national heart failure audit
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1National Heart Failure Audit April 2011-March 2012
Title
NATIONAL HEART
FAILURE AUDIT
APRIL 2011 - MARCH 2012
BRITISH SOCIETY FOR HEART FAILURE
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2 National Heart Failure Audit April 2011-March 2012
National Heart Failure AuditNational Institute for Cardiovascular Outcomes Research (NICOR) Institute of Cardiovascular Science, University College London3rd floor, 170 Tottenham Court Road, London W1T 7HA
Tel: 0203 108 3927Email: polly.mitchell@ucl.ac.uk
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.
AuthorsReport 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)
AcknowledgmentsThe 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
Data cleaning and analysis Emmanuel Lazaridis (NICOR) Darragh O’Neill (NICOR)
Published 27th November 2012. The contents of this report may not be published or used commercially without permission
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.
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3National Heart Failure Audit April 2011-March 2012
Tel: 0203 108 3927Email: polly.mitchell@ucl.ac.uk
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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4 National Heart Failure Audit April 2011-March 2012
Contents
The Authors 2
Contents 4
List of figures 5
Foreword 6
1. Executive summary 7 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
1.3 Recommendations 8
2. Introduction 10 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
2.5 The scope of the audit 11
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
3.3 Demographics 14
Age 14
Age and sex 14
Age and Index of Multiple Deprivation 14
3.4 Demographics 15
In-hospital care 15
Length of stay 15
Readmission 15
3.5 Aetiology 16
Symptoms 16
Aetiology 16
3.6 Diagnosis 16
Echocardiography 16
Diagnosis 17
3.7 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
3.8 Monitoring heart failure patients 18
Follow-up services 18
Palliative care 18
3.9 Analysis by hospital 19
Participation and case ascertainment 19
Clinical practice 30
3.10 Mortality 42
2011/12 in-hospital mortality 42
2011/12 post-discharge mortality 42
3.11 Three-year trends 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 51
5. Research use of National Heart Failure 54
Audit data
6. Conclusions 55 6.1 Quality of care and patient outcomes 55
6.2 Data completeness and participation 55
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7. Appendices 56 A1 National Heart Failure Audit Project Board 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
Table 1 Records excluded from analysis in this report 13
Table 2 Records excluded from mortality analysis in 13
this report
Figure 1 Age at first admission by sex 14
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
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 44 inhibitor and/or ARB on discharge for patients with LVSD
Figure 13 Post-discharge survival by prescription of ACE 45 inhibitor and/or ARB on discharge (all patients)
Figure 14 Post-discharge survival by prescription of beta 45 blockers on discharge for patients with LVSD
Figure 15 Post-discharge survival by prescription of beta 45 blockers on discharge (all patients)
Figure 16 Post-discharge survival by prescription of loop 45 diuretics on discharge for patients with LVSD
Figure 17 Post-discharge survival by prescription of loop 46 diuretics on discharge (all patients)
Figure 18 Post-discharge survival by additive drug 46 treatment on discharge for patients with a diagnosis of LVSD
Figure 19 Post-discharge survival by referral to 46 cardiology follow-up services
Figure 20 Post-discharge survival by referral to 46 heart failure liason follow-up services
Table 9 Cox proportional hazards model for 48 post-discharge mortality (2009-12)
Figure 21 Three-year post-discharge survival (2009-12) 48
Figure 22 Three-year post-discharge survival by 48 sex (2009-12)
Figure 23 Three-year post-discharge survival by 48 age (2009-12)
Figure 24 Three-year post-discharge survival by place 49 of care (2009-12)
Figure 25 Three-year post-discharge survival by presence 49 or absence of LVSD (2009-12)
Figure 26 Three-year post-discharge survival by 49 prescription of ACE inhibitor and/or ARB on discharge in patients with LVSD (2009-12)
Figure 27 Three-year post-discharge survival by 49 prescription of beta blockers on discharge in patients with LVSD (2009-12)
Figure 28 Three-year post-discharge survival by 50 prescription of loop diuretics on discharge in patients with LVSD (2009-12)
Figure 29 Three-year post-discharge survival by 50 additive drug treatment on discharge in patients with LVSD (2009-12)
Figure 30 Three-year post-discharge survival by referral 50 to cardiology follow-up services (2009-12)
Figure 31 Three-year post-discharge survival by referral 50 to heart failure liason follow-up services (2009-12)
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6 National Heart Failure Audit April 2011-March 2012
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.
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
Foreword
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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.
1.1 National Heart Failure AuditThe 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.
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
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.
1 Executive Summary
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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 follow-up 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
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 RecommendationsThe 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 angiotensin-converting 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 FailureHeart 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 sub-optimal 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 auditNational 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.
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 dataIn 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 auditThe 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 databaseIn 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 ITUser 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 platformEarlier 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 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.
2.9 Improving analysisThe 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.
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.
HF Report 2012 Design B.indd 12 28/11/2012 14:19
13National Heart Failure Audit April 2011-March 2012
3 Findings
3.1 Data cleaning and data qualityAs 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.
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*
*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.
Table 2: Records excluded from mortality analysis in this report
Number secluded from 2009-12 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
3.2 Participation
3.2.1 Number of Trusts
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
Airedale NHS Foundation Trust
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*
The Royal Bournemouth and Christchurch Hospitals NHS
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.
HF Report 2012 Design B.indd 13 28/11/2012 14:19
14 National Heart Failure Audit April 2011-March 2012
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
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.
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.
3.2.3 Case ascertainment
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.
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.
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.
3.3.2 Age and sex
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%).
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.
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
Age group
Num
ber
of p
atie
nts
8000
6000
4000
2000
0 18-44 45-54 55-64 65-74 75-84 85+
Fig 1: Age at first admission by sex
Men
Women
6505
5304
2127
4051
862
2072
371862
219433
5836
4243
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15National Heart Failure Audit April 2011-March 2012
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 Hospitalisation
3.4.1 In-hospital care
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 74-84 age group, and 32.1% of patients over 85.
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 2: The effect of deprivation on age of first admission
Index of multiple deprivation
Mea
n ag
e at
firs
t adm
issi
on
in a
udit
per
iod
2011
/12
80
79
78
77
76
75
74
73
72
71
70 1 2 3 4 5
74.5
76.9
78.3
79.179.6
1= least deprived 5= most deprived
Fig 3: Mean length of stay by hospital
0 5 10 15 20 25
Hos
pita
ls
Length of stay (mean) in days
Fig 4: Median length of stay by hospital
0 5 10 15 20
Hos
pita
ls
Length of stay (median) in days
HF Report 2012 Design B.indd 15 28/11/2012 14:19
16 National Heart Failure Audit April 2011-March 2012
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.
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
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.
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
Acute Myocardial Infarction
37 22
Valvular Heart Disease 19 28
Hypertension 52 58
Renal Impairment 26 17
p-value ≤0.001 in all cases
3.6 Diagnosis
3.6.1 Echocardiography
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
1.4%3%14.4%
81.2% 1 readmission
2 readmissions
3 readmissions
4+ readmissions
Fig 5: Number of readmissions in 2011/12
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17National Heart Failure Audit April 2011-March 2012
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 left-ventricular 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 LVSDAll 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
As with ACEI/ARB prescription, patients treated in a cardiology ward, men, and younger patients were all more likely to be
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).
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18 National Heart Failure Audit April 2011-March 2012
3.8 Monitoring heart failure patients
3.8.1 Follow-up services
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.
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.
76.5% of patients were referred onwards to their GP for follow-up, and 13.5% were referred to care of the elderly 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.
Age group
% o
f pat
ient
s ke
y he
art f
ailu
re d
rugs
100
90
80
70
60
50
40
30
20
10
0 18-44 45-54 55-64 65-74 75-84 85+
Fig 6: Treatment for LVSD on discharge by age
ACEI
Beta blocker
Loop diuretic
MRA
HF Report 2012 Design B.indd 18 28/11/2012 14:19
19National Heart Failure Audit April 2011-March 2012
3.9
Ana
lysi
s by
hos
pita
lFo
r th
e fir
st ti
me
sinc
e it
was
est
ablis
hed,
the
Nat
iona
l Hea
rt F
ailu
re A
udit
is p
ublis
hing
a s
erie
s of
ana
lyse
s at
a h
ospi
tal l
evel
. All
hosp
itals
are
incl
uded
that
sub
mitt
ed o
ver
100
reco
rds
or
over
70%
of t
heir
HES
/PED
W fi
gure
s. T
here
is s
igni
fican
t var
iatio
n ac
ross
hos
pita
ls, b
ut th
is is
to s
ome
exte
nt d
own
to h
ospi
tals
incl
udin
g un
repr
esen
tativ
e pa
tient
pop
ulat
ions
in th
e au
dit.
3.9.
1 P
arti
cipa
tion
and
cas
e as
cert
ainm
ent
Tabl
es 4
and
5 c
ompa
re th
e nu
mbe
r of
pat
ient
rec
ords
sub
mitt
ed to
the
audi
t (af
ter
data
cle
anin
g) to
the
num
ber
of in
patie
nts
disc
harg
ed w
ith a
pri
mar
y di
agno
sis
of h
eart
failu
re, a
s re
cord
ed b
y H
ES fo
r En
glis
h Tr
usts
and
PED
W fo
r W
elsh
Hea
lth
Boa
rds.
iiiv T
he n
umbe
r of
pat
ient
s w
ith a
sec
onda
ry a
nd te
rtia
ry d
iagn
osis
of h
eart
failu
re a
re a
lso
incl
uded
. Par
ticip
atio
n is
defi
ned
as a
Tru
st o
r H
ealt
h B
oard
sub
mitt
ing
eith
er 2
0 ca
ses
per
cale
ndar
mon
th, o
r gr
eate
r th
an 7
0% o
f the
ir H
ES/P
EDW
rec
orde
d fig
ures
.
Tabl
e 4:
Par
tici
pati
on a
nd c
ase
asce
rtai
nmen
t in
Engl
and
Trus
t nam
eTr
ust
reco
rds
subm
itte
d
% H
ES
subm
itte
dPa
rtic
ipat
ion
stat
usP
rim
ary
HES
hea
rt
failu
re
disc
harg
es
Seco
ndar
y H
ES h
eart
fa
ilure
di
scha
rges
Tert
iary
HES
he
art f
ailu
re
disc
harg
es
NIC
OR
ho
spit
al
code
Hos
pita
l nam
eH
ospi
tal
reco
rds
subm
itte
d
Engl
and
3655
961
.9%
5908
352
471
5031
536
559
Ain
tree
Uni
vers
ity H
ospi
tal N
HS
Foun
datio
n Tr
ust
296
110.
9%Ye
s26
722
121
8FA
ZU
nive
rsity
Hos
pita
l A
intr
ee29
6
Air
edal
e N
HS
Foun
datio
n Tr
ust
00.
0%N
o24
524
217
2A
IRA
ired
ale
Gen
eral
Hos
pita
l0
Ash
ford
and
St P
eter
's H
ospi
tals
NH
S Tr
ust
296
90.2
%Ye
s32
830
529
9SP
HSt
Pet
er's
Hos
pita
l29
6
Bar
king
, Hav
erin
g an
d R
edbr
idge
Uni
vers
ity
Hos
pita
ls N
HS
Trus
t71
911
3.1%
Yes
636
492
500
OLD
Que
en's
Hos
pita
l (R
omfo
rd)
424
KG
GK
ing
Geo
rge
Hos
pita
l29
5
Bar
net a
nd C
hase
Far
m H
ospi
tals
NH
S Tr
ust
519
106.
1%Ye
s48
939
140
6B
NT
Bar
net G
ener
al H
ospi
tal
294
CH
SC
hase
Far
m H
ospi
tal
225
Bar
nsle
y H
ospi
tal N
HS
Foun
datio
n Tr
ust
201
72.6
%Ye
s27
725
621
1B
AR
Bar
nsle
y H
ospi
tal
201
Bar
ts a
nd th
e Lo
ndon
155
39.9
%P
artia
l38
847
861
3B
AL
The
Lond
on C
hest
H
ospi
tal/
The
Roy
al
Lond
on H
ospi
tal
155
Bas
ildon
and
Thu
rroc
k U
nive
rsity
Hos
pita
ls
NH
S Fo
unda
tion
Trus
t35
9.7%
Par
tial
362
339
480
BA
SB
asild
on U
nive
rsity
H
ospi
tal
35
Bed
ford
Hos
pita
l NH
S Tr
ust
220
75.6
%Ye
s29
122
924
4B
EDB
edfo
rd H
ospi
tal
220
Bla
ckpo
ol T
each
ing
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
903
243.
4%Ye
s37
136
337
5VI
CB
lack
pool
Vic
tori
a H
ospi
tal
903
Bol
ton
NH
S Fo
unda
tion
Trus
t8
1.9%
Par
tial
423
327
261
BO
LR
oyal
Bol
ton
Hos
pita
l8
iv. HES data is from 2010/11, and PEDW data from 2011/12, due to availability.
HF Report 2012 Design B.indd 19 28/11/2012 14:19
20 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eTr
ust
reco
rds
subm
itte
d
% H
ES
subm
itte
dPa
rtic
ipat
ion
stat
usP
rim
ary
HES
hea
rt
failu
re
disc
harg
es
Seco
ndar
y H
ES h
eart
fa
ilure
di
scha
rges
Tert
iary
HES
he
art f
ailu
re
disc
harg
es
NIC
OR
ho
spit
al
code
Hos
pita
l nam
eH
ospi
tal
reco
rds
subm
itte
d
Bra
dfor
d Te
achi
ng H
ospi
tals
NH
S Fo
unda
tion
Trus
t17
032
.3%
Par
tial
527
429
403
BR
DB
radf
ord
Roy
al In
firm
ary
170
Bri
ghto
n an
d Su
ssex
Uni
vers
ity H
ospi
tals
N
HS
Trus
t62
811
4.8%
Yes
547
513
447
RSC
Roy
al S
usse
x C
ount
y H
ospi
tal
406
PR
HP
rinc
ess
Roy
al H
ospi
tal
(Hay
war
ds H
eath
)22
2
Buc
king
ham
shir
e H
ealt
hcar
e N
HS
Trus
t22
094
.0%
Yes
234
205
161
AM
GW
ycom
be G
ener
al
Hos
pita
l22
0
SMV
Stok
e M
ande
ville
Hos
pita
l0
Bur
ton
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
239
91.6
%Ye
s26
123
416
6B
RT
Que
en's
Hos
pita
l (B
urto
n)23
9
Cal
derd
ale
and
Hud
ders
field
NH
S Fo
unda
tion
Trus
t36
771
.7%
Yes
512
444
452
RH
IC
alde
rdal
e R
oyal
Hos
pita
l18
5
HU
DH
udde
rsfie
ld R
oyal
In
firm
ary
182
Cam
brid
ge U
nive
rsity
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
224.
