicator (16)

 The Norwegian quality register Norsk hjertesviktregister quality indicators (17)

  • % of HF patients with LVEF ≤40% treated with ACE-I/ARB/ARNI
  • % of HF patients with LVEF ≤40% treated with beta blocker
  • % of HF patients with LVEF ≤40% treated with MRA
  • % of HF patients with LVEF ≤40% treated with SGLT2-inhibitor
  • % of HF patients with LVEF ≤40% treated with all four medications

Set quality targets

The Norwegian quality register Norsk hjertesviktregister targets (17):

  • ≥90% of HF patients with LVEF ≤40% are treated with ACE-I/ARB/ARNI
  • ≥90% of HF patients with LVEF ≤40% are treated with beta blocker
  • ≥70% of HF patients with LVEF ≤40% are treated with MRA
  • ≥70% of HF patients with LVEF ≤40% are treated with SGLT2-inhibitor
  • ≥70% of HF patients with LVEF ≤40% are treated with all four medications

Similar or related indicators in international scientific literature

  • ER visit/hospitalization due to systolic heart failure in patient with history of systolic heart failure, and use of a beta blocker (e.g., propranolol, nadolol, etc.) (18)
  • % of patients with a diagnosis of CHF prescribed beta blocker, ACE-I at hospital discharge for CHF (19)
  • Appropriate & necessary: beta blockers in patients with a history of CHF (20)
  • Appropriate & necessary: ACEIs or ARBs in patients with a history of CHF (20)
  • % of patients with CHF treated with beta-blockers, ACEI/ARBs, lipid-lowering medications (21)
  • Hospitalisation due to CHF in patient with history of CHF (in 2 years prior to admission), and not using a heart failure indicated β-blocker (in 3 months prior to admission (22)
  • Guideline-based prescribing: Use beta blocker, ACE-I/ARB in heart failure (23)
  • Medications in heart failure: start ACEI or ARB, beta-blocker (24)
  • (Avoidable) hospitalisation due to congestive heart failure or fluid overload, in patient with history of HF and no use of ACEI, ARB or ARNi at time of admission (25)

