title: Core Measures for Congestive Heart Failure in a Tertiary Care Setting in Pakistan.
abstract: OBJECTIVE
  Heart failure presents a huge burden for individual patients and the healthcare system as a whole. This study aims to assess the adherence to these core measures as identified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)/ American Heart Association (AHA) by physicians of Pakistan.
  
  
  METHODS
  We conducted a cross-sectional study in Shifa International Hospital, Islamabad, Pakistan from the period of April 2013 to April 2016. Patients with a primary diagnosis of heart failure were drawn from a coding section of hospital's record department. Data was evaluated to assess how strictly doctors were following core measures identified by JCAHO/AHA for the given diagnosis. Inclusion criteria for this study were patients ≥ 17 years of age and patients with a primary diagnosis of heart failure according to New York Heart Association (NYHA) classification. Patients with congenital anomalies and structural heart wall problems, like sarcoidosis, hemochromatosis, and amyloidosis, were excluded from the study.
  
  
  RESULTS
  Mean ejection fraction (EF) was found to be 27.23 ± 11.72 percent. Symptoms assessment of heart failure was done in 16/421 (3.8%) patients according to NYHA classification and in 405/421 (96.2%) patients according to outpatient-based heart failure assessment based on physician's experience other than NYHA classification. Left ventricle ejection fraction (LVEF) was assessed in 411/421 (97%) patients. Out of these, 336/411 (81.7%) patients had EF < 40%. Mean EF was found to be significantly higher in females as compared to males (p < 0.001). Three hundred and thirty-six out of 411 (81.7%) patients with EF < 40% needed angiotensin converting enzyme inhibitors (ACEi) and beta-blocker (BB) prescriptions. ACEi were prescribed only to 230/336 (68.7%) patients and 248/336 (73.8%) patients were given BB with documented contraindication to ACEi and BB in 7.36% and 17% patients, respectively. There was no significant association between gender and mean duration of hospitalization (p = 0.411). No significant association was found between EF ≤ 40% and mean duration of hospitalization (p = 0.426).
  
  
  CONCLUSIONS
  We found that symptom assessment of congestive heart failure (CHF) patients, according to NYHA guidelines, are strikingly low. Also, a significant percentage of patients who need ACEi and BB are not prescribed the required medications despite echocardiography showing low left ventricular function.
authors.affiliation: Department of Cardiology, Shifa College of Medicine, Islamabad, Pakistan.
authors.forename: Rizwan
authors.initials: R
authors.lastname: Zafar
authors.affiliation: Department of Cardiology, Shifa College of Medicine, Islamabad, Pakistan.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Haris
authors.affiliation: Department of Neurology & Neurosurgery, Shifa Tameer-e-Millat University, Islamabad, Pakistan.
authors.forename: Salman
authors.initials: S
authors.lastname: Assad
authors.affiliation: Department of Urology, Shifa College of Medicine, Islamabad, Pakistan.
authors.forename: Muhammad Usman
authors.initials: MU
authors.lastname: Shabbir
authors.affiliation: Department of Pathology, Shifa College Of Medicine, Islamabad, Pakistan.
authors.forename: Haider
authors.initials: H
authors.lastname: Ghazanfar
authors.affiliation: Department of Internal Medicine, Shifa College of Medicine, Islamabad, Pakistan.
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Malik
authors.affiliation: Shifa College of Medicine, Islamabad, Pakistan.
authors.forename: Tehreem
authors.initials: T
authors.lastname: Khalid
authors.affiliation: Department of Internal Medicine, Shifa College of Medicine, Islamabad, Pakistan.
authors.forename: Ali H
authors.initials: AH
authors.lastname: Abbas
authors.affiliation: Department of Cardiology, Shifa College of Medicine, Islamabad, Pakistan.
authors.forename: Asad A
authors.initials: AA
authors.lastname: Saleem
keywords: chronic disease management; heart failure; morbidity; mortality; pakistan