Quality of care and risk of incident atrial fibrillation in patients with newly diagnosed heart failure: a nationwide cohort study

Abstract

Aims: Incident atrial fibrillation (AF) is an adverse prognostic indicator in heart failure (HF); identifying modifiable targets may be relevant to reduce the incidence and morbidity of AF. Therefore, we examined the association between quality of HF care and risk of AF.

Methods and results: Using the Danish Heart Failure Registry, we conducted a nationwide registry-based cohort study of all incident HF patients diagnosed between 2008 and 2018 and without history of AF. Quality of HF care was assessed by seven process performance measures, including echocardiographic examination, New York Heart Association classification, treatment with angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta-blockers, and mineralocorticoid antagonists, physical training, and patient education. In the main analysis, we examined adherence with all measures in a cohort of 25 100 patients (mean age 68.5 ± 13.2 years; 33.6% women). The median follow-up was 3.1 years. Cox proportional hazard regressions estimated the hazard ratios (HRs) with 95% confidence intervals (95% CIs) between the number of fulfilled measures and incident AF. In a multivariable-adjusted analysis with 0 fulfilled performance measures as reference, the HRs (95% CIs) were 1: 0.78 (0.61-1.00), 2: 0.63 (0.49-0.80), 3: 0.53 (0.36-0.80), 4: 0.64 (0.44-0.94), 5: 0.56 (0.39-0.82), 6: 0.51 (0.35-0.74), and 7: 0.49 (0.33-0.73), with a significant decreasing linear trend (P < 0.001).

Conclusion: In patients with incident HF, fulfilment of guideline-based process performance measures was associated with decreased long-term risk of AF. This study supports initiatives to improve the quality of care for patients with HF to prevent incident AF.

Keywords: Atrial fibrillation; Heart failure; Process performance measure; Quality indicators; Quality of health care.

Figure 1

Flowchart. *Numbers stated with a precision ±2 to adhere to applicable rules for discretion in the handling of data on an individual level. ACE-I, angiotensin-converting enzyme inhibitors; AF, atrial fibrillation; ARB, angiotensin II receptor blockers; echo, echocardiography; HF, heart failure; HTX, heart transplantation; MRA, mineralocorticoid antagonists; NYHA, New York Heart Association.

Figure 2

Number of patients by fulfilled measures (A) and relevant measures (B), and fulfilled measures according to number of relevant measures (C). No patients were eligible for 0 or 1 process performance measure, as echocardiography and NYHA class were considered relevant for all patients. *Numbers stated with a precision ±2 to adhere to applicable rules for discretion in the handling of data on an individual level. NYHA, New York Heart Association

Figure 3

Hazard ratios with 95% confidence intervals for the association between number of fulfilled performance measures and incident AF. Model 1: Adjusted for number of relevant process performance measures, age, and sex. Model 2: Adjusted for number of relevant process performance measures, age, sex, elevated alcohol consumption, smoking, left ventricular ejection fraction, New York Heart Association classification, histories of myocardial infarction, ischaemic stroke, diabetes, chronic obstructive pulmonary disease, hypertension, chronic kidney disease, obesity, valvular disease, obstructive sleep apnoea, income, and level of education, after multiple imputation.