Admission to an appropriate ward

Independent of age and disease severity, managing HF on a cardiology ward affords better survival for patients in hospital and 1 year postdischarge; they are more likely to receive up-to-date echocardiography and on finding HFREF, more likely to receive disease-modifying therapies.2 10 11 In comparison, even after adjusting for age and comorbidities, patients with decompensated HF treated on general medical wards have a 59% increased risk of in-hospital death (HR 1.59 from 2010 to 2016, CI 1.54 to 1.65, p<0.001).2 Patients with more advanced HF on cardiology wards may be more likely to be considered for cardiac resynchronisation therapy or implantable cardioverter defibrillators as primary or secondary prevention, than those treated on general medical wards.10 11 According to the NHFA, 46% of patients were admitted to cardiology: static in the last 3 years2. At UHCW, this figure was 28% (table 1). Of patients not admitted to cardiology, 15% should have been (eg, for outliers on gynaecology and neurology), while the remaining had overarching medical needs that were best provided by another specialty. For example, patients with complex airways disease on non-invasive ventilation were appropriately transferred to the respiratory ward, and cases of advanced dementia and neurodegenerative disease were managed on geriatric units. From individual case descriptions, patients on non-cardiology wards tended to have more documentations of ‘frailty’ and ‘cachexia’; however, specific data for comparison with those on cardiology wards were not collected. Nonetheless, frailty is associated with worse outcomes and higher mortality in elderly patients with HF.12 Despite the place of care, patients can be referred to the HF specialist team to review and support the HF management. This outreach service, known to improve mortality, was delivered to 33% of UHCW patients in non-cardiology settings, which is better than the national figure of 24% reported in the latest NHFA.2 For equity of specialist care irrespective of ward allocation, UHCW’s HF specialist team has expanded over the last 3 years and integrated with the electronic referral system to meet this increasing demand which seems to be having a positive impact.

Resuscitation status

Similar to the NHFA, the median age of our sample population was around 84 years (figure 1), risen from 78 years in 2008.2 13 This progressively ageing population constitutes the majority of HF admissions and with higher prevalence of HFPEF, comorbidity burden and frailty carries a higher risk of mortality.5 Accordingly, resuscitation status needs to be reviewed early and regularly, especially given the unpredictable clinical trajectory of HF.14 If measures such as cardiopulmonary resuscitation (CPR) are anticipated to prolong suffering and deemed futile, a Do Not Attempt CPR (DNACPR) decision should be clearly communicated and documented. Of the 100 patients reviewed, DNACPR was appropriate in 91% but only 74% had this in place owing to inconsistencies in communication and documentation. In these instances, DNACPR was either written as a management plan but awaiting family discussion or verbally agreed in family meetings without completing the DNACPR form. In some cases, this resulted in inappropriate CPR attempts.

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Figure 1

Age distribution of patients.

Barriers to resuscitation discussions often come down to communication and misunderstanding. Patients may misconceive HF as a benign condition and even at end-stages, may pursue aggressive life-prolonging therapies which clinicians may accept to avoid conflict or despondence.15 Withdrawal of treatment such as deactivating ICDs is one example.16 Doctors and nurses may mix DNACPR with end-of-life care, denying patients the opportunity of active treatment.15 In one observational study, patients with DNACPRs were less likely to have echocardiograms or receive disease-modifying therapy than their counterparts.17 To overcome these obstacles, UHCW has established the Recommended Summary plan for Emergency Care and Treatment (ReSPECT), replacing DNACPR forms (figure 2). ReSPECT provides a decision support framework for clinicians to form a tailored patient-centred plan on emergency treatments, including CPR, for all patients regardless of their functional status. It contextualises resuscitation within a patient’s broader goals of care.18

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Figure 2

ReSPECT Form (top) which has replaced the DNACpR form (bottom) at UHCW.

