Title
BRITISH SOCIETY FOR HEART FAILURE
NATIONAL
HEART
FAILURE
AUDIT
APRIL 2011 - MARCH 2012
National Heart Failure Audit April 2011-March 2012
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NICOR (National Institute for Cardiovascular Outcomes Research) is a partnership of clinicians,
IT experts, statisticians, academics and managers which manages six cardiovascular clinical
audits and three clinical registers. NICOR analyses and disseminates information about clinical
practice in order to drive up the quality of care and outcomes for patients.
The British Society for Heart Failure (BSH) is a national organisation of healthcare
professionals which aims to improve care and outcomes for patients with heart failure by
increasing knowledge and promoting research about its diagnosis, causes and management.
The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the
Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its
aim is to promote quality improvement, and in particular to increase the impact of clinical
audit in England and Wales. HQIP hosts the contract to manage and develop the National
Clinical Audit and Patient Outcomes Programme (NCAPOP). The programme comprises 40
clinical audits that cover care provided to people with a wide range of medical, surgical and
mental health conditions.
Founded in 1826, UCL (University College London) was the first English university
established after Oxford and Cambridge, the first to admit students regardless of race,
class, religion or gender, and the first to provide systematic teaching of law, architecture
and medicine. It is among the world’s top universities, as reflected by performance in a
range of international rankings and tables. UCL currently has 24,000 students from almost
140 countries, and more than 9,500 employees. Its annual income is over £800 million.
Authors
Report produced by
John Cleland (University of Hull)
Henry Dargie (University of Glasgow)
Suzanna Hardman (Whittington NHS Trust)
Theresa McDonagh (King’s College London)
Polly Mitchell (NICOR)
Data cleaning and analysis
Emmanuel Lazaridis (NICOR)
Darragh O’Neill (NICOR)
Acknowledgments
The National Heart Failure Audit is managed by the National Institute for Cardiovascular Outcomes Research (NICOR),
which is part of the National Centre for Cardiovascular Prevention and Outcomes, based at University College London. The
National Heart Failure Audit is funded and commissioned by the Healthcare Quality Improvement Partnership (HQIP).
Specialist clinical knowledge and leadership is provided by the British Society for Heart Failure (BSH) and the audit’s
clinical lead, Professor Theresa McDonagh. The strategic direction and development of the audit is determined by
the audit Project Board. This includes major stakeholders in the audit, including cardiologists, the BSH, heart failure
specialist nurses, clinical audit and effectiveness managers, cardiac networks, patients, NICOR managers and
developers, and HQIP.
This report was completed in close collaboration with the NICOR technical team, formerly known as the Central Cardiac
Audit Database (CCAD). Marion Standing has again been especially involved.
We would especially like to thank the contribution of all NHS Trusts, Welsh Heath Boards and the individual nurses,
clinicians and audit teams who collect data and participate in the audit. Without this input the audit could not continue to
produce credible analysis, or to effectively monitor and assess the standard of heart failure care in England and Wales.
This report is available online at www.ucl.ac.uk/nicor/audits/heartfailure/additionalfiles
National Heart Failure Audit
National Institute for Cardiovascular Outcomes Research (NICOR)
Institute of Cardiovascular Science, University College London
3rd floor, 170 Tottenham Court Road, London W1T 7HA
Tel: 0203 108 3927
Email: polly.mitchell@ucl.ac.uk
National
Heart
Failure Audit
April
2011-March
2
Published
27th
November
2012.
The
contents2012
of this report may not be published or used commercially without permission
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National Heart Failure Audit
April 2011 - March 2012
The fifth annual report for the National Heart Failure Audit presents findings
and recommendations based on patients discharged with a diagnosis of heart
failure between 1 April 2011 and 31 March 2012, covering all NHS Trusts in
England and Health Boards in Wales which admit acute heart failure patients.
The report is aimed at those involved in collecting data for the National Heart
Failure Audit, as well as clinicians, healthcare managers, clinical governance
leads, and all those interested in improving the outcomes and well-being of
patients with heart failure. The report includes clinical findings at national
and local levels and patient outcomes for the audit year.
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Contents
The Authors
2
Contents
4
List of figures
Readmission
15
Aetiology
16
5
Symptoms
16
Foreword
6
Aetiology
16
1. Executive summary
7
Diagnosis
16
Echocardiography
16
Diagnosis
17
Treatment on discharge for LVSD
17
ACE inhibitor and ARB
17
Beta blocker
17
MRA
17
Loop diuretics
17
Thiazide diuretics
17
Digoxin
17
Treatment on discharge by age
17
Monitoring heart failure patients
18
Follow-up services
18
Palliative care
18
Analysis by hospital
19
Participation and case ascertainment
19
Clinical practice
30
1.1
National Heart Failure Audit
7
1.2
Findings
7
Participation
7
Hospitalisation
7
Diagnosis
7
Treatment
7
Referrals on discharge
7
Hospital level analysis
7
In-hospital mortality
8
Mortality for survivors to discharge
8
Recommendations
8
1.3
2. Introduction
3.6
3.7
3.8
3.9
2.1
Heart Failure
10
2.2
The role of the audit
10
2.3
National use of audit data
10
2.4
Organisation of the audit
11
2011/12 in-hospital mortality
42
2.5
The scope of the audit
11
2011/12 post-discharge mortality
42
2.6
The database
11
2.7
Data collection and IT
11
2.8
Improving our IT platform
12
2.9
Improving analysis
12
3. Findings
13
3.1
Data cleaning and data quality
13
3.2
Participation
13
Number of Trusts
13
Number of patients
14
Case ascertainment
14
Demographics
14
Age
14
Age and sex
14
Age and Index of Multiple Deprivation
14
3.3
3.4
4
10
3.5
3.10 Mortality
3.11 Three-year trends
42
47
Three-year in-hospital mortality
47
Three-year post-discharge mortality
47
4. Case studies
51
4.1
Improving clinical practice and patient outcomes
51
4.2
Using data to drive improvement
51
4.3
An example of local practice in conducting the
51
national Heart Failure Audit
4.4
The national perspective
5. Research use of National Heart Failure
51
54
Audit data
6. Conclusions
Demographics
15
6.1
In-hospital care
15
6.2
Length of stay
15
55
Quality of care and patient outcomes
55
Data completeness and participation
55
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7. Appendices
A1
National Heart Failure Audit Project Board
56
56
membership
A2
HALO Group
56
A3
Data for 2011/12 mortality analysis
56
A4
Data for 2009-12 mortality analysis
58
A5
Glossary
59
8. References
61
List of figures and tables
Figure 14 Post-discharge survival by prescription of beta
blockers on discharge for patients with LVSD
45
Figure 15 Post-discharge survival by prescription of beta
blockers on discharge (all patients)
45
Figure 16 Post-discharge survival by prescription of loop
diuretics on discharge for patients with LVSD
45
Figure 17 Post-discharge survival by prescription of loop
diuretics on discharge (all patients)
46
Figure 18 Post-discharge survival by additive drug
treatment on discharge for patients with a
diagnosis of LVSD
46
Figure 19 Post-discharge survival by referral to
cardiology follow-up services
46
46
48
Table 1
Records excluded from analysis in this report
13
Figure 20 Post-discharge survival by referral to
heart failure liason follow-up services
Table 2
Records excluded from mortality analysis in
13
Table 9
this report
Figure 1
Age at first admission by sex
Figure 2
The effect of deprivation on age of first admission 15
Figure 3
Mean length of stay by hospital
15
Figure 4
Median length of stay by hospital
15
Figure 5
Number of readmissions in 2011/12
16
Table 3
Previous medical history and diagnosis of LVSD
16
Figure 6
Treatment for LVSD on discharge by age
18
Table 4
Participation and case ascertainment in England 19
Table 5
Participation and case ascertainment in Wales
29
Table 6
Clinical practice in England (2011/12)
30
Table 7
Clinical practice in Wales (2011/12)
41
Table 8
Cox proportional hazards model for post-
43
14
discharge mortality (2011/12)
Figure 7
Overall post-discharge survival
43
Figure 8
Post-discharge survival by sex
43
Figure 9
Post-discharge survival by age at admission
44
Figure 10 Post-discharge survival by place of care
44
Figure 11 Post-discharge survival by presence or
44
absence of LVSD
Figure 12 Post-discharge survival by prescription of ACE
inhibitor and/or ARB on discharge for patients
with LVSD
44
Figure 13 Post-discharge survival by prescription of ACE
inhibitor and/or ARB on discharge (all patients)
45
Cox proportional hazards model for
post-discharge mortality (2009-12)
Figure 21 Three-year post-discharge survival (2009-12)
48
Figure 22 Three-year post-discharge survival by
sex (2009-12)
48
Figure 23 Three-year post-discharge survival by
age (2009-12)
48
Figure 24 Three-year post-discharge survival by place
of care (2009-12)
49
Figure 25 Three-year post-discharge survival by presence 49
or absence of LVSD (2009-12)
Figure 26 Three-year post-discharge survival by
prescription of ACE inhibitor and/or ARB on
discharge in patients with LVSD (2009-12)
49
Figure 27 Three-year post-discharge survival by
prescription of beta blockers on discharge in
patients with LVSD (2009-12)
49
Figure 28 Three-year post-discharge survival by
prescription of loop diuretics on discharge
in patients with LVSD (2009-12)
50
Figure 29 Three-year post-discharge survival by
additive drug treatment on discharge in
patients with LVSD (2009-12)
50
Figure 30 Three-year post-discharge survival by referral
to cardiology follow-up services (2009-12)
50
Figure 31 Three-year post-discharge survival by referral
50
to heart failure liason follow-up services (2009-12)
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Foreword
The ability of high quality national audit data to
improve clinical cardiovascular care and its role in
delivering important outcome benefits has already
been well demonstrated through initiatives such as
MINAP (Myocardial Ischaemia National Audit Project).
However, heart failure remains one of the biggest
challenges for modern cardiovascular care and an
area where robust audit data has major potential to
inform change for the benefit of patients.
The National Heart Failure Audit 2011/2012 highlights the
importance of heart failure which affects around 900,000
individuals in the UK, accounts for 5% of all emergency
hospital admissions and utilises 2% of all NHS hospital bed
days. It is associated with a high annual mortality, especially
if poorly treated, and the effect of heart failure on quality of
life cannot be underestimated. Yet optimal management can
result in a better prognosis with fewer symptoms and an
increased life expectancy.
The National Heart Failure Audit, now in its sixth year, has
evolved to include data on acute heart failure admissions
from 90% of the Trusts and Health Boards in England and
Wales and now represents 59% of all heart failure admissions.
It provides a valuable insight into the diversity of both
management and outcomes, highlighting the importance of
specialist care, optimising medical therapy and appropriate
specialist follow-up as key indicators of improved mortality.
Although in-hospital mortality remains high at 11.1% the
differences between specialist and non-specialist care are
striking, with 7.8% in-hospital mortality for patients managed
under cardiology care versus 13.2% mortality under general
medicine and 17.4% for those managed in other wards.
6
The additional mortality benefits of specialist follow-up
by cardiology and heart failure teams also highlight the
importance of integrated care beyond hospital admission.
These insights into the significant outcome gains possible
through evidence based, specialist delivered management
are a powerful vehicle for driving up quality, addressing
variations in care, and for planning and commissioning of
future heart failure services.
The National Heart Failure Audit is managed by the National
Institute for Cardiovascular Outcomes Research (NICOR),
receiving clinical direction and leadership from the British
Society for Heart Failure which, along with the clinical teams
managing the patients and all those submitting the data,
deserves enormous credit for its development and continued
evolution. From April 2013, when hospitals will be required
to submit data on all heart failure admissions, the increasing
importance of this audit in driving up the quality of heart
failure management will be further enhanced.
Dr Iain A Simpson
President, British Cardiovascular SocietyChair, British
Cardiovascular Society
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1 Executive Summary
Heart failure is a highly prevalent condition, often
with poor outcomes: an estimated 900,000 people in
the U.K. have heart failure and over a third will die
within a year of diagnosis. Despite an elderly patient
group, many of whom have extensive comorbidities
contributing to or complicating their heart failure,
good clinical management has been shown to
substantially improve patient outcomes.
Overall mean length of stay was 13.1 days on first admission
and 13.4 days on readmission. This is an increase from last
year’s audit (11 days on admission and 13 days on readmission).
In contrast to last year, when cardiology patients had longer
lengths of stay than patients treated on other wards, in 2011/12
cardiology patients had shorter lengths of stay (12.7 days) than
patients on general medical wards (13.1 days) and those on
other wards (14.7 days).
1.2.3 Diagnosis
1.1 National Heart Failure Audit
The National Heart Failure Audit was established in 2007 to
monitor the care and treatment of patients admitted to hospital
in England and Wales with heart failure. The audit reports on
the clinical practice and patient outcomes of acute patients
discharged from hospital with a primary diagnosis of heart
failure. The audit collects data based on recommended clinical
indicators with a view to driving up standards by encouraging
the implementation of guideline recommendations and
reporting on practice statistics and outcomes.
Audit data is used by a number of national groups, including
the NHS Information Centre, the Care Quality Commission
and data.gov.uk. However improvements in standards of care
depend on participating hospitals using and reviewing their
own data to change and improve practice.
The audit is strongly supported by the British Society
for Heart Failure and is one of six cardiovascular audits
managed by NICOR, part of the National Centre for
Cardiovascular Prevention and Outcomes at UCL. The audits
are funded and commissioned by HQIP.
1.2 Findings
1.2.1 Participation
Between April 2011 and March 2012 142 out of 155 NHS Trusts
in England and Health Boards in Wales (92%) submitted data
to the audit. 12 NHS Trusts and one Health Board did not
submit any data to the audit.
After data cleaning, the total number of records in the 2011/12
audit was 37,076, made up of 32,906 index admissions and
4,170 readmissions within the audit period.
Nationally the audit represents 59% of all heart failure patients
in England and Wales. Case ascertainment was 62% for
England and 12% for Wales.
1.2.2 Hospitalisation
48% of patients were treated in cardiology wards, with 41%
treated on general medical wards and 11% on other wards.
Men were far more likely to be treated on cardiology wards
than women, as were younger patients.
The use of echocardiography remains high, with 86% receiving
an echo during the admission.
1.2.4 Treatment
Prescription rates of disease modifying treatments at discharge
for patients with left ventricular systolic dysfunction (LVSD)
remain broadly similar to those recorded in the 2010/11 audit.
Prescription of angiotensin-converting enzyme (ACE) inhibitors
or angiotensin receptor blockers (ARB) remains high, with 84% of
patients discharged on either of the therapies (81% in 2010/11).
Prescription of some recommended therapies increased:
78% of patients were prescribed beta blockers on discharge,
compared to 65% in 2010/11. 45% of patients were discharged
on a mineralocorticoid receptor antagonist (MRA), an increase
from 36% in 2010/11. Some of the apparent increase in
prescribing between years may be accounted for by changes in
analytical method.
As observed in previous years, prescription rates for ACE
inhibitors/ARBs, beta blockers and MRAs are all higher when
patients are admitted to cardiology wards, as opposed to
general medical or other wards.
1.2.5 Referral on discharge
54% of patients were referred to a heart failure liaison service
on discharge, and 52% to cardiology follow-up. Referral rates
were higher for patients who were younger, male and treated
on a cardiology ward.
1.2.6 Hospital level analysis
For the first time, the National Heart Failure Audit includes
analysis on clinical practice at a hospital level, for all hospitals
which submitted at least 100 patient records (or more than
70% of their Hospital Episode Statistics (HES) recorded heart
failure admissions) to the audit. The findings show fairly wide
variation in clinical practice between hospitals, but it is unclear
how representative the patients in the audit are of the heart
failure patient population at many hospitals, due to the small
number of returns. As of April 2013, hospitals will be required
to enter data on all of their heart failure patients, and this will
hopefully give a more accurate picture of the variation in the
treatment and management of heart failure at a hospital level.
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1.2.7 In-hospital mortality
In hospital mortality remains high, with 11.1% of patients
discharged in 2011/12 dying during their admission, similar
to the 11.6% recorded in 2010/11. These findings are higher
than in-hospital mortality rates reported by other European
registries,1 and this is likely to reflect the more comprehensive
approach taken by the National Heart Failure Audit.
In-hospital mortality rates were 7.8% for patients treated on
cardiology wards, compared with 13.2% for those treated on
general medical wards and 17.4% for those on other wards. The
benefit of treatment in a cardiology ward persists when these
findings are adjusted for confounding factors such as age and
New York Heart Association (NYHA) class. These findings are
similar to previous years’ results, and highlight the benefits of
specialist treatment.
1.2.8 Mortality for survivors to discharge
Of those patients who survived to discharge, 26% died within the
follow-up period. Outcomes were significantly better for patients
treated on cardiology wards (22%) compared to those treated on
general medical wards (30%) and other wards (33%).
Mortality rates with key medical treatment (ACEI/ ARBs,
beta blockers, MRAs) were substantially lower than without
such therapy. The benefits of disease modifying treatment
were present in patients with diagnosed with non-systolic
heart failure as well as patients with left ventricular systolic
dysfunction when taken alone. Patients discharged from
cardiology wards were more likely to be prescribed these drugs.
The benefits of disease modifying therapies were additive.
Patients discharged on all of ACEI/ARBs, beta blockers and
MRAs had better survival outcomes than patients prescribed
an ACEI/ARB and a beta blocker but no MRA, and patients
prescribed an ACEI/ARB alone. All of these patients had
substantially lower mortality than patients discharged on none
of the three therapies.
Patients referred to heart failure nurse and cardiology followup services also had better survival, only 20% of patients
referred to cardiology follow-up services on discharge died,
compared with 32% of patients not referred to follow-up with
a cardiologist. 25% of patients referred to heart failure nurse
liaison services within the audit year died, compared with 28%
of those not referred to nurse led follow-up.
Cox proportional hazards models appear to show that even
with adjustment for age, severity of symptoms and history
of acute myocardial infarction, for patients who survived to
discharge, those not prescribed ACE inhibitors/ARBs and beta
blockers on discharge had higher mortality rates. Patients
prescribed loop diuretics on discharge had increased mortality
8
rates following adjustment for these confounding factors. After
adjusting for possible differences in patient characteristics,
patients who were not managed on cardiology wards and
those who did not receive cardiology follow-up continued to
have higher mortality rates. (The analysis was adjusted for the
following covariates: age>75, NHYA class III/IV, previous AMI,
no ACEI/ARB, no beta blocker, loop diuretic, no cardiology
follow-up, not treated on cardiology ward).
Mortality analyses for the three year period between April
2009 and March 2012 show similar findings. 42% of patients
who survived to discharge died during this period, but optimal
treatment and management in hospital had beneficial effects
on patient outcomes, which continued long after discharge.
1.3 Recommendations
The National Heart Failure Audit provides key information
to improve outcomes in acute heart failure, one of the great
unmet needs in the management of the condition. Considerable
progress has been made in case ascertainment since the audit
began. The aim now should be to strive for inclusion of all
patients admitted to hospital with a primary diagnosis of heart
failure to ensure a more representative dataset.
The following recommendations are made based on the
findings of the audit in this and previous years:
This audit has consistently shown that specialist cardiology
care and follow up is associated with better outcomes for
patients with heart failure even after adjusting for age, severity
and other observed differences in patient characteristics.
Trusts should ensure that patients with a primary diagnosis
of heart failure have specialist input to their care as proposed
in NICE guidelines and are managed on cardiology or wards
specialising in heart failure wherever feasible.
Implementation of key evidence-based medicine i.e. the
use of ACE inhibitors, beta blockers and MRAs for those
with systolic dysfunction is associated with much improved
patient outcomes. Trusts need to concentrate on getting these
cornerstone therapies initiated in hospital, wherever possible.
Robust arrangements for the optimisation of therapy for
cardiac dysfunction via cardiology follow-up, heart failure
liaison services and primary care need to be firmly in place
prior to discharge. The next phase of the audit will address
this discharge planning phase more specifically. As access
to specialist medical and nursing care is the gatekeeper to
optimal care for heart failure patients, Trusts should ensure
that key personnel are in place to deliver this care.
The audit also shows that outcome is poorer for patients
without, compared to those with, left ventricular systolic
dysfunction (LVSD). This likely reflects the greater age of
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patients who do not have LVSD but other possibilities will
be explored by the audit group. The continuing increase in
case ascertainment coupled with data already accrued from
previous audits will provide a robust basis for these aims and
should be a focus of interest for subsequent audit reports.
In 2011 the National Institute for Health and Clinical
Excellence produced a quality standard for chronic heart
failure, comprising 13 statements summarising the optimal
and recommended management of heart failure.2 Hospitals
should adhere to these standards in the treatment and care
of heart failure patients, with the following statements being
particularly relevant:
Statement 7: People with chronic heart failure due to left
ventricular systolic dysfunction are offered angiotensinconverting enzyme inhibitors (or angiotensin II receptor
antagonists licensed for heart failure if there are intolerable
side effects with angiotensin-converting enzyme inhibitors)
and beta-blockers licensed for heart failure, which are
gradually increased up to the optimal tolerated or target dose
with monitoring after each increase.
Statement 10: People admitted to hospital because of heart
failure have a personalised management plan that is shared
with them, their carer(s) and their GP.
Statement 11: People admitted to hospital because of heart
failure receive input to their management plan from a
multidisciplinary heart failure team.
Statement 12: People admitted to hospital because of heart
failure are discharged only when stable and receive a clinical
assessment from a member of the multidisciplinary heart
failure team within 2 weeks of discharge.
Statement 13: People with moderate to severe chronic heart
failure, and their carer(s), have access to a specialist in heart
failure and a palliative care service.
