national heart failure audit

1National Heart Failure Audit April 2011-March 2012

Title

NATIONAL HEART

FAILURE AUDIT

APRIL 2011 - MARCH 2012

BRITISH SOCIETY FOR HEART FAILURE

HF Report 2012 Design B.indd 1 28/11/2012 14:19

2 National Heart Failure Audit April 2011-March 2012

National Heart Failure AuditNational Institute for Cardiovascular Outcomes Research (NICOR) Institute of Cardiovascular Science, University College London3rd floor, 170 Tottenham Court Road, London W1T 7HA

Tel: 0203 108 3927Email: [email protected]

NICOR (National Institute for Cardiovascular Outcomes Research) is a partnership of clinicians, IT experts, statisticians, academics and managers which manages six cardiovascular clinical audits and three clinical registers. NICOR analyses and disseminates information about clinical practice in order to drive up the quality of care and outcomes for patients.

The British Society for Heart Failure (BSH) is a national organisation of healthcare professionals which aims to improve care and outcomes for patients with heart failure by increasing knowledge and promoting research about its diagnosis, causes and management.

The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact of clinical audit in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The programme comprises 40 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions.

AuthorsReport produced by John Cleland (University of Hull) Henry Dargie (University of Glasgow) Suzanna Hardman (Whittington NHS Trust) Theresa McDonagh (King’s College London) Polly Mitchell (NICOR)

AcknowledgmentsThe National Heart Failure Audit is managed by the National Institute for Cardiovascular Outcomes Research (NICOR), which is part of the National Centre for Cardiovascular Prevention and Outcomes, based at University College London. The National Heart Failure Audit is funded and commissioned by the Healthcare Quality Improvement Partnership (HQIP).

Specialist clinical knowledge and leadership is provided by the British Society for Heart Failure (BSH) and the audit’s clinical lead, Professor Theresa McDonagh. The strategic direction and development of the audit is determined by the audit Project Board. This includes major stakeholders in the audit, including cardiologists, the BSH, heart failure specialist nurses, clinical audit and effectiveness managers, cardiac networks, patients, NICOR managers and developers, and HQIP.

This report was completed in close collaboration with the NICOR technical team, formerly known as the Central Cardiac Audit Database (CCAD). Marion Standing has again been especially involved.

We would especially like to thank the contribution of all NHS Trusts, Welsh Heath Boards and the individual nurses, clinicians and audit teams who collect data and participate in the audit. Without this input the audit could not continue to produce credible analysis, or to effectively monitor and assess the standard of heart failure care in England and Wales.

This report is available online at www.ucl.ac.uk/nicor/audits/heartfailure/additionalfiles

Data cleaning and analysis Emmanuel Lazaridis (NICOR) Darragh O’Neill (NICOR)

Published 27th November 2012. The contents of this report may not be published or used commercially without permission

Founded in 1826, UCL (University College London) was the first English university established after Oxford and Cambridge, the first to admit students regardless of race, class, religion or gender, and the first to provide systematic teaching of law, architecture and medicine. It is among the world’s top universities, as reflected by performance in a range of international rankings and tables. UCL currently has 24,000 students from almost 140 countries, and more than 9,500 employees. Its annual income is over £800 million.



Tel: 0203 108 3927Email: [email protected]

National Heart Failure Audit

April 2011 - March 2012

The fifth annual report for the National Heart Failure Audit presents findings and recommendations based on patients discharged with a diagnosis of heart failure between 1 April 2011 and 31 March 2012, covering all NHS Trusts in England and Health Boards in Wales which admit acute heart failure patients.

The report is aimed at those involved in collecting data for the National Heart Failure Audit, as well as clinicians, healthcare managers, clinical governance leads, and all those interested in improving the outcomes and well-being of patients with heart failure. The report includes clinical findings at national and local levels and patient outcomes for the audit year.



Contents

The Authors 2

Contents 4

List of figures 5

Foreword 6

1. Executive summary 7 1.1 National Heart Failure Audit 7

1.2 Findings 7

Participation 7

Hospitalisation 7

Diagnosis 7

Treatment 7

Referrals on discharge 7

Hospital level analysis 7

In-hospital mortality 8

Mortality for survivors to discharge 8

1.3 Recommendations 8

2. Introduction 10 2.1 Heart Failure 10

2.2 The role of the audit 10

2.3 National use of audit data 10

2.4 Organisation of the audit 11

2.5 The scope of the audit 11

2.6 The database 11

2.7 Data collection and IT 11

2.8 Improving our IT platform 12

2.9 Improving analysis 12

3. Findings 13 3.1 Data cleaning and data quality 13

3.2 Participation 13

Number of Trusts 13

Number of patients 14

Case ascertainment 14

3.3 Demographics 14

Age 14

Age and sex 14

Age and Index of Multiple Deprivation 14

3.4 Demographics 15

In-hospital care 15

Length of stay 15

Readmission 15

3.5 Aetiology 16

Symptoms 16

Aetiology 16

3.6 Diagnosis 16

Echocardiography 16

Diagnosis 17

3.7 Treatment on discharge for LVSD 17

ACE inhibitor and ARB 17

Beta blocker 17

MRA 17

Loop diuretics 17

Thiazide diuretics 17

Digoxin 17

Treatment on discharge by age 17

3.8 Monitoring heart failure patients 18

Follow-up services 18

Palliative care 18

3.9 Analysis by hospital 19

Participation and case ascertainment 19

Clinical practice 30

3.10 Mortality 42

2011/12 in-hospital mortality 42

2011/12 post-discharge mortality 42

3.11 Three-year trends 47

Three-year in-hospital mortality 47

Three-year post-discharge mortality 47

4. Case studies 51 4.1 Improving clinical practice and patient outcomes 51

4.2 Using data to drive improvement 51

4.3 An example of local practice in conducting the 51

national Heart Failure Audit

4.4 The national perspective 51

5. Research use of National Heart Failure 54

Audit data

6. Conclusions 55 6.1 Quality of care and patient outcomes 55

6.2 Data completeness and participation 55



7. Appendices 56 A1 National Heart Failure Audit Project Board 56

membership

A2 HALO Group 56

A3 Data for 2011/12 mortality analysis 56

A4 Data for 2009-12 mortality analysis 58

A5 Glossary 59

8. References 61

List of figures and tables

Table 1 Records excluded from analysis in this report 13

Table 2 Records excluded from mortality analysis in 13

this report

Figure 1 Age at first admission by sex 14

Figure 2 The effect of deprivation on age of first admission 15

Figure 3 Mean length of stay by hospital 15

Figure 4 Median length of stay by hospital 15

Figure 5 Number of readmissions in 2011/12 16

Table 3 Previous medical history and diagnosis of LVSD 16

Figure 6 Treatment for LVSD on discharge by age 18

Table 4 Participation and case ascertainment in England 19

Table 5 Participation and case ascertainment in Wales 29

Table 6 Clinical practice in England (2011/12) 30

Table 7 Clinical practice in Wales (2011/12) 41

Table 8 Cox proportional hazards model for post- 43

discharge mortality (2011/12)

Figure 7 Overall post-discharge survival 43

Figure 8 Post-discharge survival by sex 43

Figure 9 Post-discharge survival by age at admission 44

Figure 10 Post-discharge survival by place of care 44

Figure 11 Post-discharge survival by presence or 44

absence of LVSD

Figure 12 Post-discharge survival by prescription of ACE 44 inhibitor and/or ARB on discharge for patients with LVSD

Figure 13 Post-discharge survival by prescription of ACE 45 inhibitor and/or ARB on discharge (all patients)

Figure 14 Post-discharge survival by prescription of beta 45 blockers on discharge for patients with LVSD