Palliative care

One important lesson from the mortality alert is to look at our PC services. For some patients, the treatment goal is palliation where the focus is not on improving survival but on quality of life, and early identification and referral is a key NICE recommendation monitored by NHFA.1 2 19 Nationally, only 4% of patients were formally referred to PC.2 Equally in our sample, 64% patients were considered palliative but only 4.6% were referred (mostly when death was imminent) to the PC team. The issue does not lie in prescribing palliative medications, which clinicians do well, but rather acknowledging the need for PC and communicating this to patients.20 In a primary and tertiary care survey of clinicians including cardiologists, 30% reported a lack of confidence in discussing or providing end-of-life care. Some felt that this responsibility rests with the PC team.21 In an effort to improve this, the latest European Society of Cardiology HF guidelines has included guidance on PC. For example, it describes warning signs that should trigger consideration for palliation, for example, cardiac cachexia or recurrent exacerbations within 6 months despite optimal tolerated therapy.22 Over the last year at UHCW, PC has had a more recognised and integral role in the HF services; supporting fast-track discharges of patients who prefer to die at home and providing ethical guidance on withdrawal of life-sustaining therapies.

NCEPOD grading

UHCW has an extensive mortality review system to assess the quality of care in patients before death and cases graded below NCEPOD grade A undergo in-depth secondary reviews by another consultant. The spread of NCEPOD classifications of our sample population is shown in table 2, which also explains the grades from A to E. Several recurring themes were identified in cases graded B–D and these echoed the aspects of care reviewed above. These include inappropriate ward allocation, no referral to PC and absence of DNACpR leading to inappropriate CPR. Notably, patients graded as D often related to admissions to inappropriate wards without outreach cardiology input, reflecting a deficit in both clinical and organisational care.

Following our review of the deaths for appropriateness of the allotted grading, 6% of grade A cases were felt to be actually at the lower grade B for reasons similar to above: no referral to PC and inappropriate place of care. One case was regraded to C due to a delayed discharge linked with multiple hospital-acquired infections. Primary mortality reviews at this time were carried out by the consultant responsible for the patient’s care; however as illustrated, this can sometimes introduce a degree of bias and hinder opportunities for further improvement. Learning from this and similar retrospective reviews done in the hospital, the practice has now changed to the primary mortality reviews now being done by a consultant not responsible for the patient's care during that admission.

Limitations of HSMR

In 2013–2014, DFI identified 107 patients who died with a primary diagnosis of HF at UHCW. DFI calculated the expected deaths at 81.42 and HSMR at 131, triggering a mortality risk alert. A high HSMR has huge reputational and financial implications on a hospital so it is crucial that the patient administrative database on which the actual deaths is based and variables that affect the expected deaths are as accurate and complete as possible.23 Observed deaths (the numerator of HSMR) will be influenced by correct diagnosis of HF and coding of primary diagnosis while the expected deaths (denominator of HSMR) will depend on demographics, comorbidities, severity of HF and palliative status as well as immeasurable case-mix factors. Many studies have highlighted limitations with HSMR and even argued against its use.23–25 In a case-note review of 86 patients (out of 107) in 2013–2014, we identified some practical shortcomings and caveats in interpreting HSMR in HF.

