Dr Mark Charny describes the development of an audit tool for chronic heart failure that is being made available to individual practices and primary care organisations

Chronic heart failure (CHF) is common, has a very poor prognosis and impacts badly on the patient's quality of life. It is costly in terms of time and resources and is underdiagnosed and under-treated despite the availability of treatments whose effectiveness has been proven in extensive clinical trials. For these reasons (detailed in Table 1, below), it is important to audit the care provided to patients with CHF.

Table 1: Heart failure: key points

Heart failure is a common condition

  • There is around one new case of heart failure per 1000 population per year
  • The incidence increases with age (to more than 10 per 1000 population in those aged 85+)
  • It is estimated that between 3 and 20 people per 1000 have the disease, increasing to at least 80 cases per 1000 among people aged 75+
  • An average GP will see two new cases each year, and may have between 6 and 40 patients with heart failure on his or her list4
  • Around 50% of cases of heart failure are due to CHD and 30% are secondary to hypertension

Heart failure has a very poor prognosis

  • Survival rates are worse than for breast and prostate cancer
  • Annual mortality for those with heart failure ranges from 10% to more than 50%, depending on severity
People with heart failure have a worse quality of life than people with most other common medical conditions

Heart failure is costly in time and resources

  • It accounts for around 5% of all medical admissions to hospital and 2% of all healthcare costs, one third of which are in primary care
  • Readmission rates for heart failure are high
  • Effective treatment reduces hospital admissions and readmissions
  • About half of these readmissions may be preventable

Making an accurate diagnosis of heart failure and determining its cause(s) can be difficult because the symptoms and signs of heart failure are often non-specific

  • Diagnosis and treatment are not as good as they could be
  • Many people have heart failure that has not been recognised
  • Others who have been correctly diagnosed are not given the most appropriate treatment
  • Some people who are treated do not have heart failure

New, effective treatments (such as ACE inhibitors) that control symptoms, improve quality of life and slow disease progression are available

  • There is good evidence that appropriate diagnosis, treatment and ongoing support can improve quality of life and reduce morbidity and mortality

Another reason for auditing the care of patients with heart failure is the requirements of good clinical practice outlined in national guidance and in the National Service Framework (NSF) for Coronary Heart Disease (CHD) published in March 2000.1

The NSF sets out standards and milestones for CHF to which all practices and primary care organisations are expected to respond. For example:

  • The goal of good clinical practice and the NSF is that every primary care team should ensure that all patients with heart failure are receiving a full package of appropriate investigation and treatment, demonstrated by clinical audit no more than 12 months old.
  • Standard 11 requires doctors to arrange for people with suspected heart failure to be offered appropriate nvestigations (e.g. electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely both to relieve their symptoms and to reduce their risk of death should be offered (to identify the cause of heart failure in those who have it, and to offer the most effective treatments).
  • By October 2000, every practice should have clinical teams meeting at least once every quarter to plan and discuss the results of clinical audit (Milestone 1).
  • By April 2001, every practice should have a systematically developed and maintained practice-based CHD register in place, including those with heart failure, and be actively using it to provide structured care to patients with CHD (Milestone 2).
  • By April 2002, every practice should have a protocol describing the systematic assessment, treatment and follow-up of people with heart failure agreed locally and be using it to provide structured care to people with heart failure (Milestone 3).
  • By April 2003, practices should have clinical audit data available that are no more than 12 months old and describe relevant data items (Milestone 4).

The audit described below has been developed by the Clinical Audit Development Centre (CADC). In developing the audit, the CADC has been conscious of the fact that everyone in the NHS is already overloaded and the audit has therefore been designed to help practices and primary care organisations fulfil the above requirements.

The audit is based on independent professional guidelines produced by the North of England Evidence Based Guideline Development Project,2 the Task Force of the Working Group on Heart Failure of the European Society of Cardiology,3 and SIGN (Scottish Intercollegiate Guidelines Network).4

To give participants the best return on effort, the audit is limited in scope. It concentrates on key aspects of the management of CHF.

