Quality of care and outcomes among patients with heart failure and chronic kidney disease: A Get With the Guidelines -- Heart Failure Program study

Abstract

Background: Both heart failure (HF) and chronic kidney disease (CKD) are highly prevalent conditions that often coexist; however, the quality of care received by hospitalized patients with both is not known.

Methods: The Get With the Guidelines - HF registry and performance improvement program prospectively collects data on patients hospitalized with HF. Performance measures to improve treatment of patients with HF and inhospital mortality were examined by kidney function based on glomerular filtration rate (GFR) categorized as normal (GFR > or = 90), mild (60 < or = GFR < 90), moderate (30 < or = GFR < 60), severe (15 < or = GFR < 30), and kidney failure (GFR < 15 or dialysis).

Results: Nearly two thirds of hospitalized patients with HF (15,560 patients from 137 hospitals) also had CKD: moderate CKD (43.9%), severe CKD (14.2%), and kidney failure (6.6%). Inpatient mortality was higher for patients with more severe renal dysfunction. Those with kidney failure were significantly less likely to receive nearly all guidelines-based therapies. In contrast, those with moderate or severe CKD often received similar care when compared with those with normal kidney function, except for lower use of angiotensin-converting enzyme inhibitors or receptor blockers (odds ratio 0.19 [0.13-0.28] and 0.47 [0.36-0.62], respectively) and lower proportions with blood pressure control (odds ratio 0.70 [0.58-0.85] and 0.52 [0.42-0.63], respectively).

Conclusions: In a large contemporary cohort of patients hospitalized with HF, we found that renal dysfunction was a highly prevalent comorbidity. Despite higher mortality rates, patients with increased severity of renal dysfunction were less likely to receive important guideline-recommended therapies. Further efforts are needed to improve the care of patients with HF and CKD.

Figure 1. Unadjusted and Risk-Adjusted In-hospital Mortality

Unadjusted rates of in-hospital mortality (A) increased with more severe renal dysfunction and were highest among those with severe renal dysfunction. After multivariable adjustment (B), in-hospital mortality rates increased with more severe renal dysfunction with the highest rates among patients with kidney failure. Variables for risk-adjustment – age, gender, race, body mass index at admission, systolic blood pressure at admission, heart rate at admission, anemia, cerebrovascular disease, diabetes, hyperlipidemia, hypertension, pulmonary disease, peripheral vascular disease, coronary artery disease/ischemic etiology, ejection fraction (%).

Figure 2. Conformance to Performance and Quality Measures, According to Kidney Function Groups

Conformance to several performance measures (A) decreased with more severe renal dysfunction, including assessment of left ventricular function, ACEI or ARB therapy, and β-blocker therapy. However, provision of discharge instructions and smoking cessation referral were only significantly lower among those with kidney failure. Conformance to quality measures (B) decreased with more severe renal dysfunction for last blood pressure < 140/90 and anticoagulation with atrial fibrillation, while they were lower only among those with kidney failure for specific evidence-based β-blocker therapy. Error bars represent 95% confidence intervals and P-values are for trends across kidney function groups for each performance and quality measure.