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2 Introduction
2.1 Heart Failure
Heart Failure is a complex clinical syndrome characterised
by the reduced ability of the heart to pump blood around
the body. It is caused by structural or functional cardiac
abnormalities, including previous myocardial infarction,
cardiomyopathies, valvular heart disease and hypertension.
It is thought that around 70% of all heart failure cases
are caused by coronary heart disease. Atrial fibrillation
and renal dysfunction are common precipitating factors
and complications of heart failure, and the condition is
characterised by symptoms such as shortness of breath and
fatigue, and signs such as fluid retention.
Around 900,000 people in the U.K. suffer from heart failure,
and this number is set to rise due to an ageing population,
improved post-infarction survival rates, and more effective
treatments3. In 2007 it was estimated that 1.81% of the
population aged 45 years or older suffered from heart failure4.
The prevalence of heart failure rises steeply with age, with
the British Heart Foundation Statistics Database estimating
in 2009 that 13.7% of men and 12.5% of women aged over
75 years in England suffer from the condition5. Heart failure
constitutes a large burden on the NHS, accounting for one
million inpatient bed-days – 2% of the NHS total – and 5% of
all emergency hospital admissions6.
Survival rates for heart failure patients who receive suboptimal care are poor. 40% of newly diagnosed patients die
within a year,7 and total annual mortality ranges from 10-50%,
depending on severity. These figures are supported by the
mortality rates reported by the National Heart Failure Audit,
which has consistently recorded one-year mortality of around
30% since 2008.8 Heart failure patients can also experience
poor quality of life, experiencing pain, dyspnoea (shortness
of breath) and fatigue. Heart failure patients also often suffer
from mental health problems, with studies showing that over
half report low mood, and more than a third suffer from major
depression.9 10 These outcomes reflect considerable variation
in standards of care: optimal treatment and management of
heart failure results in significantly improved prognosis, with
fewer symptoms and increased life expectancy.
2.2 The role of the audit
National clinical audit is designed to monitor clinical practice
and patient outcomes with a view to evaluating hospital
performance and driving up standards of care. The National
Heart Failure Audit was established in 2007 with the aim of
helping clinicians improve the quality of heart failure services
and to achieve better outcomes for patients. The audit aims
to capture data on clinical indicators which have a proven link
to improved outcomes, and to encourage the increased use of
clinically recommended diagnostic tools, disease modifying
treatments and referral pathways.
10
A series of clinical care standards for heart failure have been
developed, including the National Service Framework for
Coronary Heart Disease (2000),11 NICE Clinical Guidance for
Chronic Heart Failure (2010),12 NICE chronic heart failure
quality standards (2011)13 and a standard for delivering
heart failure care produced by the European Society of
Cardiology Heart Failure Association (2011).14 The audit
dataset corresponds to these standards, in order to evaluate
the implementation of these existing evidence-based
recommendations by hospitals in England and Wales. The
audit dataset is regularly reviewed and updated to ensure it is
in line with contemporary guidance.
2.3 National use of audit data
In addition to this publicly available annual report, the analysis
produced by the National Heart Failure Audit are used by
national groups with a legitimate interest in the analysis.
The NHS Information Centre’s Indicators for Quality
Improvement (IQI), a set of indicators developed to describe
the quality of NHS service, include participation in the
National Heart Failure Audit,15 and the NHS Choices website
includes details of participation in the audit in its ‘scorecard’
for Trust performance.
Furthermore, the audit currently provides participation
rates to the Care Quality Commission’s (CQC) ‘Quality and
Risk Profiles’ (QRP),16 a tool used for gathering together key
information about NHS organisations, which allows the CQC to
monitor compliance with the essential standards of quality and
safety. The QRP enable compliance inspectors to assess where
risks lie and may prompt front line regulatory activity, such as
further enquiries.
Clinical audit was one of six key areas raised under the
heading ‘NHS’ in the Prime Minister’s Letter to Cabinet
Ministers on transparency and open data which stated:
Clinical audit data, detailing the performance of publicly
funded clinical teams in treating key healthcare conditions,
will be published from April 2012. This service will be piloted
in December 2011 using data from the latest National Lung
Cancer Audit, commissioned by the Healthcare Quality
Improvement Partnership (HQIP) as part of the National
Clinical Audit and Patient Outcomes Programme (NCAPOP).17
National Heart Failure Audit data will be published on data.gov.
uk following the publication of this report in November 2012.
There are future plans to provide anonymised National Heart
Failure Audit data, at a hospital level, to Cardiac Networks
and Clinical Commissioning Groups. An archive of annual
audit reports, containing national aggregate data, is also
available for download on NICOR’s publicly accessible website.
The National Heart Failure Audit had also been published in
Heart journal.18
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2.4 Organisation of the audit
The National Heart Failure Audit is managed by the National
Institute for Cardiovascular Outcomes Research (NICOR),
and receives clinical direction and leadership from the British
Society for Heart Failure. It is overseen by a Project Board which
represents key stakeholders, including cardiologists, heart
failure nurses, Cardiac Networks and heart failure patients.i
The audit is one of six national clinical audits managed by
NICOR, part of the National Centre for Cardiovascular Prevention
and Outcomes at University College London. These audits
are funded by HQIP, which holds commissioning and funding
responsibility for 40 national clinical audits in the NACPOP.19
2.5 The scope of the audit
The National Heart Failure Audit collects data on acute
patients discharged from hospitals in England and Wales with
a primary diagnosis of heart failure on discharge, designated
by any of the following ICD-10 codes:
I11.0 Hypertensive heart disease with (congestive) heart failure
I25.5 Ischaemic cardiomyopathy
I42.0 Dilated cardiomyopathy
I42.9 Cardiomyopathy, unspecified
I50.0 Congestive heart failure
I50.1 Left ventricular failure
I50.9 Heart failure, unspecified
Only acute patients should be included in the National
Heart Failure Audit, so those patients admitted for elective
procedures, for example elective pacemaker implantation
or angiography, ought not to be included. Large numbers of
these patients being included in the audit has led to several
thousand records being deleted from the dataset in the data
cleaning process (this is detailed in section 3.1).
Participation is currently defined as an NHS Trust or Welsh
Health Board submitting a minimum of 20 cases to the audit
database each calendar month, or the full number of cases
if fewer than 20 patients with heart failure are discharged
from the Trust in a month. Participation in the audit has been
mandated in the Department of Health’s standard terms and
conditions for acute hospital services in 2011/12, covering all
acute hospitals in England.20 Participation in the audit has been
mandatory for Welsh Local Health Boards since April 2012.21
Although a large proportion of the treatment of chronic heart
failure occurs in the community, the National Heart Failure
Audit currently only covers acute heart failure admissions
to hospital, partly due to IT limitations. The development of
a web-based platform for the database in 2013 will make
it feasible for community hospitals and other primary care
institutions to participate in the audit.
2.6 The database
In 2011/12 the dataset contained 38 core fields, covering
patient details and demographics, medical history, symptoms,
diagnosis, treatment on discharge, referral to follow-up
services and place of care in hospital.
In March 2011 a revision of the dataset increased the number of
core fields to 59. New fields have been added to bring the audit
in line with latest NICE guidance,22 23 as well as to ensure that
mortality analysis can be adequately risk adjusted to account for
known confounding factors. The new fields include input from a
multidisciplinary heart failure team, discharge planning, as well
as increasing the data collected on medical history, diagnostic
tests and follow-up services. These new fields will be included
in the analysis in the 2012/13 annual report.
2.7 Data collection and IT
User roles vary between hospitals, but the personnel
involved in collecting and inputting data tend to be Heart
Failure Specialist Nurses, clinical audit leads, and clinical
effectiveness managers. Some of the more effective systems
of data collection and data entry use nurses or other clinical
staff to interpret medical notes and collect data, and clerical
staff or clinical audit facilitators to enter it onto the database.
This ensures that the data is clinically accurate whilst making
optimal use of clinicians’ time.
Hospitals are responsible for ensuring that data is entered
accurately but the database contains a series of validation
checks to ensure that contradictory and clinically improbable
data are not entered into the audit. A pro forma, designed to aid
data collection, can be downloaded from the NICOR website,
along with a set of application notes which defines and explains
core data items.24 The application notes will be regularly
reviewed to ensure they are clinically accurate and will be
amended in response to comments and questions from users to
cover frequently asked questions and points of contention.
All data are submitted electronically by hospital into a secure
central database. To ensure patient confidentiality the database
uses advanced data encryption technology and access control
through a secure key system. Data can be inputted manually
or imported from locally developed systems or third party
commercial databases.
i. See Appendix 1 for details of project board membership.
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2.8 Improving our IT platform
2.9 Improving analysis
Earlier this year NICOR began a major project to upgrade its
data collection and management systems. The current Lotus
Notes software has become increasingly unwieldy as the
NICOR databases have grown in size and complexity. A new
platform will substantially improve NICOR’s ability to derive
high-quality analyses from the National Heart Failure Audit to
inform hospitals, Cardiac Networks and patients regarding the
provision of cardiac care.
The processes that NICOR uses for analysing National
Heart Failure Audit data have also undergone substantial
changes this year. Until recently NICOR data were analysed
using software and ad hoc analytic codes that were neither
consistent nor easy to manage. In preparation for the
incorporation of analytic technologies into the new NICOR
system, code that was written in SPSS and Excel spreadsheets
(for analyses presented in this annual report) was migrated
to a standard cross-audit analytic platform based on the R
statistical processing language - precise details are available
from NICOR.
The first step in this project involved a transfer of all data from
the NHS Information Centre for Health and Social Care onto
secure NICOR servers. This involved re-issuing a new user ID
to every database user. The migration was not easy, and it led
to some delays in accessing the National Heart Failure Audit.
Despite these difficulties, participating hospitals submitted
their data on time, making possible the timely publication of
this report. We would like to thank everyone for their effort and
patience during the migration.
The second phase involves the development of a new IT
platform which will be rolled out in stages throughout 2013,
with the National Heart Failure Audit being the first to be
transferred in April.
12
Migration of the National Heart Failure Audit to the new
platform for statistical analysis began in August 2012 and
continues, with an intended completion date of June 2013.
The results presented in this annual report were generated
using some, but not all, elements of the new platform.
Because the new analytic platform is still under development,
with incremental improvements expected over the next
few months, the results presented in this report should be
considered preliminary and subject to change. Any substantive
differences that follow improvements in filtering and more
sophisticated statistical modelling of the data will be
highlighted in next year’s annual report.
National Heart Failure Audit April 2011-March 2012
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3 Findings
3.1 Data cleaning and data quality
3.2 Participation
As of 31st June 2012, the total number of records submitted
to the National Heart Failure Audit database since 2007 was
137,637. Of these, 41,635 were patients discharged from
hospital between 1st April 2011 and 31st March 2012.
3.2.1 Number of Trusts
Table 1: Records excluded from analysis in this report
Number excluded
from full dataset
(number excluded
from 2011/12 dataset)
Admission/
readmission
dataset
Reason
16 (3)
Admission
Missing or invalid
hospital identifier
8 (5)
Readmission
Missing or invalid
hospital identifier
14 (2)
Admission
Identical duplicate
of another row
67 (2)
Readmission
Identical duplicate
of another row
6 (6)
Admission
Non-identical rows
with duplicate
‘unique’ ID
4268 (299)
Admission/
Readmission
Time to discharge
<0
14204 (3952)
Admission/
Readmission
Time to discharge
0 or 1 day, and
survived to
discharge*
1174 (286)
Admission/
Readmission
Time to discharge
0 or 1 day, and no
MRIS life status*
149 NHS Acute Trusts in England and six Health Boards in
Wales discharged patients with a coded diagnosis of heart
failure in 2011/12, according to HES and PEDW data.iii Out of
these 137 NHS Trusts (91.9%) and five Health Boards (83.3%)
submitted data to the audit – a total of 91.6% of all eligible
institutions. In England 88 of the eligible institutions (64.2%)
met the National Heart Failure Audit participation requirements
of 20 cases per calendar month, or submitted more than
70% of their HES-recorded heart failure discharges. 70% was
chosen as the cut-off point because this was the overall case
ascertainment rate aimed for in the 2011/12 audit. A further 37
Trusts (27.0%) submitted less than 70% of their HES figures, but
still between 10 and 20 cases per month. In Wales no Health
Boards met the participation requirements, and three (50.0%)
submitted between 10 and 20 cases per month.
The audit has therefore met its participation target of at
least 90% of NHS Trusts in England and Health Boards in
Wales submitting data to the audit in 2011/12. This marks a
significant improvement on the 85% of Trusts taking part in
2010/11. Participation analysis, by Trust, can be found in the
hospital level analysis in section 3.7 of this report.
No data were submitted by 12 Trusts in England and one
Health Board in Wales (those marked with a * have not
registered to participate at time of publication):
Non-submitting Trusts in England
*0 and 1 day admissions who survived to discharge were
determined to be outside of the scope of the audit. The
National Heart Failure Audit measures acute admissions
to hospital, and these patients were deemed very likely
to be elective admissions for pacemaker implantation or
angiography, and so were excluded from the audit. Patients
who had a length of stay of 0 or 1 days and died in hospital
were not excluded.
Airedale NHS Foundation Trust
Table 2: Records excluded from mortality analysis in
this report
The Royal Bournemouth and Christchurch Hospitals NHS
Number secluded from 200912 survival analysis (number
excluded from 2001/12 dataset)
Reason
4370 (2019)
No MRISii life status
708 (303)
Time from discharge to
follow-up either < 0 or >
longest possible interval
East Kent Hospitals University NHS Foundation Trust
Medway NHS Foundation Trust*
Papworth Hospital NHS Foundation Trust*
Plymouth Hospitals NHS Trust*
Royal United Hospital Bath NHS Trust
South Warwickshire NHS Foundation Trust
The Princess Alexandra Hospital NHS Trust*
Foundation Trust
Trafford Healthcare NHS Trust*
University Hospitals of Leicester NHS Trust
University Hospitals of Morecambe Bay NHS Foundation Trust*
ii. The life status of all patients in the National Heart Failure Audit is provided by
the Data Linkage Service of the NHS Information Centre (NHS IC). The audit data is
linked to death registration data from the Office of National Statistics (ONS).
iii. Hospital Episode Statistics (HES) and Patient Episode Database for Wales
(PEDW) are the national statistical data warehouses for England and Wales
respectively, recording details of all patient admissions to NHS hospitals.
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Non-submitting Health Boards in Wales
Cardiff & Vale University Health Board
From April 2013 Trusts will be required to submit all of the
patients discharged with a coded diagnosis of heart failure,
and this number will be measured against the number of heart
failure coded discharges recorded by HES in England and
PEDW in Wales. Collecting data on all heart failure discharges
will prevent any selection bias in the patient records submitted
to the audit, and will thus ensure the representativeness of the
National Heart Failure Audit. It will also significantly augment
the research value of the dataset.
3.2.2 Number of patients
Although Welsh case ascertainment has improved, it remains
unsatisfactorily low. However as of April 2012 participation in the
National Heart Failure Audit has been mandated by the Welsh
Government, and as a result of this all Welsh Health Boards and
the majority of hospitals have registered with the audit.
3.3 Demographics
3.3.1 Age
The mean age of patients on their first admission in 2011/12
was 77.7, and on readmission 77.2; the median age was 80.1
on admission and 79.6 on readmission. 66.6% of patients
were over 75 at their first admission, and 64.9% of readmitted
patients were over 75.
The total number of records submitted to the National Heart
Failure Audit in 2011/12 was 41,635. After data cleaning and
exclusion of invalid records (detailed above in section 3.1),
the total number of records was 37,076. This was made up of
32,906 index admissions and 4,170 readmissions within the
audit period.
3.3.2 Age and sex
Of the index admissions, 24649 (74.9%) were recorded as
having a confirmed diagnosis of heart failure, defined as a
diagnosis of heart failure that has been confirmed by imaging
or brain natriuretic peptide (BNP) measurement either during
this admission or at a previous time. It is acknowledged that in
some cases a clinician may justifiably diagnose heart failure in
the absence of tests.
Overall there were more men recorded in the audit than
women, with men comprising 55.2% of the patient group at
index admission and 58.2% at readmission.
The mean age at first admission for men was 75.5 years, and
80.3 years for women. As in previous reports, the majority of
patients up to the age of 85 were men (61.1%); in those over
the age of 85 there were more women (57.9%).
Fig 1: Age at first admission by sex
8000
3.2.3 Case ascertainment
In England records were submitted on a total of 36,559 heart
failure admissions, 61.9% of the 59,083 patients with heart
failure recorded by HES in 2010/11; in Wales 517 records were
submitted, 11.9% of the 4,348 total reported by PEDW
in 2011/12.
Overall this does not constitute a large increase compared
to the number of patients recorded in the audit in 2010/11
(36,504 records, case ascertainment 54%). However if case
ascertainment were judged against the 41,635 records counted
prior to the data cleaning process, it would stand at 70.5%
of all heart failure admissions. The lower-than-anticipated
case ascertainment reflects the large number of 0 and 1
day admissions which were deleted as part of an extensive
data cleaning process detailed in section 3.1 above. This has
highlighted the need to remind participating hospitals not to
include elective patients in the audit.
14
5836
6000
Number of patients
The total number of cases where a patient was discharged
with a primary diagnosis of heart failure recorded by HES and
PEDW is 63,431, so the National Heart Failure audit currently
represents 58.5% of all heart failure discharges in England
and Wales.
6505
5304
4243
4051
4000
2127
2072
2000
862
433
0
219
18-44
862
371
45-54
55-64
65-74
75-84
85+
Age group
Men
Women
3.3.3 Age and Index of Multiple Deprivation
As recorded in previous years, age at admission was related
to Index of Multiple Deprivation. Index of Multiple Deprivation
was assigned to each patient based on their postcode of
residence. Indices of Multiple Deprivation are allocated to 34,378
National Heart Failure Audit April 2011-March 2012
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areas in England and Wales, each with an average of 1,500
and a minimum of 1,000 residents. There are seven factors
considered: income deprivation; employment deprivation;
health deprivation and disability; education, skills and training
deprivation; barriers to housing and services; crime; and living
environment deprivation.
Mean age of admission for patients in the most deprived
quintile, with a deprivation score of 5, was 74.5 years,
compared with a mean age at admission of 79.6 years for
patients in the least deprived quintile, with a deprivation score
of 1 (figure 2). This is similar to the average age difference
recorded last year (4.9 years). The National Heart Failure Audit
intends to carry out further analysis on the variation in the
treatment and management of heart failure in patients based
on their Index of Multiple Deprivation.
3.4.2 Length of stay
The overall mean length of stay was 13.1 days on index
admission and 13.4 days on readmission, and the median
length of stay was 9.0 days for both index admissions and
readmissions. Mean length of stay was 12.7 days for those
patients treated in a cardiology ward, 13.1 days for those treated
in a general medical wards, and 14.7 days for patients in other
wards. Median length of stay was 9 days for patients treated on
cardiology wards, 8 days for patients treated on general medical
wards, and 10 days for patients on other wards.
Both mean and median length of stay varied significantly
between hospitals, although the very high and very low mean
figures may in many cases be explained by low numbers of
Fig 3: Mean length of stay by hospital
Fig 2: The effect of deprivation on age of first admission
80
79.6
79.1
78.3
78
76.9
77
76
75
74.5
Hospitals
Mean age at first admission
in audit period 2011/12
79
74
73
72
71
70
1
2
3
4
5
Index of multiple deprivation
0
5
10
15
20
25
Length of stay (mean) in days
1= least deprived 5= most deprived
Fig 4: Median length of stay by hospital
3.4 Hospitalisation
47.6% of heart failure patients in the audit were treated
in cardiology wards, with 41.3% being treated on general
medical wards, and 10.8% on other wards. These findings do
not show much change from 2010/11, when 45% of patients
were treated on both cardiology wards and general medical
wards, and the demographic characteristics of these patients
also reflect last year’s findings. 54.1% of men were treated
on cardiology wards, compared with only 39.5% of women.
Women were more likely to be treated on general medical
wards (47.9% vs. 36.0%) and other wards (12.4% vs. 9.5%). The
likelihood of being treated on a cardiology ward decreased
with age: 76.3% of patients who were 16-44 were treated on
cardiology wards, compared with 47.1% of patients in the 7484 age group, and 32.1% of patients over 85.
Hospitals
3.4.1 In-hospital care
0
5
10
15
Length of stay (median) in days
National Heart Failure Audit April 2011-March 2012
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patients submitted, with abnormally long or short admission
spells (figure 3, figure 4).
3.4.3 Readmission
Readmission data are incomplete since only readmission with
a primary diagnosis of heart failure will be identified and not
all cases even with a primary diagnosis have been recorded.
The audit group is planning to identify readmissions from
HES data in future years. This should provide robust data
on readmission.
There were 4,170 readmissions to hospital recorded in
2011/12. The analysis for this report defines an admission as
the index admission within the audit period. There are some
records of patients who were admitted to hospital with heart
failure in 2011/12 who had been previously admitted in an
earlier audit year. Such a record is treated as an admission for
the purpose of this analysis, because it is the first admission
for a patient within the audit period, although it is not the
patient’s first admission to hospital with heart failure. 7,357
(19.8%) of the 37,076 records submitted to the National Heart
Failure Audit in 2011/12 were readmissions, although only
4,170 (11.2%) were readmissions within the audit period.
Most of these patients were only readmitted once, but some
were readmitted two times or more (figure 5). The highest
number of readmissions for a single patient was 10.
Unsurprisingly, these symptoms were worse for readmissions
to hospital, with 78% of readmitted patients in NYHA class III
or IV, and 52% with moderate or severe oedema.
3.5.2 Aetiology
The aetiology of heart failure reported by the audit is very
similar to that reported in previous years. Hypertension (54%)
and ischaemic heart disease (IHD) (46%) were the most
common contributory causes of heart failure; 26% of patients
had a history of both.
31% of patients in the audit had suffered a previous acute
myocardial infarction (AMI), and 36% had a history of
arrhythmia. Diabetes (31%) and valve disease (22%) were also
very common.
Patients with a history of IHD, atrial fibrillation, AMI and
renal impairment were more likely to be diagnosed with
LVSD, whereas patients with a history of valve disease or
hypertension were more likely to be diagnosed with heart
failure without LVSD (table 3).
Table 3: Previous medical history and diagnosis of LVSD
Medical History
LVSD (%)
Non-LVSD (%)
Ischaemic Heart
Disease
51
39
Atrial Fibrillation
41
30
2 readmissions
Acute Myocardial
Infarction
37
22
3 readmissions
Valvular Heart Disease
19
28
Hypertension
52
58
Renal Impairment
26
17
Fig 5: Number of readmissions in 2011/12
81.2%
to be in NYHA class IV, with breathlessness at rest. 29% of
patients were admitted with moderate peripheral oedema, and
16% with severe peripheral oedema.
1 readmission
4+ readmissions
p-value ≤0.001 in all cases
3.6 Diagnosis
3.6.1 Echocardiography
14.4%
3% 1.4%
3.5 Aetiology
3.5.1 Symptoms
40% of patients were in NYHA class III at first admission, with
breathlessness on minimal activity, and 32% were deemed
16
86.0% of the patients recorded in the audit had an
echocardiogram (echo) or other NICE-recommended imaging
test, for example radionuclide imaging, computerised
tomography (CT) scan or cardiac magnetic resonance
imaging (MRI).
Echocardiography rates continue to be commendably high,
with 2011/12 findings representing an increase on the 82%
recorded in 2010/11. However access to echocardiography was
dependent on several factors: Patients were more likely to
receive a diagnostic imaging test if they were men, with 88.8%
of men having an echo compared to 82.6% of women. Patients
National Heart Failure Audit April 2011-March 2012
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aged less than 75 years were also more likely to have an echo
(91.4% vs. 83.3%) as were those admitted to a cardiology ward
(92.9% vs. 80.1% of those admitted to general medical wards,
and 77.8% of patients admitted to other wards).
3.6.2 Diagnosis
Of those patients who had an echo, 65.0% were diagnosed with
LVSD. 13.8% of patients were diagnosed with valve disease
following an echo, but only 3.8% were reported to have leftventricular hypertrophy (LVH) and 4.3% diastolic dysfunction. It
is likely that low rates of LVH and diastolic dysfunction reflect
under-reporting.
Men were more likely to be diagnosed with LVSD, as were
younger patients. 53.1% of patients over 75 were diagnosed
with LVSD, compared with 70.7% of patients aged under
75 years. 67.6% of men and 48.3% of women had an echo
diagnosis of LVSD, but women were more likely to be
diagnosed with diastolic dysfunction (5.0% vs. 3.1%), LVH (4.0%
vs. 3.0%) and valve disease (15.7% vs. 9.9%).
3.7 Treatment on discharge for LVSD
All analyses on prescription rates for disease modifying
treatments were performed on a denominator of those
patients with a diagnosis of LVSD who survived to discharge.
3.7.1 ACE inhibitor and ARB
72% of patients were discharged on an angiotensin-converting
enzyme (ACE) inhibitor, and 84% were discharged on either an
ACE inhibitor or an angiotensin receptor blocker (ARB), or both.
1% were prescribed both an ACE inhibitor and an ARB.
87% of patients treated in a cardiology ward were discharged
on an ACE inhibitor and/or an ARB, compared to 80% of those
treated in a general medical ward and 76% of patients treated
in other wards. Men were more likely to receive an ACE inhibitor
and/or ARB than women, as were younger patients. Prescription
rates of ACEI/ARB were 85% for men and 83% for women,
and 89% of patients under 75 were discharged on either of the
treatments, compared with 80% of patients over 75.
3.7.2 Beta blocker
78% of patients were prescribed a beta blocker on discharge.
This is considerably higher than the 65% recorded in the
2010/11 audit, which was considered unsatisfactorily low.
This is consistent with NICE guidance on prescription of
beta blockers, which recommends that they are given to all
patients with a diagnosis of LVSD, including older patients
and patients with chronic obstructive pulmonary disease
(COPD) without reversibility.25
discharged on a beta blocker. 83% of patients treated on a
cardiology ward were given beta blockers, compared with 71%
for both general medical patients and those on other wards.
79% of men were discharged on beta blockers, compared with
76% of women, and 84% of patients under 75 received the
treatment versus 74% of those over 75.
3.7.3 MRA
45% of patients with LVSD were discharged on a
mineralocorticoid receptor antagonist (MRA).
Patients treated on cardiology wards were more likely to be
prescribed an MRA (51%) compared with those on a general
medical ward (37%) and patients on other wards (33%). Men
were more likely to be discharged on an MRA than women
(48% vs. 40%) as were patients under 75, compared with those
over 75 (53% vs. 39%).
3.7.4 Loop diuretics
89% of patients in the audit were discharged on loop diuretics.
87% of patients on cardiology wards were prescribed a loop
diuretic on discharge, slightly lower than the 93% of patients
on general medical wards, and 90% of patients on other
wards. Rates of prescription were similar in women and
men (90% vs. 89%). Patients who were aged over 75 years on
admission were more likely to be discharged on loop diuretics
than younger patients (92% vs. 86%).
3.7.5 Thiazide diuretics
4% of patients were prescribed thiazide diuretics on discharge.
Prescription rates were a little higher for those patients
treated on a cardiology ward (5%) than for those treated on a
general medical ward (3%) and on other wards (3%). Men were
more likely to be prescribed thiazide diuretics than women (5%
vs. 3%), as were patients over 75 compared with those under
75 (6% vs. 3%).
3.7.6 Digoxin
23% of patients were prescribed digoxin on discharge.
Rates of prescription were similar in women and men (24%
vs. 22%) and amongst patients aged above or below 75 years.
Prescription rates were similar for patients on general medical
(23%), cardiology (22%) and other wards (23%).
3.7.7 Treatment on discharge by age
The prescription of ACE inhibitors, beta blockers and MRAs
decreased with age. Only prescription of loop diuretics was
higher amongst older patients (figure 6).
As with ACEI/ARB prescription, patients treated in a cardiology
ward, men, and younger patients were all more likely to be
National Heart Failure Audit April 2011-March 2012
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Fig 6: Treatment for LVSD on discharge by age
100
% of patients key heart failure drugs
90
80
70
60
50
40
30
76.5% of patients were referred onwards to their GP for followup, and 13.5% were referred to care of the elderly follow-up
services.
20
10
0
51.7% of patients were referred to cardiology follow-up, that
is, any follow-up involving a consultant cardiologist. As with
heart failure liaison follow-up, cardiology patients were far
more likely to be referred to cardiology follow-up, with 69.6%
receiving onwards referral, compared with 34.4% of general
medical patients and 31.7% of patients on other wards. Men
were more likely to be referred to cardiology follow-up than
women (57.6% vs. 44.2%), as were those under 75, of whom
67.2% received cardiology follow-up, compared to only 43.3%
of patients over 75.
18-44
45-54
55-64
65-74
75-84
85+
Age group
ACEI
Loop diuretic
Beta blocker
MRA
3.8 Monitoring heart failure patients
3.8.1 Follow-up services
3.8.2 Palliative care
Only 3.1% of patients were referred to palliative care
services following the first admission, and 7.3% following
a readmission.
This does not constitute a significant improvement on 2010/11
data, which recorded referral levels of 4% on admission and
6% on readmission. These numbers are surprisingly low
considering the age of the patient population, and the high
mortality rates in the year following discharge.
53.7% of patients were referred to a heart failure liaison
service, which is defined as a nurse led heart failure clinic.
Patients treated in a cardiology ward were more likely to be
referred to heart failure liaison services: 64.1% compared to
only 43.3% for those on general medical wards and 42.9% for
those on other wards. 59.0% of men and 47.1% of women were
referred to nurse-led follow-up, and 60.8% of those under 75,
compared with 49.9% of patients over 75.
18
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iv. HES data is from 2010/11, and PEDW data from 2011/12, due to availability.
National Heart Failure Audit April 2011-March 2012
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8
903
Blackpool Teaching Hospitals NHS
Foundation Trust
Bolton NHS Foundation Trust
220
35
1.9%
243.4%
75.6%
9.7%
39.9%
155
Bedford Hospital NHS Trust
Basildon and Thurrock University Hospitals
NHS Foundation Trust
Barts and the London
106.1%
72.6%
519
Barnet and Chase Farm Hospitals NHS Trust
113.1%
90.2%
0.0%
110.9%
61.9%
% HES
submitted
201
719
Barking, Havering and Redbridge University
Hospitals NHS Trust
Barnsley Hospital NHS Foundation Trust
296
0
296
36559
Trust
records
submitted
Ashford and St Peter's Hospitals NHS Trust
Airedale NHS Foundation Trust
Aintree University Hospital NHS Foundation
Trust
England
Trust name
Table 4: Participation and case ascertainment in England
Partial
Yes
Yes
Partial
Partial
Yes
Yes
Yes
Yes
No
Yes
Participation
status
423
371
291
362
388
277
489
636
328
245
267
59083
Primary
HES heart
failure
discharges
327
363
229
339
478
256
391
492
305
242
221
52471
Secondary
HES heart
failure
discharges
261
375
244
480
613
211
406
500
299
172
218
50315
Tertiary HES
heart failure
discharges
King George Hospital
Barnet General Hospital
Chase Farm Hospital
KGG
BNT
CHS
BOL
VIC
BED
BAS
BAL
Royal Bolton Hospital
Blackpool Victoria
Hospital
Bedford Hospital
Basildon University
Hospital
The London Chest
Hospital/The Royal
London Hospital
Barnsley Hospital
Queen's Hospital
(Romford)
OLD
BAR
St Peter's Hospital
Airedale General Hospital
University Hospital
Aintree
Hospital name
SPH
AIR
FAZ
NICOR
hospital
code
8
903
220
35
155
201
225
294
295
424
296
0
296
36559
Hospital
records
submitted
Tables 4 and 5 compare the number of patient records submitted to the audit (after data cleaning) to the number of inpatients discharged with a primary diagnosis of heart failure, as
recorded by HES for English Trusts and PEDW for Welsh Health Boards.iiivThe number of patients with a secondary and tertiary diagnosis of heart failure are also included. Participation
is defined as a Trust or Health Board submitting either 20 cases per calendar month, or greater than 70% of their HES/PEDW recorded figures.
3.9.1 Participation and case ascertainment
For the first time since it was established, the National Heart Failure Audit is publishing a series of analyses at a hospital level. All hospitals are included that submitted over 100 records or
over 70% of their HES/PEDW figures. There is significant variation across hospitals, but this is to some extent down to hospitals including unrepresentative patient populations in the audit.
3.9 Analysis by hospital
20
National Heart Failure Audit April 2011-March 2012
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239
367
Burton Hospitals NHS Foundation Trust
Calderdale and Huddersfield NHS
Foundation Trust
223
341
Countess of Chester Hospital NHS
Foundation Trust
Croydon Health Services NHS Trust
381
Colchester Hospital University NHS
Foundation Trust
325
245
City Hospitals Sunderland NHS Foundation
Trust
County Durham and Darlington NHS
Foundation Trust
178
84
Chelsea and Westminster Hospital NHS
Foundation Trust
Chesterfield Royal Hospital NHS Foundation
Trust
221
Central Manchester University Hospitals
NHS Foundation Trust
22
220
Buckinghamshire Healthcare NHS Trust
Cambridge University Hospitals NHS
Foundation Trust
628
170
Trust
records
submitted
Brighton and Sussex University Hospitals
NHS Trust
Bradford Teaching Hospitals NHS Foundation
Trust
Trust name
75.6%
58.9%
132.2%
86.8%
67.7%
63.1%
46.4%
71.1%
4.7%
71.7%
91.6%
94.0%
114.8%
32.3%
% HES
submitted
Yes
Yes
Yes
Yes
Yes
Partial
Partial
Yes
Partial
Yes
Yes
Yes
Yes
Partial
Participation
status
295
552
258
439
362
282
181
311
467
512
261
234
547
527
Primary
HES heart
failure
discharges
232
529
215
362
436
269
107
327
362
444
234
205
513
429
Secondary
HES heart
failure
discharges
205
558
208
310
475
257
112
436
304
452
166
161
447
403
Tertiary HES
heart failure
discharges
Stoke Mandeville Hospital
SMV
Darlington Memorial
Hospital
DAR
Croydon University
Hospital
University Hospital of
North Durham
DRY
MAY
Countess of Chester
Hospital
Colchester General
Hospital
Sunderland Royal
Hospital
Chesterfield Royal
Hospital
Chelsea and Westminster
Hospital
Manchester Royal
Infirmary
Addenbrooke's Hospital
Huddersfield Royal
Infirmary
COC
COL
SUN
CHE
WES
MRI
ADD
HUD
Calderdale Royal Hospital
Wycombe General
Hospital
AMG
RHI
Princess Royal Hospital
(Haywards Heath)
PRH
Queen's Hospital (Burton)
Royal Sussex County
Hospital
RSC
BRT
Bradford Royal Infirmary
Hospital name
BRD
NICOR
hospital
code
223
145
180
341
381
245
178
84
221
22
182
185
239
0
220
222
406
170
Hospital
records
submitted
National Heart Failure Audit April 2011-March 2012
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21
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481
167
East and North Hertfordshire NHS Trust
East Cheshire NHS Trust
210
287
128
261
121
Epsom and St Helier University Hospitals
NHS Trust
Frimley Park Hospital NHS Foundation Trust
Gateshead Health NHS Foundation Trust
George Eliot Hospital NHS Trust
Gloucestershire Hospitals NHS Foundation
Trust
212
424
East Sussex Healthcare NHS Trust
Great Western Hospitals NHS Foundation
Trust
234
East Lancashire Hospitals NHS Trust
0
262
Ealing Hospital NHS Trust
East Kent Hospitals University NHS
Foundation Trust
176
197
Doncaster and Bassetlaw Hospitals NHS
Foundation Trust
Dorset County Hospital NHS Foundation
Trust
196
73
Derby Hospitals NHS Foundation Trust
Dartford and Gravesham NHS Trust
83.8%
23.9%
133.2%
56.6%
121.6%
57.9%
69.3%
47.4%
0.0%
64.0%
134.7%
118.0%
89.8%
37.4%
38.4%
23.7%
Yes
Partial
Yes
Partial
Yes
Partial
Yes
Partial
No
Partial
Yes
Yes
Yes
Partial
Partial
Partial
253
507
196
226
236
363
612
494
833
261
357
222
196
527
510
308
275
467
217
262
236
349
476
515
661
152
305
158
201
446
418
228
276
412
191
249
257
319
338
536
636
171
253
181
179
441
380
191
Bassetlaw Hospital
BSL
Cheltenham General
Hospital
CHG
The Great Western
Hospital
Gloucestershire Royal
Hospital
GLO
PMS
George Eliot Hospital
Queen Elizabeth Hospital
(Gateshead)
Frimley Park Hospital
NUN
QEG
FRM
Epsom Hospital
St Helier Hospital
SHC
EPS
Eastbourne District
General Hospital
Conquest Hospital
CGH
DGE
Royal Blackburn Hospital
William Harvey Hospital
WHH
BLA
Queen Elizabeth The
Queen Mother Hospital
Kent and Canterbury
Hospital
KCC
QEQ
Macclesfield District
General Hospital
MAC
Queen Elizabeth II
Hospital
Lister Hospital
LIS
QEW
Ealing Hospital
EAL
Dorset County Hospital
Doncaster Royal Infirmary
DID
WDH
Royal Derby Hospital
Darent Valley Hospital
DER
DVH
212
54
67
261
128
287
100
110
206
218
234
0
0
0
167
214
267
262
176
69
128
196
73
22
National Heart Failure Audit April 2011-March 2012
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309
94.5%
Yes
Yes
327
397
264
332
230
204
362
252
KTH
KCH
KGH
JPH
Kingston Hospital NHS Trust
61.7%
302
310
245
Yes
292
King's College Hospital NHS Foundation
Trust
79.1%
329
239
Partial
118
Kettering General Hospital NHS Foundation
Trust
34.7%
148
114
196
James Paget University Hospitals NHS
Foundation Trust
Yes
IOW
88.3%
173
Isle of Wight NHS PCT
621
CCH
594
CHH
Imperial College Healthcare NHS Trust
621
464
HOM
HIN
Kingston Hospital
King's College Hospital
Kettering General
Hospital
James Paget University
Hospital
St Mary's Hospital,
Newport
Charing Cross Hospital
Hammersmith Hospital
St Mary's Hospital
Paddington
Hull Royal Infirmary
Castle Hill Hospital
Homerton University
Hospital
Hinchingbrooke Hospital
Wexham Park Hospital
Good Hope Hospital
GHS
WEX
Solihull Hospital
SOL
Birmingham Heartlands
Hospital
EBH
Royal Hampshire County
Hospital
RHC
Harrogate District
Hospital
Basingstoke and North
Hampshire Hospital
NHH
HAR
St Thomas' Hospital
Hospital name
STH
NICOR
hospital
code
HAM
Yes
411
154
111
279
757
162
295
351
Tertiary HES
heart failure
discharges
Imperial College Healthcare NHS Trust
79.1%
431
144
151
292
740
153
265
368
Secondary
HES heart
failure
discharges
STM
491
Yes
245
169
388
1122
215
333
406
Primary
HES heart
failure
discharges
Imperial College Healthcare NHS Trust
171.0%
Yes
Partial
Partial
Yes
Partial
Partial
Partial
Participation
status
HRI
737
Hull and East Yorkshire Hospitals NHS Trust
86.5%
22.5%
18.3%
32.8%
60.5%
