title: Variation in hospital performance for heart failure management in the National Heart Failure Audit for England and Wales.
abstract: Investigation of variations in provider performance and its determinants may help inform strategies for improving patient outcomes.
  
  
  
  We used the National Heart Failure Audit comprising 68 772 patients with heart failure with reduced left ventricular ejection fraction (HFREF), admitted to 185 hospitals in England and Wales (2007-2013). We investigated hospital adherence to three recommended key performance measures (KPMs) for inhospital care (ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) on discharge, β-blockers on discharge and referral to specialist follow-up) individually and as a composite performance score. Hierarchical regression models were used to investigate hospital-level variation.
  
  
  
  Hospital-level variation in adherence to composite KPM ranged from 50% to 97% (median 79%), but after adjustments for patient characteristics and year of admission, only 8% (95% CI 7% to 10%) of this variation was attributable to variations in hospital features. Similarly, hospital prescription rates for ACE-I/ARB and β-blocker showed low adjusted hospital-attributable variations (7% CI 6% to 9% and 6% CI 5% to 8%, for ACE-I/ARB and β-blocker, respectively). Referral to specialist follow-up, however, showed larger variations (median 81%; range; 20%, 100%) with 26% of this being attributable to hospital-level differences (CI 22% to 31%).
  
  
  
  Only a small proportion of hospital variation in medication prescription after discharge was attributable to hospital-level features. This suggests that differences in hospital practices are not a major determinant of observed variations in prescription of investigated medications and outcomes. Future healthcare delivery efforts should consider evaluation and improvement of more ambitious KPMs.
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK.
authors.forename: Connor A
authors.initials: CA
authors.lastname: Emdin
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Conrad
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK.
authors.forename: Amit
authors.initials: A
authors.lastname: Kiran
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK.
authors.forename: Gholamreza
authors.initials: G
authors.lastname: Salimi-Khorshidi
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK.|The George Institute for Global Health, University of Sydney, Sydney, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Woodward
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK.
authors.forename: Simon G
authors.initials: SG
authors.lastname: Anderson
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK.
authors.forename: Hamid
authors.initials: H
authors.lastname: Mohseni
authors.affiliation: Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
authors.forename: Henry J
authors.initials: HJ
authors.lastname: Dargie
authors.affiliation: Clinical & Academic Department of Cardiovascular Medicine, Whittington Health, London, UK.
authors.forename: Suzanna M C
authors.initials: SM
authors.lastname: Hardman
authors.affiliation: Cardiology Department, King's College Hospital, London, UK.
authors.forename: Theresa
authors.initials: T
authors.lastname: McDonagh
authors.affiliation: Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
authors.forename: John J V
authors.initials: JJ
authors.lastname: McMurray
authors.affiliation: Faculty of Medicine, Imperial College, London, UK.
authors.forename: John G F
authors.initials: JG
authors.lastname: Cleland
authors.affiliation: Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK.|Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Kazem
authors.initials: K
authors.lastname: Rahimi
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D019468:Disease Management; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D004363:Drug Utilization / Q000706:statistics & numerical data; D004739:England; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006302:Health Services Research / Q000379:methods; D006333:Heart Failure / Q000628:therapy*; D006760:Hospitalization; D006761:Hospitals / Q000592:standards*; D006801:Humans; D008297:Male; D008485:Medical Audit / Q000379:methods; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D014852:Wales
chemical_list: D000319:Adrenergic beta-Antagonists; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors