title: Association between process quality measures for heart failure and mortality among US veterans.
abstract: BACKGROUND
  The few available studies of the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting (IQR) care process indicators have not linked receipt of recommended care processes in heart failure (HF) with lower mortality. Because the Veterans Health Administration (VHA) also tracks hospital inpatient quality reporting indicators, in addition to VHA-specific inpatient (pneumococcal and influenza vaccination) and outpatient (angiotensin-converting enzyme inhibitor [ACEI] or angiotensin receptor blocker [ARB] use for left ventricular [LV] dysfunction and LV function documentation) care process indicators, we examined the association between receipt of these care processes and 30-day and 1-year mortality.
  
  
  METHODS
  Retrospective study of 107,045 patients with HF treated at 128 VHA hospitals between 2001 and 2007 and followed up through 2008. We assessed the relationship between receipt of each HF care process and death at 30 days (inpatients only) and 1 year (all patients), using generalized estimating equations to adjust for clinical characteristics and clustering within hospitals.
  
  
  RESULTS
  Overall, inpatient/outpatient use of ACEI/ARB and receipt of pneumococcal or influenza vaccinations were related to lower risks of 30-day and/or 1-year mortality (adjusted odds ratios 0.51-0.77 for vaccinations and 0.60-0.78 for ACEI/ARB use). Conversely, discharge instructions, inpatient/outpatient LV function assessment, or weight instructions before admission were either not related or related to a slightly increase in mortality. Stratified analyses by various mortality risk subgroups did not reveal discernable "dose-response" relationship between mortality risk stratification and the association of care process and mortality.
  
  
  CONCLUSIONS
  Receipt of care processes related to recommended medications and vaccinations were associated with lower 30-day and/or 1-year risk-adjusted mortality in patients with HF. Receipt of care processes that assess patient counseling or chart documentation was not related to lower mortality.
authors.affiliation: Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; Department of Medicine, Alpert Medical School of Brown University, Providence, RI; Medical Service, Providence Veterans Affairs, Providence, RI. Electronic address: Wen-Chih.Wu@va.gov.
authors.forename: Wen-Chih
authors.initials: WC
authors.lastname: Wu
authors.affiliation: Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI.
authors.forename: Lan
authors.initials: L
authors.lastname: Jiang
authors.affiliation: Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; Department of Medicine, Alpert Medical School of Brown University, Providence, RI; Department of Community Health, Brown University, Providence, RI.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Friedmann
authors.affiliation: Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; Department of Community Health, Brown University, Providence, RI; Medical Service, Providence Veterans Affairs, Providence, RI.
authors.forename: Amal
authors.initials: A
authors.lastname: Trivedi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006333:Heart Failure / Q000401:mortality / Q000628:therapy*; D017052:Hospital Mortality; D006801:Humans; D007252:Influenza Vaccines / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care; D010353:Patient Education as Topic / Q000706:statistics & numerical data; D022242:Pneumococcal Vaccines / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care; D014481:United States; D014493:United States Department of Veterans Affairs; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis; D016277:Ventricular Function, Left; D014728:Veterans
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D007252:Influenza Vaccines; D022242:Pneumococcal Vaccines