Coding the primary diagnosis

Inaccurate clinical coding is a well-known universal problem but the particular clinical coding problems for HF deaths is less familiar. HSMR is based on the primary diagnosis: the condition that led to hospital admission.8 For instance, all patients admitted with HF who die regardless of the cause, for example, pneumonia are coded as HF deaths, while patients admitted for another reason but die from HF should not be included. Retrospective case note analysis offered the reviewers the benefit of having the full clinical picture from admission to the date of death in order to differentiate the primary diagnoses from secondary diagnoses. For example, in one case where HF was initially suspected and coded as ‘heart failure’ as the primary diagnosis, a subsequent chest radiograph revealed evidence of pneumonia and was treated as such the following few days. Pneumonia would have been the primary diagnosis. In another example, a patient with known history of HF presented with legs swelling and ascites. This was initially treated as decompensated HF; however ensuing tests, for example, ascitic analysis, CT abdomen and blood cultures later revealed secondary peritonitis and liver disease. Altogether, we found that 34% of primary diagnosis were incorrectly coded as HF in our cohort as the actual primary diagnosis became clearer later on during admission (figure 3). Similarly, the NHFA 2013–2014 omitted almost 5000 patient records because the primary diagnosis was not HF despite being coded as such.26 A possible explanation was that the primary diagnosis only became apparent much later on but some clinical coders may only analyse the first few consultant episodes from the time of admission, which is often brief with important investigations still pending, for example, echocardiogram or B-type natriuretic peptide (BNP). During this period, patients may be provisionally treated and coded as HF (especially, if this was one of their comorbidities). In some patients, HF was a complication rather than the reason for admission (eg, decompensated HF from pneumonia). Furthermore, elderly patients often present with multiple problems, symptomatic comorbidities and organ failures; deciding which one should be the primary diagnosis is difficult for clinicians, let alone clinical coders.

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Figure 3

Breakdown of actual primary diagnoses leading to admission.

Diagnosis

Correct diagnosis is another quality issue and can be challenging to establish in elderly patients because of the variable non-specific complaints (eg, fatigue and weakness) while some die quickly before BNP and echocardiogram are available.27 Occasionally, there may be alternative explanations for the symptoms but HF becomes a diagnostic scapegoat.28 In our review, 40% had BNP checked and 94% had echocardiography of which four who did not still had convincing evidence of HF clinically. Three patients were misdiagnosed. Even when HF is subsequently ruled out by cardiology, the coding of HF may remain in future discharge summaries. This can create errors in clinical coding and in prospective assessments of elderly patients with vague symptoms.

Immeasurable confounding variables

Just as important as proper diagnosis is attention to comorbidities. On average, patients with HF have 4.5 comorbidities and the depth of coding influences the Charlson comorbidity score which positively correlates with mortality.29–31 However, Charlson score only includes chronic conditions that were present before admission and does not include conditions that are newly identified during hospital stay, for example, undiagnosed Chronic Obstructive Airways Disease (COPD), thus potentially biasing the depth of coding and HSMR.24 Also, the former very much depends on the veracity of recorded comorbidities in clinical notes which is often incomplete.

Another problem is that the current ICD-10 coding for HF does not capture severity of HF and is only based on aetiology and pathophysiology. Since higher New York Heart Association classes are associated with higher mortality in both HFREF and HFPEF groups,32 it can be argued that a high HSMR in 1 year may be due to greater numbers of hospitalised patients with more severe or end-stage HF.

Clearly, patients admitted palliatively or treated on the end-of-life pathway are inherently more likely to die in hospital, regardless of the quality of hospital care. In 2004, the PC specialty code Z515 was introduced and was found to have a modest impact on HSMR.33 In our review, 16 patients were treated palliatively but none of them were PC coded. Since 2014, patients at UHCW who are seen by the PC team have stickers labelled ‘Palliative Care Team’ in their notes; this may help overcome undercoding of PC cases.

Actual causes of death

HSMR does not tell us the actual causes of death and in many NHS trusts including UHCW, coders do not have access to death certificates to ascertain this. It is striking that about a quarter of HF deaths are non-cardiac, with the most common being pneumonia, sepsis and malignancy.34 35 Patients with HF have double the risk of developing pneumonia whereby one mechanism suggests pulmonary congestion hampering respiratory microbial clearance.36 In our review, while the majority of deaths were due to cardiac causes (72% from HF and 6% from myocardial infarction), 21% were non-cardiac deaths which consisted of pneumonia (10%), sepsis (4%), pulmonary disease (4%), gastrointestinal bleed (2%) and malignancy (2%). Non-cardiac conditions can increase mortality, precipitate and complicate HF admissions, and we therefore need to better recognise this when managing HF and interpreting the HSMR.34