38.4%
56.4%
% HES
submitted
Hull and East Yorkshire Hospitals NHS Trust
212
Homerton University Hospital NHS
Foundation Trust
38
368
Heart of England NHS Foundation Trust
Hinchingbrooke Health Care NHS Trust
130
Harrogate and District NHS Foundation Trust
71
128
Hampshire Hospitals NHS Foundation Trust
Heatherwood and Wexham Park Hospitals
NHS Foundation Trust
229
Trust
records
submitted
Guy's and St Thomas' NHS Foundation Trust
Trust name
309
245
239
114
173
99
151
241
110
627
212
38
71
0
161
207
130
0
128
229
Hospital
records
submitted
National Heart Failure Audit April 2011-March 2012
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23
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117
136
346
404
Lewisham Healthcare NHS Trust
Liverpool Heart and Chest Hospital NHS
Foundation Trust
Luton and Dunstable Hospital NHS
Foundation Trust
Maidstone and Tunbridge Wells NHS Trust
North Middlesex University Hospital NHS
Trust
171
78
484
North Bristol NHS Trust
North Cumbria University Hospitals NHS
Trust
374
2
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Newham University Hospital NHS Trust
154
Milton Keynes Hospital NHS Foundation
Trust
74
Mid Staffordshire NHS Foundation Trust
420
136
Mid Essex Hospital Services NHS Trust
Mid Yorkshire Hospitals NHS Trust
263
Mid Cheshire Hospitals NHS Foundation
Trust
0
248
Leeds Teaching Hospitals NHS Trust
Medway NHS Foundation Trust
566
Lancashire Teaching Hospitals NHS
Foundation Trust
55.3%
22.3%
126.7%
51.4%
0.8%
75.9%
64.9%
25.2%
34.7%
126.4%
0.0%
90.2%
121.8%
64.5%
40.5%
30.4%
123.3%
Partial
Partial
Yes
Yes
Partial
Yes
Yes
Partial
Partial
Yes
No
Yes
Yes
Partial
Partial
Yes
Yes
309
350
382
728
242
203
647
294
392
208
300
448
284
211
289
815
459
176
372
373
696
169
164
491
227
211
228
241
448
271
118
181
719
581
156
310
324
746
169
129
393
187
201
216
256
336
255
150
175
704
469
Southmead Hospital
Cumberland Infirmary
BSM
CMI
NMH
North Middlesex
University Hospital
West Cumberland
Hospital
Frenchay Hospital
FRY
WCI
Norfolk and Norwich
University Hospital
Newham University
Hospital
Milton Keynes General
Hospital
NOR
NWG
MKH
Dewsbury and District
Hospital
Pinderfields Hospital
PIN
DEW
Stafford Hospital
Broomfield Hospital
Leighton Hospital
SDG
BFH
LGH
Medway Maritime
Hospital
Tunbridge Wells Hospital
KSX
MDW
Maidstone Hospital
Luton and Dunstable
Hospital
Liverpool Heart and Chest
Hospital
University Hospital
Lewisham
Leeds General Infirmary
Chorley and South Ribble
Hospital
Royal Preston Hospital
MAI
LDH
BHL
LEW
LGI
CHO
RPH
171
32
46
205
279
374
2
154
119
301
74
136
263
0
178
226
346
136
117
248
232
334
24
National Heart Failure Audit April 2011-March 2012
HF Report 2012 Design B.indd 24
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212
256
400
203
736
Northern Devon Healthcare NHS Trust
Northern Lincolnshire and Goole Hospitals
NHS Foundation Trust
Northumbria Healthcare NHS Foundation Trust
Nottingham University Hospitals NHS Trust
Oxford Radcliffe Hospitals NHS Trust
Poole Hospital NHS Foundation Trust
307
0
296
Peterborough and Stamford Hospitals NHS
Foundation Trust
Plymouth Hospitals NHS Trust
645
Pennine Acute Hospitals NHS Trust
0
217
Northampton General Hospital NHS Trust
Papworth Hospital NHS Foundation Trust
383
Trust
records
submitted
North Tees and Hartlepool NHS Foundation
Trust
Trust name
146.2%
0.0%
89.4%
88.5%
0.0%
102.5%
25.5%
60.6%
75.5%
74.9%
77.0%
140.3%
% HES
submitted
Yes
No
Yes
Yes
No
Yes
Partial
Yes
Yes
Yes
Yes
Yes
Participation
status
210
635
331
729
274
718
797
660
339
283
282
273
Primary
HES heart
failure
discharges
237
525
280
929
282
615
722
530
278
231
290
329
Secondary
HES heart
failure
discharges
198
498
251
881
227
534
719
503
311
219
227
316
Tertiary HES
heart failure
discharges
Queen's Medical Centre
Nottingham City Hospital
John Radcliffe Hospital
Horton General Hospital
UHN
CHN
RAD
HOR
PGH
PLY
Poole General Hospital
Derriford Hospital
Peterborough City
Hospital
Rochdale Infirmary
BHH
PET
North Manchester
General Hospital
NMG
Royal Oldham Hospital
Hexham General Hospital
HEX
OHM
Wansbeck General
Hospital
ASH
Fairfield General Hospital
North Tyneside Hospital
NTY
BRY
Scunthorpe General
Hospital
SCU
Papworth Hospital
Diana Princess of Wales
Hospital
GGH
PAP
North Devon District
Hospital
NDD
Northampton General
Hospital
University Hospital of
Hartlepool
HGH
NTH
University Hospital of
North Tees
Hospital name
NTG
NICOR
hospital
code
307
0
296
53
183
204
205
0
112
624
44
159
56
125
219
95
161
212
217
149
234
Hospital
records
submitted
National Heart Failure Audit April 2011-March 2012
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25
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449
234
155
225
223
330
144
Royal Berkshire NHS Foundation Trust
Royal Brompton and Harefield NHS
Foundation Trust
Royal Cornwall Hospitals NHS Trust
Royal Devon and Exeter NHS Foundation
Trust
Royal Free London NHS Trust
Royal Liverpool and Broadgreen University
Hospitals NHS Trust
Royal Surrey County Hospital NHS
Foundation Trust
345
Sandwell and West Birmingham Hospitals
NHS Trust
85
Shrewsbury and Telford Hospitals NHS Trust
359
315
Sherwood Forest Hospitals NHS Foundation
Trust
South Devon Healthcare NHS Foundation
Trust
452
Sheffield Teaching Hospitals NHS Foundation
Trust
7
342
Salisbury NHS Foundation Trust
Scarborough and North East Yorkshire NHS
Trust
241
Salford Royal NHS Foundation Trust
0
227
Rotherham NHS Foundation Trust
Royal United Hospital Bath NHS Trust
319
Portsmouth Hospitals NHS Trust
87.1%
19.5%
72.2%
51.3%
2.7%
48.8%
209.8%
94.1%
0.0%
81.8%
148.6%
84.8%
71.9%
32.2%
46.7%
111.4%
78.8%
59.5%
Yes
Partial
Yes
Yes
Partial
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Partial
Partial
Yes
Yes
Yes
412
437
436
881
258
707
163
256
455
176
222
263
313
481
501
403
288
536
236
331
269
905
256
614
139
331
395
141
237
229
389
428
512
305
323
543
243
304
221
736
212
608
150
301
434
144
272
224
620
395
375
261
250
509
Harefield Hospital
HH
Royal Hallamshire
Hospital
King's Mill Hospital
Newark Hospital
Princess Royal Hospital
(Telford)
Royal Shrewsbury
Hospital
RHA
KMH
NHN
TLF
RSS
Torbay Hospital
Northern General
Hospital
NGS
TOR
Scarborough General
Hospital
SCA
Sandwell General
Hospital
Birmingham City Hospital
DUD
SAN
Salisbury District Hospital
Salford Royal
Royal United Hospital Bath
Royal Surrey County
Hospital
Royal Liverpool University
Hospital
Royal Free Hospital
Royal Devon & Exeter
Hospital
SAL
SLF
BAT
RSU
RLU
RFH
RDE
Royal Cornwall Hospital
Royal Brompton Hospital
NHB
RCH
Royal Berkshire Hospital
Rotherham Hospital
Queen Alexandra Hospital
BHR
ROT
QAP
359
37
48
13
302
10
442
7
155
190
342
241
0
144
330
223
225
155
24
210
449
227
319
26
National Heart Failure Audit April 2011-March 2012
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267
South Tyneside NHS Foundation Trust
555
203
229
226
175
302
178
300
180
197
203
170
Southend University Hospital NHS
Foundation Trust
Southport and Ormskirk Hospital NHS Trust
St George's Healthcare NHS Trust
St Helens and Knowsley Teaching Hospitals
NHS Trust
Stockport NHS Foundation Trust
Surrey and Sussex Healthcare NHS Trust
Tameside Hospital NHS Foundation Trust
Taunton and Somerset NHS Foundation Trust
The Dudley Group NHS Foundation Trust
The Hillingdon Hospitals NHS Foundation
Trust
The Ipswich Hospital NHS Trust
The Newcastle Upon Tyne Hospitals NHS
Foundation Trust
0
209
South Tees Hospitals NHS Foundation Trust
South Warwickshire NHS Foundation Trust
262
Trust
records
submitted
South London Healthcare NHS Trust
Trust name
24.1%
53.0%
86.8%
38.7%
87.2%
73.0%
90.7%
50.0%
68.5%
43.3%
74.6%
165.2%
0.0%
147.5%
43.1%
34.7%
% HES
submitted
Partial
Partial
Yes
Partial
Yes
Yes
Yes
Partial
Partial
Partial
Yes
Yes
No
Yes
Partial
Yes
Participation
status
704
383
227
465
344
244
333
350
330
529
272
336
126
181
485
756
Primary
HES heart
failure
discharges
680
418
171
375
343
286
302
399
390
506
224
241
232
140
563
550
Secondary
HES heart
failure
discharges
559
429
155
379
292
223
242
358
354
608
191
268
180
112
817
526
Tertiary HES
heart failure
discharges
Queen Mary's Hospital
(Sidcup)
James Cook University
Hospital
Friarage Hospital
QMH
SCM
FRH
The Ipswich Hospital
Freeman Hospital
Royal Victoria Infirmary
FRE
RVN
Hillingdon Hospital
Russells Hall Hospital
Musgrove Park Hospital
Tameside General
Hospital
East Surrey Hospital
Stepping Hill Hospital
Whiston Hospital
St George's Hospital
Southport and Formby
District General Hospital
Southend Hospital
Warwick Hospital
IPS
HIL
RUS
MPH
TGA
ESU
SHH
WHI
GEO
SOU
SEH
WAR
South Tyneside District
Hospital
Princess Royal University
Hospital (Bromley)
BRO
STD
Queen Elizabeth Hospital
(Woolwich)
Hospital name
GWH
NICOR
hospital
code
0
170
203
197
180
300
178
302
175
226
229
203
555
0
267
0
209
1
24
237
Hospital
records
submitted
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27
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181
137
The Royal Wolverhampton Hospitals NHS
Trust
The Whittington Hospital NHS Trust
209
304
142
292
384
University Hospital of North Staffordshire
NHS Trust
University Hospital of South Manchester NHS
Foundation Trust
University Hospital Southampton NHS Trust
University Hospitals Birmingham NHS
Foundation Trust
University Hospitals Bristol NHS Foundation
Trust
0
0
University Hospitals of Leicester NHS Trust
University Hospitals of Morecambe Bay NHS
Foundation Trust
309
335
University College London Hospitals NHS
Foundation Trust
University Hospitals Coventry and
Warwickshire NHS Trust
253
United Lincolnshire Hospitals NHS Trust
0
0
The Royal Bournemouth and Christchurch
Hospitals NHS Foundation Trust
Trafford Healthcare NHS Trust
201
0
The Princess Alexandra Hospital NHS Trust
The Queen Elizabeth Hospital King's Lynn
NHS Foundation Trust
360
The North West London Hospitals NHS Trust
0.0%
0.0%
60.7%
94.6%
44.0%
27.3%
88.6%
28.1%
129.3%
32.0%
0.0%
53.9%
41.0%
0.0%
66.3%
0.0%
77.9%
No
No
Yes
Yes
Yes
Partial
Yes
Partial
Yes
Yes
No
Partial
Partial
No
Partial
No
Yes
449
1169
509
406
663
521
343
743
259
790
96
254
442
584
303
290
462
351
741
577
423
382
464
473
483
272
748
104
160
317
662
291
218
361
281
658
671
458
357
443
444
461
298
693
83
165
304
615
316
238
335
Lincoln County Hospital
Grantham and District
Hospital
LIN
GRA
Hospital of St Cross
Glenfield Hospital
Leicester Royal Infirmary
Furness General Hospital
RUG
GRL
LER
FGH
Royal Lancaster Infirmary
University Hospital
Coventry
WAL
RLI
Bristol Royal Infirmary
Queen Elizabeth Hospital
(Edgbaston)
Southampton General
Hospital
Wythenshawe Hospital
University Hospital of
North Staffordshire
BRI
QEB
SGH
WYT
STO
University College
Hospital
Pilgrim Hospital
PIL
UCL
Trafford General Hospital
Whittington Hospital
New Cross Hospital
Royal Bournemouth
General Hospital
Queen Elizabeth Hospital
(King's Lynn)
Princess Alexandra
Hospital
Central Middlesex
Hospital
Northwick Park Hospital
TRA
WHT
NCR
BOU
QKL
PAH
CMH
NPH
0
0
0
0
28
281
384
292
142
304
209
335
46
101
106
0
137
181
0
201
0
14
346
28
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74.7%
101.0%
245
212
218
639
116
206
219
392
513
188
253
220
West Hertfordshire Hospitals NHS Trust
West Middlesex University Hospital NHS
Trust
West Suffolk NHS Foundation Trust
Western Sussex Hospitals NHS Trust
Weston Area Health NHS Trust
Whipps Cross University Hospital NHS Trust
Wirral University Teaching Hospital NHS
Foundation Trust
Worcestershire Acute Hospitals NHS Trust
Wrightington, Wigan and Leigh NHS
Foundation Trust
Wye Valley NHS Trust
Yeovil District Hospital NHS Foundation Trust
York Teaching Hospital NHS Foundation Trust
85.3%
128.4%
92.6%
181.3%
71.9%
44.2%
66.9%
59.2%
86.8%
84.5%
66.8%
145
Warrington and Halton Hospitals NHS
Foundation Trust
72.4%
% HES
submitted
241
Trust
records
submitted
Walsall Healthcare NHS Trust
Trust name
Yes
Yes
Yes
Yes
Yes
Partial
Partial
Partial
Yes
Yes
Yes
Yes
Partial
Yes
Participation
status
258
197
203
283
545
496
308
196
736
258
210
328
217
333
Primary
HES heart
failure
discharges
276
163
180
334
454
383
268
144
561
229
181
287
265
345
Secondary
HES heart
failure
discharges
226
132
181
348
500
303
266
133
495
225
216
220
218
297
Tertiary HES
heart failure
discharges
St Richard's Hospital
STR
YDH
YEO
HCH
AEI
York District Hospital
Yeovil District Hospital
County Hospital Hereford
Royal Albert Edward
Infirmary
Worcestershire Royal
Hospital
Alexandra Hospital
RED
WRC
Arrowe Park Hospital
Whipps Cross University
Hospital
WIR
WHC
Weston General Hospital
Worthing Hospital
WRG
WGH
West Suffolk Hospital
West Middlesex University
Hospital
Watford General Hospital
Warrington Hospital
Manor Hospital
Hospital name
WSH
WMU
WAT
WDG
WMH
NICOR
hospital
code
220
253
188
513
165
227
219
206
116
276
363
218
212
245
145
241
Hospital
records
submitted
National Heart Failure Audit April 2011-March 2012
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29
28/11/2012 14:19
Hywel Dda Health Board
Cwm Taf Health Board
161
2
0
172
Betsi Cadwaladr University Health Board
Cardiff & Vale University Health Board
175
7
517
Trust
records
submitted
Aneurin Bevan Health Board
Abertawe Bro Morgannwg University Health
Board
Wales
Trust name
23.4%
0.4%
0.0%
18.5%
19.4%
0.9%
11.9%
% PEDW
submitted
Table 5: Participation and case ascertainment in Wales
Partial
Partial
No
Partial
Partial
Partial
Participation
status
688
467
541
928
901
823
4348
Primary
PEDW heart
failure
discharges
479
332
497
478
713
804
3303
Secondary
PEDW heart
failure
discharges
417
236
432
719
647
929
3380
Tertiary
PEDW heart
failure
discharges
Ysbyty Gwynedd
GWY
University Hospital of
Wales
Prince Charles Hospital
Royal Glamorgan
Bronglais General
Hospital
Prince Philip Hospital
West Wales General
Withybush General
Hospital
UHW
PCH
RGH
BRG
PPH
WWG
WYB
Llandough Hospital
Glan Clwyd Hospital
CLW
LLD
Caerphilly District Miners
Hospital/Ysbyty Ystrad
Fawr
YYF
Wrexham Maelor Hospital
Nevill Hall Hospital
NEV
WRX
Royal Gwent Hospital
GWE
Llandudno General
Hospital
Singleton Hospital
SIN
LLA
Princess Of Wales
Hospital
Neath Port Talbot Hospital
NGH
POW
Morriston Hospital
Hospital name
MOR
NICOR
hospital
code
4
5
6
146
1
1
0
0
172
0
0
0
0
175
0
0
7
0
0
517
Hospital
records
submitted
30
National Heart Failure Audit April 2011-March 2012
HF Report 2012 Design B.indd 30
SPH
KGG
OLD
BNT
CHS
Ashford and St Peter's Hospitals
NHS Trust
Barking, Havering and Redbridge
University Hospitals NHS Trust
Barking, Havering and Redbridge
University Hospitals NHS Trust
Barnet and Chase Farm Hospitals
NHS Trust
Barnet and Chase Farm Hospitals
NHS Trust
BAR
AIR
Airedale NHS Foundation Trust
Barnsley Hospital NHS Foundation
Trust
FAZ
Aintree University Hospital NHS
Foundation Trust
Barnsley Hospital
Chase Farm Hospital
Barnet General Hospital
Queen's Hospital (Romford)
King George Hospital
St Peter's Hospital
Airedale General Hospital
University Hospital Aintree
201
225
294
424
295
296
0
296
36559
Records
submitted
England
Hospital name
37076
NICOR
hospital
code
England and Wales
Trust name
• % referred to cardiology follow-up: all records where patient survived to discharge.
• % referred to HF liaison service: all records where patient had LVSD and survived to discharge.
• % beta blocker on discharge: all records where patient had LVSD and survived to discharge.
• % ACEI/ARB on discharge: all records where patient had LVSD and survived to discharge.
• % cardiology inpatient: all records.
• % received echo: all records.
Denominators for tables 6 and 7 as follows:
Table 6: Clinical practice in England (2011/12)
84.1%
86.2%
91.8%
98.6%
98.6%
84.8%
98.3%
85.9%
85.9%
% received
echo
20.4%
37.8%
59.5%
19.6%
21.0%
49.3%
83.4%
47.0%
47.1%
% cardiology
inpatient
92.9%
81.5%
97.2%
79.0%
72.0%
59.0%
65.6%
82.7%
82.7%
% ACEI/ARB
on discharge
82.1%
80.6%
86.2%
78.3%
70.8%
56.4%
75.1%
76.3%
76.4%
% beta
blocker on
discharge
24.6%
71.9%
63.4%
82.0%
73.1%
51.4%
97.7%
63.2%
63.2%
% referred
to HF liaison
service
43.2%
58.3%
50.6%
55.5%
55.5%
50.6%
91.2%
51.5%
51.1%
% referred
to cardiology
follow-up
Please note that these outputs have not been risk adjusted, but the denominators used for each analysis have been chosen to ensure that the outcomes are as representative as
possible. The audit Project Board has decided to refrain from publishing outcomes data (e.g. readmission and mortality rates) at a hospital level until a satisfactory risk adjustment
model has been developed. However, since April 2012 the National Heart Failure Audit has included a series of new mandatory data items, which will enable a sophisticated risk
adjustment of the data to account for known confounders. This will enable the audit to publish outcome data at a hospital level in the near future.
Tables 6 and 7 show the percentages of cases at each hospital receiving key diagnostic tests, therapies and referral to follow-up services at hospitals in England and Wales. Hospitallevel data on clinical practice has only been published if a hospital submitted more than 100 records to the audit, or greater than 70% of their HES recorded figures. An asterisk (*) in a
cell indicates that too few records were submitted for a percentage to be published.
harge.
3.9.2 Clinical practice
arge.
