Rethinking the Focus of Heart Failure Quality Measures

By the early 2000s, several landmark trials had demonstrated clear morbidity and mortality benefit for neurohormonal antagonists and vasodilators in patients with heart failure and reduced ejection fraction (HFrEF), including beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), aldosterone antagonists (AldA), and the combination of hydralazine and isosorbide dinitrate (H-ISDN). These therapies were justifiably assimilated into guidelines for the treatment of patients with HFrEF, but evidence emerged documenting wide variability in compliance with evidence-based therapies and clinical outcomes. 1 At the same time, important studies highlighted that patients started on ACEi and BB while hospitalized for heart failure (HF) were much more likely to remain on these therapies during follow-up than if initiation was deferred to the outpatient setting. 2, 3 Hospital-based interventions to improve compliance with HF therapies suggested clinical benefit with reduced HF readmissions and mortality 4 , and support for this inpatient strategy was buttressed by similar efforts aimed at patients with coronary artery disease. 5