• heart failure
• systemic review
• quality and outcomes of care

Heart failure, once lacking in therapies, now has a rich and growing armamentarium that is available to reduce the morbidity and mortality and improve the quality of life for patients. But are we delivering this to patients and what is the evidence (beyond the randomised controlled trials (RCTs) of individual therapies) that we should do so in a systematic and auditable way via quality improvement initiatives? Analyses from England show an association of six hospital-based process measures to that of lower heart failure (HF) readmission rates (but not all-cause hospitalisations).1 Indeed, caution should be exercised as when focus is placed on one disease, and there may be missed opportunities on treating other diseases.2 Notably, individual measures were only modestly linked to better outcomes and the durability of this effect waned over the year as patients spent more time out of hospital than in.

But is association causation? To this end, Agarwal and colleagues3 provide insight into this via a systematic review of RCTs that tested the efficacy of hospital-based improvements initiatives.4 They identified 14 RCTs across five countries—all high-income countries (HIC)—that employed a variety of techniques to improve the care of patients with HF. Of interest, two very large RCTs dominated the area and the heterogeneity (both clinical and statistical) limited the ability to numerically combine the results.

The authors identified three key findings emanating from this body of work. First, there was substantial heterogeneity in the existing trials and datasets, and therefore this went from a meta-analysis to a narrative review. Second, baseline care of patients (in …