Figure 15 Post-discharge survival by prescription of beta 45 blockers on discharge (all patients)

Figure 16 Post-discharge survival by prescription of loop 45 diuretics on discharge for patients with LVSD

Figure 17 Post-discharge survival by prescription of loop 46 diuretics on discharge (all patients)

Figure 18 Post-discharge survival by additive drug 46 treatment on discharge for patients with a diagnosis of LVSD

Figure 19 Post-discharge survival by referral to 46 cardiology follow-up services

Figure 20 Post-discharge survival by referral to 46 heart failure liason follow-up services

Table 9 Cox proportional hazards model for 48 post-discharge mortality (2009-12)

Figure 21 Three-year post-discharge survival (2009-12) 48

Figure 22 Three-year post-discharge survival by 48 sex (2009-12)

Figure 23 Three-year post-discharge survival by 48 age (2009-12)

Figure 24 Three-year post-discharge survival by place 49 of care (2009-12)

Figure 25 Three-year post-discharge survival by presence 49 or absence of LVSD (2009-12)

Figure 26 Three-year post-discharge survival by 49 prescription of ACE inhibitor and/or ARB on discharge in patients with LVSD (2009-12)

Figure 27 Three-year post-discharge survival by 49 prescription of beta blockers on discharge in patients with LVSD (2009-12)

Figure 28 Three-year post-discharge survival by 50 prescription of loop diuretics on discharge in patients with LVSD (2009-12)

Figure 29 Three-year post-discharge survival by 50 additive drug treatment on discharge in patients with LVSD (2009-12)

Figure 30 Three-year post-discharge survival by referral 50 to cardiology follow-up services (2009-12)

Figure 31 Three-year post-discharge survival by referral 50 to heart failure liason follow-up services (2009-12)



The ability of high quality national audit data to improve clinical cardiovascular care and its role in delivering important outcome benefits has already been well demonstrated through initiatives such as MINAP (Myocardial Ischaemia National Audit Project). However, heart failure remains one of the biggest challenges for modern cardiovascular care and an area where robust audit data has major potential to inform change for the benefit of patients.

The National Heart Failure Audit 2011/2012 highlights the importance of heart failure which affects around 900,000 individuals in the UK, accounts for 5% of all emergency hospital admissions and utilises 2% of all NHS hospital bed days. It is associated with a high annual mortality, especially if poorly treated, and the effect of heart failure on quality of life cannot be underestimated. Yet optimal management can result in a better prognosis with fewer symptoms and an increased life expectancy.

The National Heart Failure Audit, now in its sixth year, has evolved to include data on acute heart failure admissions from 90% of the Trusts and Health Boards in England and Wales and now represents 59% of all heart failure admissions. It provides a valuable insight into the diversity of both management and outcomes, highlighting the importance of specialist care, optimising medical therapy and appropriate specialist follow-up as key indicators of improved mortality. Although in-hospital mortality remains high at 11.1% the differences between specialist and non-specialist care are striking, with 7.8% in-hospital mortality for patients managed under cardiology care versus 13.2% mortality under general medicine and 17.4% for those managed in other wards.

The additional mortality benefits of specialist follow-up by cardiology and heart failure teams also highlight the importance of integrated care beyond hospital admission. These insights into the significant outcome gains possible through evidence based, specialist delivered management are a powerful vehicle for driving up quality, addressing variations in care, and for planning and commissioning of future heart failure services.

The National Heart Failure Audit is managed by the National Institute for Cardiovascular Outcomes Research (NICOR), receiving clinical direction and leadership from the British Society for Heart Failure which, along with the clinical teams managing the patients and all those submitting the data, deserves enormous credit for its development and continued evolution. From April 2013, when hospitals will be required to submit data on all heart failure admissions, the increasing importance of this audit in driving up the quality of heart failure management will be further enhanced.

Dr Iain A Simpson President, British Cardiovascular SocietyChair, British Cardiovascular Society

Foreword



Heart failure is a highly prevalent condition, often with poor outcomes: an estimated 900,000 people in the U.K. have heart failure and over a third will die within a year of diagnosis. Despite an elderly patient group, many of whom have extensive comorbidities contributing to or complicating their heart failure, good clinical management has been shown to substantially improve patient outcomes.

1.1 National Heart Failure AuditThe National Heart Failure Audit was established in 2007 to monitor the care and treatment of patients admitted to hospital in England and Wales with heart failure. The audit reports on the clinical practice and patient outcomes of acute patients discharged from hospital with a primary diagnosis of heart failure. The audit collects data based on recommended clinical indicators with a view to driving up standards by encouraging the implementation of guideline recommendations and reporting on practice statistics and outcomes.

Audit data is used by a number of national groups, including the NHS Information Centre, the Care Quality Commission and data.gov.uk. However improvements in standards of care depend on participating hospitals using and reviewing their own data to change and improve practice.

The audit is strongly supported by the British Society for Heart Failure and is one of six cardiovascular audits managed by NICOR, part of the National Centre for Cardiovascular Prevention and Outcomes at UCL. The audits are funded and commissioned by HQIP.

1.2 Findings

1.2.1 Participation

Between April 2011 and March 2012 142 out of 155 NHS Trusts in England and Health Boards in Wales (92%) submitted data to the audit. 12 NHS Trusts and one Health Board did not submit any data to the audit.

After data cleaning, the total number of records in the 2011/12 audit was 37,076, made up of 32,906 index admissions and 4,170 readmissions within the audit period.

Nationally the audit represents 59% of all heart failure patients in England and Wales. Case ascertainment was 62% for England and 12% for Wales.

1.2.2 Hospitalisation

48% of patients were treated in cardiology wards, with 41% treated on general medical wards and 11% on other wards. Men were far more likely to be treated on cardiology wards than women, as were younger patients.

Overall mean length of stay was 13.1 days on first admission and 13.4 days on readmission. This is an increase from last year’s audit (11 days on admission and 13 days on readmission). In contrast to last year, when cardiology patients had longer lengths of stay than patients treated on other wards, in 2011/12 cardiology patients had shorter lengths of stay (12.7 days) than patients on general medical wards (13.1 days) and those on other wards (14.7 days).

1.2.3 Diagnosis

The use of echocardiography remains high, with 86% receiving an echo during the admission.

1.2.4 Treatment

Prescription rates of disease modifying treatments at discharge for patients with left ventricular systolic dysfunction (LVSD) remain broadly similar to those recorded in the 2010/11 audit.

Prescription of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) remains high, with 84% of patients discharged on either of the therapies (81% in 2010/11).

Prescription of some recommended therapies increased: 78% of patients were prescribed beta blockers on discharge, compared to 65% in 2010/11. 45% of patients were discharged on a mineralocorticoid receptor antagonist (MRA), an increase from 36% in 2010/11. Some of the apparent increase in prescribing between years may be accounted for by changes in analytical method.

As observed in previous years, prescription rates for ACE inhibitors/ARBs, beta blockers and MRAs are all higher when patients are admitted to cardiology wards, as opposed to general medical or other wards.

1.2.5 Referral on discharge

54% of patients were referred to a heart failure liaison service on discharge, and 52% to cardiology follow-up. Referral rates were higher for patients who were younger, male and treated on a cardiology ward.

1.2.6 Hospital level analysis

For the first time, the National Heart Failure Audit includes analysis on clinical practice at a hospital level, for all hospitals which submitted at least 100 patient records (or more than 70% of their Hospital Episode Statistics (HES) recorded heart failure admissions) to the audit. The findings show fairly wide variation in clinical practice between hospitals, but it is unclear how representative the patients in the audit are of the heart failure patient population at many hospitals, due to the small number of returns. As of April 2013, hospitals will be required to enter data on all of their heart failure patients, and this will hopefully give a more accurate picture of the variation in the treatment and management of heart failure at a hospital level.