7%P
artia
l46
736
230
4A
DD
Add
enbr
ooke
's H
ospi
tal
22
Cen
tral
Man
ches
ter
Uni
vers
ity H
ospi
tals
N
HS
Foun
datio
n Tr
ust
221
71.1
%Ye
s31
132
743
6M
RI
Man
ches
ter
Roy
al
Infir
mar
y22
1
Che
lsea
and
Wes
tmin
ster
Hos
pita
l NH
S Fo
unda
tion
Trus
t84
46.4
%P
artia
l18
110
711
2W
ESC
hels
ea a
nd W
estm
inst
er
Hos
pita
l84
Che
ster
field
Roy
al H
ospi
tal N
HS
Foun
datio
n Tr
ust
178
63.1
%P
artia
l28
226
925
7C
HE
Che
ster
field
Roy
al
Hos
pita
l17
8
City
Hos
pita
ls S
unde
rlan
d N
HS
Foun
datio
n Tr
ust
245
67.7
%Ye
s36
243
647
5SU
NSu
nder
land
Roy
al
Hos
pita
l24
5
Col
ches
ter
Hos
pita
l Uni
vers
ity N
HS
Foun
datio
n Tr
ust
381
86.8
%Ye
s43
936
231
0C
OL
Col
ches
ter
Gen
eral
H
ospi
tal
381
Cou
ntes
s of
Che
ster
Hos
pita
l NH
S Fo
unda
tion
Trus
t34
113
2.2%
Yes
258
215
208
CO
CC
ount
ess
of C
hest
er
Hos
pita
l34
1
Cou
nty
Dur
ham
and
Dar
lingt
on N
HS
Foun
datio
n Tr
ust
325
58.9
%Ye
s55
252
955
8
DR
YU
nive
rsity
Hos
pita
l of
Nor
th D
urha
m18
0
DA
RD
arlin
gton
Mem
oria
l H
ospi
tal
145
Cro
ydon
Hea
lth
Serv
ices
NH
S Tr
ust
223
75.6
%Ye
s29
523
220
5M
AYC
royd
on U
nive
rsity
H
ospi
tal
223
HF Report 2012 Design B.indd 20 28/11/2012 14:19
21National Heart Failure Audit April 2011-March 2012
Dar
tfor
d an
d G
rave
sham
NH
S Tr
ust
7323
.7%
Par
tial
308
228
191
DVH
Dar
ent V
alle
y H
ospi
tal
73
Der
by H
ospi
tals
NH
S Fo
unda
tion
Trus
t19
638
.4%
Par
tial
510
418
380
DER
Roy
al D
erby
Hos
pita
l19
6
Don
cast
er a
nd B
asse
tlaw
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
197
37.4
%P
artia
l52
744
644
1D
IDD
onca
ster
Roy
al In
firm
ary
128
BSL
Bas
setl
aw H
ospi
tal
69
Dor
set C
ount
y H
ospi
tal N
HS
Foun
datio
n Tr
ust
176
89.8
%Ye
s19
620
117
9W
DH
Dor
set C
ount
y H
ospi
tal
176
Ealin
g H
ospi
tal N
HS
Trus
t26
211
8.0%
Yes
222
158
181
EAL
Ealin
g H
ospi
tal
262
East
and
Nor
th H
ertf
ords
hire
NH
S Tr
ust
481
134.
7%Ye
s35
730
525
3
LIS
List
er H
ospi
tal
267
QEW
Que
en E
lizab
eth
II H
ospi
tal
214
East
Che
shir
e N
HS
Trus
t16
764
.0%
Par
tial
261
152
171
MAC
Mac
cles
field
Dis
tric
t G
ener
al H
ospi
tal
167
East
Ken
t Hos
pita
ls U
nive
rsity
NH
S Fo
unda
tion
Trus
t0
0.0%
No
833
661
636
KC
CK
ent a
nd C
ante
rbur
y H
ospi
tal
0
QEQ
Que
en E
lizab
eth
The
Que
en M
othe
r H
ospi
tal
0
WH
HW
illia
m H
arve
y H
ospi
tal
0
East
Lan
cash
ire
Hos
pita
ls N
HS
Trus
t23
447
.4%
Par
tial
494
515
536
BLA
Roy
al B
lack
burn
Hos
pita
l23
4
East
Sus
sex
Hea
lthc
are
NH
S Tr
ust
424
69.3
%Ye
s61
247
633
8
CG
HC
onqu
est H
ospi
tal
218
DG
EEa
stbo
urne
Dis
tric
t G
ener
al H
ospi
tal
206
Epso
m a
nd S
t Hel
ier
Uni
vers
ity H
ospi
tals
N
HS
Trus
t21
057
.9%
Par
tial
363
349
319
SHC
St H
elie
r H
ospi
tal
110
EPS
Epso
m H
ospi
tal
100
Frim
ley
Par
k H
ospi
tal N
HS
Foun
datio
n Tr
ust
287
121.
6%Ye
s23
623
625
7FR
MFr
imle
y P
ark
Hos
pita
l28
7
Gat
eshe
ad H
ealt
h N
HS
Foun
datio
n Tr
ust
128
56.6
%P
artia
l22
626
224
9Q
EGQ
ueen
Eliz
abet
h H
ospi
tal
(Gat
eshe
ad)
128
Geo
rge
Elio
t Hos
pita
l NH
S Tr
ust
261
133.
2%Ye
s19
621
719
1N
UN
Geo
rge
Elio
t Hos
pita
l26
1
Glo
uces
ters
hire
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
121
23.9
%P
artia
l50
746
741
2
GLO
Glo
uces
ters
hire
Roy
al
Hos
pita
l67
CH
GC
helt
enha
m G
ener
al
Hos
pita
l54
Gre
at W
este
rn H
ospi
tals
NH
S Fo
unda
tion
Trus
t21
283
.8%
Yes
253
275
276
PM
STh
e G
reat
Wes
tern
H
ospi
tal
212
HF Report 2012 Design B.indd 21 28/11/2012 14:19
22 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eTr
ust
reco
rds
subm
itte
d
% H
ES
subm
itte
dPa
rtic
ipat
ion
stat
usP
rim
ary
HES
hea
rt
failu
re
disc
harg
es
Seco
ndar
y H
ES h
eart
fa
ilure
di
scha
rges
Tert
iary
HES
he
art f
ailu
re
disc
harg
es
NIC
OR
ho
spit
al
code
Hos
pita
l nam
eH
ospi
tal
reco
rds
subm
itte
d
Guy
's a
nd S
t Tho
mas
' NH
S Fo
unda
tion
Trus
t22
956
.4%
Par
tial
406
368
351
STH
St T
hom
as' H
ospi
tal
229
Ham
pshi
re H
ospi
tals
NH
S Fo
unda
tion
Trus
t12
838
.4%
Par
tial
333
265
295
NH
HB
asin
gsto
ke a
nd N
orth
H
amps
hire
Hos
pita
l12
8
RH
CR
oyal
Ham
pshi
re C
ount
y H
ospi
tal
0
Har
roga
te a
nd D
istr
ict N
HS
Foun
datio
n Tr
ust
130
60.5
%P
artia
l21
515
316
2H
AR
Har
roga
te D
istr
ict
Hos
pita
l13
0
Hea
rt o
f Eng
land
NH
S Fo
unda
tion
Trus
t36
832
.8%
Yes
1122
740
757
EBH
Bir
min
gham
Hea
rtla
nds
Hos
pita
l20
7
SOL
Solih
ull H
ospi
tal
161
GH
SG
ood
Hop
e H
ospi
tal
0
Hea
ther
woo
d an
d W
exha
m P
ark
Hos
pita
ls
NH
S Fo
unda
tion
Trus
t71
18.3
%P
artia
l38
829
227
9W
EXW
exha
m P
ark
Hos
pita
l71
Hin
chin
gbro
oke
Hea
lth
Car
e N
HS
Trus
t38
22.5
%P
artia
l16
915
111
1H
INH
inch
ingb
rook
e H
ospi
tal
38
Hom
erto
n U
nive
rsity
Hos
pita
l NH
S Fo
unda
tion
Trus
t21
286
.5%
Yes
245
144
154
HO
MH
omer
ton
Uni
vers
ity
Hos
pita
l21
2
Hul
l and
Eas
t Yor
kshi
re H
ospi
tals
NH
S Tr
ust
737
171.
0%Ye
s43
141
146
4C
HH
Cas
tle H
ill H
ospi
tal
627
Hul
l and
Eas
t Yor
kshi
re H
ospi
tals
NH
S Tr
ust
HR
IH
ull R
oyal
Infir
mar
y11
0
Impe
rial
Col
lege
Hea
lthc
are
NH
S Tr
ust
491
79.1
%Ye
s62
159
462
1ST
MSt
Mar
y's
Hos
pita
l P
addi
ngto
n24
1
Impe
rial
Col
lege
Hea
lthc
are
NH
S Tr
ust
HA
MH
amm
ersm
ith H
ospi
tal
151
Impe
rial
Col
lege
Hea
lthc
are
NH
S Tr
ust
CC
HC
hari
ng C
ross
Hos
pita
l99
Isle
of W
ight
NH
S P
CT
173
88.3
%Ye
s19
614
811
8IO
WSt
Mar
y's
Hos
pita
l, N
ewpo
rt17
3
Jam
es P
aget
Uni
vers
ity H
ospi
tals
NH
S Fo
unda
tion
Trus
t11
434
.7%
Par
tial
329
292
310
JPH
Jam
es P
aget
Uni
vers
ity
Hos
pita
l11
4
Ket
teri
ng G
ener
al H
ospi
tal N
HS
Foun
datio
n Tr
ust
239
79.1
%Ye
s30
223
025
2K
GH
Ket
teri
ng G
ener
al
Hos
pita
l23
9
Kin
g's
Col
lege
Hos
pita
l NH
S Fo
unda
tion
Trus
t24
561
.7%
Yes
397
332
362
KC
HK
ing'
s C
olle
ge H
ospi
tal
245
Kin
gsto
n H
ospi
tal N
HS
Trus
t30
994
.5%
Yes
327
264
204
KTH
Kin
gsto
n H
ospi
tal
309
HF Report 2012 Design B.indd 22 28/11/2012 14:19
23National Heart Failure Audit April 2011-March 2012
Lanc
ashi
re T
each
ing
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
566
123.
3%Ye
s45
958
146
9
RP
HR
oyal
Pre
ston
Hos
pita
l33
4
CH
OC
horl
ey a
nd S
outh
Rib
ble
Hos
pita
l23
2
Leed
s Te
achi
ng H
ospi
tals
NH
S Tr
ust
248
30.4
%Ye
s81
571
970
4LG
ILe
eds
Gen
eral
Infir
mar
y24
8
Lew
isha
m H
ealt
hcar
e N
HS
Trus
t11
740
.5%
Par
tial
289
181
175
LEW
Uni
vers
ity H
ospi
tal
Lew
isha
m11
7
Live
rpoo
l Hea
rt a
nd C
hest
Hos
pita
l NH
S Fo
unda
tion
Trus
t13
664
.5%
Par
tial
211
118
150
BH
LLi
verp
ool H
eart
and
Che
st
Hos
pita
l13
6
Luto
n an
d D
unst
able
Hos
pita
l NH
S Fo
unda
tion
Trus
t34
612
1.8%
Yes
284
271
255
LDH
Luto
n an
d D
unst
able
H
ospi
tal
346
Mai
dsto
ne a
nd T
unbr
idge
Wel
ls N
HS
Trus
t40
490
.2%
Yes
448
448
336
MA
IM
aids
tone
Hos
pita
l22
6
KSX
Tunb
ridg
e W
ells
Hos
pita
l17
8
Med
way
NH
S Fo
unda
tion
Trus
t0
0.0%
No
300
241
256
MD
WM
edw
ay M
ariti
me
Hos
pita
l0
Mid
Che
shir
e H
ospi
tals
NH
S Fo
unda
tion
Trus
t26
312
6.4%
Yes
208
228
216
LGH
Leig
hton
Hos
pita
l26
3
Mid
Ess
ex H
ospi
tal S
ervi
ces
NH
S Tr
ust
136
34.7
%P
artia
l39
221
120
1B
FHB
room
field
Hos
pita
l13
6
Mid
Sta
ffor
dshi
re N
HS
Foun
datio
n Tr
ust
7425
.2%
Par
tial
294
227
187
SDG
Staf
ford
Hos
pita
l74
Mid
Yor
kshi
re H
ospi
tals
NH
S Tr
ust
420
64.9
%Ye
s64
749
139
3
PIN
Pin
derfi
elds
Hos
pita
l30
1
DEW
Dew
sbur
y an
d D
istr
ict
Hos
pita
l11
9
Milt
on K
eyne
s H
ospi
tal N
HS
Foun
datio
n Tr
ust
154
75.9
%Ye
s20
316
412
9M
KH
Milt
on K
eyne
s G
ener
al
Hos
pita
l15
4
New
ham
Uni
vers
ity H
ospi
tal N
HS
Trus
t2
0.8%
Par
tial
242
169
169
NW
GN
ewha
m U
nive
rsity
H
ospi
tal
2
Nor
folk
and
Nor
wic
h U
nive
rsity
Hos
pita
ls
NH
S Fo
unda
tion
Trus
t37
451
.4%
Yes
728
696
746
NO
RN
orfo
lk a
nd N
orw
ich
Uni
vers
ity H
ospi
tal
374
Nor
th B
rist
ol N
HS
Trus
t48
412
6.7%
Yes
382
373
324
FRY
Fren
chay
Hos
pita
l27
9
BSM
Sout
hmea
d H
ospi
tal
205
Nor
th C
umbr
ia U
nive
rsity
Hos
pita
ls N
HS
Trus
t78
22.3
%P
artia
l35
037
231
0
CM
IC
umbe
rlan
d In
firm
ary
46
WC
IW
est C
umbe
rlan
d H
ospi
tal
32
Nor
th M
iddl
esex
Uni
vers
ity H
ospi
tal N
HS
Trus
t17
155
.3%
Par
tial
309
176
156
NM
HN
orth
Mid
dles
ex
Uni
vers
ity H
ospi
tal
171
HF Report 2012 Design B.indd 23 28/11/2012 14:19
24 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eTr
ust
reco
rds
subm
itte
d
% H
ES
subm
itte
dPa
rtic
ipat
ion
stat
usP
rim
ary
HES
hea
rt
failu
re
disc
harg
es
Seco
ndar
y H
ES h
eart
fa
ilure
di
scha
rges
Tert
iary
HES
he
art f
ailu
re
disc
harg
es
NIC
OR
ho
spit
al
code
Hos
pita
l nam
eH
ospi
tal
reco
rds
subm
itte
d
Nor
th T
ees
and
Har
tlepo
ol N
HS
Foun
datio
n Tr
ust
383
140.