28/11/2012 14:19
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28/11/2012 14:19
BAL
BAS
BED
VIC
BOL
BRD
PRH
RSC
SMV
AMG
BRT
RHI
HUD
ADD
MRI
WES
CHE
SUN
COL
COC
Barts and the London
Basildon and Thurrock University
Hospitals NHS Foundation Trust
Bedford Hospital NHS Trust
Blackpool Teaching Hospitals NHS
Foundation Trust
Bolton NHS Foundation Trust
Bradford Teaching Hospitals NHS
Foundation Trust
Brighton and Sussex University
Hospitals NHS Trust
Brighton and Sussex University
Hospitals NHS Trust
Buckinghamshire Healthcare NHS
Trust
Buckinghamshire Healthcare NHS
Trust
Burton Hospitals NHS Foundation
Trust
Calderdale and Huddersfield NHS
Foundation Trust
Calderdale and Huddersfield NHS
Foundation Trust
Cambridge University Hospitals
NHS Foundation Trust
Central Manchester University
Hospitals NHS Foundation Trust
Chelsea and Westminster Hospital
NHS Foundation Trust
Chesterfield Royal Hospital NHS
Foundation Trust
City Hospitals Sunderland NHS
Foundation Trust
Colchester Hospital University NHS
Foundation Trust
Countess of Chester Hospital NHS
Foundation Trust
Countess of Chester Hospital
Colchester General Hospital
Sunderland Royal Hospital
Chesterfield Royal Hospital
Chelsea and Westminster Hospital
Manchester Royal Infirmary
Addenbrooke's Hospital
Huddersfield Royal Infirmary
Calderdale Royal Hospital
Queen's Hospital (Burton)
Wycombe General Hospital
Stoke Mandeville Hospital
Royal Sussex County Hospital
Princess Royal Hospital (Haywards
Heath)
Bradford Royal Infirmary
Royal Bolton Hospital
Blackpool Victoria Hospital
Bedford Hospital
Basildon University Hospital
The London Chest Hospital/The Royal
London Hospital
341
381
245
178
84
221
22
182
185
239
220
0
406
222
170
8
903
220
35
155
99.1%
99.5%
85.7%
75.3%
*
88.2%
*
91.8%
94.1%
72.4%
97.7%
82.3%
68.0%
82.4%
*
91.4%
90.0%
*
89.7%
68.0%
50.5%
24.5%
44.9%
*
47.0%
*
50.5%
62.2%
43.9%
70.5%
50.0%
6.8%
46.5%
*
60.3%
38.6%
*
69.7%
95.7%
81.4%
81.8%
91.5%
*
89.0%
*
95.6%
93.0%
90.4%
90.9%
86.5%
89.4%
79.5%
*
85.1%
64.3%
*
78.8%
92.0%
80.0%
77.4%
86.4%
*
90.6%
*
73.2%
69.6%
92.2%
81.3%
74.5%
84.6%
70.5%
*
83.8%
74.1%
*
83.5%
90.6%
94.6%
31.3%
48.8%
*
77.8%
*
53.2%
58.2%
43.2%
62.7%
75.0%
34.2%
59.0%
*
70.9%
29.1%
*
86.4%
51.9%
39.5%
50.7%
28.6%
*
72.9%
*
42.7%
55.2%
51.5%
79.1%
55.4%
33.5%
63.2%
*
21.8%
55.1%
*
85.7%
32
National Heart Failure Audit April 2011-March 2012
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28/11/2012 14:19
QEW
MAC
KCC
QEQ
WHH
BLA
CGH
DGE
EPS
East and North Hertfordshire NHS
Trust
East Cheshire NHS Trust
East Kent Hospitals University NHS
Foundation Trust
East Kent Hospitals University NHS
Foundation Trust
East Kent Hospitals University NHS
Foundation Trust
East Lancashire Hospitals NHS
Trust
East Sussex Healthcare NHS Trust
East Sussex Healthcare NHS Trust
Epsom and St Helier University
Hospitals NHS Trust
DID
Doncaster and Bassetlaw Hospitals
NHS Foundation Trust
LIS
BSL
Doncaster and Bassetlaw Hospitals
NHS Foundation Trust
East and North Hertfordshire NHS
Trust
DER
Derby Hospitals NHS Foundation
Trust
EAL
DVH
Dartford and Gravesham NHS Trust
Ealing Hospital NHS Trust
MAY
Croydon Health Services NHS Trust
WDH
DRY
County Durham and Darlington
NHS Foundation Trust
Dorset County Hospital NHS
Foundation Trust
DAR
NICOR
hospital
code
County Durham and Darlington
NHS Foundation Trust
Trust name
Epsom Hospital
Eastbourne District General Hospital
Conquest Hospital
Royal Blackburn Hospital
William Harvey Hospital
Queen Elizabeth The Queen Mother
Hospital
Kent and Canterbury Hospital
Macclesfield District General Hospital
Queen Elizabeth II Hospital
Lister Hospital
Ealing Hospital
Dorset County Hospital
Doncaster Royal Infirmary
Bassetlaw Hospital
Royal Derby Hospital
Darent Valley Hospital
Croydon University Hospital
University Hospital of North Durham
Darlington Memorial Hospital
Hospital name
100
206
218
234
0
0
0
167
214
267
262
176
128
69
196
73
223
180
145
Records
submitted
49.0%
89.3%
88.1%
76.1%
75.4%
84.6%
62.9%
93.9%
71.0%
85.9%
*
89.80%
*
79.8%
97.8%
93.1%
% received
echo
43.0%
56.3%
53.2%
61.5%
56.3%
16.4%
57.7%
37.0%
21.0%
17.3%
*
51.03%
*
30.5%
53.9%
47.6%
% cardiology
inpatient
80.0%
73.2%
64.0%
82.0%
89.7%
62.6%
87.0%
72.5%
68.9%
95.0%
*
81.11%
*
63.3%
69.4%
86.5%
% ACEI/ARB
on discharge
40.0%
62.6%
57.0%
85.7%
86.5%
66.1%
82.4%
90.8%
80.5%
75.6%
*
67.78%
*
67.2%
71.7%
73.7%
% beta
blocker on
discharge
63.6%
70.3%
63.2%
89.5%
50.0%
25.2%
78.4%
11.5%
47.3%
52.2%
*
98.94%
*
31.8%
46.6%
50.8%
% referred
to HF liaison
service
35.6%
53.6%
44.9%
75.9%
62.9%
30.1%
74.2%
82.0%
29.5%
53.6%
*
76.74%
*
33.9%
48.5%
42.0%
% referred
to cardiology
follow-up
National Heart Failure Audit April 2011-March 2012
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33
28/11/2012 14:19
GHS
Heart of England NHS Foundation
Trust
HRI
EBH
Heart of England NHS Foundation
Trust
Hull and East Yorkshire Hospitals
NHS Trust
HAR
Harrogate and District NHS
Foundation Trust
CHH
RHC
Hampshire Hospitals NHS
Foundation Trust
Hull and East Yorkshire Hospitals
NHS Trust
NHH
Hampshire Hospitals NHS
Foundation Trust
HOM
STH
Guy's and St Thomas' NHS
Foundation Trust
Homerton University Hospital NHS
Foundation Trust
PMS
Great Western Hospitals NHS
Foundation Trust
HIN
GLO
Gloucestershire Hospitals NHS
Foundation Trust
Hinchingbrooke Health Care NHS
Trust
CHG
Gloucestershire Hospitals NHS
Foundation Trust
WEX
NUN
George Eliot Hospital NHS Trust
Heatherwood and Wexham Park
Hospitals NHS Foundation Trust
QEG
Gateshead Health NHS Foundation
Trust
SOL
FRM
Frimley Park Hospital NHS
Foundation Trust
Heart of England NHS Foundation
Trust
SHC
Epsom and St Helier University
Hospitals NHS Trust
Hull Royal Infirmary
Castle Hill Hospital
Homerton University Hospital
Hinchingbrooke Hospital
Wexham Park Hospital
Solihull Hospital
Good Hope Hospital
Birmingham Heartlands Hospital
Harrogate District Hospital
Royal Hampshire County Hospital
Basingstoke and North Hampshire
Hospital
St Thomas' Hospital
The Great Western Hospital
Gloucestershire Royal Hospital
Cheltenham General Hospital
George Eliot Hospital
Queen Elizabeth Hospital (Gateshead)
Frimley Park Hospital
St Helier Hospital
110
627
212
38
71
161
0
207
130
0
128
229
212
67
54
261
128
287
110
64.5%
89.0%
84.0%
*
*
97.5%
97.1%
81.5%
85.9%
98.7%
85.4%
*
*
87.4%
78.1%
87.5%
69.1%
0.9%
75.8%
50.0%
*
*
78.0%
50.0%
51.5%
69.5%
60.3%
55.9%
*
*
34.1%
30.8%
72.1%
40.9%
77.3%
86.8%
82.7%
*
*
88.2%
84.5%
90.0%
92.6%
82.2%
95.4%
*
*
77.3%
65.1%
84.8%
83.3%
68.2%
83.8%
89.6%
*
*
75.6%
66.1%
90.2%
63.0%
77.8%
84.8%
*
*
85.0%
55.5%
65.2%
81.8%
60.9%
66.8%
72.6%
*
*
82.1%
68.3%
66.7%
83.3%
92.3%
89.1%
*
*
0.0%
65.1%
84.8%
70.3%
39.0%
84.6%
60.5%
*
*
40.1%
55.6%
44.4%
19.5%
80.3%
70.1%
*
*
50.7%
46.8%
60.2%
37.8%
34
National Heart Failure Audit April 2011-March 2012
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28/11/2012 14:19
LDH
MAI
KSX
MDW
LGH
Maidstone and Tunbridge Wells
NHS Trust
Maidstone and Tunbridge Wells
NHS Trust
Medway NHS Foundation Trust
Mid Cheshire Hospitals NHS
Foundation Trust
RPH
Lancashire Teaching Hospitals NHS
Foundation Trust
Luton and Dunstable Hospital NHS
Foundation Trust
CHO
Lancashire Teaching Hospitals NHS
Foundation Trust
BHL
KTH
Kingston Hospital NHS Trust
Liverpool Heart and Chest Hospital
NHS Foundation Trust
KCH
King's College Hospital NHS
Foundation Trust
LEW
KGH
Kettering General Hospital NHS
Foundation Trust
Lewisham Healthcare NHS Trust
JPH
James Paget University Hospitals
NHS Foundation Trust
LGI
IOW
Isle of Wight NHS PCT
Leeds Teaching Hospitals NHS
Trust
St Mary's Hospital Paddington
STM
Imperial College Healthcare NHS
Trust
Leighton Hospital
Medway Maritime Hospital
Tunbridge Wells Hospital
Maidstone Hospital
Luton and Dunstable Hospital
Liverpool Heart and Chest Hospital
University Hospital Lewisham
Leeds General Infirmary
Royal Preston Hospital
Chorley and South Ribble Hospital
Kingston Hospital
King's College Hospital
Kettering General Hospital
James Paget University Hospital
St Mary's Hospital, Newport
Hammersmith Hospital
HAM
Imperial College Healthcare NHS
Trust
Charing Cross Hospital
Hospital name
CCH
NICOR
hospital
code
Imperial College Healthcare NHS
Trust
Trust name
263
0
178
226
346
136
117
248
334
232
309
245
239
114
173
241
151
99
Records
submitted
100.0%
82.0%
93.8%
90.5%
95.6%
99.1%
98.8%
98.8%
100.0%
60.2%
95.1%
87.0%
83.3%
73.4%
99.2%
85.4%
91.9%
% received
echo
82.9%
43.8%
64.4%
26.3%
97.8%
45.3%
94.4%
37.7%
50.4%
34.6%
44.0%
74.9%
40.4%
26.0%
26.1%
47.0%
43.4%
% cardiology
inpatient
90.4%
97.7%
90.9%
92.3%
72.9%
86.7%
81.5%
80.0%
97.1%
80.0%
89.0%
83.0%
89.6%
71.4%
88.2%
89.4%
100.0%
% ACEI/ARB
on discharge
89.2%
55.7%
78.0%
71.4%
79.8%
92.9%
82.6%
81.6%
84.7%
48.5%
85.6%
85.7%
82.2%
42.0%
81.0%
86.5%
64.0%
% beta
blocker on
discharge
69.7%
80.9%
89.2%
69.0%
76.2%
88.6%
98.7%
98.8%
96.6%
0.0%
49.2%
93.3%
12.8%
93.5%
30.3%
48.2%
60.7%
% referred
to HF liaison
service
46.5%
60.7%
74.7%
47.1%
99.1%
96.7%
88.6%
86.4%
78.4%
44.7%
36.2%
53.3%
27.1%
48.3%
53.9%
76.2%
35.8%
% referred
to cardiology
follow-up
National Heart Failure Audit April 2011-March 2012
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35
28/11/2012 14:19
HEX
NTY
Northumbria Healthcare NHS
Foundation Trust
Northumbria Healthcare NHS
Foundation Trust
NTG
North Tees and Hartlepool NHS
Foundation Trust
SCU
HGH
North Tees and Hartlepool NHS
Foundation Trust
Northern Lincolnshire and Goole
Hospitals NHS Foundation Trust
NMH
North Middlesex University Hospital
NHS Trust
GGH
WCI
North Cumbria University Hospitals
NHS Trust
Northern Lincolnshire and Goole
Hospitals NHS Foundation Trust
CMI
North Cumbria University Hospitals
NHS Trust
NDD
BSM
North Bristol NHS Trust
Northern Devon Healthcare NHS
Trust
FRY
North Bristol NHS Trust
NTH
NOR
Norfolk and Norwich University
Hospitals NHS Foundation Trust
Northampton General Hospital NHS
Trust
NWG
PIN
Mid Yorkshire Hospitals NHS Trust
Newham University Hospital NHS
Trust
DEW
Mid Yorkshire Hospitals NHS Trust
MKH
SDG
Mid Staffordshire NHS Foundation
Trust
Milton Keynes Hospital NHS
Foundation Trust
BFH
Mid Essex Hospital Services NHS
Trust
North Tyneside Hospital
Hexham General Hospital
Scunthorpe General Hospital
Diana Princess of Wales Hospital
North Devon District Hospital
Northampton General Hospital
University Hospital of North Tees
University Hospital of Hartlepool
North Middlesex University Hospital
West Cumberland Hospital
Cumberland Infirmary
Southmead Hospital
Frenchay Hospital
Norfolk and Norwich University
Hospital
Newham University Hospital
Milton Keynes General Hospital
Pinderfields Hospital
Dewsbury and District Hospital
Stafford Hospital
Broomfield Hospital
219
56
95
161
212
217
234
149
171
32
46
205
279
374
2
154
301
119
74
136
90.9%
*
*
22.4%
84.9%
86.6%
78.2%
96.0%
83.0%
*
*
94.6%
93.2%
80.5%
*
76.6%
94.0%
79.8%
*
99.3%
45.7%
*
*
31.7%
50.2%
49.3%
58.5%
64.4%
7.6%
*
*
55.1%
34.4%
100.0%
*
48.7%
53.5%
31.1%
*
30.1%
60.5%
*
*
78.3%
74.0%
100.0%
97.7%
100.0%
92.9%
*
*
58.5%
80.2%
84.0%
*
76.0%
84.9%
90.4%
*
97.0%
79.3%
*
*
69.6%
54.3%
98.7%
93.2%
98.0%
79.3%
*
*
71.8%
72.4%
79.0%
*
68.0%
87.6%
77.1%
*
95.9%
47.1%
*
*
0.0%
71.3%
99.0%
75.6%
63.6%
86.2%
*
*
13.7%
1.9%
33.2%
*
75.9%
69.7%
92.7%
*
78.0%
29.6%
*
*
43.5%
30.1%
29.0%
30.4%
32.8%
36.0%
*
*
45.6%
21.0%
68.5%
*
46.2%
60.4%
61.3%
*
63.8%
36
National Heart Failure Audit April 2011-March 2012
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BHH
OHM
PET
PLY
PGH
QAP
ROT
BHR
Pennine Acute Hospitals NHS Trust
Pennine Acute Hospitals NHS Trust
Peterborough and Stamford
Hospitals NHS Foundation Trust
Plymouth Hospitals NHS Trust
Poole Hospital NHS Foundation
Trust
Portsmouth Hospitals NHS Trust
Rotherham NHS Foundation Trust
Royal Berkshire NHS Foundation
Trust
RDE
NMG
Pennine Acute Hospitals NHS Trust
Royal Devon and Exeter NHS
Foundation Trust
BRY
Pennine Acute Hospitals NHS Trust
RCH
PAP
Papworth Hospital NHS Foundation
Trust
Royal Cornwall Hospitals NHS Trust
RAD
Oxford Radcliffe Hospitals NHS
Trust
NHB
HOR
Oxford Radcliffe Hospitals NHS
Trust
Royal Brompton and Harefield NHS
Foundation Trust
UHN
Nottingham University Hospitals
NHS Trust
HH
CHN
Nottingham University Hospitals
NHS Trust
Royal Brompton and Harefield NHS
Foundation Trust
ASH
NICOR
hospital
code
Northumbria Healthcare NHS
Foundation Trust
Trust name
Royal Devon & Exeter Hospital
Royal Cornwall Hospital
Royal Brompton Hospital
Harefield Hospital
Royal Berkshire Hospital
Rotherham Hospital
Queen Alexandra Hospital
Poole General Hospital
Derriford Hospital
Peterborough City Hospital
Royal Oldham Hospital
Rochdale Infirmary
North Manchester General Hospital
Fairfield General Hospital
Papworth Hospital
John Radcliffe Hospital
Horton General Hospital
Queen's Medical Centre
Nottingham City Hospital
Wansbeck General Hospital
Hospital name
225
155
210
24
449
227
319
307
0
296
204
53
183
205
0
624
112
159
44
125
Records
submitted
77.78%
84.52%
100.00%
*
88.2%
83.3%
96.6%
70.7%
87.5%
90.7%
*
95.1%
80.0%
95.7%
96.4%
88.7%
*
93.6%
% received
echo
52.89%
43.23%
98.50%
*
46.1%
32.6%
94.0%
23.1%
71.6%
4.4%
*
40.4%
63.4%
22.8%
17.9%
18.9%
*
49.6%
% cardiology
inpatient
100.00%
81.08%
92.00%
*
83.3%
80.4%
79.9%
70.5%
75.4%
87.8%
*
83.0%
86.0%
99.6%
100.0%
75.8%
*
81.1%
% ACEI/ARB
on discharge
100.00%
70.54%
87.84%
*
83.4%
81.9%
74.8%
67.0%
65.7%
63.4%
*
82.5%
80.4%
98.7%
97.1%
67.4%
*
67.6%
% beta
blocker on
discharge
75.00%
61.86%
52.27%
*
72.9%
69.5%
77.9%
20.0%
51.7%
97.1%
*
91.2%
93.9%
91.7%
93.0%
70.0%
*
69.3%
% referred
to HF liaison
service
40.21%
37.14%
97.52%
*
28.2%
37.1%
43.7%
28.0%
59.6%
83.3%
*
55.3%
31.9%
54.1%
17.3%
31.9%
*
12.0%
% referred
to cardiology
follow-up
National Heart Failure Audit April 2011-March 2012
HF Report 2012 Design B.indd 37
37
28/11/2012 14:19
NHN
TLF
Sherwood Forest Hospitals NHS
Foundation Trust
Shrewsbury and Telford Hospitals
NHS Trust
FRH
KMH
Sherwood Forest Hospitals NHS
Foundation Trust
South Tees Hospitals NHS
Foundation Trust
RHA
Sheffield Teaching Hospitals NHS
Foundation Trust
QMH
NGS
Sheffield Teaching Hospitals NHS
Foundation Trust
South London Healthcare NHS
Trust
SCA
Scarborough and North East
Yorkshire NHS Trust
GWH
SAN
Sandwell and West Birmingham
Hospitals NHS Trust
South London Healthcare NHS
Trust
DUD
Sandwell and West Birmingham
Hospitals NHS Trust
BRO
SAL
Salisbury NHS Foundation Trust
South London Healthcare NHS
Trust
SLF
Salford Royal NHS Foundation Trust
TOR
BAT
Royal United Hospital Bath NHS
Trust
South Devon Healthcare NHS
Foundation Trust
RSU
Royal Surrey County Hospital NHS
Foundation Trust
RSS
RLU
Royal Liverpool and Broadgreen
University Hospitals NHS Trust
Shrewsbury and Telford Hospitals
NHS Trust
RFH
Royal Free London NHS Trust
Friarage Hospital
Queen Mary's Hospital (Sidcup)
Queen Elizabeth Hospital (Woolwich)
Princess Royal University Hospital
(Bromley)
Torbay Hospital
Royal Shrewsbury Hospital
Princess Royal Hospital (Telford)
Newark Hospital
King's Mill Hospital
Royal Hallamshire Hospital
Northern General Hospital
Scarborough General Hospital
Sandwell General Hospital
Birmingham City Hospital
Salisbury District Hospital
Salford Royal
Royal United Hospital Bath
Royal Surrey County Hospital
Royal Liverpool University Hospital
Royal Free Hospital
0
1
237
24
359
37
48
13
302
10
442
7
155
190
342
241
0
144
330
223
*
92.4%
*
63.0%
*
*
*
78.1%
*
100.0%
*
94.2%
88.4%
95.0%
90.0%
72.9%
83.3%
93.27%
*
61.2%
*
31.8%
*
*
*
49.3%
*
26.9%
*
69.0%
56.3%
61.7%
30.7%
26.4%
56.4%
45.29%
*
89.2%
*
60.0%
*
*
*
79.8%
*
78.6%
*
88.6%
67.7%
87.2%
65.0%
86.7%
75.5%
97.47%
*
93.8%
*
47.0%
*
*
*
81.4%
*
72.3%
*
62.4%
54.0%
76.1%
74.3%
65.2%
87.6%
95.18%
*
82.9%
*
20.2%
*
*
*
65.0%
*
0.0%
*
98.9%
64.9%
31.3%
91.8%
8.9%
92.0%
64.55%
*
63.6%
*
33.1%
*
*
*
51.5%
*
29.0%
*
84.3%
76.7%
46.8%
46.3%
38.9%
42.8%
58.51%
38
National Heart Failure Audit April 2011-March 2012
HF Report 2012 Design B.indd 38
28/11/2012 14:19
SCM
STD
WAR
SEH
SOU
GEO
WHI
SHH
ESU
TGA
MPH
RUS
HIL
IPS
FRE
RVN
CMH
NPH
South Tyneside NHS Foundation
Trust
South Warwickshire NHS
Foundation Trust
Southend University Hospital NHS
Foundation Trust
Southport and Ormskirk Hospital
NHS Trust
St George's Healthcare NHS Trust
St Helens and Knowsley Teaching
Hospitals NHS Trust
Stockport NHS Foundation Trust
Surrey and Sussex Healthcare NHS
Trust
Tameside Hospital NHS Foundation
Trust
Taunton and Somerset NHS
Foundation Trust
The Dudley Group NHS Foundation
Trust
The Hillingdon Hospitals NHS
Foundation Trust
The Ipswich Hospital NHS Trust
The Newcastle Upon Tyne Hospitals
NHS Foundation Trust
The Newcastle Upon Tyne Hospitals
NHS Foundation Trust
The North West London Hospitals
NHS Trust
The North West London Hospitals
NHS Trust
NICOR
hospital
code
South Tees Hospitals NHS
Foundation Trust
Trust name
Northwick Park Hospital
Central Middlesex Hospital
Royal Victoria Infirmary
Freeman Hospital
The Ipswich Hospital
Hillingdon Hospital
Russells Hall Hospital
Musgrove Park Hospital
Tameside General Hospital
East Surrey Hospital
Stepping Hill Hospital
Whiston Hospital
St George's Hospital
Southport and Formby District General
Hospital
Southend Hospital
Warwick Hospital
South Tyneside District Hospital
James Cook University Hospital
Hospital name
346
14
0
170
203
197
180
300
178
302
175
226
229
203
555
0
267
209
Records
submitted
96.5%
*
58.2%
63.5%
91.9%
96.1%
80.3%
71.9%
76.2%
95.4%
92.5%
99.1%
96.1%
87.2%
91.8%
95.7%
% received
echo
84.7%
*
68.8%
25.6%
52.8%
65.6%
52.7%
34.8%
54.4%
16.6%
77.0%
13.1%
18.3%
39.1%
64.0%
87.1%
% cardiology
inpatient
77.0%
*
85.7%
86.8%
80.2%
77.8%
83.7%
80.8%
81.5%
92.7%
78.7%
87.3%
67.5%
70.8%
94.4%
90.1%
% ACEI/ARB
on discharge
71.9%
*
72.3%
81.3%
60.2%
74.7%
73.1%
76.7%
63.7%
87.5%
72.1%
84.9%
42.7%
77.4%
80.3%
77.5%
% beta
blocker on
discharge
72.4%
*
52.8%
46.1%
70.5%
72.5%
0.0%
72.6%
57.7%
32.2%
95.6%
94.9%
70.9%
85.3%
93.8%
93.3%
% referred
to HF liaison
service
47.7%
*
93.1%
22.3%
29.0%
68.6%
37.2%
50.4%
52.5%
42.2%
34.6%
48.7%
70.8%
38.7%
73.7%
63.6%
% referred
to cardiology
follow-up
National Heart Failure Audit April 2011-March 2012
HF Report 2012 Design B.indd 39
39
28/11/2012 14:19
SGH
University Hospital Southampton
NHS Trust
LER
WYT
University Hospital of South
Manchester NHS Foundation Trust
University Hospitals of Leicester
NHS Trust
STO
University Hospital of North
Staffordshire NHS Trust
GRL
UCL
University College London Hospitals
NHS Foundation Trust
University Hospitals of Leicester
NHS Trust
PIL
United Lincolnshire Hospitals NHS
Trust
WAL
LIN
United Lincolnshire Hospitals NHS
Trust
University Hospitals Coventry and
Warwickshire NHS Trust
GRA
United Lincolnshire Hospitals NHS
Trust
RUG
TRA
Trafford Healthcare NHS Trust
University Hospitals Coventry and
Warwickshire NHS Trust
WHT
The Whittington Hospital NHS Trust
BRI
NCR
The Royal Wolverhampton Hospitals
NHS Trust
University Hospitals Bristol NHS
Foundation Trust
BOU
The Royal Bournemouth and
Christchurch Hospitals NHS
Foundation Trust
QEB
QKL
The Queen Elizabeth Hospital
King's Lynn NHS Foundation Trust
University Hospitals Birmingham
NHS Foundation Trust
PAH
The Princess Alexandra Hospital
NHS Trust
Leicester Royal Infirmary
Glenfield Hospital
University Hospital Coventry
Hospital of St Cross
Bristol Royal Infirmary
Queen Elizabeth Hospital (Edgbaston)
Southampton General Hospital
Wythenshawe Hospital
University Hospital of North
