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The CONNECT-HF Randomized Clinical Trial
Quick Takes
- A post-discharge intervention that focused on HF care education as well as audit and feedback on care process did not improve first HF rehospitalization or death.
- The baseline patient population was diverse and had high burden of comorbid conditions.
- There was no difference in the quality-of-care metrics between the intervention and usual-care group, reporting rates of 42.1% versus 45.5%, respectively.
Study Questions:
Can a hospital and post-discharge intervention focused on heart failure (HF) care education as well as audit and feedback on care processes improve post-discharge outcomes and quality of care for patients with HF with reduced ejection fraction (HFrEF)?
Methods:
The CONNECT-HF (Care Optimization Through Patient and Hospital Engagement For HF) trial was a cluster randomized clinical trial to improve hospital and post-discharge quality improvement intervention compared to usual care. The trial included 161 US hospitals and 5,647 (2,675 intervention vs. 2,972 usual care) patients with HFrEF. Hospitals (n = 82) were randomized to a hospital and post-discharge quality improvement intervention. Subsequent audit and feedback were provided to each site monthly, which included a report on process and outcomes for achievement of guideline-based HF care. The intervention group received coaching from CONNECT-HF Academy members who were trained for the study. Outcomes were assessed at patient post-hospital follow-up visits. The intervention was designed based on recommendations from the National Heart, Lung, and Blood Institute Implementation Science Working Group. The usual-care group hospitals (n = 79) had access to generalized online educational tools via the study website. Target metrics included for quality improvement were taken from nationally recognized guideline-directed medical therapy. Statistical analysis for comparisons in baseline patient and hospital characteristics were conducted using Wilcoxon rank-sum test for continuous variables X2 or Fisher exact test for categorical variables. Baseline variables for risk adjustment were imputed to modes for categorical variables and medians for continuous variables. Estimates of the event rates by groups were calculated using Kaplan-Meier cumulative risk. Comparison between the intervention and usual-care groups were calculated using an adjusted mixed-effects logistic regression model, treating each quality metric as an opportunity with the overall measure.
Results:
A total of 5,647 patients was enrolled, with a final analysis of 5,636 patients. Mean age was 63 years; 33% were women; 38% were Black; 87% had chronic HFrEF; and 49% had recent HF hospitalization. HF rehospitalization or all-cause mortality occurred in 38.6% in the intervention group versus 39.2% in the usual-care group (adjusted hazard ratio 0.92; 95% confidence interval, 0.81-1.05). The baseline quality-of-care score was 42.1% versus 45.5%, respectively, and the change from baseline to follow-up was 2.3% versus −1.0% (3.3% difference [95% confidence interval, −0.8-7.3%]), with no significant difference between the 2 groups in the odds of achieving a higher composite quality score at last follow-up (adjusted odds ratio 1.06; 95% confidence interval, 0.93-1.21])
Conclusions:
There was no statistical significance between the intervention and usual-care groups in time to first HF rehospitalization or death or in change in a composite HF quality-of-care score.
Perspective:
Implementing quality improvement projects within hospital systems can be difficult and can result in suboptimal outcomes. The authors recognized that many of the patients were transitioned after discharge to providers who were not directly involved in the study. The researchers recognized that this limited the impact of the coaching by the CONNECT-HF Academy faculty that only occurred in within the hospital systems. The authors recognized that 75% of the hospitals involved already had quality improvement process in place, that additional interventions did not have an impact. The patients enrolled in the study had low use of guideline-directed medical therapy for HFrEF at target doses recommended by the HF guidelines. The amount of effort that was put into improving outcomes at the hospital level did not translate to the outpatient setting where the health care provider may not be aware of the need to titrate medications to goal. Quality improvement is still needed in the care provided to patients with HFrEF, and future interventions should consider incorporating strategies that include patient involvement.
Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure
Keywords: Heart Failure, Stroke Volume, Aftercare, Patient Discharge, Outpatients, Quality Improvement, Feedback, Hospitalization, Quality of Health Care, Hospitals
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