3%Ye
s27
332
931
6
NTG
Uni
vers
ity H
ospi
tal o
f N
orth
Tee
s23
4
HG
HU
nive
rsity
Hos
pita
l of
Har
tlepo
ol14
9
Nor
tham
pton
Gen
eral
Hos
pita
l NH
S Tr
ust
217
77.0
%Ye
s28
229
022
7N
THN
orth
ampt
on G
ener
al
Hos
pita
l21
7
Nor
ther
n D
evon
Hea
lthc
are
NH
S Tr
ust
212
74.9
%Ye
s28
323
121
9N
DD
Nor
th D
evon
Dis
tric
t H
ospi
tal
212
Nor
ther
n Li
ncol
nshi
re a
nd G
oole
Hos
pita
ls
NH
S Fo
unda
tion
Trus
t25
675
.5%
Yes
339
278
311
GG
HD
iana
Pri
nces
s of
Wal
es
Hos
pita
l16
1
SCU
Scun
thor
pe G
ener
al
Hos
pita
l95
Nor
thum
bria
Hea
lthca
re N
HS
Foun
datio
n Tr
ust
400
60.6
%Ye
s66
053
050
3
NTY
Nor
th T
ynes
ide
Hos
pita
l21
9
ASH
Wan
sbec
k G
ener
al
Hos
pita
l12
5
HEX
Hex
ham
Gen
eral
Hos
pita
l56
Not
tingh
am U
nive
rsity
Hos
pita
ls N
HS
Trus
t20
325
.5%
Par
tial
797
722
719
UH
NQ
ueen
's M
edic
al C
entr
e15
9
CH
NN
ottin
gham
City
Hos
pita
l44
Oxf
ord
Rad
cliff
e H
ospi
tals
NH
S Tr
ust
736
102.
5%Ye
s71
861
553
4R
AD
John
Rad
cliff
e H
ospi
tal
624
HO
RH
orto
n G
ener
al H
ospi
tal
112
Pap
wor
th H
ospi
tal N
HS
Foun
datio
n Tr
ust
00.
0%N
o27
428
222
7PA
PP
apw
orth
Hos
pita
l0
Pen
nine
Acu
te H
ospi
tals
NH
S Tr
ust
645
88.5
%Ye
s72
992
988
1
BR
YFa
irfie
ld G
ener
al H
ospi
tal
205
OH
MR
oyal
Old
ham
Hos
pita
l20
4
NM
GN
orth
Man
ches
ter
Gen
eral
Hos
pita
l18
3
BH
HR
ochd
ale
Infir
mar
y53
Pet
erbo
roug
h an
d St
amfo
rd H
ospi
tals
NH
S Fo
unda
tion
Trus
t29
689
.4%
Yes
331
280
251
PET
Pet
erbo
roug
h C
ity
Hos
pita
l29
6
Ply
mou
th H
ospi
tals
NH
S Tr
ust
00.
0%N
o63
552
549
8P
LYD
erri
ford
Hos
pita
l0
Poo
le H
ospi
tal N
HS
Foun
datio
n Tr
ust
307
146.
2%Ye
s21
023
719
8P
GH
Poo
le G
ener
al H
ospi
tal
307
HF Report 2012 Design B.indd 24 28/11/2012 14:19
25National Heart Failure Audit April 2011-March 2012
Por
tsm
outh
Hos
pita
ls N
HS
Trus
t31
959
.5%
Yes
536
543
509
QA
PQ
ueen
Ale
xand
ra H
ospi
tal
319
Rot
herh
am N
HS
Foun
datio
n Tr
ust
227
78.8
%Ye
s28
832
325
0R
OT
Rot
herh
am H
ospi
tal
227
Roy
al B
erks
hire
NH
S Fo
unda
tion
Trus
t44
911
1.4%
Yes
403
305
261
BH
RR
oyal
Ber
kshi
re H
ospi
tal
449
Roy
al B
rom
pton
and
Har
efiel
d N
HS
Foun
datio
n Tr
ust
234
46.7
%P
artia
l50
151
237
5N
HB
Roy
al B
rom
pton
Hos
pita
l21
0
HH
Har
efiel
d H
ospi
tal
24
Roy
al C
ornw
all H
ospi
tals
NH
S Tr
ust
155
32.2
%P
artia
l48
142
839
5R
CH
Roy
al C
ornw
all H
ospi
tal
155
Roy
al D
evon
and
Exe
ter
NH
S Fo
unda
tion
Trus
t22
571
.9%
Yes
313
389
620
RD
ER
oyal
Dev
on &
Exe
ter
Hos
pita
l22
5
Roy
al F
ree
Lond
on N
HS
Trus
t22
384
.8%
Yes
263
229
224
RFH
Roy
al F
ree
Hos
pita
l22
3
Roy
al L
iver
pool
and
Bro
adgr
een
Uni
vers
ity
Hos
pita
ls N
HS
Trus
t33
014
8.6%
Yes
222
237
272
RLU
Roy
al L
iver
pool
Uni
vers
ity
Hos
pita
l33
0
Roy
al S
urre
y C
ount
y H
ospi
tal N
HS
Foun
datio
n Tr
ust
144
81.8
%Ye
s17
614
114
4R
SUR
oyal
Sur
rey
Cou
nty
Hos
pita
l14
4
Roy
al U
nite
d H
ospi
tal B
ath
NH
S Tr
ust
00.
0%N
o45
539
543
4B
ATR
oyal
Uni
ted
Hos
pita
l Bat
h0
Salfo
rd R
oyal
NH
S Fo
unda
tion
Trus
t24
194
.1%
Yes
256
331
301
SLF
Salfo
rd R
oyal
241
Salis
bury
NH
S Fo
unda
tion
Trus
t34
220
9.8%
Yes
163
139
150
SAL
Salis
bury
Dis
tric
t Hos
pita
l34
2
Sand
wel
l and
Wes
t Bir
min
gham
Hos
pita
ls
NH
S Tr
ust
345
48.8
%Ye
s70
761
460
8
DU
DB
irm
ingh
am C
ity H
ospi
tal
190
SAN
Sand
wel
l Gen
eral
H
ospi
tal
155
Scar
boro
ugh
and
Nor
th E
ast Y
orks
hire
NH
S Tr
ust
72.
7%P
artia
l25
825
621
2SC
ASc
arbo
roug
h G
ener
al
Hos
pita
l7
Shef
field
Tea
chin
g H
ospi
tals
NH
S Fo
unda
tion
Trus
t45
251
.3%
Yes
881
905
736
NG
SN
orth
ern
Gen
eral
H
ospi
tal
442
RH
AR
oyal
Hal
lam
shir
e H
ospi
tal
10
Sher
woo
d Fo
rest
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
315
72.2
%Ye
s43
626
922
1K
MH
Kin
g's
Mill
Hos
pita
l30
2
NH
NN
ewar
k H
ospi
tal
13
Shre
wsb
ury
and
Telfo
rd H
ospi
tals
NH
S Tr
ust
8519
.5%
Par
tial
437
331
304
TLF
Pri
nces
s R
oyal
Hos
pita
l (T
elfo
rd)
48
RSS
Roy
al S
hrew
sbur
y H
ospi
tal
37
Sout
h D
evon
Hea
lthc
are
NH
S Fo
unda
tion
Trus
t35
987
.1%
Yes
412
236
243
TOR
Torb
ay H
ospi
tal
359
HF Report 2012 Design B.indd 25 28/11/2012 14:19
26 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eTr
ust
reco
rds
subm
itte
d
% H
ES
subm
itte
dPa
rtic
ipat
ion
stat
usP
rim
ary
HES
hea
rt
failu
re
disc
harg
es
Seco
ndar
y H
ES h
eart
fa
ilure
di
scha
rges
Tert
iary
HES
he
art f
ailu
re
disc
harg
es
NIC
OR
ho
spit
al
code
Hos
pita
l nam
eH
ospi
tal
reco
rds
subm
itte
d
Sout
h Lo
ndon
Hea
lthc
are
NH
S Tr
ust
262
34.7
%Ye
s75
655
052
6
GW
HQ
ueen
Eliz
abet
h H
ospi
tal
(Woo
lwic
h)23
7
BR
OP
rinc
ess
Roy
al U
nive
rsity
H
ospi
tal (
Bro
mle
y)24
QM
HQ
ueen
Mar
y's
Hos
pita
l (S
idcu
p)1
Sout
h Te
es H
ospi
tals
NH
S Fo
unda
tion
Trus
t20
943
.1%
Par
tial
485
563
817
SCM
Jam
es C
ook
Uni
vers
ity
Hos
pita
l20
9
FRH
Fria
rage
Hos
pita
l0
Sout
h Ty
nesi
de N
HS
Foun
datio
n Tr
ust
267
147.
5%Ye
s18
114
011
2ST
DSo
uth
Tyne
side
Dis
tric
t H
ospi
tal
267
Sout
h W
arw
icks
hire
NH
S Fo
unda
tion
Trus
t 0
0.0%
No
126
232
180
WA
RW
arw
ick
Hos
pita
l0
Sout
hend
Uni
vers
ity H
ospi
tal N
HS
Foun
datio
n Tr
ust
555
165.
2%Ye
s33
624
126
8SE
HSo
uthe
nd H
ospi
tal
555
Sout
hpor
t and
Orm
skir
k H
ospi
tal N
HS
Trus
t20
374
.6%
Yes
272
224
191
SOU
Sout
hpor
t and
For
mby
D
istr
ict G
ener
al H
ospi
tal
203
St G
eorg
e's
Hea
lthc
are
NH
S Tr
ust
229
43.3
%P
artia
l52
950
660
8G
EOSt
Geo
rge'
s H
ospi
tal
229
St H
elen
s an
d K
now
sley
Tea
chin
g H
ospi
tals
N
HS
Trus
t22
668
.5%
Par
tial
330
390
354
WH
IW
hist
on H
ospi
tal
226
Stoc
kpor
t NH
S Fo
unda
tion
Trus
t17
550
.0%
Par
tial
350
399
358
SHH
Step
ping
Hill
Hos
pita
l17
5
Surr
ey a
nd S
usse
x H
ealt
hcar
e N
HS
Trus
t30
290
.7%
Yes
333
302
242
ESU
East
Sur
rey
Hos
pita
l30
2
Tam
esid
e H
ospi
tal N
HS
Foun
datio
n Tr
ust
178
73.0
%Ye
s24
428
622
3TG
ATa
mes
ide
Gen
eral
H
ospi
tal
178
Taun
ton
and
Som
erse
t NH
S Fo
unda
tion
Trus
t30
087
.2%
Yes
344
343
292
MP
HM
usgr
ove
Par
k H
ospi
tal
300
The
Dud
ley
Gro
up N
HS
Foun
datio
n Tr
ust
180
38.7
%P
artia
l46
537
537
9R
US
Rus
sells
Hal
l Hos
pita
l18
0
The
Hill
ingd
on H
ospi
tals
NH
S Fo
unda
tion
Trus
t19
786
.8%
Yes
227
171
155
HIL
Hill
ingd
on H
ospi
tal
197
The
Ipsw
ich
Hos
pita
l NH
S Tr
ust
203
53.0
%P
artia
l38
341
842
9IP
STh
e Ip
swic
h H
ospi
tal
203
The
New
cast
le U
pon
Tyne
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
170
24.1
%P
artia
l70
468
055
9FR
EFr
eem
an H
ospi
tal
170
RVN
Roy
al V
icto
ria
Infir
mar
y0
HF Report 2012 Design B.indd 26 28/11/2012 14:19
27National Heart Failure Audit April 2011-March 2012
The
Nor
th W
est L
ondo
n H
ospi
tals
NH
S Tr
ust
360
77.9
%Ye
s46
236
133
5
NP
HN
orth
wic
k P
ark
Hos
pita
l34
6
CM
HC
entr
al M
iddl
esex
H
ospi
tal
14
The
Pri
nces
s A
lexa
ndra
Hos
pita
l NH
S Tr
ust
00.
0%N
o29
021
823
8PA
HP
rinc
ess
Ale
xand
ra
Hos
pita
l0
The
Que
en E
lizab
eth
Hos
pita
l Kin
g's
Lynn
N
HS
Foun
datio
n Tr
ust
201
66.3
%P
artia
l30
329
131
6Q
KL
Que
en E
lizab
eth
Hos
pita
l (K
ing'
s Ly
nn)
201
The
Roy
al B
ourn
emou
th a
nd C
hris
tchu
rch
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
00.
0%N
o58
466
261
5B
OU
Roy
al B
ourn
emou
th
Gen
eral
Hos
pita
l0
The
Roy
al W
olve
rham
pton
Hos
pita
ls N
HS
Trus
t18
141
.0%
Par
tial
442
317
304
NC
RN
ew C
ross
Hos
pita
l18
1
The
Whi
ttin
gton
Hos
pita
l NH
S Tr
ust
137
53.9
%P
artia
l25
416
016
5W
HT
Whi
ttin
gton
Hos
pita
l13
7
Traf
ford
Hea
lthc
are
NH
S Tr
ust
00.
0%N
o96
104
83TR
ATr
affo
rd G
ener
al H
ospi
tal
0
Uni
ted
Linc
olns
hire
Hos
pita
ls N
HS
Trus
t25
332
.0%
Yes
790
748
693
PIL
Pilg
rim
Hos
pita
l10
6
LIN
Linc
oln
Cou
nty
Hos
pita
l10
1
GR
AG
rant
ham
and
Dis
tric
t H
ospi
tal
46
Uni
vers
ity C
olle
ge L
ondo
n H
ospi
tals
NH
S Fo
unda
tion
Trus
t33
512
9.3%
Yes
259
272
298
UC
LU
nive
rsity
Col
lege
H
ospi
tal
335
Uni
vers
ity H
ospi
tal o
f Nor
th S
taff
ords
hire
N
HS
Trus
t20
928
.1%
Par
tial
743
483
461
STO
Uni
vers
ity H
ospi
tal o
f N
orth
Sta
ffor
dshi
re20
9
Uni
vers
ity H
ospi
tal o
f Sou
th M
anch
este
r N
HS
Foun
datio
n Tr
ust
304
88.6
%Ye
s34
347
344
4W
YTW
ythe
nsha
we
Hos
pita
l30
4
Uni
vers
ity H
ospi
tal S
outh
ampt
on N
HS
Trus
t14
227
.3%
Par
tial
521
464
443
SGH
Sout
ham
pton
Gen
eral
H
ospi
tal
142
Uni
vers
ity H
ospi
tals
Bir
min
gham
NH
S Fo
unda
tion
Trus
t29
244
.0%
Yes
663
382
357
QEB
Que
en E
lizab
eth
Hos
pita
l (E
dgba
ston
)29
2
Uni
vers
ity H
ospi
tals
Bri
stol
NH
S Fo
unda
tion
Trus
t38
494
.6%
Yes
406
423
458
BR
IB
rist
ol R
oyal
Infir
mar
y38
4
Uni
vers
ity H
ospi
tals
Cov
entr
y an
d W
arw
icks
hire
NH
S Tr
ust
309
60.7
%Ye
s50
957
767
1
WA
LU
nive
rsity
Hos
pita
l C
oven
try
281
RU
GH
ospi
tal o
f St C
ross
28
Uni
vers
ity H
ospi
tals
of L
eice
ster
NH
S Tr
ust
00.
