Variation in hospital performance for heart failure management in the National Heart Failure Audit for England and Wales

Objective: Investigation of variations in provider performance and its determinants may help inform strategies for improving patient outcomes. Methods: We used the National Heart Failure Audit comprising 68 772 patients with heart failure with reduced left ventricular ejection fraction ( HFREF ), admitted to 185 hospitals in England and Wales ( 2007–2013 ). We investigated hospital adherence to three recommended key performance measures ( KPMs ) for inhospital care ( ACE inhibitors ( ACE-Is ) or angiotensin receptor blockers ( ARBs ) on discharge, β-blockers on discharge and referral to specialist follow-up ) individually and as a composite performance score. Hierarchical regression models were used to investigate hospital-level variation. Results: Hospital-level variation in adherence to composite KPM ranged from 50% to 97% ( median 79% ), but after adjustments for patient characteristics and year of admission, only 8% ( 95% CI 7% to 10% ) of this variation was attributable to variations in hospital features. Similarly, hospital prescription rates for ACE-I/ARB and β-blocker showed low adjusted hospital-attributable variations ( 7% CI 6% to 9% and 6% CI 5% to 8%, for ACE-I/ARB and β-blocker, respectively ). Referral to specialist follow-up, however, showed larger variations ( median 81%; range; 20%, 100% ) with 26% of this being attributable to hospital-level differences ( CI 22% to 31% ). Conclusion: Only a small proportion of hospital variation in medication prescription after discharge was attributable to hospital-level features. This suggests that differences in hospital practices are not a major determinant of observed variations in prescription of investigated medications and outcomes. Future healthcare delivery efforts should consider evaluation and improvement of more ambitious KPMs.