Staffordshire
University College Hospital
Pilgrim Hospital
Lincoln County Hospital
Grantham and District Hospital
Trafford General Hospital
Whittington Hospital
New Cross Hospital
Royal Bournemouth General Hospital
Queen Elizabeth Hospital (King's Lynn)
Princess Alexandra Hospital
0
0
281
28
384
292
142
304
209
335
106
101
46
0
137
181
0
201
0
95.0%
*
93.8%
55.7%
100.0%
75.0%
81.6%
99.1%
59.4%
62.4%
*
99.3%
75.1%
94.5%
74.6%
*
89.3%
17.4%
39.4%
49.3%
31.1%
55.8%
27.4%
30.7%
*
61.3%
11.6%
67.2%
86.1%
*
80.8%
91.1%
0.0%
94.9%
71.9%
99.4%
73.7%
60.7%
*
97.0%
78.5%
93.9%
76.3%
*
78.7%
82.9%
0.0%
90.4%
56.1%
95.0%
76.3%
69.0%
*
93.7%
67.2%
87.1%
94.2%
*
64.4%
30.8%
0.0%
57.4%
82.9%
83.3%
28.2%
47.1%
*
85.3%
65.1%
84.6%
51.7%
*
80.4%
32.2%
49.2%
38.3%
60.1%
90.2%
50.0%
53.8%
*
78.3%
30.7%
31.8%
40
National Heart Failure Audit April 2011-March 2012
HF Report 2012 Design B.indd 40
28/11/2012 14:19
WAT
WMU
WSH
STR
WRG
WGH
WHC
WIR
RED
WRC
West Hertfordshire Hospitals NHS
Trust
West Middlesex University Hospital
NHS Trust
West Suffolk NHS Foundation Trust
Western Sussex Hospitals NHS
Trust
Western Sussex Hospitals NHS
Trust
Weston Area Health NHS Trust
Whipps Cross University Hospital
NHS Trust
Wirral University Teaching Hospital
NHS Foundation Trust
Worcestershire Acute Hospitals
NHS Trust
Worcestershire Acute Hospitals
NHS Trust
HCH
YEO
YDH
Wye Valley NHS Trust
Yeovil District Hospital NHS
Foundation Trust
York Teaching Hospital NHS
Foundation Trust
AEI
WDG
Warrington and Halton Hospitals
NHS Foundation Trust
Wrightington, Wigan and Leigh NHS
Foundation Trust
WMH
RLI
University Hospitals of Morecambe
Bay NHS Foundation Trust
Walsall Healthcare NHS Trust
FGH
NICOR
hospital
code
University Hospitals of Morecambe
Bay NHS Foundation Trust
Trust name
York District Hospital
Yeovil District Hospital
County Hospital Hereford
Royal Albert Edward Infirmary
Worcestershire Royal Hospital
Alexandra Hospital
Arrowe Park Hospital
Whipps Cross University Hospital
Weston General Hospital
Worthing Hospital
St Richard's Hospital
West Suffolk Hospital
West Middlesex University Hospital
Watford General Hospital
Warrington Hospital
Manor Hospital
Royal Lancaster Infirmary
Furness General Hospital
Hospital name
220
253
188
513
165
227
219
206
116
363
276
218
212
245
145
241
0
0
Records
submitted
72.3%
92.1%
80.9%
97.3%
44.8%
87.7%
95.0%
83.0%
78.4%
75.5%
84.8%
69.3%
83.5%
94.7%
100.0%
100.0%
% received
echo
9.5%
55.6%
25.0%
62.0%
53.9%
35.9%
43.8%
33.0%
25.9%
40.5%
48.9%
33.0%
23.1%
50.6%
67.6%
52.3%
% cardiology
inpatient
84.0%
92.3%
77.4%
88.0%
83.0%
71.1%
98.7%
84.8%
69.8%
75.9%
76.8%
83.6%
71.8%
100.0%
94.1%
100.0%
% ACEI/ARB
on discharge
80.0%
85.3%
58.1%
87.7%
61.5%
79.8%
85.9%
77.3%
65.1%
72.4%
72.5%
68.0%
77.9%
99.1%
85.7%
100.0%
% beta
blocker on
discharge
28.6%
100.0%
58.1%
68.2%
18.2%
42.2%
97.4%
75.0%
0.0%
59.0%
53.7%
12.8%
76.8%
81.6%
98.9%
90.4%
% referred
to HF liaison
service
32.2%
40.5%
30.4%
66.0%
39.6%
53.3%
40.9%
47.4%
20.6%
47.1%
46.1%
34.2%
30.7%
92.1%
69.7%
78.0%
% referred
to cardiology
follow-up
HF Report 2012 Design B.indd 41
RGH
BRG
PPH
WWG
WYB
Hywel Dda Health Board
Hywel Dda Health Board
Hywel Dda Health Board
Hywel Dda Health Board
WRX
Betsi Cadwaladr University Health
Board
Cwm Taf Health Board
LLA
Betsi Cadwaladr University Health
Board
PCH
CLW
Betsi Cadwaladr University Health
Board
Cwm Taf Health Board
GWE
Aneurin Bevan Health Board
UHW
NEV
Aneurin Bevan Health Board
Cardiff & Vale University Health Board
YYF
Aneurin Bevan Health Board
LLD
SIN
Abertawe Bro Morgannwg
University Health Board
Cardiff & Vale University Health
Board
POW
Abertawe Bro Morgannwg
University Health Board
GWY
NGH
Abertawe Bro Morgannwg
University Health Board
Betsi Cadwaladr University Health
Board
MOR
NICOR
hospital
code
Abertawe Bro Morgannwg
University Health Board
Wales
England and Wales
Health Board name
Singleton Hospital
Princess of Wales Hospital
Neath Port Talbot Hospital
Morriston Hospital
Hospital name
Withybush General Hospital
West Wales General
Prince Philip Hospital
Bronglais General Hospital
Royal Glamorgan
Prince Charles Hospital
University Hospital of Wales
Llandough Hospital
Ysbyty Gwynedd
Wrexham Maelor Hospital
Llandudno General Hospital
Glan Clwyd Hospital
Royal Gwent Hospital
Nevill Hall Hospital
Caerphilly District Miners Hospital/Ysbyty
Ystrad Fawr
Table 7: Clinical practice in Wales (2011/12)
National Heart Failure Audit April 2011-March 2012
41
28/11/2012 14:19
4
5
6
146
1
1
0
0
0
172
0
0
0
175
0
0
7
0
0
517
37076
Records
submitted
*
*
*
94.5%
*
*
79.1%
87.4%
*
87.0%
85.9%
% received
echo
*
*
*
82.2%
*
*
37.2%
39.4%
*
52.9%
47.1%
% cardiology
inpatient
*
*
*
88.2%
*
*
64.2%
92.3%
*
81.6%
82.7%
% ACEI/ARB
on discharge
*
*
*
70.2%
*
*
74.7%
92.9%
*
79.3%
76.4%
% beta
blocker on
discharge
*
*
*
66.2%
*
*
78.9%
48.4%
*
64.5%
63.2%
% referred
to HF liaison
service
*
*
*
34.2%
*
*
33.9%
19.5%
*
29.2%
51.1%
% referred
to cardiology
follow-up
3.10 Mortality
Mortality in the National Heart Failure Audit database is
determined by linking audit data with mortality data from
the Office of National Statistics (ONS) via NHS number, and
other patient identifiable data collected by the audit. The
total number of patients in the audit database who could be
assigned a mortality status by MRIS was 24,744. The followup period refers to the period from date of discharge to date
of death for those patients who died, and date of discharge to
date of census for those who survived.
Currently the audit uses all-cause mortality as the basis
for all mortality analysis, but NICOR has now been granted
permission by the National Information Governance Board
(NIGB) to obtain cause of death for patients included in its
audits and registers.v This will allow for a more accurate
representation of the number of deaths caused by heart
failure, as an elderly patient group with high levels of
comorbidity is guaranteed to register a significant number of
non-cardiovascular deaths.
3.10.1 2011/12 in-hospital mortalityvi
Overall 11.1% of patients died in hospital but in-hospital
mortality rates varied depending on the ward on which the
patient was treated: 7.8% of those on cardiology ward died in
hospital, compared with 13.2% of patients treated on general
medicine and 17.4% of those on other wards.
In-hospital mortality stood at 10.2% for men and 12.1% for
women, and, predictably, was much higher for older patients:
only 2.5% of patients in the 16-44 age group died in hospital,
compared with 10.9% of patients who were aged 75-84 at
admission, and 16.8% of patients over 85 years of age.
Following adjustment for confounding factors (age >75 years;
NYHA class III/IV; previous AMI), a significant association
remained between not being treated on a cardiology ward
and worse survival outcomes (HR=1.66, 95% CI 1.52 to 1.81,
p<0.001.
3.10.2 2011/12 post-discharge mortality
Overall mortality for those patients who survived to discharge
stood at 26.2% for the audit year. Median follow-up was 211
days for all patients, 281 days for those who survived to the
end of the follow-up period and 39 days for patients who
deceased (figure 7).
Sex: Mortality rates were similar for men and women who
survived to discharge, with 26.6% of women and 25.9% of men
dying within the follow-up period (median follow-up of 231
days for both men and women) (figure 8).
v. The NIGB monitors NHS and health-related information governance.
vi. Data for the 2011/2012 mortality analysis can be found in appendix 3 at the end
of this report.
42
Age: Predictably, mortality increased significantly with age,
7.4% of those aged 16-44 died (301 days median follow-up),
compared with 26.9% of patients the 75-84 age group (229
days median follow-up) and 37.2% of those over 85 years
(median follow-up of 200 days) (figure 9).
Place of care: Patients treated on a cardiology ward had better
outcomes than those treated on general medical or other
wards, with 21.8% of patients treated on cardiology wards
dying (242 day median follow-up), compared with 29.8% on
general medicine (225 day median follow-up), and 33.4% on
other wards (215 day median follow-up) (figure 10).
Diagnosis of LVSD: Of patients without LVSD 28.3% died during
the follow-up period, compared to 24.8% of those with LVSD
(median follow-up time of 227 days for those without LVSD and
236 days for those with LVSD) (figure 11).
ACE inhibitor and/or ARB on discharge: For those patients
with an echo diagnosis of LVSD, 38.8% of those who were
not discharged on an ACE inhibitor and/or ARB died, with a
median follow-up of 201 days. Only 20.2% of patients with
LVSD who were discharged on ACE inhibitor and/or ARB died
within the follow-up period (median follow-up of 249 days)
(figure 12).
Mortality rates by ACEI/ARB prescription showed similar
patterns when all patients were considered, rather than just
those with a diagnosis of LVSD: 36.7% of patients who were
discharged without ACE inhibitors and/or ARBs died, with a
median follow-up period of 207 days, compared with 21.0%
of patients discharged on the drugs (median follow-up of 247
days) (figure 13).
Beta blocker on discharge: 33.0% of patients with LVSD who
were not discharged on beta blockers died within the follow-up
period (median 220 day follow-up), compared with only 21.1%
of patients who were prescribed the treatment on discharge
(median follow-up of 245 days) (figure 14).
Irrespective of echo diagnosis, 32.1% of those discharged on
no beta blocker died (227 median follow-up), compared with
22.2% of patients discharged on beta blockers (242 day median
follow-up) (figure 15).
Loop diuretic on discharge: 17.0% of patients with a diagnosis
of LVSD who were discharged in 2011/12 without a prescription
of loop diuretics died within the follow-up period, with a
median 262 day follow-up, compared with 25.6% of patients
who were discharged on loop diuretics (median follow-up
period of 235 days) (figure 16).
For all patients, including those without LVSD, 20.6% of
patients discharged without loop diuretics died within the
follow-up period (median 250 days), compared with 26.5%
of patients discharged on a loop (231 day median follow-up)
(figure 17).
National Heart Failure Audit April 2011-March 2012
HF Report 2012 Design B.indd 42
28/11/2012 14:19
modifying drugs a patient was prescribed on discharge had
a significant impact on survival: 45.8% of patients with LVSD
discharged without a prescription for an ACEI/ARB, beta
blocker or MRA died (median follow-up of 183 days), compared
with 27.1% of those discharged on ACEI/ARB only (median
follow-up 242 days) and 18.4% of patients discharged on an
ACEI/ARB and a beta blocker (median follow-up 251 days).
Mortality was 16.8% for patients discharged on ACEI/ARB, beta
blocker and an MRA (257 days median follow-up) (figure 18).
Referral to follow-up services: 20.1% of patients who were
referred to cardiology follow-up in 2011/12 died (median
follow-up 249 days), compared to 32.1% of patients who did
not receive a cardiology referral (median follow-up of 216 days)
(figure 19).
Fig 7: Overall post-discharge survival
100
90
80
70
% survived
Additive drug treatment: The number of recommended disease
Table 8: Cox proportional hazards model for postdischarge mortality (2011/12)
Predictor
Hazard
ratio
Lower
.95
Upper
.95
p-value
Previous AMI
1.28
1.20
1.36
< 0.001
Age > 75
1.77
1.65
1.90
< 0.001
NYHA class III/IV
1.22
1.13
1.31
< 0.001
No ACEI/ARB on
discharge
1.69
1.59
1.81
< 0.001
No beta blocker
on discharge
1.26
1.19
1.35
< 0.001
Loop diuretic on
discharge
1.16
1.04
1.29
0.006
No cardiology
follow-up
1.36
1.28
1.45
< 0.001
Not a cardiology
inpatient
1.10
1.03
1.17
0.003
40
20
10
0
0
100
200
300
400
Days after discharge
Fig 8: Post-discharge survival by sex
100
90
80
70
% survived
A Cox proportional hazards model appears to show that for
patients who survived to discharge, even with adjustment
for age, severity of symptoms and history of AMI, those
not prescribed ACE inhibitors/ARBs and beta blockers on
discharge had higher mortality rates. Patients prescribed
loop diuretics on discharge also had increased mortality rates
following adjustment for these confounding factors. Patients
who were not cardiology inpatients and those who did not
receive cardiology follow-up also had increased mortality rates
when the confounding patient characteristics were taken into
account (table 8).
50
30
Mortality was 24.8% for patients who were referred to a heart
failure liaison service on discharge (median follow-up 232
days), compared to 27.9% for patients not referred to heart
failure nurse led follow-up (median follow-up period of 231
days) (figure 20).
Predictors of mortality for survivors to discharge
60
60
50
40
30
20
10
0
0
100
200
300
400
Days after discharge
Women
Men
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Fig 9: Post-discharge survival by age at admission
Fig 11: Post-discharge survival by presence or
absence of LVSD
100
100
90
90
80
80
70
70
% Survived
60
% Survived
50
40
30
60
50
40
30
20
20
10
10
0
0
100
200
300
0
400
0
Days after discharge
100
200
300
400
Days after discharge
16-44
55-64
75-84
45-54
65-74
85+
Fig 10: Post-discharge survival by place of care
Diagnosis of LVSD
No diagnosis of LVSD
Fig 12: Post-discharge survival by prescription of ACE
inhibitor and/or ARB on discharge for patients with LVSD
100
100
90
90
80
80
70
60
% Survived
% Survived
70
50
40
30
50
40
30
20
20
10
10
0
0
100
200
300
Days after discharge
Cardiology
Other
General Medicine
44
60
400
0
0
100
200
300
400
Days after discharge
ACE inhibitor/ARB
No ACE inhibitor/ARB
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Fig 13: Post-discharge survival by prescription of ACE
inhibitor and/or ARB on discharge (all patients)
Fig 15: Post-discharge survival by prescription of
beta blockers on discharge (all patients)
90
90
80
80
70
70
60
60
% Survived
100
% Survived
100
50
40
50
40
30
30
20
20
10
10
0
0
0
100
200
300
0
400
100
Days after discharge
ACE inhibitor/ARB
Beta blocker
No ACE inhibitor/ARB
No beta blocker
90
90
80
80
70
70
60
60
% Survived
% Survived
100
50
40
50
40
30
30
20
20
10
10
0
0
200
300
400
0
100
Days after discharge
Beta blocker
No beta blocker
400
Fig 16: Post-discharge survival by prescription of loop
diuretics on discharge for patients with LVSD
100
100
300
Days after discharge
Fig 14: Post-discharge survival by prescription of beta
blockers on discharge for patients with LVSD
0
200
200
300
400
Days after discharge
No loop diuretic
Loop diuretic
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Fig 19: Post-discharge survival by referral to
cardiology follow-up services
100
100
90
90
80
80
70
70
60
60
% Survived
% Survived
Fig 17: Post-discharge survival by prescription of loop
diuretics on discharge (all patients)
50
40
50
40
30
30
20
20
10
10
0
0
0
100
200
300
400
0
100
Days after discharge
300
400
Days after discharge
No loop diuretic
Referred to cardiology follow-up
Loop diuretic
Not referred to cardiology follow-up
Fig 18: Post-discharge survival by additive drug
treatment on discharge for patients with a
diagnosis of LVSD
Fig 20: Post-discharge survival by referral to heart
failure liason follow-up services
100
100
90
90
80
80
70
70
60
% Survived
% Survived
200
50
40
60
50
40
30
30
20
20
10
10
0
0
0
100
200
300
400
Days after discharge
0
100
200
300
400
Days after discharge
ACEI inhibitor/ARB, beta blocker and MRA
Referred to heart failure liaison follow-up
ACEI inhibitor/ARB and beta blocker
Not referred to heart failure liaison follow-up
ACE inhibitor/ARB
No ACEI inhibitor/ARB, beta blocker or MRA
46
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3.11 Three-year trends
3.11.1 Three-year in-hospital mortalityvii
Over the three years from April 2009 to March 2012, 12.1% of
patients died in hospital. Only 8.2% of patients treated on a
cardiology ward died, compared with 14.7% of patient treated
on general medical wards, and 18.5% of patients on other
wards. 11.2% of men died in hospital, compared with 13.1% of
women, in the three-year period.
3.11.2 Three-year post-discharge mortality
Over the three years from 2009-2012, out of 66,249 patients,
24,590 (37.1%) died, with a median follow-up period between
discharge and death/censoring of 331 days. Median followup was 504 days for patients who survived, and 89 days for
patients who died (figure 21). The audit is not yet in a position
to report place or cause of death for the majority of patients
but hopes to do so in future reports.
Sex: Long term mortality was broadly similar for men and
women: 37.8% of women discharged alive within the three
years died, with a 375 day follow-up period, compared to 36.6%
of men (median follow-up 376 days) (figure 22).
Age: Unsurprisingly age had a major impact on mortality, with
52.0% of patients over the age of 85 (median follow-up of 281
days) and 38.4% of patients between 75 and 84 (median followup of 369 days), dying within the follow-up period, compared
with only 10.8% of the youngest patients, aged 16-44 (538 day
median follow-up period) (figure 23).
Place of care: Heart failure patients’ main place of care
continued to have an impact on mortality long after discharge,
with 31.1% of cardiology patients dying (404 day follow-up),
compared with 42.4% of general medical patients (355 day
follow-up) and 45.0% of patients on other wards (323 day
follow-up) (figure 24).
Diagnosis of LVSD: 40.7% of patients diagnosed with heart
failure without LVSD admitted between 2009 and 2012 died,
compared with 34.7% of patients diagnosed with LVSD (Median
follow-up period of 362 days for no LVSD and 384 days for
LVSD) (figure 25).
ACE inhibitor and/or ARB on discharge: Of those patients
discharged in 2009-12 diagnosed with LVSD, 50.1% of those
who did not receive an ACE inhibitor or ARB on discharge
died (median follow-up of 285 days), whereas only 30.2% of
those who were prescribed an ACE inhibitor and/or ARB died
(median follow-up of 417 days) (figure 26).
361 days for those discharged on no beta blocker and 403 days
for patients discharged on a beta blocker) (figure 27).
Loop diuretic on discharge: Of patients diagnosed with LVSD
discharged between 2009 and 2012, 25.0% died within the
follow-up period if they were not discharged on loop diuretics,
compared with 35.8% of patients discharged on loop diuretics
(follow-up 423 days for patients without loop diuretics, and 384
days for patients with loop diuretics) (figure 28).
Additive drug treatment: Patients with a diagnosis of LVSD
discharged on all three of ACEI/ARBs, beta blockers and MRAs
had mortality rates of 25.0% over three years (median followup of 419 days). 26.9% of patients discharged on ACEI/ARBs
and beta blockers in 2009-12 died (427 days median follow-up),
compared with 40.6% for those discharged on an ACEI/ARB
alone (412 days median follow-up). 56.7% of patients who left
hospital on none of the three NICE recommended treatments
in 2009-12 died (median follow-up of 257 days) (figure 29).
Referral to follow-up services on discharge: Patients referred
for cardiology follow-up had far better outcomes than those not
referred for follow-up with a cardiologist, with mortality of 29.3%
(422 days median follow-up) for the former, compared with
44.6% for the latter (327 days median follow-up) (figure 30).