0%N
o11
6974
165
8G
RL
Gle
nfiel
d H
ospi
tal
0
LER
Leic
este
r R
oyal
Infir
mar
y0
Uni
vers
ity H
ospi
tals
of M
orec
ambe
Bay
NH
S Fo
unda
tion
Trus
t0
0.0%
No
449
351
281
FGH
Furn
ess
Gen
eral
Hos
pita
l0
RLI
Roy
al L
anca
ster
Infir
mar
y0
HF Report 2012 Design B.indd 27 28/11/2012 14:19
28 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eTr
ust
reco
rds
subm
itte
d
% H
ES
subm
itte
dPa
rtic
ipat
ion
stat
usP
rim
ary
HES
hea
rt
failu
re
disc
harg
es
Seco
ndar
y H
ES h
eart
fa
ilure
di
scha
rges
Tert
iary
HES
he
art f
ailu
re
disc
harg
es
NIC
OR
ho
spit
al
code
Hos
pita
l nam
eH
ospi
tal
reco
rds
subm
itte
d
Wal
sall
Hea
lthc
are
NH
S Tr
ust
241
72.4
%Ye
s33
334
529
7W
MH
Man
or H
ospi
tal
241
War
ring
ton
and
Hal
ton
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
145
66.8
%P
artia
l21
726
521
8W
DG
War
ring
ton
Hos
pita
l14
5
Wes
t Her
tfor
dshi
re H
ospi
tals
NH
S Tr
ust
245
74.7
%Ye
s32
828
722
0W
ATW
atfo
rd G
ener
al H
ospi
tal
245
Wes
t Mid
dles
ex U
nive
rsity
Hos
pita
l NH
S Tr
ust
212
101.
0%Ye
s21
018
121
6W
MU
Wes
t Mid
dles
ex U
nive
rsity
H
ospi
tal
212
Wes
t Suf
folk
NH
S Fo
unda
tion
Trus
t21
884
.5%
Yes
258
229
225
WSH
Wes
t Suf
folk
Hos
pita
l21
8
Wes
tern
Sus
sex
Hos
pita
ls N
HS
Trus
t63
986
.8%
Yes
736
561
495
WR
GW
orth
ing
Hos
pita
l36
3
STR
St R
icha
rd's
Hos
pita
l27
6
Wes
ton
Are
a H
ealt
h N
HS
Trus
t11
659
.2%
Par
tial
196
144
133
WG
HW
esto
n G
ener
al H
ospi
tal
116
Whi
pps
Cro
ss U
nive
rsity
Hos
pita
l NH
S Tr
ust
206
66.9
%P
artia
l30
826
826
6W
HC
Whi
pps
Cro
ss U
nive
rsity
H
ospi
tal
206
Wir
ral U
nive
rsity
Tea
chin
g H
ospi
tal N
HS
Foun
datio
n Tr
ust
219
44.2
%P
artia
l49
638
330
3W
IRA
rrow
e P
ark
Hos
pita
l21
9
Wor
cest
ersh
ire
Acu
te H
ospi
tals
NH
S Tr
ust
392
71.9
%Ye
s54
545
450
0
RED
Ale
xand
ra H
ospi
tal
227
WR
CW
orce
ster
shir
e R
oyal
H
ospi
tal
165
Wri
ghtin
gton
, Wig
an a
nd L
eigh
NH
S Fo
unda
tion
Trus
t51
318
1.3%
Yes
283
334
348
AEI
Roy
al A
lber
t Edw
ard
Infir
mar
y51
3
Wye
Val
ley
NH
S Tr
ust
188
92.6
%Ye
s20
318
018
1H
CH
Cou
nty
Hos
pita
l Her
efor
d18
8
Yeov
il D
istr
ict H
ospi
tal N
HS
Foun
datio
n Tr
ust
253
128.
4%Ye
s19
716
313
2YE
OYe
ovil
Dis
tric
t Hos
pita
l25
3
York
Tea
chin
g H
ospi
tal N
HS
Foun
datio
n Tr
ust
220
85.3
%Ye
s25
827
622
6YD
HYo
rk D
istr
ict H
ospi
tal
220
HF Report 2012 Design B.indd 28 28/11/2012 14:19
29National Heart Failure Audit April 2011-March 2012
Tabl
e 5:
Par
tici
pati
on a
nd c
ase
asce
rtai
nmen
t in
Wal
es
Trus
t nam
eTr
ust
reco
rds
subm
itte
d
% P
EDW
su
bmit
ted
Part
icip
atio
n st
atus
Pri
mar
y P
EDW
hea
rt
failu
re
disc
harg
es
Seco
ndar
y P
EDW
hea
rt
failu
re
disc
harg
es
Tert
iary
P
EDW
hea
rt
failu
re
disc
harg
es
NIC
OR
ho
spit
al
code
Hos
pita
l nam
eH
ospi
tal
reco
rds
subm
itte
d
Wal
es51
711
.9%
4348
3303
3380
517
Abe
rtaw
e B
ro M
orga
nnw
g U
nive
rsity
Hea
lth
Boa
rd7
0.9%
Par
tial
823
804
929
MO
RM
orri
ston
Hos
pita
l0
NG
HN
eath
Por
t Tal
bot H
ospi
tal
0
PO
WP
rinc
ess
Of W
ales
H
ospi
tal
7
SIN
Sing
leto
n H
ospi
tal
0
Ane
urin
Bev
an H
ealt
h B
oard
175
19.4
%P
artia
l90
171
364
7
GW
ER
oyal
Gw
ent H
ospi
tal
0
NEV
Nev
ill H
all H
ospi
tal
175
YYF
Cae
rphi
lly D
istr
ict M
iner
s H
ospi
tal/
Ysby
ty Y
stra
d Fa
wr
0
Bet
si C
adw
alad
r U
nive
rsity
Hea
lth
Boa
rd17
218
.5%
Par
tial
928
478
719
CLW
Gla
n C
lwyd
Hos
pita
l0
GW
YYs
byty
Gw
yned
d0
LLA
Llan
dudn
o G
ener
al
Hos
pita
l0
WR
XW
rexh
am M
aelo
r H
ospi
tal
172
Car
diff
& V
ale
Uni
vers
ity H
ealt
h B
oard
00.
0%N
o54
149
743
2
LLD
Llan
doug
h H
ospi
tal
0
UH
WU
nive
rsity
Hos
pita
l of
Wal
es0
Cw
m T
af H
ealt
h B
oard
20.
4%P
artia
l46
733
223
6P
CH
Pri
nce
Cha
rles
Hos
pita
l1
RG
HR
oyal
Gla
mor
gan
1
Hyw
el D
da H
ealt
h B
oard
161
23.4
%P
artia
l68
847
941
7
BR
GB
rong
lais
Gen
eral
H
ospi
tal
146
PP
HP
rinc
e P
hilip
Hos
pita
l6
WW
GW
est W
ales
Gen
eral
5
WYB
With
ybus
h G
ener
al
Hos
pita
l4
HF Report 2012 Design B.indd 29 28/11/2012 14:19
30 National Heart Failure Audit April 2011-March 2012
3.9.
2 C
linic
al p
ract
ice
Tabl
es 6
and
7 s
how
the
perc
enta
ges
of c
ases
at e
ach
hosp
ital r
ecei
ving
key
dia
gnos
tic te
sts,
ther
apie
s an
d re
ferr
al to
follo
w-u
p se
rvic
es a
t hos
pita
ls in
Eng
land
and
Wal
es. H
ospi
tal-
leve
l dat
a on
clin
ical
pra
ctic
e ha
s on
ly b
een
publ
ishe
d if
a ho
spita
l sub
mitt
ed m
ore
than
100
rec
ords
to th
e au
dit,
or g
reat
er th
an 7
0% o
f the
ir H
ES r
ecor
ded
figur
es. A
n as
teri
sk (*
) in
a ce
ll in
dica
tes
that
too
few
rec
ords
wer
e su
bmitt
ed fo
r a
perc
enta
ge to
be
publ
ishe
d.
Ple
ase
note
that
thes
e ou
tput
s ha
ve n
ot b
een
risk
adj
uste
d, b
ut th
e de
nom
inat
ors
used
for
each
ana
lysi
s ha
ve b
een
chos
en to
ens
ure
that
the
outc
omes
are
as
repr
esen
tativ
e as
po
ssib
le. T
he a
udit
Pro
ject
Boa
rd h
as d
ecid
ed to
ref
rain
from
pub
lishi
ng o
utco
mes
dat
a (e
.g. r
eadm
issi
on a
nd m
orta
lity
rate
s) a
t a h
ospi
tal l
evel
unt
il a
satis
fact
ory
risk
adj
ustm
ent
mod
el h
as b
een
deve
lope
d. H
owev
er, s
ince
Apr
il 20
12 th
e N
atio
nal H
eart
Fai
lure
Aud
it ha
s in
clud
ed a
ser
ies
of n
ew m
anda
tory
dat
a ite
ms,
whi
ch w
ill e
nabl
e a
soph
istic
ated
ris
k ad
just
men
t of t
he d
ata
to a
ccou
nt fo
r kn
own
conf
ound
ers.
Thi
s w
ill e
nabl
e th
e au
dit t
o pu
blis
h ou
tcom
e da
ta a
t a h
ospi
tal l
evel
in th
e ne
ar fu
ture
.
Tabl
e 6:
Clin
ical
pra
ctic
e in
Eng
land
(201
1/12
)
Den
omin
ator
s fo
r ta
bles
6 a
nd 7
as
foll
ows:
• %
rec
eive
d ec
ho: a
ll re
cord
s.•
% c
ardi
olog
y in
patie
nt: a
ll re
cord
s.•
% A
CE
I/A
RB
on
disc
harg
e: a
ll re
cord
s w
here
pat
ient
had
LVS
D a
nd s
urvi
ved
to d
isch
arge
.•
% b
eta
bloc
ker
on d
isch
arge
: all
reco
rds
whe
re p
atie
nt h
ad L
VSD
and
sur
vive
d to
dis
char
ge.
• %
ref
erre
d to
HF
liais
on s
ervi
ce: a
ll re
cord
s w
here
pat
ient
had
LVS
D a
nd s
urvi
ved
to d
isch
arge
.•
% r
efer
red
to c
ardi
olog
y fo
llow
-up:
all
reco
rds
whe
re p
atie
nt s
urvi
ved
to d
isch
arge
.
Trus
t nam
eN
ICO
R
hosp
ital
code
Hos
pita
l nam
eR
ecor
ds
subm
itted
% r
ecei
ved
echo
%
car
diol
ogy
inpa
tien
t %
AC
EI/A
RB
on
dis
char
ge
% b
eta
bloc
ker
on
disc
harg
e
% r
efer
red
to H
F lia
ison
se
rvic
e
% re
ferr
ed
to c
ardi
olog
y fo
llow
-up
Engl
and
and
Wal
es37
076
85.9
%47
.1%
82.7
%76
.4%
63.2
%51
.1%
Engl
and
3655
985
.9%
47.0
%82
.7%
76.3
%63
.2%
51.5
%
Ain
tree
Uni
vers
ity H
ospi
tal N
HS
Foun
datio
n Tr
ust
FAZ
Uni
vers
ity H
ospi
tal A
intr
ee29
698
.3%
83.4
%65
.6%
75.1
%97
.7%
91.2
%
Air
edal
e N
HS
Foun
datio
n Tr
ust
AIR
Air
edal
e G
ener
al H
ospi
tal
0
Ash
ford
and
St P
eter
's H
ospi
tals
N
HS
Trus
tSP
HSt
Pet
er's
Hos
pita
l29
684
.8%
49.3
%59
.0%
56.4
%51
.4%
50.6
%
Bar
king
, Hav
erin
g an
d R
edbr
idge
U
nive
rsity
Hos
pita
ls N
HS
Trus
tK
GG
Kin
g G
eorg
e H
ospi
tal
295
98.6
%21
.0%
72.0
%70
.8%
73.1
%55
.5%
Bar
king
, Hav
erin
g an
d R
edbr
idge
U
nive
rsity
Hos
pita
ls N
HS
Trus
tO
LDQ
ueen
's H
ospi
tal (
Rom
ford
)42
498
.6%
19.6
%79
.0%
78.3
%82
.0%
55.5
%
Bar
net a
nd C
hase
Far
m H
ospi
tals
N
HS
Trus
tB
NT
Bar
net G
ener
al H
ospi
tal
294
91.8
%59
.5%
97.2
%86
.2%
63.4
%50
.6%
Bar
net a
nd C
hase
Far
m H
ospi
tals
N
HS
Trus
tC
HS
Cha
se F
arm
Hos
pita
l22
586
.2%
37.8
%81
.5%
80.6
%71
.9%
58.3
%
Bar
nsle
y H
ospi
tal N
HS
Foun
datio
n Tr
ust
BA
RB
arns
ley
Hos
pita
l20
184
.1%
20.4
%92
.9%
82.1
%24
.6%
43.2
%
Denominators for tables 6 and 7 as follows:
• % received echo: all records.
• % cardiology inpatient: all records.
• % ACEI/ARB on discharge: all records where patient had LVSD and survived to discharge.
• % beta blocker on discharge: all records where patient had LVSD and survived to discharge.
• % referred to HF liaison service: all records where patient had LVSD and survived to discharge.
• % referred to cardiology follow-up: all records where patient survived to discharge.
