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Variation in hospital performance for heart failure management in the National Heart Failure Audit for England and Wales
  1. Connor A Emdin1,
  2. Nathalie Conrad1,
  3. Amit Kiran1,
  4. Gholamreza Salimi-Khorshidi1,
  5. Mark Woodward1,2,
  6. Simon G Anderson1,
  7. Hamid Mohseni1,
  8. Henry J Dargie3,
  9. Suzanna M C Hardman4,
  10. Theresa McDonagh5,
  11. John J V McMurray3,
  12. John G F Cleland6,
  13. Kazem Rahimi1,7
  1. 1Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK
  2. 2The George Institute for Global Health, University of Sydney, Sydney, Australia
  3. 3Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
  4. 4Clinical & Academic Department of Cardiovascular Medicine, Whittington Health, London, UK
  5. 5Cardiology Department, King's College Hospital, London, UK
  6. 6Faculty of Medicine, Imperial College, London, UK
  7. 7Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
  1. Correspondence to Professor Kazem Rahimi, Associate Professor of Cardiovascular Medicine, Division of Cardiovascular Medicine, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK; kazem.rahimi{at}


Objective Investigation of variations in provider performance and its determinants may help inform strategies for improving patient outcomes.

Methods We used the National Heart Failure Audit comprising 68 772 patients with heart failure with reduced left ventricular ejection fraction (HFREF), admitted to 185 hospitals in England and Wales (2007–2013). We investigated hospital adherence to three recommended key performance measures (KPMs) for inhospital care (ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) on discharge, β-blockers on discharge and referral to specialist follow-up) individually and as a composite performance score. Hierarchical regression models were used to investigate hospital-level variation.

Results Hospital-level variation in adherence to composite KPM ranged from 50% to 97% (median 79%), but after adjustments for patient characteristics and year of admission, only 8% (95% CI 7% to 10%) of this variation was attributable to variations in hospital features. Similarly, hospital prescription rates for ACE-I/ARB and β-blocker showed low adjusted hospital-attributable variations (7% CI 6% to 9% and 6% CI 5% to 8%, for ACE-I/ARB and β-blocker, respectively). Referral to specialist follow-up, however, showed larger variations (median 81%; range; 20%, 100%) with 26% of this being attributable to hospital-level differences (CI 22% to 31%).

Conclusion Only a small proportion of hospital variation in medication prescription after discharge was attributable to hospital-level features. This suggests that differences in hospital practices are not a major determinant of observed variations in prescription of investigated medications and outcomes. Future healthcare delivery efforts should consider evaluation and improvement of more ambitious KPMs.

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  • Contributors CAE and KR were involved in the design, implementation and analysis of the study and in the writing of the final manuscript. All authors were involved in revision of the manuscript for important intellectual content.

  • Funding KR is supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre and NIHR Career Development Fellowship. CAE is supported by the Rhodes Trust. MW is supported by a Principal Research Fellowship from the Australian Health and Medical Research Council and is a consultant for Amgen and Novartis. The work of the George Institute is supported by the Oxford Martin School. SGA is an Academic Clinical Lecturer in Cardiology and is funded by the NIHR. The study was funded by the UK NIHR.

  • Competing interests MW declares consultancy fees from Amgen and Novartis.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data and code are available from the lead author on request.

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