1 Executive Summary



1.2.7 In-hospital mortality

In hospital mortality remains high, with 11.1% of patients discharged in 2011/12 dying during their admission, similar to the 11.6% recorded in 2010/11. These findings are higher than in-hospital mortality rates reported by other European registries,1 and this is likely to reflect the more comprehensive approach taken by the National Heart Failure Audit.

In-hospital mortality rates were 7.8% for patients treated on cardiology wards, compared with 13.2% for those treated on general medical wards and 17.4% for those on other wards. The benefit of treatment in a cardiology ward persists when these findings are adjusted for confounding factors such as age and New York Heart Association (NYHA) class. These findings are similar to previous years’ results, and highlight the benefits of specialist treatment.

1.2.8 Mortality for survivors to discharge

Of those patients who survived to discharge, 26% died within the follow-up period. Outcomes were significantly better for patients treated on cardiology wards (22%) compared to those treated on general medical wards (30%) and other wards (33%).

Mortality rates with key medical treatment (ACEI/ ARBs, beta blockers, MRAs) were substantially lower than without such therapy. The benefits of disease modifying treatment were present in patients with diagnosed with non-systolic heart failure as well as patients with left ventricular systolic dysfunction when taken alone. Patients discharged from cardiology wards were more likely to be prescribed these drugs.

The benefits of disease modifying therapies were additive. Patients discharged on all of ACEI/ARBs, beta blockers and MRAs had better survival outcomes than patients prescribed an ACEI/ARB and a beta blocker but no MRA, and patients prescribed an ACEI/ARB alone. All of these patients had substantially lower mortality than patients discharged on none of the three therapies.

Patients referred to heart failure nurse and cardiology follow-up services also had better survival, only 20% of patients referred to cardiology follow-up services on discharge died, compared with 32% of patients not referred to follow-up with a cardiologist. 25% of patients referred to heart failure nurse liaison services within the audit year died, compared with 28% of those not referred to nurse led follow-up.

Cox proportional hazards models appear to show that even with adjustment for age, severity of symptoms and history of acute myocardial infarction, for patients who survived to discharge, those not prescribed ACE inhibitors/ARBs and beta blockers on discharge had higher mortality rates. Patients prescribed loop diuretics on discharge had increased mortality

rates following adjustment for these confounding factors. After adjusting for possible differences in patient characteristics, patients who were not managed on cardiology wards and those who did not receive cardiology follow-up continued to have higher mortality rates. (The analysis was adjusted for the following covariates: age>75, NHYA class III/IV, previous AMI, no ACEI/ARB, no beta blocker, loop diuretic, no cardiology follow-up, not treated on cardiology ward).

Mortality analyses for the three year period between April 2009 and March 2012 show similar findings. 42% of patients who survived to discharge died during this period, but optimal treatment and management in hospital had beneficial effects on patient outcomes, which continued long after discharge.

1.3 RecommendationsThe National Heart Failure Audit provides key information to improve outcomes in acute heart failure, one of the great unmet needs in the management of the condition. Considerable progress has been made in case ascertainment since the audit began. The aim now should be to strive for inclusion of all patients admitted to hospital with a primary diagnosis of heart failure to ensure a more representative dataset.

The following recommendations are made based on the findings of the audit in this and previous years:

This audit has consistently shown that specialist cardiology care and follow up is associated with better outcomes for patients with heart failure even after adjusting for age, severity and other observed differences in patient characteristics. Trusts should ensure that patients with a primary diagnosis of heart failure have specialist input to their care as proposed in NICE guidelines and are managed on cardiology or wards specialising in heart failure wherever feasible.

Implementation of key evidence-based medicine i.e. the use of ACE inhibitors, beta blockers and MRAs for those with systolic dysfunction is associated with much improved patient outcomes. Trusts need to concentrate on getting these cornerstone therapies initiated in hospital, wherever possible.

Robust arrangements for the optimisation of therapy for cardiac dysfunction via cardiology follow-up, heart failure liaison services and primary care need to be firmly in place prior to discharge. The next phase of the audit will address this discharge planning phase more specifically. As access to specialist medical and nursing care is the gatekeeper to optimal care for heart failure patients, Trusts should ensure that key personnel are in place to deliver this care.

The audit also shows that outcome is poorer for patients without, compared to those with, left ventricular systolic dysfunction (LVSD). This likely reflects the greater age of



patients who do not have LVSD but other possibilities will be explored by the audit group. The continuing increase in case ascertainment coupled with data already accrued from previous audits will provide a robust basis for these aims and should be a focus of interest for subsequent audit reports.

In 2011 the National Institute for Health and Clinical Excellence produced a quality standard for chronic heart failure, comprising 13 statements summarising the optimal and recommended management of heart failure.2 Hospitals should adhere to these standards in the treatment and care of heart failure patients, with the following statements being particularly relevant:

Statement 7: People with chronic heart failure due to left ventricular systolic dysfunction are offered angiotensin-converting enzyme inhibitors (or angiotensin II receptor antagonists licensed for heart failure if there are intolerable side effects with angiotensin-converting enzyme inhibitors) and beta-blockers licensed for heart failure, which are gradually increased up to the optimal tolerated or target dose with monitoring after each increase.

Statement 10: People admitted to hospital because of heart failure have a personalised management plan that is shared with them, their carer(s) and their GP.

Statement 11: People admitted to hospital because of heart failure receive input to their management plan from a multidisciplinary heart failure team.

Statement 12: People admitted to hospital because of heart failure are discharged only when stable and receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.

Statement 13: People with moderate to severe chronic heart failure, and their carer(s), have access to a specialist in heart failure and a palliative care service.



2 Introduction

2.1 Heart FailureHeart Failure is a complex clinical syndrome characterised by the reduced ability of the heart to pump blood around the body. It is caused by structural or functional cardiac abnormalities, including previous myocardial infarction, cardiomyopathies, valvular heart disease and hypertension. It is thought that around 70% of all heart failure cases are caused by coronary heart disease. Atrial fibrillation and renal dysfunction are common precipitating factors and complications of heart failure, and the condition is characterised by symptoms such as shortness of breath and fatigue, and signs such as fluid retention.

Around 900,000 people in the U.K. suffer from heart failure, and this number is set to rise due to an ageing population, improved post-infarction survival rates, and more effective treatments3. In 2007 it was estimated that 1.81% of the population aged 45 years or older suffered from heart failure4. The prevalence of heart failure rises steeply with age, with the British Heart Foundation Statistics Database estimating in 2009 that 13.7% of men and 12.5% of women aged over 75 years in England suffer from the condition5. Heart failure constitutes a large burden on the NHS, accounting for one million inpatient bed-days – 2% of the NHS total – and 5% of all emergency hospital admissions6.

Survival rates for heart failure patients who receive sub-optimal care are poor. 40% of newly diagnosed patients die within a year,7 and total annual mortality ranges from 10-50%, depending on severity. These figures are supported by the mortality rates reported by the National Heart Failure Audit, which has consistently recorded one-year mortality of around 30% since 2008.8 Heart failure patients can also experience poor quality of life, experiencing pain, dyspnoea (shortness of breath) and fatigue. Heart failure patients also often suffer from mental health problems, with studies showing that over half report low mood, and more than a third suffer from major depression.9 10 These outcomes reflect considerable variation in standards of care: optimal treatment and management of heart failure results in significantly improved prognosis, with fewer symptoms and increased life expectancy.