HF Report 2012 Design B.indd 30 28/11/2012 14:19
31National Heart Failure Audit April 2011-March 2012
Bar
ts a
nd th
e Lo
ndon
BA
LTh
e Lo
ndon
Che
st H
ospi
tal/
The
Roy
al
Lond
on H
ospi
tal
155
89.7
%69
.7%
78.8
%83
.5%
86.4
%85
.7%
Bas
ildon
and
Thu
rroc
k U
nive
rsity
H
ospi
tals
NH
S Fo
unda
tion
Trus
tB
AS
Bas
ildon
Uni
vers
ity H
ospi
tal
35*
**
**
*
Bed
ford
Hos
pita
l NH
S Tr
ust
BED
Bed
ford
Hos
pita
l22
090
.0%
38.6
%64
.3%
74.1
%29
.1%
55.1
%
Bla
ckpo
ol T
each
ing
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
VIC
Bla
ckpo
ol V
icto
ria
Hos
pita
l90
391
.4%
60.3
%85
.1%
83.8
%70
.9%
21.8
%
Bol
ton
NH
S Fo
unda
tion
Trus
tB
OL
Roy
al B
olto
n H
ospi
tal
8*
**
**
*
Bra
dfor
d Te
achi
ng H
ospi
tals
NH
S Fo
unda
tion
Trus
tB
RD
Bra
dfor
d R
oyal
Infir
mar
y17
082
.4%
46.5
%79
.5%
70.5
%59
.0%
63.2
%
Bri
ghto
n an
d Su
ssex
Uni
vers
ity
Hos
pita
ls N
HS
Trus
tP
RH
Pri
nces
s R
oyal
Hos
pita
l (H
ayw
ards
H
eath
)22
268
.0%
6.8%
89.4
%84
.6%
34.2
%33
.5%
Bri
ghto
n an
d Su
ssex
Uni
vers
ity
Hos
pita
ls N
HS
Trus
tR
SCR
oyal
Sus
sex
Cou
nty
Hos
pita
l40
682
.3%
50.0
%86
.5%
74.5
%75
.0%
55.4
%
Buc
king
ham
shir
e H
ealt
hcar
e N
HS
Trus
tSM
VSt
oke
Man
devi
lle H
ospi
tal
0
Buc
king
ham
shir
e H
ealt
hcar
e N
HS
Trus
tA
MG
Wyc
ombe
Gen
eral
Hos
pita
l22
097
.7%
70.5
%90
.9%
81.3
%62
.7%
79.1
%
Bur
ton
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
BR
TQ
ueen
's H
ospi
tal (
Bur
ton)
239
72.4
%43
.9%
90.4
%92
.2%
43.2
%51
.5%
Cal
derd
ale
and
Hud
ders
field
NH
S Fo
unda
tion
Trus
tR
HI
Cal
derd
ale
Roy
al H
ospi
tal
185
94.1
%62
.2%
93.0
%69
.6%
58.2
%55
.2%
Cal
derd
ale
and
Hud
ders
field
NH
S Fo
unda
tion
Trus
tH
UD
Hud
ders
field
Roy
al In
firm
ary
182
91.8
%50
.5%
95.6
%73
.2%
53.2
%42
.7%
Cam
brid
ge U
nive
rsity
Hos
pita
ls
NH
S Fo
unda
tion
Trus
tA
DD
Add
enbr
ooke
's H
ospi
tal
22*
**
**
*
Cen
tral
Man
ches
ter
Uni
vers
ity
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
MR
IM
anch
este
r R
oyal
Infir
mar
y22
188
.2%
47.0
%89
.0%
90.6
%77
.8%
72.9
%
Che
lsea
and
Wes
tmin
ster
Hos
pita
l N
HS
Foun
datio
n Tr
ust
WES
Che
lsea
and
Wes
tmin
ster
Hos
pita
l84
**
**
**
Che
ster
field
Roy
al H
ospi
tal N
HS
Foun
datio
n Tr
ust
CH
EC
hest
erfie
ld R
oyal
Hos
pita
l17
875
.3%
44.9
%91
.5%
86.4
%48
.8%
28.6
%
City
Hos
pita
ls S
unde
rlan
d N
HS
Foun
datio
n Tr
ust
SUN
Sund
erla
nd R
oyal
Hos
pita
l24
585
.7%
24.5
%81
.8%
77.4
%31
.3%
50.7
%
Col
ches
ter
Hos
pita
l Uni
vers
ity N
HS
Foun
datio
n Tr
ust
CO
LC
olch
este
r G
ener
al H
ospi
tal
381
99.5
%50
.5%
81.4
%80
.0%
94.6
%39
.5%
Cou
ntes
s of
Che
ster
Hos
pita
l NH
S Fo
unda
tion
Trus
tC
OC
Cou
ntes
s of
Che
ster
Hos
pita
l34
199
.1%
68.0
%95
.7%
92.0
%90
.6%
51.9
%
HF Report 2012 Design B.indd 31 28/11/2012 14:19
32 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eN
ICO
R
hosp
ital
code
Hos
pita
l nam
eR
ecor
ds
subm
itted
% r
ecei
ved
echo
% c
ardi
olog
y in
pati
ent
% A
CEI
/AR
B
on d
isch
arge
% b
eta
bloc
ker
on
disc
harg
e
% r
efer
red
to H
F lia
ison
se
rvic
e
% re
ferr
ed
to c
ardi
olog
y fo
llow
-up
Cou
nty
Dur
ham
and
Dar
lingt
on
NH
S Fo
unda
tion
Trus
tD
AR
Dar
lingt
on M
emor
ial H
ospi
tal
145
93.1
%47
.6%
86.5
%73
.7%
50.8
%42
.0%
Cou
nty
Dur
ham
and
Dar
lingt
on
NH
S Fo
unda
tion
Trus
tD
RY
Uni
vers
ity H
ospi
tal o
f Nor
th D
urha
m18
097
.8%
53.9
%69
.4%
71.7
%46
.6%
48.5
%
Cro
ydon
Hea
lth
Serv
ices
NH
S Tr
ust
MAY
Cro
ydon
Uni
vers
ity H
ospi
tal
223
79.8
%30
.5%
63.3
%67
.2%
31.8
%33
.9%
Dar
tfor
d an
d G
rave
sham
NH
S Tr
ust
DVH
Dar
ent V
alle
y H
ospi
tal
73*
**
**
*
Der
by H
ospi
tals
NH
S Fo
unda
tion
Trus
tD
ERR
oyal
Der
by H
ospi
tal
196
89.8
0%51
.03%
81.1
1%67
.78%
98.9
4%76
.74%
Don
cast
er a
nd B
asse
tlaw
Hos
pita
ls
NH
S Fo
unda
tion
Trus
tB
SLB
asse
tlaw
Hos
pita
l69
**
**
**
Don
cast
er a
nd B
asse
tlaw
Hos
pita
ls
NH
S Fo
unda
tion
Trus
tD
IDD
onca
ster
Roy
al In
firm
ary
128
85.9
%17
.3%
95.0
%75
.6%
52.2
%53
.6%
Dor
set C
ount
y H
ospi
tal N
HS
Foun
datio
n Tr
ust
WD
HD
orse
t Cou
nty
Hos
pita
l17
671
.0%
21.0
%68
.9%
80.5
%47
.3%
29.5
%
Ealin
g H
ospi
tal N
HS
Trus
tEA
LEa
ling
Hos
pita
l26
293
.9%
37.0
%72
.5%
90.8
%11
.5%
82.0
%
East
and
Nor
th H
ertf
ords
hire
NH
S Tr
ust
LIS
List
er H
ospi
tal
267
62.9
%57
.7%
87.0
%82
.4%
78.4
%74
.2%
East
and
Nor
th H
ertf
ords
hire
NH
S Tr
ust
QEW
Que
en E
lizab
eth
II H
ospi
tal
214
84.6
%16
.4%
62.6
%66
.1%
25.2
%30
.1%
East
Che
shir
e N
HS
Trus
tM
ACM
accl
esfie
ld D
istr
ict G
ener
al H
ospi
tal
167
75.4
%56
.3%
89.7
%86
.5%
50.0
%62
.9%
East
Ken
t Hos
pita
ls U
nive
rsity
NH
S Fo
unda
tion
Trus
tK
CC
Ken
t and
Can
terb
ury
Hos
pita
l0
East
Ken
t Hos
pita
ls U
nive
rsity
NH
S Fo
unda
tion
Trus
tQ
EQQ
ueen
Eliz
abet
h Th
e Q
ueen
Mot
her
Hos
pita
l0
East
Ken
t Hos
pita
ls U
nive
rsity
NH
S Fo
unda
tion
Trus
tW
HH
Will
iam
Har
vey
Hos
pita
l0
East
Lan
cash
ire
Hos
pita
ls N
HS
Trus
tB
LAR
oyal
Bla
ckbu
rn H
ospi
tal
234
76.1
%61
.5%
82.0
%85
.7%
89.5
%75
.9%
East
Sus
sex
Hea
lthc
are
NH
S Tr
ust
CG
HC
onqu
est H
ospi
tal
218
88.1
%53
.2%
64.0
%57
.0%
63.2
%44
.9%
East
Sus
sex
Hea
lthc
are
NH
S Tr
ust
DG
EEa
stbo
urne
Dis
tric
t Gen
eral
Hos
pita
l20
689
.3%
56.3
%73
.2%
62.6
%70
.3%
53.6
%
Epso
m a
nd S
t Hel
ier
Uni
vers
ity
Hos
pita
ls N
HS
Trus
tEP
SEp
som
Hos
pita
l10
049
.0%
43.0
%80
.0%
40.0
%63
.6%
35.6
%
HF Report 2012 Design B.indd 32 28/11/2012 14:19
33National Heart Failure Audit April 2011-March 2012
Epso
m a
nd S
t Hel
ier
Uni
vers
ity
Hos
pita
ls N
HS
Trus
tSH
CSt
Hel
ier
Hos
pita
l11
069
.1%
40.9
%83
.3%
81.8
%70
.3%
37.8
%
Frim
ley
Par
k H
ospi
tal N
HS
Foun
datio
n Tr
ust
FRM
Frim
ley
Par
k H
ospi
tal
287
87.5
%72
.1%
84.8
%65
.2%
84.8
%60
.2%
Gat
eshe
ad H
ealt
h N
HS
Foun
datio
n Tr
ust
QEG
Que
en E
lizab
eth
Hos
pita
l (G
ates
head
)12
878
.1%
30.8
%65
.1%
55.5
%65
.1%
46.8
%
Geo
rge
Elio
t Hos
pita
l NH
S Tr
ust
NU
NG
eorg
e El
iot H
ospi
tal
261
87.4
%34
.1%
77.3
%85
.0%
0.0%
50.7
%
Glo
uces
ters
hire
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
CH
GC
helt
enha
m G
ener
al H
ospi
tal
54*
**
**
*
Glo
uces
ters
hire
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
GLO
Glo
uces
ters
hire
Roy
al H
ospi
tal
67*
**
**
*
Gre
at W
este
rn H
ospi
tals
NH
S Fo
unda
tion
Trus
tP
MS
The
Gre
at W
este
rn H
ospi
tal
212
85.4
%55
.9%
95.4
%84
.8%
89.1
%70
.1%
Guy
's a
nd S
t Tho
mas
' NH
S Fo
unda
tion
Trus
tST
HSt
Tho
mas
' Hos
pita
l22
998
.7%
60.3
%82
.2%
77.8
%92
.3%
80.3
%
Ham
pshi
re H
ospi
tals
NH
S Fo
unda
tion
Trus
tN
HH
Bas
ings
toke
and
Nor
th H
amps
hire
H
ospi
tal
128
85.9
%69
.5%
92.6
%63
.0%
83.3
%19
.5%
Ham
pshi
re H
ospi
tals
NH
S Fo
unda
tion
Trus
tR
HC
Roy
al H
amps
hire
Cou
nty
Hos
pita
l0
Har
roga
te a
nd D
istr
ict N
HS
Foun
datio
n Tr
ust
HA
RH
arro
gate
Dis
tric
t Hos
pita
l13
081
.5%
51.5
%90
.0%
90.2
%66
.7%
44.4
%
Hea
rt o
f Eng
land
NH
S Fo
unda
tion
Trus
tEB
HB
irm
ingh
am H
eart
land
s H
ospi
tal
207
97.1
%50
.0%
84.5
%66
.1%
68.3
%55
.6%
Hea
rt o
f Eng
land
NH
S Fo
unda
tion
Trus
tG
HS
Goo
d H
ope
Hos
pita
l0
Hea
rt o
f Eng
land
NH
S Fo
unda
tion
Trus
tSO
LSo
lihul
l Hos
pita
l16
197
.5%
78.0
%88
.2%
75.6
%82
.1%
40.1
%
Hea
ther
woo
d an
d W
exha
m P
ark
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
WEX
Wex
ham
Par
k H
ospi
tal
71*
**
**
*
Hin
chin
gbro
oke
Hea
lth
Car
e N
HS
Trus
tH
INH
inch
ingb
rook
e H
ospi
tal
38*
**
**
*
Hom
erto
n U
nive
rsity
Hos
pita
l NH
S Fo
unda
tion
Trus
tH
OM
Hom
erto
n U
nive
rsity
Hos
pita
l21
284
.0%
50.0
%82
.7%
89.6
%72
.6%
60.5
%
Hul
l and
Eas
t Yor
kshi
re H
ospi
tals
N
HS
Trus
tC
HH
Cas
tle H
ill H
ospi
tal
627
89.0
%75
.8%
86.8
%83
.8%
66.8
%84
.6%
Hul
l and
Eas
t Yor
kshi
re H
ospi
tals
N
HS
Trus
tH
RI
Hul
l Roy
al In
firm
ary
110
64.5
%0.
9%77
.3%
68.2
%60
.9%
39.0
%
HF Report 2012 Design B.indd 33 28/11/2012 14:19
34 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eN
ICO
R
hosp
ital
code
Hos
pita
l nam
eR
ecor
ds
subm
itted
% r
ecei
ved
echo
% c
ardi
olog
y in
pati
ent
% A
CEI
/AR
B
on d
isch
arge
% b
eta
bloc
ker
on
disc
harg
e
% r
efer
red
to H
F lia
ison
se
rvic
e
% re
ferr
ed
to c
ardi
olog
y fo
llow
-up
Impe
rial
Col
lege
Hea
lthc
are
NH
S Tr
ust
CC
HC
hari
ng C
ross
Hos
pita
l99
91.9
%43
.4%
100.
0%64
.0%
60.7
%35
.8%
Impe
rial
Col
lege
Hea
lthc
are
NH
S Tr
ust
HA
MH
amm
ersm
ith H
ospi
tal
151
85.4
%47
.0%
89.4
%86
.5%
48.2
%76
.2%
Impe
rial
Col
lege
Hea
lthc
are
NH
S Tr
ust
STM
St M
ary'
s H
ospi
tal P
addi
ngto
n24
199
.2%
26.1
%88
.2%
81.0
%30
.3%
53.9
%
Isle
of W
ight
NH
S P
CT
IOW
St M
ary'
s H
ospi
tal,
New
port
173
73.4
%26
.0%
71.4
%42
.0%
93.5
%48
.3%
Jam
es P
aget
Uni
vers
ity H
ospi
tals
N
HS
Foun
datio
n Tr
ust
JPH
Jam
es P
aget
Uni
vers
ity H
ospi
tal
114
83.3
%40
.4%
89.6
%82
.2%
12.8
%27
.1%
Ket
teri
ng G
ener
al H
ospi
tal N
HS
Foun
datio
n Tr
ust
KG
HK
ette
ring
Gen
eral
Hos
pita
l23
987
.0%
74.9
%83
.0%
85.7
%93
.3%
53.3
%
Kin
g's
Col
lege
Hos
pita
l NH
S Fo
unda
tion
Trus
tK
CH
Kin
g's
Col
lege
Hos
pita
l24
595
.1%
44.0
%89
.0%
85.6
%49
.2%
36.2
%
Kin
gsto
n H
ospi
tal N
HS
Trus
tK
THK
ings
ton
Hos
pita
l30
960
.2%
34.6
%80
.0%
48.5
%0.
0%44
.7%
Lanc
ashi
re T
each
ing
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
CH
OC
horl
ey a
nd S
outh
Rib
ble
Hos
pita
l23
210
0.0%
50.4
%97
.1%
84.7
%96
.6%
78.4
%
Lanc
ashi
re T
each
ing
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
RP
HR
oyal
Pre
ston
Hos
pita
l33
498
.8%
37.7
%80
.0%
81.6
%98
.8%
86.4
%
Leed
s Te
achi
ng H
ospi
tals
NH
S Tr
ust
LGI
Leed
s G
ener
al In
firm
ary
248
98.8
%94
.4%
81.5
%82
.6%
98.7
%88
.6%
Lew
isha
m H
ealt
hcar
e N
HS
Trus
tLE
WU
nive
rsity
Hos
pita
l Lew
isha
m11
799
.1%
45.3
%86
.7%
92.9
%88
.6%
96.7
%
Live
rpoo
l Hea
rt a
nd C
hest
Hos
pita
l N
HS
Foun
datio
n Tr
ust
BH
LLi
verp
ool H
eart
and
Che
st H
ospi
tal
136
95.6
%97
.8%
72.9
%79
.8%
76.2
%99
.1%
Luto
n an
d D
unst
able
Hos
pita
l NH
S Fo
unda
tion
Trus
tLD
HLu
ton
and
Dun
stab
le H
ospi
tal
346
90.5
%26
.3%
92.3
%71
.4%
69.0
%47
.1%
Mai
dsto
ne a
nd T
unbr
idge
Wel
ls
NH
S Tr
ust
MA
IM
aids
tone
Hos
pita
l22
693
.8%
64.4
%90
.9%
78.0
%89
.2%
74.7
%
Mai
dsto
ne a
nd T
unbr
idge
Wel
ls
NH
S Tr
ust
KSX
Tunb
ridg
e W
ells
Hos
pita
l17
882
.0%
43.8
%97
.7%
55.7
%80
.9%
60.7
%
Med
way
NH
S Fo
unda
tion
Trus
tM
DW
Med
way
Mar
itim
e H
ospi
tal
0
Mid
Che
shir
e H
ospi
tals
NH
S Fo
unda
tion
Trus
tLG
HLe
ight
on H
ospi
tal
263
100.