Those referred to heart failure liaison follow-up services had
lower mortality (34.7%) than those not referred to nurse led
follow-up (39.4%) across the three year audit period (median
follow-up of 363 for those not referred to HF liaison service
follow-up, and 384 days for patients referred to nurse led
services on discharge) (figure 31).
Three-year predictors of mortality for survivors
to discharge
Similar to the findings of the 2011/12 survival analyses, a
Cox proportional hazards model shows that in 2009-12, even
when accounting for age, severity of symptoms on admission
and previous AMI, those patients who were not prescribed an
ACE inhibitor/ARB and those not prescribed a beta blocker on
discharge were more likely to die during the follow-up period
than those given these therapies on discharge. The mortality
rate also remained higher for patients discharged on a loop
diuretic, those not referred to cardiology follow-up, and those
who were not treated on a cardiology ward (table 9).
Beta blocker on discharge: Of those patients discharged with
a diagnosis of LVSD between 2009 and 2012, 45.9% of those
not discharged on beta blockers died, compared with 29.4% of
patients prescribed a beta blocker (median follow-up period of
vii. Data for the 2009-12 mortality analysis can be found in appendix 4 at the end of
this report.
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Table 9: Cox proportional hazards model for postdischarge mortality (2009-12)
Fig 22: Three-year post-discharge survival by sex
(2009-12)
Predictor
Hazard
ratio
Lower
.95
Upper
.95
p value
Previous AMI
1.26
1.22
1.31
< 0.001
Age > 75
1.82
1.75
1.89
< 0.001
NYHA class III/IV
1.15
1.11
1.19
< 0.001
No ACEI/ARB on
discharge
1.58
1.52
1.63
< 0.001
No beta blocker
on discharge
1.29
1.25
1.33
< 0.001
Loop diuretic on
discharge
1.21
1.14
1.28
< 0.001
No cardiology
follow-up
1.34
1.30
1.39
< 0.001
Not a cardiology
inpatient
1.11
100
90
80
70
% Survived
60
50
40
30
20
1.08
1.15
< 0.001
10
0
0
Fig 21: Three-year post-discharge survival (2009-12)
200
400
600
800
1000
1200
Days after discharge
100
Women
Men
90
80
Fig 23: Three-year post-discharge survival by age
(2009-12)
% Survived
70
60
100
50
90
40
80
30
70
% Survived
20
10
0
0
200
400
600
800
Days after discharge
1000
1200
60
50
40
30
20
10
0
0
200
400
600
800
1000
1200
Days after discharge
48
16-44
55-64
75-84
45-54
65-74
85+
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Fig 24: Three-year post-discharge survival by place of
care (2009-12)
Fig 26: Three-year post-discharge survival by
prescription of ACE inhibitor and/or ARB on discharge
in patients with LVSD (2009-12)
100
100
90
90
80
80
% Survival post-discharge
% Survived
70
60
50
40
30
20
10
70
60
50
40
30
20
10
0
0
200
400
600
800
1000
0
1200
0
200
400
600
Days after discharge
1000
1200
Days
Other
Cardiology
800
ACE inhibitor/ARB
General Medicine
No ACE inhibitor/ARB
Fig 27: Three-year post-discharge survival by
prescription of beta blockers on discharge in patients
with LVSD (2009-12)
Fig 25: Three-year post-discharge survival by
presence or absence of LVSD (2009-12)
100
100
90
90
80
80
70
60
% Survived
% Survived
70
50
40
30
60
50
40
30
20
20
10
10
0
0
200
400
600
800
Days after discharge
1000
1200
0
0
200
400
800
1000
1200
Days after discharge
Diagnosis of LVSD
No diagnosis of LVSD
600
Beta blocker
No beta blocker
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Fig 28: Three-year post-discharge survival by
prescription of loop diuretics on discharge in patients
with LVSD (2009-12)
Fig 30: Three-year post-discharge survival by referral
to cardiology follow-up services (2009-12)
100
100
90
90
80
80
70
% Survived
70
% Survived
60
50
40
60
50
40
30
30
20
20
10
10
0
0
0
200
400
600
800
1000
0
1200
200
400
600
800
1000
1200
Days after discharge
Days after discharge
Beta blocker
Referred to cardiology follow-up
No beta blocker
Not referred to cardiology follow-up
Fig 29: Three-year post-discharge survival by
additive drug treatment on discharge in patients
with LVSD (2009-12)
Fig 31: Three-year post-discharge survival by referral
to heart failure liaison follow-up services (2009-12)
100
100
90
90
80
80
70
60
% Survived
% Survived
70
60
50
40
50
40
30
30
20
20
10
10
0
0
0
0
200
400
600
800
1000
1200
200
400
600
800
1000
1200
Days after discharge
Days after discharge
ACEI inhibitor/ARB, beta blocker and MRA
ACEI inhibitor/ARB and beta blocker
Referred to heart failure liaison services
Not referred to heart failure liaison services
ACE inhibitor/ARB
No ACEI inhibitor/ARB, beta blocker or MRA
50
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4 Case studies
4.1 Improving clinical practice and
patient outcomes
Lee Taaffe, North Central London Cardiovascular and
Stroke Network
In North Central London, data from the National Heart
Failure Audit is used to measure and improve the heart failure
services across the six hospitals in the North Central London
Cardiovascular and Stroke Network. The North Central London
Heart Failure Task Group, which is hosted by the Network,
devised a suite of local measures covering activity, admissions,
diagnostics, prescribing, length of stay, and mortality. The
data from the National Heart Failure Audit, along with HES
data, is analysed quarterly and presented at the Heart Failure
Task Group for discussion and learning. At the end of the
financial year an annual report is produced that details the
outcomes for each hospital across the year and benchmarks
performance against local and national report findings.
Furthermore, the report benchmarks against previous years’
findings to show how each hospital is progressing in its
delivery of services to patients.
4.2 Using data to drive improvement
Pauline Wortman, Enhancing Quality & Recovery
Enhancing Quality & Recovery (EQ&R) is an innovative and
award winning clinician-led quality improvement programme
across Kent, Surrey and Sussex. The programme works
with teams in 10 Acute Trusts, six Community Providers and
three Mental Health Trusts and spans 10 clinical pathways.
Clinicians identify between four and seven evidence-based
measures, aligned wherever possible to NICE guidance, in
order to benchmark performance and drive forward quality
improvement focussed on improving patient outcomes and
reducing variation in care.
Quality improvement that is clinically-led, data
driven and focussed on patient outcomes is a very,
very potent cocktail.
EQ&R has recognised that when clinicians take ownership
of their data and believe and trust it, this provides a very
strong motivation to improve against it. Making this happen
requires a clear focus on data quality: the need for a tightly
defined population and clinical criteria so that ”apples are
being compared with apples” and for a high level of data
completeness (all patients, not just patients on the cardiology
ward, for example). Improvement builds on clinicians “knowing
where they are”, not just “where they think they are”. It also
depends on clinical leadership and the development of wider
teams, including coders and data analysts, for example, and
truly collaborative working focussed on sharing of best practice
and using the skills and knowledge of multi-disciplinary
teams. At the core of the EQ&R approach is a focus on
producing transparent measurement which is hard to ignore for
accountability and improvement, rather than judgement.
Collecting timely and relevant data on every patient, every
time can appear to be a chore especially before the value of
the information being produced is realised. EQ&R has found
engagement needs to encompass all those involved in the
audit loop with active sharing of results within teams. Action
against the data is more likely if analysis is available as soon
as is practicable. In this way quality data can be reflected upon
and action taken harnessing and maintaining the momentum
and enthusiasm for improvement in patient care. This
immediacy and impetus for service improvement can be lost
where data is not fed back in a timely and consistent way.
Collaboration between EQ&R and MINAP and the National
Heart Failure Audit is securing advantages for all parties.
By sharing data, the duplication of data input is avoided. By
capturing the full population rather than a sample population,
data completeness is improved and the discipline of a monthly
rather than yearly data deadline feeds into a faster service
improvement cycle.
Data collection and reporting provides the canvas on which
to build service improvements, outcome improvements
and variation reductions. The data collected within the EQ
programme is specifically designed to monitor:
• That every heart failure patient in hospital has appropriate
Professor Sir Bruce Keogh, NHS Medical Director, EQ&R
What a difference a year makes conference, Gatwick 25th
January 2012.
EQ&R is the inaugural winner of the Cardiac care category of the
Health Service Journal & Nursing Times 2012 Integration Award.
This achievement reflects the success of clinical teams across
the region in introducing quality improvement metrics for the
full heart failure pathway as well as collaborative working that
has led to action to improve quality of patient care with reduced
variation and improved patient outcomes across the region.
diagnosis, management and appropriate information
provided to them about their condition prior to discharge.
• That every patient has a continuing plan.
• That the ‘transfer of care’ between sectors contains
minimum information.
• Personalised care plans and patient held records meet
‘best practice’ standards and are completed with the
patient within two weeks of discharge.
• That medical management is optimised in the community.
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• That end-of-life care is planned.
Process
• That there is a reduction in variations in clinical practice
and outcomes.
• That the patient experience is improved.
Quality data provides the evidence that services are making
improvements to reach the ultimate goal of delivering the
care that each and every patient can expect: A quality of care
delivered to every patient, every time, regardless of their local
hospital or community provider, where they live, or who their
GP is.
4.3 An example of local practice in conducting
the National Heart Failure Audit
Rachel Kindred, Denise Hockey and Lynne Thomas,
Aneurin Bevan Health Board, South Wales
Cases are identified monthly by the Information
Department based on discharge codes
Q&PS Improvement & Measurement Assistant
obtains notes
Heart Failure Specialist Nurse team analyses notes
and completes audit pro forma
Q&PS Improvement & Measurement Co-ordinator
inputs data to the NICOR database, then exports
data for analysis and feedback to Heart Failure
clinical team meeting every two months.
Challenges
Left to right: Lynne Thomas (Quality and Patient Safety Improvement and Measurement Assistant), Denise Hockey (Heart
Failure Nurse Specialist), Rachel Kindred (Quality and Patient
Safety Improvement & Measurement Co-ordinator)
Background
Participation in the National Heart Failure Audit began at Nevill
Hall Hospital in 2008 with a small patient group, namely those
patients referred to the Heart Failure Specialist Nurse team. In
2009 the Clinical Audit Department (now the Quality & Patient
Safety Improvement & Measurement Department), became
involved with the data input, also using the data for the All
Wales 1000 Lives Campaign. The patient group was widened in
2010 to include all those with a coded diagnosis of heart failure
on discharge. In 2012 data collection began at Royal Gwent
Hospital, the Health Board’s other main acute hospital.
52
The biggest challenge has been to achieve collaboration
between the three departments (Information, Quality & Patient
Safety and the Heart Failure Specialist Nurse team). This has
involved regular communication to refine the identification of
cases and the obtaining of case notes for the audit. Obtaining
case notes has proved time consuming and requires close
communication to ensure the notes are available at the
right time to be viewed by a busy clinical team, before being
removed when required by other departments of the hospital.
Benefits
The biggest benefit to participation has been the ability to
export and review the data regularly as a team, allowing the
comparison of data over time in order to resolve areas of
lower compliance.
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4.4 The national perspective
Hugh F McIntyre, Chair NICE Heart Failure Quality
Standard and Heart Failure Commissioning Outcome
Framework/Quality Outcome Framework
The central purpose of improving the quality of care is
to reduce variation and improve outcome. Improving
the quality of care requires defined standards and the
systematic measurement of care against those standards.
These measurements must then be made available to
those accountable for delivering care to allow them both to
benchmark and where necessary improve care.
Based upon the heart failure guideline update (2010),
measurable indicators of care - the heart failure quality
standards - were published in 2011. These define the
components of high quality care which services for
patients with heart failure should seek to deliver and
which commissioners will increasingly expect from any
provider. Consistent delivery of improved standards of care
should lead to better outcome. It is the role of the National
Commissioning Board to deliver such improvement in
outcomes - to do so will require a set of integrated indicators
(currently under development) which will be delivered
through the Commissioning Outcome Framework/Quality
Outcome Framework process and will be used by the National
Commissioning Board to hold Clinical Commissioning Groups
to account.
With standards established, the second component of quality
improvement - consistent reliable local data - is fundamental
to enable clinical teams to understand the quality of local care
they deliver. Now in its sixth year, the National Heart Failure
Audit, which covers nearly all of England and Wales, provides
a dataset that not only addresses the majority of the hospitalbased quality standards but already indicates the potential
link between better quality of care (for example place of care
and optimal therapy) and better outcome. For the first time
the introduction of hospital-level reporting provides specialist
teams with measures of the inclusiveness and quality of the
care which they deliver, and allows teams to compare their
performance with that of local and national peers.
Looking to the future, two areas are likely to become
increasingly important. The National Commissioning Board
sets five domains of outcome, which can be summarised
as enhanced survival; quality of life; recovery (including
both hospital admission and long term conditions); patient
experience and safety. These move beyond the traditional
‘medical’ outcomes of death and readmission and are
particularly relevant to heart failure - especially in older
populations. Secondly the local mechanisms that deliver
comparative data reporting (which are under development) will
need to address not only the organised delivery of comparative
data through networks, but also the mechanisms whereby
local variations in quality of care can be targeted and reduced.
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5 Research use of National Heart Failure Audit data
Professor Henry Dargie, HALO Chair
The National Heart Failure Audit is in its sixth year
of activity, and is now collecting data on 60% of all
patients discharged from hospital with heart failure in
England and Wales. With over 130,000 records in the
database, the audit has become a valuable research
resource, and as the size and representativeness of
the audit increases, so too will its significance for
research projects. In 2011 HALO – the Heart failure
Audit anaLysis and Outcomes group - was established
to handle applications for the use of National Heart
Failure Audit data from external groups, and to
manage internal research projects.
The National Heart Failure Audit has recently revised its
dataset to include a series of new fields that will allow credible
risk adjusted data to be produced. This data can be used for
comparisons of outcomes among centres, and will allow
the audit to start answering more sophisticated questions
about variation in outcomes and to investigate the correlation
between treatment and management, and outcomes for
patients. We hope to start publishing risk adjusted data at a
hospital level by 2013.
Of particular interest to HALO is the prospect of investigating
the very high mortality recorded by the audit, which is highly
variable between centres. In 2011/12 overall mortality during
admission stood at 11.1%, with much lower mortality in
cardiology wards (7.8%) compared to General Medical wards
(13.2%) and other wards (17.4%). The one-year mortality for
those surviving to discharge was also very high (26.2%) and it
is quite possible that recorded mortality rates will continue to
rise as a result of increasing representativeness of the audit.
Much higher than reported from Europe and the US, these
high mortality rates probably reflect the relatively unselective
nature of the data.
The data seem to suggest that managing heart failure patients
in a specialist setting has benefits beyond those conferred
by higher prescription rates and optimal titration of evidence
based drugs. This was shown dramatically for AMI when
coronary care units (CCUs) were introduced by Desmond
Julian in 1960s to provide early cardiopulmonary resuscitation
(CPR), and mortality rates fell dramatically within a couple of
years. Our hypothesis is that this was not due to CPR alone but
to better management by cardiologists of the most common
cause of death in CCUs which was then, and still remains,
heart failure. However the extent to which the myriad factors
affecting the outcomes for heart failure patients are managed
better by specialists remains an unanswered and key research
question, and one which HALO hopes to address.
54
Current HALO projects include a collaborative application for
funding to the NIHR Health Technology Assessment (HTA)
programme with Professor Barnaby Reeves of the University of
Bristol and his team. The study has been commissioned by the
HTA to determine the effect of BNP and NT-proBNP testing on
outcomes for chronic heart failure patients, and to assess the
cost-effectiveness of the technology. The HALO/University of
Bristol application proposes to use audit data to supplement
this systematic review, and to evaluate the efficacy of BNP
testing in reducing mortality and readmission rates in heart
failure patients.
HALO is also involved in a collaborative project with Professor
Kazem Rahimi from the George Centre for Healthcare
Innovation at the University of Oxford, which will investigate the
diverse factors affecting outcomes for heart failure patients.
The project, funded by an NIHR grant, will look into various
aspects of the delivery of heart failure care, in an attempt to
determine the percentage of variation in outcomes that is
determined by hospital related factors. This project ties in
closely with the ambition of the National Heart Failure Audit
to deliver risk adjusted data, and will be extremely valuable
towards the goal of generating and publishing risk adjusted,
hospital level analysis.
Adam Timmis, Chair of MAG (MINAP academic group), has
recently joined the group in order to develop a programme of
research between MAG and HALO, looking at the incidence
of heart failure and outcomes in post-infarction patients.
This would involve linkage of MINAP and National Heart
Failure Audit data, and tracking patients across multiple
cardiovascular admissions to hospital. In addition to this,
HALO is working with the European Society of Cardiology
Heart Failure Association to produce an educational tool
which incorporates the ESC guideline for the treatment and
care of heart failure patients into the audit application. This
will provide guidance on best practice and clinical standards
alongside the data entry application, and will turn the audit
database into a powerful tool for promoting and implementing
optimal heart failure care.
As HALO moves from strength to strength, we welcome
applications for use of National Heart Failure Audit data from
hospitals, universities and research groups.
National Heart Failure Audit April 2011-March 2012
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6 Conclusions
This audit confirms that patients admitted to hospital with
a primary diagnosis of heart failure have a poor outcome
despite contemporary pharmacological therapy, but
that optimal treatment and management, which follows
recommended clinical guidelines, is associated with
improved outcomes. Patients are much more likely to
receive this treatment if they are treated on a cardiology
ward, and these patients consequently have lower
mortality, both within hospital and following discharge.
Improving the outcome of patients with heart failure requires
four major approaches:
• Improved case-ascertainment
• Better treatments
• Better implementation of existing treatment and
management pathways
• Better recognition and management of the end of life
This cannot be achieved without better coordination and
organisation of care across the spectrum of health and
social care.
Future audits will provide more detailed information on risk
factors and devices. Increased access to other datasets will
provide comprehensive data on the rate, duration and reasons
for re-hospitalisation, and information on the cause of death will
allow for more sophisticated mortality analyses.
The audit group would like to thank all of the nurses, clinicians,
clinical audit facilitators and all others involved in collecting
and submitting data to the audit over the last five years. As the
audit continues to grow it becomes more useful as a tool for
monitoring the treatment and management of heart failure
in England and Wales, both at a local and national level. The
continued support and participation of hospitals, Trusts and
Health Boards is essential for the success and development
of the audit, and all of the work and input from individuals and
hospitals across the U.K. is greatly appreciated.
6.1 Quality of care and patient outcomes
The 2011/12 report supports the findings of previous years in
emphasising the benefits of specialist cardiology input in the
management of acute heart failure patients. The National Heart
Failure Audit strongly supports the NICE guidance relating to
heart failure, and continues to encourage its implementation.
NICE has produced both a clinical guideline (2010) and a quality
standard (2011) for chronic heart failure, which outline evidence
based clinical guidance as to the most effective treatment and
management of heart failure patients.26
On the basis of the findings in this report, the National Heart
Failure Audit group recommends that Trusts and Health Boards
ensure that patients with heart failure have specialist input
to their care and are managed on cardiology wards wherever
HF Report 2012 Design B.indd 55
feasible. Access to specialist medical and nursing care is
essential to optimal care for heart failure patients, so Trusts
should ensure that key personnel are in place to deliver this care.
Key, evidence-based therapies should be initiated during a
patient’s hospital admission. The use of ACE inhibitors/ARBs,
beta blockers and MRAs for patients with left ventricular systolic
dysfunction is associated with improved patient outcomes, and
these treatments should be implemented wherever possible.
Furthermore, audit findings suggest that robust arrangements
for optimisation of therapy for cardiac dysfunction via cardiology
follow-up, nurse-led heart failure liaison services and primary
care need to be firmly in place prior to discharge. The next
phase of the audit will address this discharge planning phase
more specifically, but 2011/12 findings clearly show that referral
to specialist follow-up services on discharge has beneficial
effects on outcomes for heart failure patients.
The audit showed in 2011/12 that outcomes for patients with
heart failure without LVSD are poorer than for those with LVSD.
This likely reflects the greater age of patients who do not have
LVSD, but this aspect of heart failure care requires greater
attention to identify other possible reasons for this difference
and to determine improved management strategies. The
continuing increase in case ascertainment coupled with data
already accrued from previous audits will provide a robust basis
for these aims and should be a focus of interest for subsequent
audit reports.
6.2 Data completeness and participation
The National Heart Failure Audit is a key tool for gathering
information to improve outcomes in acute heart failure.
Even though considerable progress has been made in case
ascertainment since the audit began, the data is still not
fully representative of the population of heart failure patients
in England and Wales. The aim now should be to strive for
inclusion of all patients admitted to hospital with a primary
diagnosis of heart failure to ensure a more representative
dataset. As of April 2013 hospitals will be required to submit
data pertaining to all acute admissions with a primary discharge
diagnosis of heart failure.
By 2012/13, the audit aims to enrol 95% of eligible Trusts in
England and Health Boards in Wales, and to capture 70% of all
acute patients admitted to hospital with heart failure in England
and Wales.
Following the deletion of several thousand 0 and 1 day
admissions from the 2011/12 data, which were believed to be
elective admissions for patients with heart failure, hospitals
are reminded that only acute heart failure patients should be
included in the National Heart Failure Audit. The inclusion of
elective admissions has the potential to skew survival analysis
and misrepresent the treatment and management of heart
failure in England and Wales.