The target groups are men and women with CHF due to (or thought to be due to) systolic dysfunction.

In order to identify patients with CHF who may not have been diagnosed, or may have been excluded from the disease register in error, patients will be eligible for inclusion without a diagnosis of CHF:

  • if they have a past history of myocardial infarction at any age
  • if they have CHD (including those who have undergone coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) and are aged 65-74 years
  • lf they are prescribed loop diuretics, potassium-sparing diuretics, or thiazides and are aged 65-74 years.

The audit has been developed through a series of carefully planned stages:

  • Draft materials were produced by audit experts using three sets of published guidelines.2–4
  • These draft materials were considered by a group of primary and secondary care experts in cardiovascular disease.
  • The materials, redrafted in the light of the comments of this 'technical group', were considered by a group consisting of a range of non-specialist clinicians and non-clinicians working in practices and primary care organisations chosen to represent the cross-section of staff who would be involved in making the audit happen on the ground
  • The materials, redrafted in the light of the comments of this 'user group' were piloted in five general practices, to ensure that they would work in a wide range of situations.

The aim has been to produce materials that are robust, straightforward to use, well designed, and linked to &urrent NHS priorities and objectives.

The materials form a complete package to support a practice or a primary care organisation in carrying out a first-class audit with minimum effort. The elements of the package are:

  • An outline introducing the audit so that practices can make an informed decision about whether to participate
  • An instruction manual supporting four aspects of the audit:
    • identifying eligible patients
    • completing individual patient data collection forms
    • completing a brief assessment of the local availability of echocardiography
    • peer review by suggesting how to interpret findings and what actions might be considered
  • Three forms:
    • for collecting data on patients included in the audit (see Figure 1,below)
    • for assessing the local availability of echocardiography
    • for collating data on individual patients to provide a concise basis for peer review discussions.
Figure 1: Extract from the individual patient data collection form
patient data collection form

On the basis of the experience in pilot practices, it has been estimated that it will take a practice between 1 and 2 hours to identify eligible patients, 40 minutes to complete the first patient data collection tool and 5–10 minutes to complete subsequent patient data collection tools.

In a typical practice, therefore, we might expect 10 eligible patients per GP, so in a four-partner practice the total time for gathering information might be approximately 8 hours.

The audit has been designed so that GPs do not have to be involved in identifying eligible patients or filling in data collection forms.

To take part, GPs need to:

  • Give permission for the records of their patients to be included in the audit.

    The audit has been designed to protect the confidentiality of patient information.

  • Agree whether they want to share (anonymised) data with other practices.

    The audit can be carried out within a single practice, but it is often helpful to be able to compare results between practices as well as between partners.

  • Commit to reviewing the care of their patients.

    The process of peer review is the key to understanding what lies behind the results of data collection, and what action should be taken.

  1. Department of Health. National Service Framework for Coronary Heart Disease. London: March, 2000.
  2. North of England Evidence Based Guideline Development Project. ACE inhibitors in the primary care management of adults with symptomatic heart failure. Centre for Health Services Research, University of Newcastle upon Tyne. Br Med J 1998; 316: 1369-75.
  3. The Task Force of the Working Group on Heart Failure of the European Society of Cardiology. The treatment of heart failure. Eur Heart J 1997; 18: 736-53.
  4. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and Treatment of Heart Failure due to Left Ventricular Systolic Dysfunction. SIGN publication number 35, February 1999.
  • The CADC was sponsored by Servier Laboratories to develop the audit package and has had complete editorial control over it. The results of the audit will remain confidential. Further information is available from Servier Laboratories, Fulmer Hall, Windmill Road, Fulmer, Slough, SL3 6HH (tel: 01753 666226).

Guidelines in Practice, October 2000, Volume 3
© 2000 MGP Ltd
further information | subscribe