0%82
.9%
90.4
%89
.2%
69.7
%46
.5%
HF Report 2012 Design B.indd 34 28/11/2012 14:19
35National Heart Failure Audit April 2011-March 2012
Mid
Ess
ex H
ospi
tal S
ervi
ces
NH
S Tr
ust
BFH
Bro
omfie
ld H
ospi
tal
136
99.3
%30
.1%
97.0
%95
.9%
78.0
%63
.8%
Mid
Sta
ffor
dshi
re N
HS
Foun
datio
n Tr
ust
SDG
Staf
ford
Hos
pita
l74
**
**
**
Mid
Yor
kshi
re H
ospi
tals
NH
S Tr
ust
DEW
Dew
sbur
y an
d D
istr
ict H
ospi
tal
119
79.8
%31
.1%
90.4
%77
.1%
92.7
%61
.3%
Mid
Yor
kshi
re H
ospi
tals
NH
S Tr
ust
PIN
Pin
derfi
elds
Hos
pita
l30
194
.0%
53.5
%84
.9%
87.6
%69
.7%
60.4
%
Milt
on K
eyne
s H
ospi
tal N
HS
Foun
datio
n Tr
ust
MK
HM
ilton
Key
nes
Gen
eral
Hos
pita
l15
476
.6%
48.7
%76
.0%
68.0
%75
.9%
46.2
%
New
ham
Uni
vers
ity H
ospi
tal N
HS
Trus
tN
WG
New
ham
Uni
vers
ity H
ospi
tal
2*
**
**
*
Nor
folk
and
Nor
wic
h U
nive
rsity
H
ospi
tals
NH
S Fo
unda
tion
Trus
tN
OR
Nor
folk
and
Nor
wic
h U
nive
rsity
H
ospi
tal
374
80.5
%10
0.0%
84.0
%79
.0%
33.2
%68
.5%
Nor
th B
rist
ol N
HS
Trus
tFR
YFr
ench
ay H
ospi
tal
279
93.2
%34
.4%
80.2
%72
.4%
1.9%
21.0
%
Nor
th B
rist
ol N
HS
Trus
tB
SMSo
uthm
ead
Hos
pita
l20
594
.6%
55.1
%58
.5%
71.8
%13
.7%
45.6
%
Nor
th C
umbr
ia U
nive
rsity
Hos
pita
ls
NH
S Tr
ust
CM
IC
umbe
rlan
d In
firm
ary
46*
**
**
*
Nor
th C
umbr
ia U
nive
rsity
Hos
pita
ls
NH
S Tr
ust
WC
IW
est C
umbe
rlan
d H
ospi
tal
32*
**
**
*
Nor
th M
iddl
esex
Uni
vers
ity H
ospi
tal
NH
S Tr
ust
NM
HN
orth
Mid
dles
ex U
nive
rsity
Hos
pita
l17
183
.0%
7.6%
92.9
%79
.3%
86.2
%36
.0%
Nor
th T
ees
and
Har
tlepo
ol N
HS
Foun
datio
n Tr
ust
HG
HU
nive
rsity
Hos
pita
l of H
artle
pool
149
96.0
%64
.4%
100.
0%98
.0%
63.6
%32
.8%
Nor
th T
ees
and
Har
tlepo
ol N
HS
Foun
datio
n Tr
ust
NTG
Uni
vers
ity H
ospi
tal o
f Nor
th T
ees
234
78.2
%58
.5%
97.7
%93
.2%
75.6
%30
.4%
Nor
tham
pton
Gen
eral
Hos
pita
l NH
S Tr
ust
NTH
Nor
tham
pton
Gen
eral
Hos
pita
l21
786
.6%
49.3
%10
0.0%
98.7
%99
.0%
29.0
%
Nor
ther
n D
evon
Hea
lthc
are
NH
S Tr
ust
ND
DN
orth
Dev
on D
istr
ict H
ospi
tal
212
84.9
%50
.2%
74.0
%54
.3%
71.3
%30
.1%
Nor
ther
n Li
ncol
nshi
re a
nd G
oole
H
ospi
tals
NH
S Fo
unda
tion
Trus
tG
GH
Dia
na P
rinc
ess
of W
ales
Hos
pita
l16
122
.4%
31.7
%78
.3%
69.6
%0.
0%43
.5%
Nor
ther
n Li
ncol
nshi
re a
nd G
oole
H
ospi
tals
NH
S Fo
unda
tion
Trus
tSC
USc
unth
orpe
Gen
eral
Hos
pita
l95
**
**
**
Nor
thum
bria
Hea
lthc
are
NH
S Fo
unda
tion
Trus
tH
EXH
exha
m G
ener
al H
ospi
tal
56*
**
**
*
Nor
thum
bria
Hea
lthc
are
NH
S Fo
unda
tion
Trus
tN
TYN
orth
Tyn
esid
e H
ospi
tal
219
90.9
%45
.7%
60.5
%79
.3%
47.1
%29
.6%
HF Report 2012 Design B.indd 35 28/11/2012 14:19
36 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eN
ICO
R
hosp
ital
code
Hos
pita
l nam
eR
ecor
ds
subm
itted
% r
ecei
ved
echo
% c
ardi
olog
y in
pati
ent
% A
CEI
/AR
B
on d
isch
arge
% b
eta
bloc
ker
on
disc
harg
e
% r
efer
red
to H
F lia
ison
se
rvic
e
% re
ferr
ed
to c
ardi
olog
y fo
llow
-up
Nor
thum
bria
Hea
lthc
are
NH
S Fo
unda
tion
Trus
tA
SHW
ansb
eck
Gen
eral
Hos
pita
l12
593
.6%
49.6
%81
.1%
67.6
%69
.3%
12.0
%
Not
tingh
am U
nive
rsity
Hos
pita
ls
NH
S Tr
ust
CH
NN
ottin
gham
City
Hos
pita
l44
**
**
**
Not
tingh
am U
nive
rsity
Hos
pita
ls
NH
S Tr
ust
UH
NQ
ueen
's M
edic
al C
entr
e15
988
.7%
18.9
%75
.8%
67.4
%70
.0%
31.9
%
Oxf
ord
Rad
cliff
e H
ospi
tals
NH
S Tr
ust
HO
RH
orto
n G
ener
al H
ospi
tal
112
96.4
%17
.9%
100.
0%97
.1%
93.0
%17
.3%
Oxf
ord
Rad
cliff
e H
ospi
tals
NH
S Tr
ust
RA
DJo
hn R
adcl
iffe
Hos
pita
l62
495
.7%
22.8
%99
.6%
98.7
%91
.7%
54.1
%
Pap
wor
th H
ospi
tal N
HS
Foun
datio
n Tr
ust
PAP
Pap
wor
th H
ospi
tal
0
Pen
nine
Acu
te H
ospi
tals
NH
S Tr
ust
BR
YFa
irfie
ld G
ener
al H
ospi
tal
205
80.0
%63
.4%
86.0
%80
.4%
93.9
%31
.9%
Pen
nine
Acu
te H
ospi
tals
NH
S Tr
ust
NM
GN
orth
Man
ches
ter
Gen
eral
Hos
pita
l18
395
.1%
40.4
%83
.0%
82.5
%91
.2%
55.3
%
Pen
nine
Acu
te H
ospi
tals
NH
S Tr
ust
BH
HR
ochd
ale
Infir
mar
y53
**
**
**
Pen
nine
Acu
te H
ospi
tals
NH
S Tr
ust
OH
MR
oyal
Old
ham
Hos
pita
l20
490
.7%
4.4%
87.8
%63
.4%
97.1
%83
.3%
Pet
erbo
roug
h an
d St
amfo
rd
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
PET
Pet
erbo
roug
h C
ity H
ospi
tal
296
87.5
%71
.6%
75.4
%65
.7%
51.7
%59
.6%
Ply
mou
th H
ospi
tals
NH
S Tr
ust
PLY
Der
rifo
rd H
ospi
tal
0
Poo
le H
ospi
tal N
HS
Foun
datio
n Tr
ust
PG
HP
oole
Gen
eral
Hos
pita
l30
770
.7%
23.1
%70
.5%
67.0
%20
.0%
28.0
%
Por
tsm
outh
Hos
pita
ls N
HS
Trus
tQ
AP
Que
en A
lexa
ndra
Hos
pita
l31
996
.6%
94.0
%79
.9%
74.8
%77
.9%
43.7
%
Rot
herh
am N
HS
Foun
datio
n Tr
ust
RO
TR
othe
rham
Hos
pita
l22
783
.3%
32.6
%80
.4%
81.9
%69
.5%
37.1
%
Roy
al B
erks
hire
NH
S Fo
unda
tion
Trus
tB
HR
Roy
al B
erks
hire
Hos
pita
l44
988
.2%
46.1
%83
.3%
83.4
%72
.9%
28.2
%
Roy
al B
rom
pton
and
Har
efiel
d N
HS
Foun
datio
n Tr
ust
HH
Har
efiel
d H
ospi
tal
24*
**
**
*
Roy
al B
rom
pton
and
Har
efiel
d N
HS
Foun
datio
n Tr
ust
NH
BR
oyal
Bro
mpt
on H
ospi
tal
210
100.
00%
98.5
0%92
.00%
87.8
4%52
.27%
97.5
2%
Roy
al C
ornw
all H
ospi
tals
NH
S Tr
ust
RC
HR
oyal
Cor
nwal
l Hos
pita
l15
584
.52%
43.2
3%81
.08%
70.5
4%61
.86%
37.1
4%
Roy
al D
evon
and
Exe
ter
NH
S Fo
unda
tion
Trus
tR
DE
Roy
al D
evon
& E
xete
r H
ospi
tal
225
77.7
8%52
.89%
100.
00%
100.
00%
75.0
0%40
.21%
HF Report 2012 Design B.indd 36 28/11/2012 14:19
37National Heart Failure Audit April 2011-March 2012
Roy
al F
ree
Lond
on N
HS
Trus
tR
FHR
oyal
Fre
e H
ospi
tal
223
93.2
7%45
.29%
97.4
7%95
.18%
64.5
5%58
.51%
Roy
al L
iver
pool
and
Bro
adgr
een
Uni
vers
ity H
ospi
tals
NH
S Tr
ust
RLU
Roy
al L
iver
pool
Uni
vers
ity H
ospi
tal
330
83.3
%56
.4%
75.5
%87
.6%
92.0
%42
.8%
Roy
al S
urre
y C
ount
y H
ospi
tal N
HS
Foun
datio
n Tr
ust
RSU
Roy
al S
urre
y C
ount
y H
ospi
tal
144
72.9
%26
.4%
86.7
%65
.2%
8.9%
38.9
%
Roy
al U
nite
d H
ospi
tal B
ath
NH
S Tr
ust
BAT
Roy
al U
nite
d H
ospi
tal B
ath
0
Salfo
rd R
oyal
NH
S Fo
unda
tion
Trus
tSL
FSa
lford
Roy
al24
190
.0%
30.7
%65
.0%
74.3
%91
.8%
46.3
%
Salis
bury
NH
S Fo
unda
tion
Trus
tSA
LSa
lisbu
ry D
istr
ict H
ospi
tal
342
95.0
%61
.7%
87.2
%76
.1%
31.3
%46
.8%
Sand
wel
l and
Wes
t Bir
min
gham
H
ospi
tals
NH
S Tr
ust
DU
DB
irm
ingh
am C
ity H
ospi
tal
190
88.4
%56
.3%
67.7
%54
.0%
64.9
%76
.7%
Sand
wel
l and
Wes
t Bir
min
gham
H
ospi
tals
NH
S Tr
ust
SAN
Sand
wel
l Gen
eral
Hos
pita
l15
594
.2%
69.0
%88
.6%
62.4
%98
.9%
84.3
%
Scar
boro
ugh
and
Nor
th E
ast
York
shir
e N
HS
Trus
tSC
ASc
arbo
roug
h G
ener
al H
ospi
tal
7*
**
**
*
Shef
field
Tea
chin
g H
ospi
tals
NH
S Fo
unda
tion
Trus
tN
GS
Nor
ther
n G
ener
al H
ospi
tal
442
100.
