Institutional members access full text with Ovid®

Share this article on:

Process of Care Performance Measures and Long-Term Outcomes in Patients Hospitalized With Heart Failure

Patterson, Mark E. MPH, PhD*; Hernandez, Adrian F. MD, MHS†‡; Hammill, Bradley G. MS*; Fonarow, Gregg C. MD§; Peterson, Eric D. MD, MPH†‡; Schulman, Kevin A. MD*‡; Curtis, Lesley H. PhD*‡

doi: 10.1097/MLR.0b013e3181ca3eb4
Original Article

Background: Recent efforts to improve care for patients hospitalized with heart failure have focused on process-based performance measures. Data supporting the link between current process measures and patient outcomes are sparse.

Objective: To examine the relationship between adherence to hospital-level process measures and long-term patient-level mortality and readmission.

Research Design: Analysis of data from a national clinical registry linked to outcome data from the Centers for Medicare and Medicaid Services (CMS).

Subjects: A total of 22,750 Medicare fee-for-service beneficiaries enrolled in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure between March 2003 and December 2004.

Measures: Mortality at 1 year; cardiovascular readmission at 1 year; and adherence to hospital-level process measures, including discharge instructions, assessment of left ventricular function, prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge, prescription of beta-blockers at discharge, and smoking cessation counseling for eligible patients.

Results: Hospital conformity rates ranged from 52% to 86% across the 5 process measures. Unadjusted overall 1-year mortality and cardiovascular readmission rates were 33% and 40%, respectively. In covariate-adjusted analyses, the CMS composite score was not associated with 1-year mortality (hazard ratio, 1.00; 95% confidence interval, 0.98–1.03; P = 0.91) or readmission (hazard ratio, 1.01; 95% confidence interval, 0.99–1.04; P = 0.37). Current CMS process measures were not independently associated with mortality, though prescription of beta-blockers at discharge was independently associated with lower mortality (hazard ratio, 0.94; 95% confidence interval, 0.90–098; P = 0.004).

Conclusion: Hospital process performance for heart failure as judged by current CMS measures is not associated with patient outcomes within 1 year of discharge, calling into question whether existing CMS metrics can accurately discriminate hospital quality of care for heart failure.


From the *Center for Clinical and Genetic Economics, †Duke Clinical Research Institute, and ‡Department of Medicine, Duke University School of Medicine, Durham, NC; and §Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, UCLA Medical Center, Los Angeles, CA.

Supported by the Agency for Healthcare Research and Quality (grant U18HS10548); and by GlaxoSmithKline. Also, supported by the American Heart Association Pharmaceutical Roundtable grant (0675060N) (to A.F.H.), by the National Institute on Aging (grant R01AG026038) (to L.H.C. and K.A.S.), and by the Ahmanson Foundation and the Corday Family Foundation (to G.C.F.).

Trial Registration Identifier: NCT00344513.

Reprints: Lesley H. Curtis, PhD, Center for Clinical and Genetic Economics, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715. E-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

© 2010 Lippincott Williams & Wilkins, Inc.