2.2 The role of the auditNational clinical audit is designed to monitor clinical practice and patient outcomes with a view to evaluating hospital performance and driving up standards of care. The National Heart Failure Audit was established in 2007 with the aim of helping clinicians improve the quality of heart failure services and to achieve better outcomes for patients. The audit aims to capture data on clinical indicators which have a proven link to improved outcomes, and to encourage the increased use of clinically recommended diagnostic tools, disease modifying treatments and referral pathways.

A series of clinical care standards for heart failure have been developed, including the National Service Framework for Coronary Heart Disease (2000),11 NICE Clinical Guidance for Chronic Heart Failure (2010),12 NICE chronic heart failure quality standards (2011)13 and a standard for delivering heart failure care produced by the European Society of Cardiology Heart Failure Association (2011).14 The audit dataset corresponds to these standards, in order to evaluate the implementation of these existing evidence-based recommendations by hospitals in England and Wales. The audit dataset is regularly reviewed and updated to ensure it is in line with contemporary guidance.

2.3 National use of audit dataIn addition to this publicly available annual report, the analysis produced by the National Heart Failure Audit are used by national groups with a legitimate interest in the analysis.

The NHS Information Centre’s Indicators for Quality Improvement (IQI), a set of indicators developed to describe the quality of NHS service, include participation in the National Heart Failure Audit,15 and the NHS Choices website includes details of participation in the audit in its ‘scorecard’ for Trust performance.

Furthermore, the audit currently provides participation rates to the Care Quality Commission’s (CQC) ‘Quality and Risk Profiles’ (QRP),16 a tool used for gathering together key information about NHS organisations, which allows the CQC to monitor compliance with the essential standards of quality and safety. The QRP enable compliance inspectors to assess where risks lie and may prompt front line regulatory activity, such as further enquiries.

Clinical audit was one of six key areas raised under the heading ‘NHS’ in the Prime Minister’s Letter to Cabinet Ministers on transparency and open data which stated:

Clinical audit data, detailing the performance of publicly funded clinical teams in treating key healthcare conditions, will be published from April 2012. This service will be piloted in December 2011 using data from the latest National Lung Cancer Audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP).17

National Heart Failure Audit data will be published on data.gov.uk following the publication of this report in November 2012.

There are future plans to provide anonymised National Heart Failure Audit data, at a hospital level, to Cardiac Networks and Clinical Commissioning Groups. An archive of annual audit reports, containing national aggregate data, is also available for download on NICOR’s publicly accessible website. The National Heart Failure Audit had also been published in Heart journal.18



2.4 Organisation of the audit

The National Heart Failure Audit is managed by the National Institute for Cardiovascular Outcomes Research (NICOR), and receives clinical direction and leadership from the British Society for Heart Failure. It is overseen by a Project Board which represents key stakeholders, including cardiologists, heart failure nurses, Cardiac Networks and heart failure patients.i

The audit is one of six national clinical audits managed by NICOR, part of the National Centre for Cardiovascular Prevention and Outcomes at University College London. These audits are funded by HQIP, which holds commissioning and funding responsibility for 40 national clinical audits in the NACPOP.19

2.5 The scope of the auditThe National Heart Failure Audit collects data on acute patients discharged from hospitals in England and Wales with a primary diagnosis of heart failure on discharge, designated by any of the following ICD-10 codes:

I11.0 Hypertensive heart disease with (congestive) heart failure

I25.5 Ischaemic cardiomyopathy

I42.0 Dilated cardiomyopathy

I42.9 Cardiomyopathy, unspecified

I50.0 Congestive heart failure

I50.1 Left ventricular failure

I50.9 Heart failure, unspecified

Only acute patients should be included in the National Heart Failure Audit, so those patients admitted for elective procedures, for example elective pacemaker implantation or angiography, ought not to be included. Large numbers of these patients being included in the audit has led to several thousand records being deleted from the dataset in the data cleaning process (this is detailed in section 3.1).

Participation is currently defined as an NHS Trust or Welsh Health Board submitting a minimum of 20 cases to the audit database each calendar month, or the full number of cases if fewer than 20 patients with heart failure are discharged from the Trust in a month. Participation in the audit has been mandated in the Department of Health’s standard terms and conditions for acute hospital services in 2011/12, covering all acute hospitals in England.20 Participation in the audit has been mandatory for Welsh Local Health Boards since April 2012.21

Although a large proportion of the treatment of chronic heart failure occurs in the community, the National Heart Failure Audit currently only covers acute heart failure admissions to hospital, partly due to IT limitations. The development of a web-based platform for the database in 2013 will make

it feasible for community hospitals and other primary care institutions to participate in the audit.

2.6 The databaseIn 2011/12 the dataset contained 38 core fields, covering patient details and demographics, medical history, symptoms, diagnosis, treatment on discharge, referral to follow-up services and place of care in hospital.

In March 2011 a revision of the dataset increased the number of core fields to 59. New fields have been added to bring the audit in line with latest NICE guidance,22 23 as well as to ensure that mortality analysis can be adequately risk adjusted to account for known confounding factors. The new fields include input from a multidisciplinary heart failure team, discharge planning, as well as increasing the data collected on medical history, diagnostic tests and follow-up services. These new fields will be included in the analysis in the 2012/13 annual report.

2.7 Data collection and ITUser roles vary between hospitals, but the personnel involved in collecting and inputting data tend to be Heart Failure Specialist Nurses, clinical audit leads, and clinical effectiveness managers. Some of the more effective systems of data collection and data entry use nurses or other clinical staff to interpret medical notes and collect data, and clerical staff or clinical audit facilitators to enter it onto the database. This ensures that the data is clinically accurate whilst making optimal use of clinicians’ time.

Hospitals are responsible for ensuring that data is entered accurately but the database contains a series of validation checks to ensure that contradictory and clinically improbable data are not entered into the audit. A pro forma, designed to aid data collection, can be downloaded from the NICOR website, along with a set of application notes which defines and explains core data items.24 The application notes will be regularly reviewed to ensure they are clinically accurate and will be amended in response to comments and questions from users to cover frequently asked questions and points of contention.

All data are submitted electronically by hospital into a secure central database. To ensure patient confidentiality the database uses advanced data encryption technology and access control through a secure key system. Data can be inputted manually or imported from locally developed systems or third party commercial databases.

i. See Appendix 1 for details of project board membership.



2.8 Improving our IT platformEarlier this year NICOR began a major project to upgrade its data collection and management systems. The current Lotus Notes software has become increasingly unwieldy as the NICOR databases have grown in size and complexity. A new platform will substantially improve NICOR’s ability to derive high-quality analyses from the National Heart Failure Audit to inform hospitals, Cardiac Networks and patients regarding the provision of cardiac care.

The first step in this project involved a transfer of all data from the NHS Information Centre for Health and Social Care onto secure NICOR servers. This involved re-issuing a new user ID to every database user. The migration was not easy, and it led to some delays in accessing the National Heart Failure Audit. Despite these difficulties, participating hospitals submitted their data on time, making possible the timely publication of this report. We would like to thank everyone for their effort and patience during the migration.

The second phase involves the development of a new IT platform which will be rolled out in stages throughout 2013, with the National Heart Failure Audit being the first to be transferred in April.

2.9 Improving analysisThe processes that NICOR uses for analysing National Heart Failure Audit data have also undergone substantial changes this year. Until recently NICOR data were analysed using software and ad hoc analytic codes that were neither consistent nor easy to manage. In preparation for the incorporation of analytic technologies into the new NICOR system, code that was written in SPSS and Excel spreadsheets (for analyses presented in this annual report) was migrated to a standard cross-audit analytic platform based on the R statistical processing language - precise details are available from NICOR.