0%26
.9%
78.6
%72
.3%
0.0%
29.0
%
Shef
field
Tea
chin
g H
ospi
tals
NH
S Fo
unda
tion
Trus
tR
HA
Roy
al H
alla
msh
ire
Hos
pita
l10
**
**
**
Sher
woo
d Fo
rest
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
KM
HK
ing'
s M
ill H
ospi
tal
302
78.1
%49
.3%
79.8
%81
.4%
65.0
%51
.5%
Sher
woo
d Fo
rest
Hos
pita
ls N
HS
Foun
datio
n Tr
ust
NH
NN
ewar
k H
ospi
tal
13*
**
**
*
Shre
wsb
ury
and
Telfo
rd H
ospi
tals
N
HS
Trus
tTL
FP
rinc
ess
Roy
al H
ospi
tal (
Telfo
rd)
48*
**
**
*
Shre
wsb
ury
and
Telfo
rd H
ospi
tals
N
HS
Trus
tR
SSR
oyal
Shr
ewsb
ury
Hos
pita
l37
**
**
**
Sout
h D
evon
Hea
lthc
are
NH
S Fo
unda
tion
Trus
tTO
RTo
rbay
Hos
pita
l35
963
.0%
31.8
%60
.0%
47.0
%20
.2%
33.1
%
Sout
h Lo
ndon
Hea
lthc
are
NH
S Tr
ust
BR
OP
rinc
ess
Roy
al U
nive
rsity
Hos
pita
l (B
rom
ley)
24*
**
**
*
Sout
h Lo
ndon
Hea
lthc
are
NH
S Tr
ust
GW
HQ
ueen
Eliz
abet
h H
ospi
tal (
Woo
lwic
h)23
792
.4%
61.2
%89
.2%
93.8
%82
.9%
63.6
%
Sout
h Lo
ndon
Hea
lthc
are
NH
S Tr
ust
QM
HQ
ueen
Mar
y's
Hos
pita
l (Si
dcup
)1
**
**
**
Sout
h Te
es H
ospi
tals
NH
S Fo
unda
tion
Trus
tFR
HFr
iara
ge H
ospi
tal
0
HF Report 2012 Design B.indd 37 28/11/2012 14:19
38 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eN
ICO
R
hosp
ital
code
Hos
pita
l nam
eR
ecor
ds
subm
itted
% r
ecei
ved
echo
% c
ardi
olog
y in
pati
ent
% A
CEI
/AR
B
on d
isch
arge
% b
eta
bloc
ker
on
disc
harg
e
% r
efer
red
to H
F lia
ison
se
rvic
e
% re
ferr
ed
to c
ardi
olog
y fo
llow
-up
Sout
h Te
es H
ospi
tals
NH
S Fo
unda
tion
Trus
tSC
MJa
mes
Coo
k U
nive
rsity
Hos
pita
l20
995
.7%
87.1
%90
.1%
77.5
%93
.3%
63.6
%
Sout
h Ty
nesi
de N
HS
Foun
datio
n Tr
ust
STD
Sout
h Ty
nesi
de D
istr
ict H
ospi
tal
267
91.8
%64
.0%
94.4
%80
.3%
93.8
%73
.7%
Sout
h W
arw
icks
hire
NH
S Fo
unda
tion
Trus
t W
AR
War
wic
k H
ospi
tal
0
Sout
hend
Uni
vers
ity H
ospi
tal N
HS
Foun
datio
n Tr
ust
SEH
Sout
hend
Hos
pita
l55
587
.2%
39.1
%70
.8%
77.4
%85
.3%
38.7
%
Sout
hpor
t and
Orm
skir
k H
ospi
tal
NH
S Tr
ust
SOU
Sout
hpor
t and
For
mby
Dis
tric
t Gen
eral
H
ospi
tal
203
96.1
%18
.3%
67.5
%42
.7%
70.9
%70
.8%
St G
eorg
e's
Hea
lthc
are
NH
S Tr
ust
GEO
St G
eorg
e's
Hos
pita
l22
999
.1%
13.1
%87
.3%
84.9
%94
.9%
48.7
%
St H
elen
s an
d K
now
sley
Tea
chin
g H
ospi
tals
NH
S Tr
ust
WH
IW
hist
on H
ospi
tal
226
92.5
%77
.0%
78.7
%72
.1%
95.6
%34
.6%
Stoc
kpor
t NH
S Fo
unda
tion
Trus
tSH
HSt
eppi
ng H
ill H
ospi
tal
175
95.4
%16
.6%
92.7
%87
.5%
32.2
%42
.2%
Surr
ey a
nd S
usse
x H
ealt
hcar
e N
HS
Trus
tES
UEa
st S
urre
y H
ospi
tal
302
76.2
%54
.4%
81.5
%63
.7%
57.7
%52
.5%
Tam
esid
e H
ospi
tal N
HS
Foun
datio
n Tr
ust
TGA
Tam
esid
e G
ener
al H
ospi
tal
178
71.9
%34
.8%
80.8
%76
.7%
72.6
%50
.4%
Taun
ton
and
Som
erse
t NH
S Fo
unda
tion
Trus
tM
PH
Mus
grov
e P
ark
Hos
pita
l30
080
.3%
52.7
%83
.7%
73.1
%0.
0%37
.2%
The
Dud
ley
Gro
up N
HS
Foun
datio
n Tr
ust
RU
SR
usse
lls H
all H
ospi
tal
180
96.1
%65
.6%
77.8
%74
.7%
72.5
%68
.6%
The
Hill
ingd
on H
ospi
tals
NH
S Fo
unda
tion
Trus
tH
ILH
illin
gdon
Hos
pita
l19
791
.9%
52.8
%80
.2%
60.2
%70
.5%
29.0
%
The
Ipsw
ich
Hos
pita
l NH
S Tr
ust
IPS
The
Ipsw
ich
Hos
pita
l20
363
.5%
25.6
%86
.8%
81.3
%46
.1%
22.3
%
The
New
cast
le U
pon
Tyne
Hos
pita
ls
NH
S Fo
unda
tion
Trus
tFR
EFr
eem
an H
ospi
tal
170
58.2
%68
.8%
85.7
%72
.3%
52.8
%93
.1%
The
New
cast
le U
pon
Tyne
Hos
pita
ls
NH
S Fo
unda
tion
Trus
tR
VNR
oyal
Vic
tori
a In
firm
ary
0
The
Nor
th W
est L
ondo
n H
ospi
tals
N
HS
Trus
tC
MH
Cen
tral
Mid
dles
ex H
ospi
tal
14*
**
**
*
The
Nor
th W
est L
ondo
n H
ospi
tals
N
HS
Trus
tN
PH
Nor
thw
ick
Par
k H
ospi
tal
346
96.5
%84
.7%
77.0
%71
.9%
72.4
%47
.7%
HF Report 2012 Design B.indd 38 28/11/2012 14:19
39National Heart Failure Audit April 2011-March 2012
The
Pri
nces
s A
lexa
ndra
Hos
pita
l N
HS
Trus
tPA
HP
rinc
ess
Ale
xand
ra H
ospi
tal
0
The
Que
en E
lizab
eth
Hos
pita
l K
ing'
s Ly
nn N
HS
Foun
datio
n Tr
ust
QK
LQ
ueen
Eliz
abet
h H
ospi
tal (
Kin
g's
Lynn
)20
194
.5%
67.2
%93
.9%
87.1
%84
.6%
31.8
%
The
Roy
al B
ourn
emou
th a
nd
Chr
istc
hurc
h H
ospi
tals
NH
S Fo
unda
tion
Trus
t
BO
UR
oyal
Bou
rnem
outh
Gen
eral
Hos
pita
l0
The
Roy
al W
olve
rham
pton
Hos
pita
ls
NH
S Tr
ust
NC
RN
ew C
ross
Hos
pita
l18
175
.1%
11.6
%78
.5%
67.2
%65
.1%
30.7
%
The
Whi
ttin
gton
Hos
pita
l NH
S Tr
ust
WH
TW
hitt
ingt
on H
ospi
tal
137
99.3
%61
.3%
97.0
%93
.7%
85.3
%78
.3%
Traf
ford
Hea
lthc
are
NH
S Tr
ust
TRA
Traf
ford
Gen
eral
Hos
pita
l0
Uni
ted
Linc
olns
hire
Hos
pita
ls N
HS
Trus
tG
RA
Gra
ntha
m a
nd D
istr
ict H
ospi
tal
46*
**
**
*
Uni
ted
Linc
olns
hire
Hos
pita
ls N
HS
Trus
tLI
NLi
ncol
n C
ount
y H
ospi
tal
101
62.4
%30
.7%
60.7
%69
.0%
47.1
%53
.8%
Uni
ted
Linc
olns
hire
Hos
pita
ls N
HS
Trus
tP
ILP
ilgri
m H
ospi
tal
106
59.4
%27
.4%
73.7
%76
.3%
28.2
%50
.0%
Uni
vers
ity C
olle
ge L
ondo
n H
ospi
tals
N
HS
Foun
datio
n Tr
ust
UC
LU
nive
rsity
Col
lege
Hos
pita
l33
599
.1%
55.8
%99
.4%
95.0
%83
.3%
90.2
%
Uni
vers
ity H
ospi
tal o
f Nor
th
Staf
ford
shir
e N
HS
Trus
tST
OU
nive
rsity
Hos
pita
l of N
orth
St
affo
rdsh
ire
209
81.6
%31
.1%
71.9
%56
.1%
82.9
%60
.1%
Uni
vers
ity H
ospi
tal o
f Sou
th
Man
ches
ter
NH
S Fo
unda
tion
Trus
tW
YTW
ythe
nsha
we
Hos
pita
l30
475
.0%
49.3
%94
.9%
90.4
%57
.4%
38.3
%
Uni
vers
ity H
ospi
tal S
outh
ampt
on
NH
S Tr
ust
SGH
Sout
ham
pton
Gen
eral
Hos
pita
l14
210
0.0%
39.4
%0.
0%0.
0%0.
0%49
.2%
Uni
vers
ity H
ospi
tals
Bir
min
gham
N
HS
Foun
datio
n Tr
ust
QEB
Que
en E
lizab
eth
Hos
pita
l (Ed
gbas
ton)
292
55.7
%17
.4%
91.1
%82
.9%
30.8
%32
.2%
Uni
vers
ity H
ospi
tals
Bri
stol
NH
S Fo
unda
tion
Trus
tB
RI
Bri
stol
Roy
al In
firm
ary
384
93.8
%89
.3%
80.8
%78
.7%
64.4
%80
.4%
Uni
vers
ity H
ospi
tals
Cov
entr
y an
d W
arw
icks
hire
NH
S Tr
ust
RU
GH
ospi
tal o
f St C
ross
28*
**
**
*
Uni
vers
ity H
ospi
tals
Cov
entr
y an
d W
arw
icks
hire
NH
S Tr
ust
WA
LU
nive
rsity
Hos
pita
l Cov
entr
y28
195
.0%
74.6
%86
.1%
76.3
%94
.2%
51.7
%
Uni
vers
ity H
ospi
tals
of L
eice
ster
N
HS
Trus
tG
RL
Gle
nfiel
d H
ospi
tal
0
Uni
vers
ity H
ospi
tals
of L
eice
ster
N
HS
Trus
tLE
RLe
ices
ter
Roy
al In
firm
ary
0
HF Report 2012 Design B.indd 39 28/11/2012 14:19
40 National Heart Failure Audit April 2011-March 2012
Trus
t nam
eN
ICO
R
hosp
ital
code
Hos
pita
l nam
eR
ecor
ds
subm
itted
% r
ecei
ved
echo
% c
ardi
olog
y in
pati
ent
% A
CEI
/AR
B
on d
isch
arge
% b
eta
bloc
ker
on
disc
harg
e
% r
efer
red
to H
F lia
ison
se
rvic
e
% re
ferr
ed
to c
ardi
olog
y fo
llow
-up
Uni
vers
ity H
ospi
tals
of M
orec
ambe
B
ay N
HS
Foun
datio
n Tr
ust
FGH
Furn
ess
Gen
eral
Hos
pita
l0
Uni
vers
ity H
ospi
tals
of M
orec
ambe
B
ay N
HS
Foun
datio
n Tr
ust
RLI
Roy
al L
anca
ster
Infir
mar
y0
Wal
sall
Hea
lthc
are
NH
S Tr
ust
WM
HM
anor
Hos
pita
l24
110
0.0%
52.3
%10
0.0%
100.
0%90
.4%
78.0
%
War
ring
ton
and
Hal
ton
Hos
pita
ls
NH
S Fo
unda
tion
Trus
tW
DG
War
ring
ton
Hos
pita
l14
510
0.0%
67.6
%94
.1%
85.7
%98
.9%
69.7
%
Wes
t Her
tfor
dshi
re H
ospi
tals
NH
S Tr
ust
WAT
Wat
ford
Gen
eral
Hos
pita
l24
594
.7%
50.6
%10
0.0%
99.1
%81
.6%
92.1
%
Wes
t Mid
dles
ex U
nive
rsity
Hos
pita
l N
HS
Trus
tW
MU
Wes
t Mid
dles
ex U
nive
rsity
Hos
pita
l21
283
.5%
23.1
%71
.8%
77.9
%76
.8%
30.7
%
Wes
t Suf
folk
NH
S Fo
unda
tion
Trus
tW
SHW
est S
uffo
lk H
ospi
tal
218
69.3
%33
.0%
83.6
%68
.0%
12.8
%34
.2%
Wes
tern
Sus
sex
Hos
pita
ls N
HS
Trus
tST
RSt
Ric
hard
's H
ospi
tal
276
84.8
%48
.9%
76.8
%72
.5%
53.7
%46
.1%
Wes
tern
Sus
sex
Hos
pita
ls N
HS
Trus
tW
RG
Wor
thin
g H
ospi
tal
363
75.5
%40
.5%
75.9
%72
.4%
59.0
%47
.1%
Wes
ton
Are
a H
ealt
h N
HS
Trus
tW
GH
Wes
ton
Gen
eral
Hos
pita
l11
678
.4%
25.9
%69
.8%
65.1
%0.
0%20
.6%
Whi
pps
Cro
ss U
nive
rsity
Hos
pita
l N
HS
Trus
tW
HC
Whi
pps
Cro
ss U
nive
rsity
Hos
pita
l20
683
.0%
33.0
%84
.8%
77.3
%75
.0%
47.4
%
Wir
ral U
nive
rsity
Tea
chin
g H
ospi
tal
NH
S Fo
unda
tion
Trus
tW
IRA
rrow
e P
ark
Hos
pita
l21
995
.0%
43.8
%98
.7%
85.9
%97
.4%
40.9
%
Wor
cest
ersh
ire
Acu
te H
ospi
tals
N
HS
Trus
tR
EDA
lexa
ndra
Hos
pita
l22
787
.7%
35.9
%71
.1%
79.8
%42
.2%
53.3
%
Wor
cest
ersh
ire
Acu
te H
ospi
tals
N
HS
Trus
tW
RC
Wor
cest
ersh
ire
Roy
al H
ospi
tal
165
44.8
%53
.9%
83.0
%61
.5%
18.2
%39
.6%
Wri
ghtin
gton
, Wig
an a
nd L
eigh
NH
S Fo
unda
tion
Trus
tA
EIR
oyal
Alb
ert E
dwar
d In
firm
ary
513
97.3
%62
.0%
88.0
%87
.7%
68.2
%66
.0%
Wye
Val
ley
NH
S Tr
ust
HC
HC
ount
y H
ospi
tal H
eref
ord
188
80.9
%25
.0%
77.4
%58
.1%
58.1
%30
.4%
Yeov
il D
istr
ict H
ospi
tal N
HS
Foun
datio
n Tr
ust
YEO
Yeov
il D
istr
ict H
ospi
tal
253
92.1
%55
.6%
92.3
%85
.3%
100.