National Heart Failure Audit April 2011-March 2012
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7 Appendices
Appendix 1: National Heart Failure Audit Project Board membership
Name
Representation
Jackie Austin
Nurse Consultant (Aneurin Bevan Health Board) and Lead Nurse (South Wales Cardiac Network)
Gemma Baldock-Apps
Cardiology Audit and Data Manager (East Sussex Healthcare NHS Trust)
Lailaa Carr
Contract and Project Officer (HQIP)
John Cleland
Professor of Cardiology (U. of Hull)
Henry Dargie
Professor of Cardiology and Consultant Cardiologist (U. of Glasgow); Chair of the Heart Failure
Academic Group
Nadeem Fazal
National Clinical Audit Services Manager (NICOR)
Jules Grange
Heart Failure Specialist Nurse (East Sussex Healthcare NHS Trust)
Suzanna Hardman
Consultant Cardiologist (Whittington) and Chair of British Society for Heart Failure
Candy Jeffries
Interim Director (Beds and Herts Heart and Stroke Network)
Helen Laing
National Clinical Audit Lead (HQIP)
Theresa McDonagh (Chair)
National Heart Failure Audit Clinical Lead; Consultant Cardiologist and Professor of Heart Failure
(KCH/KCL)
Richard Mindham
Heart failure patient representative
Polly Mitchell
National Heart Failure Audit Project Manager (NICOR)
Marion Standing
Developer (NICOR)
Lynne Walker
NICOR Programme Manager (NICOR)
Appendix 2: HALO membership
Name
Representation
John Cleland
Professor of Cardiology (U. of Hull)
Henry Dargie (Chair)
Professor of Cardiology and Consultant Cardiologist (U. of Glasgow)
Suzanna Hardman
Consultant Cardiologist (Whittington) and Chair of BSH
Theresa McDonagh
National Heart Failure Audit Clinical Lead; Consultant Cardiologist and Professor of Heart Failure
(KCL)
Polly Mitchell
National Heart Failure Audit Project Manager (NICOR)
Appendix 3: Data for 2011/12 mortality analysis
In-hospital mortality
Analysis
Variable
Deaths
Denominator
Mortality (%)
Overall
In hospital deaths
3420
30886
11.1%
Sex
Men
1730
16969
10.2%
Sex
Women
1690
13910
12.1%
Place of care
Cardiology ward
1141
14635
7.8%
Place of care
General medical ward
1691
12833
13.2%
Place of care
Other ward
578
3316
17.4%
Age
16-44
15
594
2.5%
Age
45-54
29
1119
2.6%
Age
55-64
136
2704
5.0%
Age
65-74
416
5757
7.2%
Age
75-84
1207
11102
10.9%
Age
≥85
1617
9609
16.8%
56
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Mortality for survivors to discharge
Analysis
Variable
Deaths
Denominator
Mortality (%)
Overall
All discharges
7182
27386
26.2%
Sex
Men
3937
15186
25.9%
Sex
Women
3244
12193
26.6%
Place of care
Cardiology ward
2944
13463
21.9%
Place of care
General medical ward
3308
11100
29.8%
Place of care
Other ward
914
2734
33.4%
Age
16-44
43
576
7.5%
Age
45-54
99
1086
9.1%
Age
55-64
346
2561
13.5%
Age
65-74
1068
5320
20.1%
Age
75-84
2654
9864
26.9%
Age
≥85
2972
7978
37.3%
Diagnosis LVSD
Dx LVSD
4087
16460
24.8%
Diagnosis LVSD
No Dx LVSD
3095
10926
28.3%
ACEI/ARB on discharge (LVSD)
ACEI/ARB
2527
12470
20.2%
ACEI/ARB on discharge (LVSD)
No ACEI/ARB
915
2361
38.8%
ACEI/ARB on discharge (all)
ACEI/ARB
3977
18895
21.0%
ACEI/ARB on discharge (all)
No ACEI/ARB
1995
5444
36.7%
Beta blocker on discharge
(LVSD)
Beta blocker
2447
11592
21.1%
Beta blocker on discharge
(LVSD)
No beta blocker
1079
3270
33.0%
Beta blocker on discharge (all)
Beta blocker
3806
17134
22.2%
Beta blocker on discharge (all)
No beta blocker
2350
7329
32.1%
Loop diuretic on discharge
(LVSD)
Loop diuretic
3603
14075
25.6%
Loop diuretic on discharge
(LVSD)
No loop diuretic
281
1658
17.0%
Loop diuretic on discharge (all)
Loop diuretic
6300
23798
26.5%
Loop diuretic on discharge (all)
No loop diuretic
521
2524
20.6%
Additive drug treatment (LVSD)
ACEI/ARB, beta blocker and MRA on
discharge
734
4367
16.8%
Additive drug treatment (LVSD)
ACEI/ARB & beta blocker on
discharge
809
4408
18.4%
Additive drug treatment (LVSD)
ACEI/ARB on discharge
357
1316
27.1%
Additive drug treatment (LVSD)
No ACEI/ARB, beta blocker or MRA
on discharge
299
653
45.8%
Referral to cardiology follow-up
Cardiology follow-up
2745
13615
20.2%
Referral to cardiology follow-up
No cardiology follow-up
4082
12724
32.1%
Referral to nurse-led follow-up
HF liaison follow-up
3453
13922
24.8%
Referral to nurse-led follow-up
No HF liaison follow-up
3352
12000
27.9%
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Appendix 4: Data for 2009-12 mortality analysis
Three-year in-hospital mortality (2009-12)
Analysis
Variable
Deaths
Denominator
Mortality (%)
Overall
In hospital deaths
9082
75331
12.1%
Sex
Men
4605
41040
11.2%
Sex
Women
4472
34263
13.1%
Place of care
Cardiology ward
2872
34984
8.2%
Place of care
General medical ward
4742
32351
14.7%
Place of care
Other ward
1457
7888
18.5%
Age
16-44
15
594
2.5%
Age
45-54
29
1119
2.6%
Age
55-64
136
2704
5.0%
Age
65-74
416
5757
7.2%
Age
75-84
1207
11102
10.9%
Age
≥85
1617
9609
16.8%
Three-year mortality for survivors to discharge (2009-12)
Analysis
Variable
Deaths
Denominator
Mortality (%)
Overall
All discharges
24572
66167
37.1%
Sex
Men
13319
36380
36.6%
Sex
Women
11247
29764
37.8%
Place of care
Cardiology ward
9971
32074
31.1%
Place of care
General medical ward
11692
27572
42.4%
Place of care
Other ward
2889
6427
45.0%
Age
16-44
159
1469
10.8%
Age
45-54
384
2742
14.0%
Age
55-64
1276
6247
20.4%
Age
65-74
3868
13201
29.3%
Age
75-84
9083
23652
38.4%
Age
≥85
9799
18851
52.0%
Diagnosis LVSD
Diagnosis of LVSD
13534
39028
34.7%
Diagnosis LVSD
No Diagnosis of LVSD
11038
27139
40.7%
ACEI/ARB on discharge (LVSD)
ACEI/ARB on discharge (LVSD)
9124
30166
30.32 %
ACEI/ARB on discharge (LVSD)
No ACEI/ARB on discharge (LVSD)
2810
5604
50.1%
Beta blocker on discharge
(LVSD)
Beta blocker on discharge (LVSD)
7658
26054
29.4%
Beta blocker on discharge
(LVSD)
No beta blocker on discharge (LVSD)
4275
9317
45.9%
Loop diuretic on discharge
(LVSD)
Loop diuretic on discharge (LVSD)
12002
33525
35.8%
Loop diuretic on discharge
(LVSD)
No loop diuretic on discharge (LVSD)
1003
4005
25.0%
58
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Additive drug treatment (LVSD)
ACEI/ARB, beta blocker and MRA on
discharge
2389
9577
25.0%
Additive drug treatment (LVSD)
ACEI/ARB & beta blocker on
discharge
2814
10470
26.9%
Additive drug treatment (LVSD)
ACEI/ARB on discharge
1606
3959
40.6%
Additive drug treatment (LVSD)
No ACEI/ARB, beta blocker or MRA
on discharge
1013
1788
56.7%
Referral to cardiology follow-up
Cardiology follow-up
9581
32714
29.3%
Referral to cardiology follow-up
No cardiology follow-up
13652
30585
44.6%
Referral to nurse-led follow-up
HF liaison follow-up
11164
32175
34.7%
Referral to nurse-led follow-up
No HF liaison follow-up
11655
29575
39.4%
Appendix 5: Glossary
Term
Acronym
Acute Myocardial
Infarction
AMI
Commonly known as a heart attack, a myocardial infarction results from the interruption of blood
supply to part of the heart, which causes heart muscle cells to die. The damage to the heart muscle
carries a risk of sudden death, but those who survive often go on to suffer from heart failure.
Angiotensin II
receptor antagonist/
angiotensin receptor
blocker
ARB
A group of drugs usually prescribed for those patients who are intolerant of ACE inhibitors.
Rather than lowering levels of angiotensin II, they instead prevent the chemical from having any
effect on blood vessels.
Angiotensinconverting enzyme
inhibitor
ACE
inhibitor/
ACEI
A group of drugs used primarily for the treatment of high blood pressure and heart failure.
They stop the body’s ability to produce angiotensin II, a hormone which causes blood vessels to
contract, thus dilating blood vessels and increasing the supply of blood and oxygen to the heart.
Beta blocker
A group of drugs which slow the heart rate, decrease cardiac output and lessen the force of heart
muscle and blood vessel contractions. Used to treat abnormal or irregular heart rhythms, and
abnormally fast heart rates.
British Society for
Heart Failure
BSH
The professional society for healthcare professionals involved in the care of heart failure patients.
The BSH aims to improve care and outcomes for heart failure patients by increasing knowledge
and promoting research about the diagnosis, causes and management of heart failure.
Cardiac
resynchronisation
therapy
CRT
CRT, also known as biventricular pacing, aims to improve the heart’s pumping efficiency by
making the chambers of the heart pump together. 25-50% of all heart failure patients have hearts
whose walls do not contract simultaneously. CRT involves implanting a CRT pacemaker or ICD
(implantable cardioverter-defibrillator) that has a lead positioned in each ventricle. Most devices
also include a third lead which is positioned in the right atrium to ensure that the atria and
ventricles contract together.
Chronic obstructive
pulmonary disease
COPD
The co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing lung
diseases in which the airways become narrowed. This leads to a limitation of the flow of air to and
from the lungs, causing shortness of breath (dyspnoea). In contrast to asthma, this limitation is
poorly reversible and usually gets progressively worse over time.
Contraindication
A factor serving as a reason to withhold medical treatment, due to its unsuitability.
Diuretic
A group of drugs which help to remove extra fluid from the body by increasing the amount of
water passed through the kidneys. Loop diuretic
Echocardiography
Echo
A diagnostic test which uses ultrasound to create two-dimensional images of the heart. This
allows clinicians to examine the size of the chambers of the heart and its pumping function in
detail.
Electrocardiography
ECG
A diagnostic test which interprets the electrical activity of the heart, detected by electrode
attached to the arms, legs and chest.
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Heart failure
A syndrome characterised by the reduced ability of the heart to pump blood around the body,
caused by structural or functional cardiac abnormalities. The condition is characterised by
symptoms such as shortness of breath and fatigue, and signs such as fluid retention.
Acute heart failure refers to the rapid onset of the symptoms and signs of heart failure, often
resulting in a hospitalisation, whereas in chronic heart failure the symptoms develop more slowly.
Hospital Episode
Statistics
HES
The national statistical data warehouse for England of the care provided by NHS hospitals and for
NHS hospital patients treated elsewhere. HES is the data source for a wide range of healthcare
analysis for the NHS, government and many other organisations. The National Heart Failure
Audit uses HES data to calculate case ascertainment.
Left ventricular
dysfunction
LVD
Any functional impairment of the left ventricle of the heart.
Left ventricular
ejection fraction
LVEF
A measurement of how much blood is pumped out of the left ventricle with each heartbeat. An
ejection fraction of below 40% may be an indication of heart failure.
Left ventricular
systolic dysfunction
LVSD
A failure of the pumping function of the heart, characterized by a decreased ejection fraction and
inadequate ventricular contraction. It is often caused by damage to the heart muscle, for example
following a myocardial infarction (heart attack).
Medical Research
Information Service
MRIS
An NHS Information Centre service which links datasets at the level of individual patient records
for medical research projects. NICOR uses MRIS to determine the life status of patients included
in the audit, so as to calculate mortality rates.
Mineralocorticoid
receptor antagonist
MRA
A group of diuretic drugs, whose main action is to block the response to the hormone
aldosterone, which promotes the retention of salt and the loss of potassium and magnesium.
MRAs increase urination, reduce water and salt, and retain potassium. They help to lower blood
pressure and increase the pumping ability of the heart.
National Clinical
Audit and Patient
Outcomes
Programme
NCAPOP
A group of 30 national clinical audits, funded by the Department of Health and overseen by HQIP
that collect data on the implementation of evidence based clinical standard in U.K. Trusts, and
report on patient outcomes.
National Institute
for Cardiovascular
Outcomes Research
NICOR
Part of the National Centre for Cardiovascular Prevention and Outcomes, based in the Institute of
Cardiovascular Science at University College London. NICOR manages six national clinical audits
and three new technology registries.
National Institute for
Health and Clinical
Excellence
NICE
A special health authority in England which provides guidance, sets quality standards and
manages a national database to improve people’s health and prevent and treat ill health. NICE
makes recommendations to the NHS on new and existing medicines, treatments and procedures,
and on treating and caring for people with specific diseases and conditions.
New York Heart
Association class
NYHA class
NYHA classification is used to describe degrees of heart failure by placing patients in one of four
categories based on how much they are limited during physical activity:
Class I (Mild): No limitation of physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, or dyspnoea (shortness of breath).
Class II (Mild): Slight limitation of physical activity. Comfortable at rest, but ordinary physical
activity results in fatigue, palpitation, or dyspnoea.
Class III (Moderate): Marked limitation of physical activity. Comfortable at rest, but less than
ordinary activity causes fatigue, palpitation, or dyspnoea.
Class IV (Severe): Unable to carry out any physical activity without discomfort. Symptoms of
cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
Oedema
Patient Episode
Database of Wales
60
An excess build-up of fluid in the body, causing tissue to become swollen. Heart failure patients
often suffer from peripheral oedema, affecting the feet and ankles, and pulmonary oedema, in
which fluid collects around the lungs.
PEDW
The national statistics database for Wales, collecting data on all inpatient and outpatient activity
undertaken in NHS hospitals in Wales, and on Welsh patients treated in English NHS Trusts.
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8 References
1.
For example: EuroHeart Failure Survey II reports in-
6.
National Institute for Health and Clinical Excellence (2010),
hospital mortality rates of 6.7%, but has a patient group
CG108 Chronic heart failure: Management of chronic heart
of only 3580 (see Nieminen MS et al (2006), ‘EuroHeart
failure in adults in primary and secondary care, http://
Failure Survey II (EHFS II): a survey on hospitalized acute
publications.nice.org.uk/chronic-heart-failure-cg108.
heart failure patients: description of population’, European
Heart Journal 27(22):2725:36. http://www.ncbi.nlm.nih.
7.
gov/pubmed/17000631), and the ESC Heart Failure Pilot
Wislon P, Sutton G (2000), ‘Survival of patients with a new
Survey recorded in-hospital mortality of only 3.8%, with a
diagnosis of heart failure: a population based study’, Heart
patient population of 5118 (1892 with acute heart failure)
83, 505–510.
(see Maggioni AP et al, ‘EURObservational Research
Programme: the Heart Failure Pilot Survey (ESC-HF Pilot)’,
8.
heartfailure/additionalfiles.
www.ncbi.nlm.nih.gov/pubmed/20805094). Also see the
EuroHeart Failure survey programme. This showed 9.1%
mortality for index hospitalisation in the U.K., compared to
an average of 6.9%, but exhibited lots of evidence of biased
reporting (Cleland JG, Swedberg K, Follath F, et al (2003),
‘The EuroHeart Failure survey programme- a survey on the
quality of care among patients with heart failure in Europe.
Part 1: patient characteristics and diagnosis’, European
Heart Journal 24 (5), 442-63, http://www.ncbi.nlm.nih.gov/
pubmed/12633546).
National Institute for Health and Clinical Excellence
(2011), QS9 Chronic heart failure quality standard, http://
publications.nice.org.uk/chronic-heart-failure-qualitystandard-qs9/list-of-statements.
3.
National Institute for Health and Clinical Excellence (2010),
CG108 Chronic heart failure: Management of chronic heart
failure in adults in primary and secondary care, http://
publications.nice.org.uk/chronic-heart-failure-cg108.
4.
Commission for Healthcare Audit and Inspection
(2007), Pushing the boundaries: Improving services for
people with heart failure, p.21, http://archive.cqc.org.
uk/_db/_documents/Pushing_the_boundaries_
Improving_services_for_patients_with_heart_
failure_200707020413.pdf.
5.
Scarborough P, Bhatnagar P, Wickramasinghe K,
Smolina K, Mitchell C, Rayner M (2010), Coronary
heart disease statistics: 2010 edition, British Heart
Foundation Statistics Database, p.54, www.bhf.org.
uk/idoc.ashx?docid=9ef69170-3edf-4fbb-a202a93955c1283d&version=-1.
See National Heart Failure Audit annual reports from
2008/9, 2009/10 and 2010/11, www.ucl.ac.uk/nicor/audits/
European Journal of Heart Failure 12(10):1076-84. http://
2.
Cowie M, Woods D, Coats A, Thomson S, Suresh V, Poole-
9.
Gibbs JSR, McCoy ASM, Gibbs LME, Rogers AE, AddingtonHall JM (2002), ‘Living with and dying from heart failure: the
role of palliative care’, Heart 88, 36-39, http://heart.bmj.
com/content/88/suppl_2/ii36.full.
10. Jiang W, Alexander J et al (2001), ‘Relationship of Depression
to Increased Risk of Mortality and Rehospitalization in
Patients with Congestive Heart Failure’, Archives of Internal
Medicine 161(15), 1849-1856, http://www.ncbi.nlm.nih.gov/
pubmed/11493126.
11. NHS (2010), National Service Framework for Coronary
Heart Disease (Standard eleven: Heart failure), http://www.
dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@
dh/@en/documents/digitalasset/dh_4057526.pdf.
12. National Institute for Health and Clinical Excellence (2010),
CG108 Chronic heart failure: Management of chronic heart
failure in adults in primary and secondary care, http://
publications.nice.org.uk/chronic-heart-failure-cg108.
13. National Institute for Health and Clinical Excellence (2011),
Chronic heart failure quality standard, http://www.nice.
org.uk/guidance/qualitystandards/chronicheartfailure/
home.jsp.
14. Mcdonagh TA, Blue, L, Clark AL, Dahlström U, Ekman I,
Lainscak M, McDonald K, Ryder M, Strömberg A, Jaarsma
T (2011), ‘European Society of Cardiology Heart Failure
Association Standards for Delivering Heart Failure Care’,
European Journal of Heart Failure 13(3), 235-241, http://
eurjhf.oxfordjournals.org/content/13/3/235.full.
National Heart Failure Audit April 2011-March 2012
HF Report 2012 Design B.indd 61
61
28/11/2012 14:19
15. The NHS Information Centre, Participation Rates in the
22. National Institute for Health and Clinical Excellence (2010),
Heart Failure Audit (CV37), http://mqi.ic.nhs.uk/Search.as
CG108 Chronic heart failure: Management of chronic heart
px?query=heart%25failure&ref=1.05.27.
failure in adults in primary and secondary care, http://
publications.nice.org.uk/chronic-heart-failure-cg108.
16. Care Quality Commission, Quality and Risk Profiles, http://
www.cqc.org.uk/organisations-we-regulate/registeredservices/quality-and-risk-profiles-qrps.
23. National Institute for Health and Clinical Excellence (2011),
Chronic heart failure quality standard, http://www.nice.
org.uk/guidance/qualitystandards/chronicheartfailure/
17. Number 10, Letter to Cabinet Ministers on transparency and
home.jsp.
open data, http://www.number10.gov.uk/news/letter-tocabinet-ministers-on-transparency-and-open-data/.
18. Cleland JGF, Mcdonagh TA, Rigby AS, et al (2011), ‘The
24. See www.ucl.ac.uk/nicor/audits/heartfailure/dataset.
25. National Institute for Health and Clinical Excellence (2010),
national heart failure audit for England and Wales 2008-
CG108 Chronic heart failure: Management of chronic heart
2009’, Heart 97 (11), 876-86, http://www.ncbi.nlm.nih.gov/
failure in adults in primary and secondary care, http://
pubmed/21173198.
publications.nice.org.uk/chronic-heart-failure-cg108,
clause 1.2.2.7.
19. HQIP, National Clinical Audits, http://www.hqip.org.uk/
national-clinical-audits-including-ncapop-and-corp/.
26. National Institute for Health and Clinical Excellence (2010),
CG108 Chronic heart failure: Management of chronic heart
20. Department of Health, 2011/12 Standard terms and
failure in adults in primary and secondary care, http://
conditions for acute hospital services (Gateway reference
publications.nice.org.uk/chronic-heart-failure-cg108;
15458), http://www.dh.gov.uk/prod_consum_dh/groups/
National Institute for Health and Clinical Excellence (2011),
dh_digitalassets/documents/digitalasset/dh_124518.pdf.
Chronic heart failure quality standard, http://www.nice.
21. Welsh Government, NHS Wales National Clinical Audit and
Outcomes Review Plan 2012/13, http://www.hqip.org.uk/
org.uk/guidance/qualitystandards/chronicheartfailure/
home.jsp
assets/Core-Team/NHS-Wales-NCAOR-Plan-2012-13.pdf.
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