Migration of the National Heart Failure Audit to the new platform for statistical analysis began in August 2012 and continues, with an intended completion date of June 2013.

The results presented in this annual report were generated using some, but not all, elements of the new platform. Because the new analytic platform is still under development, with incremental improvements expected over the next few months, the results presented in this report should be considered preliminary and subject to change. Any substantive differences that follow improvements in filtering and more sophisticated statistical modelling of the data will be highlighted in next year’s annual report.



3 Findings

3.1 Data cleaning and data qualityAs of 31st June 2012, the total number of records submitted to the National Heart Failure Audit database since 2007 was 137,637. Of these, 41,635 were patients discharged from hospital between 1st April 2011 and 31st March 2012.

Table 1: Records excluded from analysis in this report

Number excluded from full dataset (number excluded from 2011/12 dataset)

Admission/readmission dataset

Reason

16 (3) Admission Missing or invalid hospital identifier

8 (5) Readmission Missing or invalid hospital identifier

14 (2) Admission Identical duplicate of another row

67 (2) Readmission Identical duplicate of another row

6 (6) Admission Non-identical rows with duplicate ‘unique’ ID

4268 (299) Admission/Readmission

Time to discharge < 0


Time to discharge 0 or 1 day, and survived to discharge*


Time to discharge 0 or 1 day, and no MRIS life status*

*0 and 1 day admissions who survived to discharge were determined to be outside of the scope of the audit. The National Heart Failure Audit measures acute admissions to hospital, and these patients were deemed very likely to be elective admissions for pacemaker implantation or angiography, and so were excluded from the audit. Patients who had a length of stay of 0 or 1 days and died in hospital were not excluded.

Table 2: Records excluded from mortality analysis in this report

Number secluded from 2009-12 survival analysis (number excluded from 2001/12 dataset)

Reason

4370 (2019) No MRISii life status

708 (303) Time from discharge to follow-up either < 0 or > longest possible interval

3.2 Participation

3.2.1 Number of Trusts

149 NHS Acute Trusts in England and six Health Boards in Wales discharged patients with a coded diagnosis of heart failure in 2011/12, according to HES and PEDW data.iii Out of these 137 NHS Trusts (91.9%) and five Health Boards (83.3%) submitted data to the audit – a total of 91.6% of all eligible institutions. In England 88 of the eligible institutions (64.2%) met the National Heart Failure Audit participation requirements of 20 cases per calendar month, or submitted more than 70% of their HES-recorded heart failure discharges. 70% was chosen as the cut-off point because this was the overall case ascertainment rate aimed for in the 2011/12 audit. A further 37 Trusts (27.0%) submitted less than 70% of their HES figures, but still between 10 and 20 cases per month. In Wales no Health Boards met the participation requirements, and three (50.0%) submitted between 10 and 20 cases per month.

The audit has therefore met its participation target of at least 90% of NHS Trusts in England and Health Boards in Wales submitting data to the audit in 2011/12. This marks a significant improvement on the 85% of Trusts taking part in 2010/11. Participation analysis, by Trust, can be found in the hospital level analysis in section 3.7 of this report.

No data were submitted by 12 Trusts in England and one Health Board in Wales (those marked with a * have not registered to participate at time of publication):

Non-submitting Trusts in England

Airedale NHS Foundation Trust

East Kent Hospitals University NHS Foundation Trust

Medway NHS Foundation Trust*

Papworth Hospital NHS Foundation Trust*

Plymouth Hospitals NHS Trust*

Royal United Hospital Bath NHS Trust

South Warwickshire NHS Foundation Trust

The Princess Alexandra Hospital NHS Trust*

The Royal Bournemouth and Christchurch Hospitals NHS

Foundation Trust

Trafford Healthcare NHS Trust*

University Hospitals of Leicester NHS Trust

University Hospitals of Morecambe Bay NHS Foundation Trust*

ii. The life status of all patients in the National Heart Failure Audit is provided by the Data Linkage Service of the NHS Information Centre (NHS IC). The audit data is linked to death registration data from the Office of National Statistics (ONS).

iii. Hospital Episode Statistics (HES) and Patient Episode Database for Wales (PEDW) are the national statistical data warehouses for England and Wales respectively, recording details of all patient admissions to NHS hospitals.



Non-submitting Health Boards in Wales

Cardiff & Vale University Health Board

From April 2013 Trusts will be required to submit all of the patients discharged with a coded diagnosis of heart failure, and this number will be measured against the number of heart failure coded discharges recorded by HES in England and PEDW in Wales. Collecting data on all heart failure discharges will prevent any selection bias in the patient records submitted to the audit, and will thus ensure the representativeness of the National Heart Failure Audit. It will also significantly augment the research value of the dataset.

3.2.2 Number of patients

The total number of records submitted to the National Heart Failure Audit in 2011/12 was 41,635. After data cleaning and exclusion of invalid records (detailed above in section 3.1), the total number of records was 37,076. This was made up of 32,906 index admissions and 4,170 readmissions within the audit period.

Of the index admissions, 24649 (74.9%) were recorded as having a confirmed diagnosis of heart failure, defined as a diagnosis of heart failure that has been confirmed by imaging or brain natriuretic peptide (BNP) measurement either during this admission or at a previous time. It is acknowledged that in some cases a clinician may justifiably diagnose heart failure in the absence of tests.

3.2.3 Case ascertainment

The total number of cases where a patient was discharged with a primary diagnosis of heart failure recorded by HES and PEDW is 63,431, so the National Heart Failure audit currently represents 58.5% of all heart failure discharges in England and Wales.

In England records were submitted on a total of 36,559 heart failure admissions, 61.9% of the 59,083 patients with heart failure recorded by HES in 2010/11; in Wales 517 records were submitted, 11.9% of the 4,348 total reported by PEDW in 2011/12.

Overall this does not constitute a large increase compared to the number of patients recorded in the audit in 2010/11 (36,504 records, case ascertainment 54%). However if case ascertainment were judged against the 41,635 records counted prior to the data cleaning process, it would stand at 70.5% of all heart failure admissions. The lower-than-anticipated case ascertainment reflects the large number of 0 and 1 day admissions which were deleted as part of an extensive data cleaning process detailed in section 3.1 above. This has highlighted the need to remind participating hospitals not to include elective patients in the audit.

Although Welsh case ascertainment has improved, it remains unsatisfactorily low. However as of April 2012 participation in the National Heart Failure Audit has been mandated by the Welsh Government, and as a result of this all Welsh Health Boards and

the majority of hospitals have registered with the audit.

3.3 Demographics

3.3.1 Age

The mean age of patients on their first admission in 2011/12 was 77.7, and on readmission 77.2; the median age was 80.1 on admission and 79.6 on readmission. 66.6% of patients were over 75 at their first admission, and 64.9% of readmitted patients were over 75.

3.3.2 Age and sex

The mean age at first admission for men was 75.5 years, and 80.3 years for women. As in previous reports, the majority of patients up to the age of 85 were men (61.1%); in those over the age of 85 there were more women (57.9%).

Overall there were more men recorded in the audit than women, with men comprising 55.2% of the patient group at index admission and 58.2% at readmission.

3.3.3 Age and Index of Multiple Deprivation

As recorded in previous years, age at admission was related to Index of Multiple Deprivation. Index of Multiple Deprivation was assigned to each patient based on their postcode of residence. Indices of Multiple Deprivation are allocated to 34,378

Age group

Num

ber

of p

atie

nts

8000

6000

4000

2000

0 18-44 45-54 55-64 65-74 75-84 85+

Fig 1: Age at first admission by sex

Men

Women

6505

5304

2127

4051

862

2072

371862

219433

5836

4243



areas in England and Wales, each with an average of 1,500 and a minimum of 1,000 residents. There are seven factors considered: income deprivation; employment deprivation; health deprivation and disability; education, skills and training deprivation; barriers to housing and services; crime; and living environment deprivation.