0%40
.5%
York
Tea
chin
g H
ospi
tal N
HS
Foun
datio
n Tr
ust
YDH
York
Dis
tric
t Hos
pita
l22
072
.3%
9.5%
84.0
%80
.0%
28.6
%32
.2%
HF Report 2012 Design B.indd 40 28/11/2012 14:19
41National Heart Failure Audit April 2011-March 2012
Tabl
e 7:
Clin
ical
pra
ctic
e in
Wal
es (2
011/
12)
Hea
lth
Boa
rd n
ame
NIC
OR
ho
spita
l co
de
Hos
pita
l nam
eR
ecor
ds
subm
itted
% r
ecei
ved
echo
% c
ardi
olog
y in
pati
ent
% A
CEI
/AR
B
on d
isch
arge
% b
eta
bloc
ker
on
disc
harg
e
% r
efer
red
to H
F lia
ison
se
rvic
e
% re
ferr
ed
to c
ardi
olog
y fo
llow
-up
Engl
and
and
Wal
es37
076
85.9
%47
.1%
82.7
%76
.4%
63.2
%51
.1%
Wal
es51
787
.0%
52.9
%81
.6%
79.3
%64
.5%
29.2
%
Abe
rtaw
e B
ro M
orga
nnw
g U
nive
rsity
Hea
lth
Boa
rdM
OR
Mor
rist
on H
ospi
tal
0
Abe
rtaw
e B
ro M
orga
nnw
g U
nive
rsity
Hea
lth
Boa
rdN
GH
Nea
th P
ort T
albo
t Hos
pita
l0
Abe
rtaw
e B
ro M
orga
nnw
g U
nive
rsity
Hea
lth
Boa
rdP
OW
Pri
nces
s of
Wal
es H
ospi
tal
7*
**
**
*
Abe
rtaw
e B
ro M
orga
nnw
g U
nive
rsity
Hea
lth
Boa
rdSI
NSi
ngle
ton
Hos
pita
l0
Ane
urin
Bev
an H
ealt
h B
oard
YYF
Caer
phill
y D
istr
ict M
iner
s H
ospi
tal/Y
sbyt
y Ys
trad
Faw
r0
Ane
urin
Bev
an H
ealt
h B
oard
NEV
Nev
ill H
all H
ospi
tal
175
87.4
%39
.4%
92.3
%92
.9%
48.4
%19
.5%
Ane
urin
Bev
an H
ealt
h B
oard
GW
ER
oyal
Gw
ent H
ospi
tal
0
Bet
si C
adw
alad
r U
nive
rsity
Hea
lth
Boa
rdC
LWG
lan
Clw
yd H
ospi
tal
0
Bet
si C
adw
alad
r U
nive
rsity
Hea
lth
Boa
rdLL
ALl
andu
dno
Gen
eral
Hos
pita
l0
Bet
si C
adw
alad
r U
nive
rsity
Hea
lth
Boa
rdW
RX
Wre
xham
Mae
lor
Hos
pita
l17
279
.1%
37.2
%64
.2%
74.7
%78
.9%
33.9
%
Bet
si C
adw
alad
r U
nive
rsity
Hea
lth
Boa
rdG
WY
Ysby
ty G
wyn
edd
0
Car
diff
& V
ale
Uni
vers
ity H
ealt
h B
oard
LLD
Llan
doug
h H
ospi
tal
0
Car
diff
& V
ale
Uni
vers
ity H
ealth
Boa
rdU
HW
Uni
vers
ity H
ospi
tal o
f Wal
es0
Cw
m T
af H
ealt
h B
oard
PC
HP
rinc
e C
harl
es H
ospi
tal
1*
**
**
*
Cw
m T
af H
ealt
h B
oard
RG
HR
oyal
Gla
mor
gan
1*
**
**
*
Hyw
el D
da H
ealt
h B
oard
BR
GB
rong
lais
Gen
eral
Hos
pita
l14
694
.5%
82.2
%88
.2%
70.2
%66
.2%
34.2
%
Hyw
el D
da H
ealt
h B
oard
PP
HP
rinc
e P
hilip
Hos
pita
l6
**
**
**
Hyw
el D
da H
ealt
h B
oard
WW
GW
est W
ales
Gen
eral
5*
**
**
*
Hyw
el D
da H
ealt
h B
oard
WYB
With
ybus
h G
ener
al H
ospi
tal
4*
**
**
*
Uni
vers
ity H
ospi
tals
of M
orec
ambe
B
ay N
HS
Foun
datio
n Tr
ust
FGH
Furn
ess
Gen
eral
Hos
pita
l0
Uni
vers
ity H
ospi
tals
of M
orec
ambe
B
ay N
HS
Foun
datio
n Tr
ust
RLI
Roy
al L
anca
ster
Infir
mar
y0
Wal
sall
Hea
lthc
are
NH
S Tr
ust
WM
HM
anor
Hos
pita
l24
110
0.0%
52.3
%10
0.0%
100.
0%90
.4%
78.0
%
War
ring
ton
and
Hal
ton
Hos
pita
ls
NH
S Fo
unda
tion
Trus
tW
DG
War
ring
ton
Hos
pita
l14
510
0.0%
67.6
%94
.1%
85.7
%98
.9%
69.7
%
Wes
t Her
tfor
dshi
re H
ospi
tals
NH
S Tr
ust
WAT
Wat
ford
Gen
eral
Hos
pita
l24
594
.7%
50.6
%10
0.0%
99.1
%81
.6%
92.1
%
Wes
t Mid
dles
ex U
nive
rsity
Hos
pita
l N
HS
Trus
tW
MU
Wes
t Mid
dles
ex U
nive
rsity
Hos
pita
l21
283
.5%
23.1
%71
.8%
77.9
%76
.8%
30.7
%
Wes
t Suf
folk
NH
S Fo
unda
tion
Trus
tW
SHW
est S
uffo
lk H
ospi
tal
218
69.3
%33
.0%
83.6
%68
.0%
12.8
%34
.2%
Wes
tern
Sus
sex
Hos
pita
ls N
HS
Trus
tST
RSt
Ric
hard
's H
ospi
tal
276
84.8
%48
.9%
76.8
%72
.5%
53.7
%46
.1%
Wes
tern
Sus
sex
Hos
pita
ls N
HS
Trus
tW
RG
Wor
thin
g H
ospi
tal
363
75.5
%40
.5%
75.9
%72
.4%
59.0
%47
.1%
Wes
ton
Are
a H
ealt
h N
HS
Trus
tW
GH
Wes
ton
Gen
eral
Hos
pita
l11
678
.4%
25.9
%69
.8%
65.1
%0.
0%20
.6%
Whi
pps
Cro
ss U
nive
rsity
Hos
pita
l N
HS
Trus
tW
HC
Whi
pps
Cro
ss U
nive
rsity
Hos
pita
l20
683
.0%
33.0
%84
.8%
77.3
%75
.0%
47.4
%
Wir
ral U
nive
rsity
Tea
chin
g H
ospi
tal
NH
S Fo
unda
tion
Trus
tW
IRA
rrow
e P
ark
Hos
pita
l21
995
.0%
43.8
%98
.7%
85.9
%97
.4%
40.9
%
Wor
cest
ersh
ire
Acu
te H
ospi
tals
N
HS
Trus
tR
EDA
lexa
ndra
Hos
pita
l22
787
.7%
35.9
%71
.1%
79.8
%42
.2%
53.3
%
Wor
cest
ersh
ire
Acu
te H
ospi
tals
N
HS
Trus
tW
RC
Wor
cest
ersh
ire
Roy
al H
ospi
tal
165
44.8
%53
.9%
83.0
%61
.5%
18.2
%39
.6%
Wri
ghtin
gton
, Wig
an a
nd L
eigh
NH
S Fo
unda
tion
Trus
tA
EIR
oyal
Alb
ert E
dwar
d In
firm
ary
513
97.3
%62
.0%
88.0
%87
.7%
68.2
%66
.0%
Wye
Val
ley
NH
S Tr
ust
HC
HC
ount
y H
ospi
tal H
eref
ord
188
80.9
%25
.0%
77.4
%58
.1%
58.1
%30
.4%
Yeov
il D
istr
ict H
ospi
tal N
HS
Foun
datio
n Tr
ust
YEO
Yeov
il D
istr
ict H
ospi
tal
253
92.1
%55
.6%
92.3
%85
.3%
100.
0%40
.5%
York
Tea
chin
g H
ospi
tal N
HS
Foun
datio
n Tr
ust
YDH
York
Dis
tric
t Hos
pita
l22
072
.3%
9.5%
84.0
%80
.0%
28.6
%32
.2%
HF Report 2012 Design B.indd 41 28/11/2012 14:19
42 National Heart Failure Audit April 2011-March 2012
3.10 MortalityMortality 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 follow-up 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).
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).
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.
HF Report 2012 Design B.indd 42 28/11/2012 14:19
43National Heart Failure Audit April 2011-March 2012
Additive drug treatment: The number of recommended disease 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).
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
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).
Table 8: Cox proportional hazards model for post-discharge 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
Days after discharge
% s
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 7: Overall post-discharge survival
Days after discharge
% s
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 8: Post-discharge survival by sex
Women
Men
HF Report 2012 Design B.indd 43 28/11/2012 14:19
44 National Heart Failure Audit April 2011-March 2012
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 9: Post-discharge survival by age at admission
16-44
45-54
55-64
65-74
75-84
85+
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 11: Post-discharge survival by presence or absence of LVSD
Diagnosis of LVSD
No diagnosis of LVSD
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 12: Post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge for patients with LVSD
ACE inhibitor/ARB
No ACE inhibitor/ARB
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 10: Post-discharge survival by place of care
Cardiology
General Medicine
Other
HF Report 2012 Design B.indd 44 28/11/2012 14:19
45National Heart Failure Audit April 2011-March 2012
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 13: Post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge (all patients)
ACE inhibitor/ARB
No ACE inhibitor/ARB
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 15: Post-discharge survival by prescription of beta blockers on discharge (all patients)
Beta blocker
No beta blocker
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 16: Post-discharge survival by prescription of loopdiuretics on discharge for patients with LVSD
No loop diuretic
Loop diuretic
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 14: Post-discharge survival by prescription of beta blockers on discharge for patients with LVSD
Beta blocker
No beta blocker
HF Report 2012 Design B.indd 45 28/11/2012 14:19
46 National Heart Failure Audit April 2011-March 2012
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 17: Post-discharge survival by prescription of loop diuretics on discharge (all patients)
No loop diuretic
Loop diuretic
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Fig 19: Post-discharge survival by referral to cardiology follow-up services
Referred to cardiology follow-up
Not referred to cardiology follow-up
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
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0 100 200 300 400
Fig 20: Post-discharge survival by referral to heart failure liason follow-up services
Referred to heart failure liaison follow-up
Not referred to heart failure liaison follow-up
Days after discharge
% S
urvi
ved
100
90
80
70
60
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0 100 200 300 400
Fig 18: Post-discharge survival by additive drug treatment on discharge for patients with a diagnosis of LVSD
ACE inhibitor/ARB
ACEI inhibitor/ARB and beta blocker
ACEI inhibitor/ARB, beta blocker and MRA
No ACEI inhibitor/ARB, beta blocker or MRA
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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 follow-up 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 follow-up 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).
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
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 follow-up 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).
vii. Data for the 2009-12 mortality analysis can be found in appendix 4 at the end of this report.
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48 National Heart Failure Audit April 2011-March 2012
Table 9: Cox proportional hazards model for post-discharge mortality (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 1.08 1.15 < 0.001
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
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0
0 200 400 600 800 1000 1200
Fig 21: Three-year post-discharge survival (2009-12)
Days after discharge
% S
urvi
ved
100
90
80
70
60
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40
30
20
10
0
Fig 22: Three-year post-discharge survival by sex (2009-12)
0 200 400 600 800 1000 1200
Women
Men
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
Fig 23: Three-year post-discharge survival by age (2009-12)
0 200 400 600 800 1000 1200
16-44
45-54
55-64
65-74
75-84
85+
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Days after discharge
% S
urvi
ved
100
90
80
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60
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Fig 24: Three-year post-discharge survival by place ofcare (2009-12)
0 200 400 600 800 1000 1200
Cardiology
General Medicine
Other
Days
% S
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val p
ost-
disc
harg
e
100
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Fig 26: Three-year post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge in patients with LVSD (2009-12)
0 200 400 600 800 1000 1200
ACE inhibitor/ARB
No ACE inhibitor/ARB
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
Fig 27: Three-year post-discharge survival by prescription of beta blockers on discharge in patients with LVSD (2009-12)
0 200 400 600 800 1000 1200
Beta blocker
No beta blocker
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
Fig 25: Three-year post-discharge survival by presence or absence of LVSD (2009-12)
0 200 400 600 800 1000 1200
Diagnosis of LVSD
No diagnosis of LVSD
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Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
Fig 28: Three-year post-discharge survival by prescription of loop diuretics on discharge in patients with LVSD (2009-12)
0 200 400 600 800 1000 1200
Beta blocker
No beta blocker
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
Fig 30: Three-year post-discharge survival by referral to cardiology follow-up services (2009-12)
0 200 400 600 800 1000 1200
Referred to cardiology follow-up
Not referred to cardiology follow-up
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
Fig 31: Three-year post-discharge survival by referral to heart failure liaison follow-up services (2009-12)
0 200 400 600 800 1000 1200
Referred to heart failure liaison services
Not referred to heart failure liaison services
Days after discharge
% S
urvi
ved
100
90
80
70
60
50
40
30
20
10
0
Fig 29: Three-year post-discharge survival by additive drug treatment on discharge in patients with LVSD (2009-12)
0 200 400 600 800 1000 1200
ACE inhibitor/ARB
ACEI inhibitor/ARB and beta blocker
ACEI inhibitor/ARB, beta blocker and MRA
No ACEI inhibitor/ARB, beta blocker or MRA
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4 Case studies
4.1 Improving clinical practice and patient outcomesLee 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.
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.
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 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.
• 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
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.
Process
Challenges
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.
Left to right: Lynne Thomas (Quality and Patient Safety Im-provement and Measurement Assistant), Denise Hockey (Heart Failure Nurse Specialist), Rachel Kindred (Quality and Patient Safety Improvement & Measurement Co-ordinator)
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.
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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 hospital-based 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.
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.
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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 outcomesThe 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
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 participationThe 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.
6 Conclusions
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7 Appendices
Appendix 1: National Heart Failure Audit Project Board membershipName 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 membershipName 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 analysisIn-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%
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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 analysisThree-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%
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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.
Angiotensin-converting 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 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.
Patient Episode Database of Wales
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-
hospital mortality rates of 6.7%, but has a patient group
of only 3580 (see Nieminen MS et al (2006), ‘EuroHeart
Failure Survey II (EHFS II): a survey on hospitalized acute
heart failure patients: description of population’, European
Heart Journal 27(22):2725:36. http://www.ncbi.nlm.nih.
gov/pubmed/17000631), and the ESC Heart Failure Pilot
Survey recorded in-hospital mortality of only 3.8%, with a
patient population of 5118 (1892 with acute heart failure)
(see Maggioni AP et al, ‘EURObservational Research
Programme: the Heart Failure Pilot Survey (ESC-HF Pilot)’,
European Journal of Heart Failure 12(10):1076-84. http://
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
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2. National Institute for Health and Clinical Excellence
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CG108 Chronic heart failure: Management of chronic heart
failure in adults in primary and secondary care, http://
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13. National Institute for Health and Clinical Excellence (2011),
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org.uk/guidance/qualitystandards/chronicheartfailure/
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T (2011), ‘European Society of Cardiology Heart Failure
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62 National Heart Failure Audit April 2011-March 2012
15. The NHS Information Centre, Participation Rates in the
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2009’, Heart 97 (11), 876-86, http://www.ncbi.nlm.nih.gov/
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19. HQIP, National Clinical Audits, http://www.hqip.org.uk/
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conditions for acute hospital services (Gateway reference
15458), http://www.dh.gov.uk/prod_consum_dh/groups/
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21. Welsh Government, NHS Wales National Clinical Audit and
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assets/Core-Team/NHS-Wales-NCAOR-Plan-2012-13.pdf.
22. 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.
23. National Institute for Health and Clinical Excellence (2011),
Chronic heart failure quality standard, http://www.nice.
org.uk/guidance/qualitystandards/chronicheartfailure/
home.jsp.
24. See www.ucl.ac.uk/nicor/audits/heartfailure/dataset.
25. 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,
clause 1.2.2.7.
26. 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;
National Institute for Health and Clinical Excellence (2011),
Chronic heart failure quality standard, http://www.nice.
org.uk/guidance/qualitystandards/chronicheartfailure/
home.jsp
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