Bradi B. Granger, professor, contributed to "Effect of a Hospital and Postdischarge Quality Improvement Intervention on Clinical Outcomes and Quality of Care for Patients With Heart Failure With Reduced Ejection Fraction: The CONNECT-HF Randomized Clinical Trial" in JAMA. Other Duke authors include: Adam D. DeVore, G Michael Felker, Robert W. Harrison, Christopher B. Granger and Adrian F. Hernandez, of Clinical Research Institute and School of Medicine, Hussein R. Al-Khalidi and Lisa A. Kaltenbach, of Clinical Research Institute, and Dan Ariely and Julie M. Miller, of Center for Advanced Hindsight.

Abstract

Importance: Adoption of guideline-directed medical therapy for patients with heart failure is variable. Interventions to improve guideline-directed medical therapy have failed to consistently achieve target metrics, and limited data exist to inform efforts to improve heart failure quality of care.

Objective: To evaluate the effect of a hospital and postdischarge quality improvement intervention compared with usual care on heart failure outcomes and care.

Design, setting, and participants: This cluster randomized clinical trial was conducted at 161 US hospitals and included 5647 patients (2675 intervention vs 2972 usual care) followed up after a hospital discharge for acute heart failure with reduced ejection fraction (HFrEF). The trial was performed from 2017 to 2020, and the date of final follow-up was August 31, 2020.

Interventions: Hospitals (n = 82) randomized to a hospital and postdischarge quality improvement intervention received regular education of clinicians by a trained group of heart failure and quality improvement experts and audit and feedback on heart failure process measures (eg, use of guideline-directed medical therapy for HFrEF) and outcomes. Hospitals (n = 79) randomized to usual care received access to a generalized heart failure education website.

Main outcomes and measures: The coprimary outcomes were a composite of first heart failure rehospitalization or all-cause mortality and change in an opportunity-based composite score for heart failure quality (percentage of recommendations followed).

Results: Among 5647 patients (mean age, 63 years; 33% women; 38% Black; 87% chronic heart failure; 49% recent heart failure hospitalization), vital status was known for 5636 (99.8%). Heart failure rehospitalization or all-cause mortality occurred in 38.6% in the intervention group vs 39.2% in usual care (adjusted hazard ratio, 0.92 [95% CI, 0.81 to 1.05). The baseline quality-of-care score was 42.1% vs 45.5%, respectively, and the change from baseline to follow-up was 2.3% vs -1.0% (difference, 3.3% [95% CI, -0.8% to 7.3%]), with no significant difference between the 2 groups in the odds of achieving a higher composite quality score at last follow-up (adjusted odds ratio, 1.06 [95% CI, 0.93 to 1.21]).

Conclusions and relevance: Among patients with HFrEF in hospitals randomized to a hospital and postdischarge quality improvement intervention vs usual care, there was no significant difference in time to first heart failure rehospitalization or death, or in change in a composite heart failure quality-of-care score.

Trial registration: ClinicalTrials.gov Identifier: NCT03035474.

Citation

DeVore, A. D., Granger, B. B., Fonarow, G. C., Al-Khalidi, H. R., Albert, N. M., Lewis, E. F., Butler, J., Piña, I. L., Allen, L. A., Yancy, C. W., Cooper, L. B., Felker, G. M., Kaltenbach, L. A., McRae, A. T., Lanfear, D. E., Harrison, R. W., Disch, M., Ariely, D., Miller, J. M., Granger, C. B., … Hernandez, A. F. (2021). Effect of a Hospital and Postdischarge Quality Improvement Intervention on Clinical Outcomes and Quality of Care for Patients With Heart Failure With Reduced Ejection Fraction: The CONNECT-HF Randomized Clinical Trial. JAMA, 326(4), 314–323. https://doi.org/10.1001/jama.2021.8844