Mean age of admission for patients in the most deprived quintile, with a deprivation score of 5, was 74.5 years, compared with a mean age at admission of 79.6 years for patients in the least deprived quintile, with a deprivation score of 1 (figure 2). This is similar to the average age difference recorded last year (4.9 years). The National Heart Failure Audit intends to carry out further analysis on the variation in the treatment and management of heart failure in patients based on their Index of Multiple Deprivation.

3.4 Hospitalisation

3.4.1 In-hospital care

47.6% of heart failure patients in the audit were treated in cardiology wards, with 41.3% being treated on general medical wards, and 10.8% on other wards. These findings do not show much change from 2010/11, when 45% of patients were treated on both cardiology wards and general medical wards, and the demographic characteristics of these patients also reflect last year’s findings. 54.1% of men were treated on cardiology wards, compared with only 39.5% of women. Women were more likely to be treated on general medical wards (47.9% vs. 36.0%) and other wards (12.4% vs. 9.5%). The likelihood of being treated on a cardiology ward decreased with age: 76.3% of patients who were 16-44 were treated on cardiology wards, compared with 47.1% of patients in the 74-84 age group, and 32.1% of patients over 85.

3.4.2 Length of stay

The overall mean length of stay was 13.1 days on index admission and 13.4 days on readmission, and the median length of stay was 9.0 days for both index admissions and readmissions. Mean length of stay was 12.7 days for those patients treated in a cardiology ward, 13.1 days for those treated in a general medical wards, and 14.7 days for patients in other wards. Median length of stay was 9 days for patients treated on cardiology wards, 8 days for patients treated on general medical wards, and 10 days for patients on other wards.

Both mean and median length of stay varied significantly between hospitals, although the very high and very low mean figures may in many cases be explained by low numbers of

Fig 2: The effect of deprivation on age of first admission

Index of multiple deprivation

Mea

n ag

e at

firs

t adm

issi

on

in a

udit

per

iod

2011

/12

80

79

78

77

76

75

74

73

72

71

70 1 2 3 4 5

74.5

76.9

78.3

79.179.6

1= least deprived 5= most deprived

Fig 3: Mean length of stay by hospital

0 5 10 15 20 25

Hos

pita

ls

Length of stay (mean) in days

Fig 4: Median length of stay by hospital

0 5 10 15 20

Hos

pita

ls

Length of stay (median) in days



patients submitted, with abnormally long or short admission spells (figure 3, figure 4).

3.4.3 Readmission

Readmission data are incomplete since only readmission with a primary diagnosis of heart failure will be identified and not all cases even with a primary diagnosis have been recorded. The audit group is planning to identify readmissions from HES data in future years. This should provide robust data on readmission.

There were 4,170 readmissions to hospital recorded in 2011/12. The analysis for this report defines an admission as the index admission within the audit period. There are some records of patients who were admitted to hospital with heart failure in 2011/12 who had been previously admitted in an earlier audit year. Such a record is treated as an admission for the purpose of this analysis, because it is the first admission for a patient within the audit period, although it is not the patient’s first admission to hospital with heart failure. 7,357 (19.8%) of the 37,076 records submitted to the National Heart Failure Audit in 2011/12 were readmissions, although only 4,170 (11.2%) were readmissions within the audit period.

Most of these patients were only readmitted once, but some were readmitted two times or more (figure 5). The highest number of readmissions for a single patient was 10.

3.5 Aetiology

3.5.1 Symptoms

40% of patients were in NYHA class III at first admission, with breathlessness on minimal activity, and 32% were deemed

to be in NYHA class IV, with breathlessness at rest. 29% of patients were admitted with moderate peripheral oedema, and 16% with severe peripheral oedema.

Unsurprisingly, these symptoms were worse for readmissions to hospital, with 78% of readmitted patients in NYHA class III or IV, and 52% with moderate or severe oedema.

3.5.2 Aetiology

The aetiology of heart failure reported by the audit is very similar to that reported in previous years. Hypertension (54%) and ischaemic heart disease (IHD) (46%) were the most common contributory causes of heart failure; 26% of patients had a history of both.

31% of patients in the audit had suffered a previous acute myocardial infarction (AMI), and 36% had a history of arrhythmia. Diabetes (31%) and valve disease (22%) were also very common.

Patients with a history of IHD, atrial fibrillation, AMI and renal impairment were more likely to be diagnosed with LVSD, whereas patients with a history of valve disease or hypertension were more likely to be diagnosed with heart failure without LVSD (table 3).

Table 3: Previous medical history and diagnosis of LVSD

Medical History LVSD (%) Non-LVSD (%)

Ischaemic Heart Disease

51 39

Atrial Fibrillation 41 30

Acute Myocardial Infarction

37 22

Valvular Heart Disease 19 28

Hypertension 52 58

Renal Impairment 26 17

p-value ≤0.001 in all cases

3.6 Diagnosis

3.6.1 Echocardiography

86.0% of the patients recorded in the audit had an echocardiogram (echo) or other NICE-recommended imaging test, for example radionuclide imaging, computerised tomography (CT) scan or cardiac magnetic resonance imaging (MRI).

Echocardiography rates continue to be commendably high, with 2011/12 findings representing an increase on the 82% recorded in 2010/11. However access to echocardiography was dependent on several factors: Patients were more likely to receive a diagnostic imaging test if they were men, with 88.8% of men having an echo compared to 82.6% of women. Patients

1.4%3%14.4%

81.2% 1 readmission

2 readmissions

3 readmissions

4+ readmissions

Fig 5: Number of readmissions in 2011/12



aged less than 75 years were also more likely to have an echo (91.4% vs. 83.3%) as were those admitted to a cardiology ward (92.9% vs. 80.1% of those admitted to general medical wards, and 77.8% of patients admitted to other wards).

3.6.2 Diagnosis

Of those patients who had an echo, 65.0% were diagnosed with LVSD. 13.8% of patients were diagnosed with valve disease following an echo, but only 3.8% were reported to have left-ventricular hypertrophy (LVH) and 4.3% diastolic dysfunction. It is likely that low rates of LVH and diastolic dysfunction reflect under-reporting.

Men were more likely to be diagnosed with LVSD, as were younger patients. 53.1% of patients over 75 were diagnosed with LVSD, compared with 70.7% of patients aged under 75 years. 67.6% of men and 48.3% of women had an echo diagnosis of LVSD, but women were more likely to be diagnosed with diastolic dysfunction (5.0% vs. 3.1%), LVH (4.0% vs. 3.0%) and valve disease (15.7% vs. 9.9%).

3.7 Treatment on discharge for LVSDAll analyses on prescription rates for disease modifying treatments were performed on a denominator of those patients with a diagnosis of LVSD who survived to discharge.

3.7.1 ACE inhibitor and ARB

72% of patients were discharged on an angiotensin-converting enzyme (ACE) inhibitor, and 84% were discharged on either an ACE inhibitor or an angiotensin receptor blocker (ARB), or both. 1% were prescribed both an ACE inhibitor and an ARB.

87% of patients treated in a cardiology ward were discharged on an ACE inhibitor and/or an ARB, compared to 80% of those treated in a general medical ward and 76% of patients treated in other wards. Men were more likely to receive an ACE inhibitor and/or ARB than women, as were younger patients. Prescription rates of ACEI/ARB were 85% for men and 83% for women, and 89% of patients under 75 were discharged on either of the treatments, compared with 80% of patients over 75.

