Current performance measures for heart failure (HF) from CMS target patients with a principal diagnosis of the disease. HF performance measures include evaluating left ventricular (LV) systolic function and providing a discharge prescription for either ACE inhibitors or angiotensin receptor blockers (ARBs). The American College of Cardiology, American Heart Association, and the American Medical Association-Physician Consortium for Performance Improvement have endorsed similar guidelines for adult HF care.

Assessing Hospitalizations

A study published in the Journal of the American College of Cardiology assessed the quality of care for HF patients who were hospitalized for all causes. Lead researcher Saul B. Blecker, MD, MHS, and colleagues assessed rates of compliance with care measures for 4,345 patients hospitalized with acute or chronic HF. “The majority of hospitalizations for individuals with HF had a principal diagnosis that was not HF,” says Dr. Blecker. Only 39.6% of patients had a primary diagnosis of HF.



The investigation also showed that, when compared with HF patients hospitalized for another primary indication, those with a primary HF diagnosis had higher rates of receiving guideline-recommended care, including evaluation of LV systolic function and higher rates of ACE inhibitor or ARB discharge prescriptions. HF patients assessed for LV systolic function had a 34% lower mortality rate in the year following discharge when compared with those who did not receive this evaluation. Prescription of ACE inhibitors or ARBs at discharge for patients with LV systolic dysfunction was associated with a 28% reduced 1-year mortality risk.

“The quality of care for hospitalized HF patients could be dramatically improved by extending the same standards of care to patients with both a primary and secondary HF diagnosis,” Dr. Blecker says. “The potential for improving quality of care for people with a secondary HF diagnosis is particularly important because these patients are more commonly seen in hospitals and are less likely to receive guideline-concordant HF-related therapies than patients with a principal HF diagnosis.”

A Call to Action

Dr. Blecker says the findings highlight the need to improve care for all HF patients. “Our results should serve as a call to action to increase adherence to HF quality measures among patients with a secondary diagnosis of HF. Each year, there are about 4 million HF-related hospitalizations, but about 3 million are not acute HF. Regardless of whether hospitalized patients have a primary or secondary HF diagnosis, quality metrics—including LV function assessment and ACE inhibitors or ARBs—appear to be associated with reduced post-discharge mortality rates. Underperformance on these quality-of-care measures represents a significant gap that must be addressed. Quality initiatives may improve care by targeting hospitalizations with either principal or secondary HF diagnoses.”


Blecker S, Agarwal SK, Chang PP, et al. Quality of care for heart failure patients hospitalized for any cause. J Am Coll Cardiol. 2013 Sept 25 [Epub ahead of print]. Available at:

Bonow RO, Gheorghiade M. Performance matters in heart failure. J Am Coll Cardiol. 2013 Sep 25 [Epub ahead of print]. Available at:

Blecker S, Paul M, Taksler G, Ogedegbe G, Katz S. Heart failure–associated hospitalizations in the United States. J Am Coll Cardiol. 2013;61:1259-1267.

Berardi C, Chamberlain AM, Bursi F, et al. Heart failure performance measures: eligibility and implementation in the community. Am Heart J. 2013;166:76-82.

Rathore SS, Foody JM, Wang Y, et al. Race, quality of care, and outcomes of elderly patients hospitalized with heart failure. JAMA. 2003; 289:2517-2524.