Heart failure learning module 1: background, epidemiology and pathophysiology

Costs to the NHS

The cost of diagnosing and managing heart failure is 1–2% of the total NHS expenditure. According to the National Institute for Health and Care Excellence (NICE), heart failure results in one million in-patient bed days (2% of all NHS in-patient bed days) and 5% of all emergency medical admissions to hospital. Readmissions to hospital are very common, with 50% of patients being readmitted within three months of discharge. Hospital admissions for heart failure are projected to rise by 50% over the next 25 years, mainly due to the ageing population.²²

The estimated annual cost of heart failure care to the NHS is £625 million, of which 60% represents in-patient care costs; only around 9% represents drug costs. Patients with heart failure consult their GP more than those without heart failure: the average annual number of contacts between a patient with heart failure and their GP or other member of the primary care team is 11 to 13.²³

The cost of prescriptions for hypertension and heart failure decreased by approximately £64 million between 2010 and 2011, to just over £330 million. However, the cost of prescriptions for cardiovascular disease did not increase in line with the number of prescriptions, which may be a reflection on the increased use of cheaper generic drugs (figure 8).

QOF indicators, quality standards and best practice tariffs

In the UK, various initiatives are in place to attempt to ensure good quality and even standard of care for patients with acute and chronic heart failure in the in-patient or community setting.

QOF indicators

The performance of general practices in managing patients with heart failure is monitored by the Quality and Outcomes Framework (QOF). QOF, under the guidance of NICE, have developed ‘indicators’ for managing patients with heart failure that act as targets that are financially incentivised (table 3).²⁶

Changes to QOF

Despite recent calls for QOF to be scrapped, with local deals being developed under Care Commission Group funding or suspension of QOF activities being negotiated by Local Medical Committees, there was no change to financial incentives offered under QOF in 2017–18.²⁷ The process is planned for review in 2018 but it is not yet clear as to what the alternative will be.

Quality standards

Additionally NICE have produced ‘quality standards’ for acute and chronic heart failure that define the standard of care to be provided.

Acute heart failure quality standard²⁸

• adults presenting to hospital with new suspected acute heart failure have a single measurement of natriuretic peptide
• adults admitted to hospital with new suspected acute heart failure and raised natriuretic peptide levels have a transthoracic Doppler 2D echocardiogram within 48 hours of admission
• adults admitted to hospital with acute heart failure have input within 24 hours of admission from a dedicated specialist heart failure team
• adults with acute heart failure due to LVSD are started on, or continue with, beta blocker treatment during their hospital admission
• adults admitted to hospital with acute heart failure and reduced LVEF are offered an ACE inhibitor and an aldosterone antagonist
• adults with acute heart failure have a follow up clinical assessment by a member of the community – or hospital based specialist heart failure team within two weeks of hospital discharge.

Chronic heart failure quality standard²⁹

• adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment
• adults with suspected chronic heart failure and either a previous myocardial infarction (MI) or very high levels of serum natriuretic peptides, who have been referred for diagnosis, have an echocardiogram and specialist assessment within two weeks
• adults with chronic heart failure due to LVSD are started on low dose ACE inhibitor and beta blocker medications that are gradually increased until the target or optimal tolerated doses are reached
• adults with chronic heart failure have a review within two weeks of any change in the dose or type of their heart failure medication.
• adults with stable chronic heart failure have a review of their condition at least every six months
• adults with stable chronic heart failure are offered an exercise based programme of cardiac rehabilitation
• adults with chronic heart failure referred to a programme of cardiac rehabilitation are offered sessions during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.

Problems with the quality standards

The quality standards require significant resources and do not take into account patient variables that may limit their treatment.

For example, only 80% of patients admitted with acute heart failure get any in-patient input from the heart failure specialist team (cardiologist or specialist nurse),² yet the quality standards for acute heart failure require that all patients receive this within the first 24 hours of admission.

Additionally, the quality standard requires that all patients get a transthoracic echocardiogram within 48 hours of admission, however, in practice, only 91% of patients get an echocardiogram at all during admission.²

Co-morbidities and patient variables such as heart rate or blood pressure limit the use of disease modifying drugs in patients with heart failure (ACE inhibitor, beta blocker, MRA). Acute heart failure quality standards require that all patients with heart failure are started on, or continue on beta blocker during admission and that all patients are offered ACE inhibitor/ ARB and MRA treatment. In practice, 86% of patients are taking beta blocker, 84% are taking ACE inhibitor or ARB and 52% are taking MRA on discharge.²

However, the requirement for every patient with acute heart failure to have follow up two weeks after discharge with either the GP or hospital specialist is the most unrealistic target in the modern NHS.

Best practice tariff

In 2010 the Department of Health in the UK introduced ‘Best Practice Tariffs’; financial incentives for hospitals to meet what was defined as ‘best practice’ for a particular condition. Base payments for treating a certain condition were reduced overall but additional money was available for meeting criteria based on national guidance and expert opinion that defined ‘best practice’ for managing that condition.³⁰

The best practice tariff for heart failure is worth a 5% increase in payment for every admission, but it is not paid on a patient by patient basis: either the hospital meets the best practice tariff criteria and gets the 5% increase in payment for every admission – or it does not.

The best practice tariff for heart failure was introduced in 2016 and includes two criteria:³¹

• 60% of patients admitted with failure must receive specialist input during admission as recorded in the national heart failure audit.
• 70% of patients coded as having heart failure must be included in the national heart failure audit.