3.7.2 Beta blocker

78% of patients were prescribed a beta blocker on discharge. This is considerably higher than the 65% recorded in the 2010/11 audit, which was considered unsatisfactorily low. This is consistent with NICE guidance on prescription of beta blockers, which recommends that they are given to all patients with a diagnosis of LVSD, including older patients and patients with chronic obstructive pulmonary disease (COPD) without reversibility.25

As with ACEI/ARB prescription, patients treated in a cardiology ward, men, and younger patients were all more likely to be

discharged on a beta blocker. 83% of patients treated on a cardiology ward were given beta blockers, compared with 71% for both general medical patients and those on other wards. 79% of men were discharged on beta blockers, compared with 76% of women, and 84% of patients under 75 received the treatment versus 74% of those over 75.

3.7.3 MRA

45% of patients with LVSD were discharged on a mineralocorticoid receptor antagonist (MRA).

Patients treated on cardiology wards were more likely to be prescribed an MRA (51%) compared with those on a general medical ward (37%) and patients on other wards (33%). Men were more likely to be discharged on an MRA than women (48% vs. 40%) as were patients under 75, compared with those over 75 (53% vs. 39%).

3.7.4 Loop diuretics

89% of patients in the audit were discharged on loop diuretics.

87% of patients on cardiology wards were prescribed a loop diuretic on discharge, slightly lower than the 93% of patients on general medical wards, and 90% of patients on other wards. Rates of prescription were similar in women and men (90% vs. 89%). Patients who were aged over 75 years on admission were more likely to be discharged on loop diuretics than younger patients (92% vs. 86%).

3.7.5 Thiazide diuretics

4% of patients were prescribed thiazide diuretics on discharge.

Prescription rates were a little higher for those patients treated on a cardiology ward (5%) than for those treated on a general medical ward (3%) and on other wards (3%). Men were more likely to be prescribed thiazide diuretics than women (5% vs. 3%), as were patients over 75 compared with those under 75 (6% vs. 3%).

3.7.6 Digoxin

23% of patients were prescribed digoxin on discharge.

Rates of prescription were similar in women and men (24% vs. 22%) and amongst patients aged above or below 75 years. Prescription rates were similar for patients on general medical (23%), cardiology (22%) and other wards (23%).

3.7.7 Treatment on discharge by age

The prescription of ACE inhibitors, beta blockers and MRAs decreased with age. Only prescription of loop diuretics was higher amongst older patients (figure 6).



3.8 Monitoring heart failure patients

3.8.1 Follow-up services

53.7% of patients were referred to a heart failure liaison service, which is defined as a nurse led heart failure clinic. Patients treated in a cardiology ward were more likely to be referred to heart failure liaison services: 64.1% compared to only 43.3% for those on general medical wards and 42.9% for those on other wards. 59.0% of men and 47.1% of women were referred to nurse-led follow-up, and 60.8% of those under 75, compared with 49.9% of patients over 75.

51.7% of patients were referred to cardiology follow-up, that is, any follow-up involving a consultant cardiologist. As with heart failure liaison follow-up, cardiology patients were far more likely to be referred to cardiology follow-up, with 69.6% receiving onwards referral, compared with 34.4% of general medical patients and 31.7% of patients on other wards. Men were more likely to be referred to cardiology follow-up than women (57.6% vs. 44.2%), as were those under 75, of whom 67.2% received cardiology follow-up, compared to only 43.3% of patients over 75.

76.5% of patients were referred onwards to their GP for follow-up, and 13.5% were referred to care of the elderly follow-up services.

3.8.2 Palliative care

Only 3.1% of patients were referred to palliative care services following the first admission, and 7.3% following a readmission.

This does not constitute a significant improvement on 2010/11 data, which recorded referral levels of 4% on admission and 6% on readmission. These numbers are surprisingly low considering the age of the patient population, and the high mortality rates in the year following discharge.

Age group

% o

f pat

ient

s ke

y he

art f

ailu

re d

rugs

100

90

80

70

60

50

40

30

20

10

0 18-44 45-54 55-64 65-74 75-84 85+

Fig 6: Treatment for LVSD on discharge by age

ACEI

Beta blocker

Loop diuretic

MRA



3.9

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the

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t (af

ter

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the

num

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Tabl

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nmen

t in

Engl

and

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t nam

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l nam

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3655

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559

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110.

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iv. HES data is from 2010/11, and PEDW data from 2011/12, due to availability.



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547

513

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Yes

234

205

161

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al

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l22

0

SMV

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Hos

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239

91.6

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123

416

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9

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ders

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S Fo

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771

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Yes

512

444

452

RH

IC

alde

rdal

e R

oyal

Hos

pita

l18

5

HU

DH

udde

rsfie

ld R

oyal

In

firm

ary

182

Cam

brid

ge U

nive

rsity

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

224.

7%P

artia

l46

736

230

4A

DD

Add

enbr

ooke

's H

ospi

tal

22

Cen

tral

Man

ches

ter

Uni

vers

ity H

ospi

tals

N

HS

Foun

datio

n Tr

ust

221

71.1

%Ye

s31

132

743

6M

RI

Man

ches

ter

Roy

al

Infir

mar

y22

1

Che

lsea

and

Wes

tmin

ster

Hos

pita

l NH

S Fo

unda

tion

Trus

t84

46.4

%P

artia

l18

110

711

2W

ESC

hels

ea a

nd W

estm

inst

er

Hos

pita

l84

Che

ster

field

Roy

al H

ospi

tal N

HS

Foun

datio

n Tr

ust

178

63.1

%P

artia

l28

226

925

7C

HE

Che

ster

field

Roy

al

Hos

pita

l17

8

City

Hos

pita

ls S

unde

rlan

d N

HS

Foun

datio

n Tr

ust

245

67.7

%Ye

s36

243

647

5SU

NSu

nder

land

Roy

al

Hos

pita

l24

5

Col

ches

ter

Hos

pita

l Uni

vers

ity N

HS

Foun

datio

n Tr

ust

381

86.8

%Ye

s43

936

231

0C

OL

Col

ches

ter

Gen

eral

H

ospi

tal

381

Cou

ntes

s of

Che

ster

Hos

pita

l NH

S Fo

unda

tion

Trus

t34

113

2.2%

Yes

258

215

208

CO

CC

ount

ess

of C

hest

er

Hos

pita

l34

1

Cou

nty

Dur

ham

and

Dar

lingt

on N

HS

Foun

datio

n Tr

ust

325

58.9

%Ye

s55

252

955

8

DR

YU

nive

rsity

Hos

pita

l of

Nor

th D

urha

m18

0

DA

RD

arlin

gton

Mem

oria

l H

ospi

tal

145

Cro

ydon

Hea

lth

Serv

ices

NH

S Tr

ust

223

75.6

%Ye

s29

523

220

5M

AYC

royd

on U

nive

rsity

H

ospi

tal

223



Dar

tfor

d an

d G

rave

sham

NH

S Tr

ust

7323

.7%

Par

tial

308

228

191

DVH

Dar

ent V

alle

y H

ospi

tal

73

Der

by H

ospi

tals

NH

S Fo

unda

tion

Trus

t19

638

.4%

Par

tial

510

418

380

DER

Roy

al D

erby

Hos

pita

l19

6

Don

cast

er a

nd B

asse

tlaw

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

197

37.4

%P

artia

l52

744

644

1D

IDD

onca

ster

Roy

al In

firm

ary

128

BSL

Bas

setl

aw H

ospi

tal

69

Dor

set C

ount

y H

ospi

tal N

HS

Foun

datio

n Tr

ust

176

89.8

%Ye

s19

620

117

9W

DH

Dor

set C

ount

y H

ospi

tal

176

Ealin

g H

ospi

tal N

HS

Trus

t26

211

8.0%

Yes

222

158

181

EAL

Ealin

g H

ospi

tal

262

East

and

Nor

th H

ertf

ords

hire

NH

S Tr

ust

481

134.

