Are You Published? March 2022

Are You Published? 

A Hospital and Post Discharge Quality Improvement Intervention and Outcomes and Care for Patients With Heart Failure With Reduced Ejection Fraction

To the Editor: We believe that the negative results of the recent study¹ of a quality improvement intervention in patients with heart failure with reduced ejection fraction may be related to
omission of 2 interventions: routine patient education about a rescue dose of diuretic and lack of focused clinician education on pseudo–worsening kidney failure. The majority of hospital readmissions for patients with heart failure with reduced ejection fraction are due to volume overload. The American College of Cardiology 2019 guidelines² specifically endorse a discharge
plan that includes a rescue diuretic, typically taken 1 to 2 times daily for worsening symptoms of heart failure. We believe that a plan that includes a rescue-dose diuretic, whether administered by a patient, caregiver, or care facility, should be standard of care and measured for all discharges.
Second, clinician education in this study¹ did not specifically focus on the misclassification of small increases in creatinine as worsening kidney failure. The DOSE study³ showed
that a higher dosage of intravenous furosemide in the hospital was associated with a lower rate of readmission and improved symptoms, although this effect did not reach statistical significance. An increase in creatinine of 0.3mg/dL or more was defined as worsening kidney failure and was considered an adverse event. However, more recent studies have shown that small increases in creatinine in the setting of diuresis and optimal medical therapy are associated with better prognosis.Small increases in creatinine should therefore not prevent optimal dose titration of diuretics. In fact, a recent heart failure position statement5 noted that “perhaps even misinterpretation of kidney function is a leading cause of not attaining decongestion in acute heart failure and insufficient dosing of guideline-directed medical therapy in general.” This position statement included flow diagrams for both inpatient and outpatient
use, showing how to differentiate pseudo–worsening kidney failure from true worsening kidney failure, which requires lowering the dose of diuretic. No studies have demonstrated that optimal diuresis improves mortality. However, a focus on optimizing diuresis could be the next step in heart failure care optimization.
Daniel S. Kim, MD
Nhu Quyen Dau, PharmD
Harry Peled, MD
Author Affiliations: Providence St Jude Medical Center, Fullerton, California
(Kim, Peled); College of Pharmacy, Marshall B. Ketchem University, Fullerton,
California (Dau).
Corresponding Author: Harry Peled, MD, Providence St Jude Medical Center,
101 Valencia Mesa Dr, Fullerton, CA 92835 (
Conflict of Interest Disclosures: None reported.
  1. DeVore AD, Granger BB, Fonarow GC, et al. Effect of a hospital and post discharge 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. 2021;326(4):314-323. doi:10.1001/jama.2021.8844 
  2. Hollenberg SM,Warner Stevenson L, Ahmad T, et al. 2019 ACC expert consensus decision pathway on risk assessment, management, and clinical trajectory of patients hospitalized with heart failure: a report of the American College of Cardiology Solution Set Oversight Committee. J AmColl Cardiol. 2019;74(15):1966-2011. doi:10.1016/j.jacc.2019.08.001
  3. Felker GM, Lee KL, Bull DA, et al; NHLBI Heart Failure Clinical Research Network. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364(9):797-805. doi:10.1056/NEJMoa1005419
  4. Ahmad T, Jackson K, Rao VS, et al.Worsening renal function in patients with acute heart failure undergoing aggressive diuresis is not associated with tubular injury. Circulation. 2018;137(19):2016-2028. doi:10.1161/CIRCULATIONAHA.117.030112
  5. MullensW, Damman K, Testani JM, et al. Evaluation of kidney function throughout the heart failure trajectory—a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2020;22(4):584-603. doi:10.1002/ejhf.1697
In Reply: A primary goal of hospital quality improvement programs for patients with heart failure is to cross the quality chasm from hospital to home and overcome a longstanding barrier to optimal care after hospital discharge. The CONNECT-HF trial1 aimed to test the efficacy of a hospital-based, guideline-informed quality improvement intervention on patient outcomes at 1 year. We specifically tested an intervention that provided education about optimal heart failure care to clinicians and patients and used audit and feedback about heart failure process measures delivered each month to clinicians.2 We allowed sites to incorporate this information
into self-selected quality improvement interventions tailored to local needs using a site-based gap analysis, focusing on treatments proven to improve survival. Optimal management of congestion using rescue diuretics in the outpatient setting was not a focus of the education intervention in our study and may be helpful if adopted and studied as a site-selected quality improvement initiative.
We agree with Dr Kim and colleagues that more data are needed about how to improve management of pulmonary congestion in patients with heart failure with reduced ejection fraction. However, a key lesson from the CONNECT-HF trial is that interventions to improve outcomes in heart failure must be implemented longitudinally across care settings and must be tested in a rigorous fashion to fully understand their effectiveness. Another lesson from our study1 is that evidence-based therapies for the use and dose of diuretics in heart failure remain insufficient. We agree that concerns about kidney dysfunction due to elevations in creatinine are common reasons for failure to titrate certain classes of medications, as was consistently reported by sites in monthly feedback calls during the CONNECT-HF trial. Yet despite education and feedback, after 12 months of participation in CONNECT-HF, less than 40% of eligible patients were treated with 3 of the 4 evidence-based pillars of heart failure therapy, and even then only at partial target doses (ie,50%target doses of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor neprilysin inhibitors, 50% target doses of evidence-based β-blockers, and any dose of mineralocorticoid receptor antagonists). In addition, only 25%were simultaneously treated with all 3 of these classes of medications and less than10%were treated at target doses with all 3 medication classes.
New approaches to quality improvement interventions for patients with heart failure with reduced ejection fraction are required. We remain hopeful about the prospect of clinic based and mobile health–based interventions, although prospective, well-designed studies are needed before widespread adoption.
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