Association between process performance measures and 1-year mortality among patients with incident heart failure:a Danish nationwide study

Aims: To examine the association between fulfilment of performance measures supported by clinical guidelines recommendations and 1-year mortality among patients with incident heart failure (HF) in Denmark.Methods and results: A nationwide population-based follow-up study based on the Danish Heart Failure Registry. All Danish hospital departments caring for patients with HF. We identified 24,308 in-and outpatients diagnosed with HF from 2003 to 2010. Quality of care was defined as receiving the guideline recommended processes of care: use of echocardiography, New-York-Heart-Association -classification, treatment with angiotensin-converting-enzyme inhibitors/angiotensin-II-receptor blocker, betablockers, physical training and patient education.Main outcome measure: 1-year mortality. We used multiple imputation and multivariable Cox Proportional Hazard Regression to compute Hazard Ratios (HRs) for 1-year mortality adjusted for potential confounding factors. Within 1 year, 17.1% of the patients died and the adjusted HRs ranged from 0.61 (95% Confidence Interval ((CI) 0.55-0.67)) for patient education to 0.99 (95% CI 0.90-1.10) for betablocker therapy. The association between meeting more performance measures and 1-year mortality appeared to follow a dose-response pattern: Using 0-25% of fulfilled measures as reference, patients who fulfilled 76- 100% of the performance measures had an adjusted HR of 0.43 (95% CI 0.38-0.48), while the adjusted HR was 0.96 (95% CI 0.86-1.07) for patients who fulfilled between 26-50% of the performance measures.Conclusion: Meeting process performance measures, which reflect care in concordance with clinical guideline recommendations, was associated with substantially lower 1-year mortality among patients with incident HF.