References

  1. Musella F, Rosano GMC, Hage C, Benson L, Guidetti F, Moura B, et al. Patient profiles in heart failure with reduced ejection fraction: Prevalence, characteristics, treatments and outcomes in a real-world heart failure population. Eur J Heart Fail. 2023;25(8):1246–53.
  2. Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: a comprehensive and updated review of epidemiology. Cardiovasc Res. 2022 Dec 1;118(17):3272–87.
  3. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2021 Sep 21;42(36):3599–726.
  4. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure – Bozkurt – 2021 – European Journal of Heart Failure – Wiley Online Library [Internet]. [cited 2024 Apr 24]. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.2115
  5. Healthcare Quality and Outcomes Indicators – OECD [Internet]. [cited 2024 Feb 29]. Available from: https://www.oecd.org/health/health-care-quality-outcomes-indicators.htm
  6. Schrage B, Lund LH, Benson L, Stolfo D, Ohlsson A, Westerling R, et al. Lower socioeconomic status predicts higher mortality and morbidity in patients with heart failure. Heart. 2021 Feb;107(3):229–36.
  7. Andersen J, Gerds TA, Gislason G, Schou M, Torp-Pedersen C, Hlatky MA, et al. Socioeconomic position and one-year mortality risk among patients with heart failure: A nationwide register-based cohort study. Eur J Prev Cardiol. 2020 Jan 1;27(1):79–88.
  8. Laugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, et al. Nordic Health Registry-Based Research: A Review of Health Care Systems and Key Registries. Clin Epidemiol. 2021 Dec 31;13:533–54.
  9. Furu K, Wettermark B, Andersen M, Martikainen JE, Almarsdottir AB, Sørensen HT. The Nordic countries as a cohort for pharmacoepidemiological research. Basic Clin Pharmacol Toxicol. 2010 Feb;106(2):86–94.
  10. Rasmussen L, Wettermark B, Steinke D, Pottegård A. Core concepts in pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data. Pharmacoepidemiol Drug Saf. 2022;31(10):1015–26.
  11. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2023 Oct 1;44(37):3627–39.
  12. Sydämen vajaatoiminta [Internet]. [cited 2024 Apr 25]. Available from: https://www.kaypahoito.fi/hoi50113
  13. Aktaa S, Polovina M, Rosano G, Abdin A, Anguita M, Lainscak M, et al. European Society of Cardiology quality indicators for the care and outcomes of adults with heart failure. Developed by the Working Group for Heart Failure Quality Indicators in collaboration with the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2022 Jan;24(1):132–42.
  14. Årsrapporter [Internet]. [cited 2024 Apr 25]. Available from: https://www.ucr.uu.se/rikssvikt/om-rikssvikt/arsrapporter
  15. Läkemedelsbehandling 0–6 månader efter sjukhusvårdad hjärtsvikt [Internet]. [cited 2024 Apr 25]. Available from: https://vardenisiffror.se/indikator/6293bc93-a05e-422b-965d-591d127d1008?datefrom=2016-01-01&dateto=2018-12-31&gender&periodtype=year&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&units=07&units=06&units=13&units=01&units=05&units=20&units=19&units=09&units=22&units=10&units=14&units=21&units=18&units=04&units=17&units=03&units=08&units=23&units=25&units=12&units=24&units=se
  16. Läkemedelsbehandling 12-18 månader efter sjukhusvårdad hjärtsvikt [Internet]. [cited 2024 Apr 25]. Available from: https://vardenisiffror.se/indikator/202be9ff-d476-473d-bed2-ecbbcd0e5c5f?datefrom=2012-01-01&dateto=2014-12-31&gender&periodtype=year&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&units=07&units=06&units=13&units=01&units=05&units=20&units=19&units=09&units=22&units=10&units=14&units=21&units=18&units=04&units=17&units=03&units=08&units=23&units=25&units=12&units=24&units=se
  17. SKDE – Kvalitetsregistre [Internet]. [cited 2024 Apr 25]. Available from: https://www.skde.no/kvalitetsregistre/hjertesvikt/sykehus/?selected_row=hjertesvikt_avlastende
  18. MacKinnon NJ, Hepler CD. Preventable drug-related morbidity in older adults 1. Indicator development. J Manag Care Pharm. 2002;8(5):365–71.
  19. Idänpään-Heikkilä UM, Lambie L, Mattke S, McLaughlin V, Palmer H, Tu JV. Selecting indicators for the quality of cardiac care at the health system level in Organization for Economic Co-operation and Development countries. Int J Qual Health Care J Int Soc Qual Health Care. 2006 Sep;18 Suppl 1:39–44.
  20. Dreischulte T, Grant AM, McCowan C, McAnaw JJ, Guthrie B. Quality and safety of medication use in primary care: consensus validation of a new set of explicit medication assessment criteria and prioritisation of topics for improvement. BMC Clin Pharmacol. 2012 Feb 8;12:5.
  21. Selim AJ, Fincke BG, Rogers WH, Qian S, Selim BJ, Kazis LE. Guideline-recommended medications: variation across medicare advantage plans and associated mortality. J Manag Care Pharm. 2013 Mar;19(2):132–8.
  22. Caughey GE, Kalisch Ellett LM, Wong TY. Development of evidence-based Australian medication-related indicators of potentially preventable hospitalisations: a modified RAND appropriateness method. BMJ Open. 2014 Apr 28;4(4):e004625.
  23. Manteuffel M, Williams S, Chen W, Verbrugge RR, Pittman DG, Steinkellner A. Influence of Patient Sex and Gender on Medication Use, Adherence, and Prescribing Alignment with Guidelines. J Womens Health 15409996. 2014 Feb;23(2):112–9.