Doctor at a computer

Cardiovascular

Key messages from the National Heart Failure Audit

The National Heart Failure Audit provides a wealth of registry data that can be used alongside national guidelines, quality standards and reports such as the NCEPOD Acute heart failure: Failure to Function publication that is useful for service development and business case opportunities.

The National Heart Failure Audit (NHFA) was established in 2007 with an initial pilot year and was made mandatory by the Department of Health in 2013. Year on year, the number of NHS Trusts providing data and the number of admissions has risen, seeing an increase from 719 admissions in its pilot year to over 68,000 in the 2017/18.

The NHFA collects data on over 50 core mandatory fields aiming “to provide comparative data to help clinicians and managers improve the quality and outcomes of their services by assessing achievement against NSF and NICE guidelines for heart failure on an ongoing basis”.

The audit collects data on acute patients aged over 18 years who have been discharged from hospital with a primary diagnosis of heart failure on discharge using ICD-10 codes. Data is entered into a web-based database after each admission with heart failure, and a yearly report is produced with hospital level data.

The most recent report shows data for 2017/18 heart failure admissions. It shows that over two-thirds of patients are over the age of 75 on their first admission to hospital with heart failure, with a mean age of 77.8 years. The majority of patients have significant breathlessness on admission, and more than half have significant fluid overload.

The majority of patients receive the appropriate diagnostic tests, although patients on a cardiology ward are more likely to receive these. Less than half of patients during their heart failure admission were on a cardiology ward. Those on outlying wards are more likely to see a heart failure specialist nurse. 

Despite improvements in treatment and care, mortality rates for patients with heart failure remain high

Who a patient sees during their inpatient stay impacts on the treatment prescribed to treat their heart failure. Patients seen by a cardiologist or a heart failure specialist are more likely to receive appropriate medical therapy at the point of discharge than those who do not. It is also clear from the audit data that receiving appropriate medical therapy also depends on age: patients under 55 years of age are more likely to receive treatment and patients aged over 85 are far less likely to receive drug therapy. 

Despite improvements in treatment and care, mortality rates for patients with heart failure remain high, with an inpatient mortality rate of just over 10 percent and a one-year mortality rate of around 30 percent for those who survive to discharge. Almost a third of newly diagnosed patients die within a year. 

It is this high inpatient mortality that led to the proposal of the Acute Heart Failure National Confidential Enquiry into Patient Outcomes and Death. Overall, since 2014 mortality rates have fallen, despite advancing age which is known to be an independent risk factor. However, there is great variation of mortality in age groups (mortality rates of nearly six percent in patients younger than 75 years compared to 12 percent in patients over 75), place of inpatient stay (over seven percent on a cardiology ward versus 14 percent on other outlier wards) and specialist input (almost nine percent with specialist input versus 15 percent with no specialist input).

The yearly audit report provides information on key performance indicators at Trust level that can be used to benchmark services and used for business case development. Given that the principal treatment for heart failure is drug therapy, and often in a multimorbid and elderly population, the recognition for pharmacist input is not unexpected. Pharmacists are ideally placed with their extensive pharmaceutical knowledge and extended skills to play a significant role in the care of heart failure patients.

The opinions expressed in this article are those of the authors. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The authors declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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