7%Ye

s35

730

525

3

LIS

List

er H

ospi

tal

267

QEW

Que

en E

lizab

eth

II H

ospi

tal

214

East

Che

shir

e N

HS

Trus

t16

764

.0%

Par

tial

261

152

171

MAC

Mac

cles

field

Dis

tric

t G

ener

al H

ospi

tal

167

East

Ken

t Hos

pita

ls U

nive

rsity

NH

S Fo

unda

tion

Trus

t0

0.0%

No

833

661

636

KC

CK

ent a

nd C

ante

rbur

y H

ospi

tal

0

QEQ

Que

en E

lizab

eth

The

Que

en M

othe

r H

ospi

tal

0

WH

HW

illia

m H

arve

y H

ospi

tal

0

East

Lan

cash

ire

Hos

pita

ls N

HS

Trus

t23

447

.4%

Par

tial

494

515

536

BLA

Roy

al B

lack

burn

Hos

pita

l23

4

East

Sus

sex

Hea

lthc

are

NH

S Tr

ust

424

69.3

%Ye

s61

247

633

8

CG

HC

onqu

est H

ospi

tal

218

DG

EEa

stbo

urne

Dis

tric

t G

ener

al H

ospi

tal

206

Epso

m a

nd S

t Hel

ier

Uni

vers

ity H

ospi

tals

N

HS

Trus

t21

057

.9%

Par

tial

363

349

319

SHC

St H

elie

r H

ospi

tal

110

EPS

Epso

m H

ospi

tal

100

Frim

ley

Par

k H

ospi

tal N

HS

Foun

datio

n Tr

ust

287

121.

6%Ye

s23

623

625

7FR

MFr

imle

y P

ark

Hos

pita

l28

7

Gat

eshe

ad H

ealt

h N

HS

Foun

datio

n Tr

ust

128

56.6

%P

artia

l22

626

224

9Q

EGQ

ueen

Eliz

abet

h H

ospi

tal

(Gat

eshe

ad)

128

Geo

rge

Elio

t Hos

pita

l NH

S Tr

ust

261

133.

2%Ye

s19

621

719

1N

UN

Geo

rge

Elio

t Hos

pita

l26

1

Glo

uces

ters

hire

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

121

23.9

%P

artia

l50

746

741

2

GLO

Glo

uces

ters

hire

Roy

al

Hos

pita

l67

CH

GC

helt

enha

m G

ener

al

Hos

pita

l54

Gre

at W

este

rn H

ospi

tals

NH

S Fo

unda

tion

Trus

t21

283

.8%

Yes

253

275

276

PM

STh

e G

reat

Wes

tern

H

ospi

tal

212



Trus

t nam

eTr

ust

reco

rds

subm

itte

d

% H

ES

subm

itte

dPa

rtic

ipat

ion

stat

usP

rim

ary

HES

hea

rt

failu

re

disc

harg

es

Seco

ndar

y H

ES h

eart

fa

ilure

di

scha

rges

Tert

iary

HES

he

art f

ailu

re

disc

harg

es

NIC

OR

ho

spit

al

code

Hos

pita

l nam

eH

ospi

tal

reco

rds

subm

itte

d

Guy

's a

nd S

t Tho

mas

' NH

S Fo

unda

tion

Trus

t22

956

.4%

Par

tial

406

368

351

STH

St T

hom

as' H

ospi

tal

229

Ham

pshi

re H

ospi

tals

NH

S Fo

unda

tion

Trus

t12

838

.4%

Par

tial

333

265

295

NH

HB

asin

gsto

ke a

nd N

orth

H

amps

hire

Hos

pita

l12

8

RH

CR

oyal

Ham

pshi

re C

ount

y H

ospi

tal

0

Har

roga

te a

nd D

istr

ict N

HS

Foun

datio

n Tr

ust

130

60.5

%P

artia

l21

515

316

2H

AR

Har

roga

te D

istr

ict

Hos

pita

l13

0

Hea

rt o

f Eng

land

NH

S Fo

unda

tion

Trus

t36

832

.8%

Yes

1122

740

757

EBH

Bir

min

gham

Hea

rtla

nds

Hos

pita

l20

7

SOL

Solih

ull H

ospi

tal

161

GH

SG

ood

Hop

e H

ospi

tal

0

Hea

ther

woo

d an

d W

exha

m P

ark

Hos

pita

ls

NH

S Fo

unda

tion

Trus

t71

18.3

%P

artia

l38

829

227

9W

EXW

exha

m P

ark

Hos

pita

l71

Hin

chin

gbro

oke

Hea

lth

Car

e N

HS

Trus

t38

22.5

%P

artia

l16

915

111

1H

INH

inch

ingb

rook

e H

ospi

tal

38

Hom

erto

n U

nive

rsity

Hos

pita

l NH

S Fo

unda

tion

Trus

t21

286

.5%

Yes

245

144

154

HO

MH

omer

ton

Uni

vers

ity

Hos

pita

l21

2

Hul

l and

Eas

t Yor

kshi

re H

ospi

tals

NH

S Tr

ust

737

171.

0%Ye

s43

141

146

4C

HH

Cas

tle H

ill H

ospi

tal

627

Hul

l and

Eas

t Yor

kshi

re H

ospi

tals

NH

S Tr

ust

HR

IH

ull R

oyal

Infir

mar

y11

0

Impe

rial

Col

lege

Hea

lthc

are

NH

S Tr

ust

491

79.1

%Ye

s62

159

462

1ST

MSt

Mar

y's

Hos

pita

l P

addi

ngto

n24

1

Impe

rial

Col

lege

Hea

lthc

are

NH

S Tr

ust

HA

MH

amm

ersm

ith H

ospi

tal

151

Impe

rial

Col

lege

Hea

lthc

are

NH

S Tr

ust

CC

HC

hari

ng C

ross

Hos

pita

l99

Isle

of W

ight

NH

S P

CT

173

88.3

%Ye

s19

614

811

8IO

WSt

Mar

y's

Hos

pita

l, N

ewpo

rt17

3

Jam

es P

aget

Uni

vers

ity H

ospi

tals

NH

S Fo

unda

tion

Trus

t11

434

.7%

Par

tial

329

292

310

JPH

Jam

es P

aget

Uni

vers

ity

Hos

pita

l11

4

Ket

teri

ng G

ener

al H

ospi

tal N

HS

Foun

datio

n Tr

ust

239

79.1

%Ye

s30

223

025

2K

GH

Ket

teri

ng G

ener

al

Hos

pita

l23

9

Kin

g's

Col

lege

Hos

pita

l NH

S Fo

unda

tion

Trus

t24

561

.7%

Yes

397

332

362

KC

HK

ing'

s C

olle

ge H

ospi

tal

245

Kin

gsto

n H

ospi

tal N

HS

Trus

t30

994

.5%

Yes

327

264

204

KTH

Kin

gsto

n H

ospi

tal

309



Lanc

ashi

re T

each

ing

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

566

123.

3%Ye

s45

958

146

9

RP

HR

oyal

Pre

ston

Hos

pita

l33

4

CH

OC

horl

ey a

nd S

outh

Rib

ble

Hos

pita

l23

2

Leed

s Te

achi

ng H

ospi

tals

NH

S Tr

ust

248

30.4

%Ye

s81

571

970

4LG

ILe

eds

Gen

eral

Infir

mar

y24

8

Lew

isha

m H

ealt

hcar

e N

HS

Trus

t11

740

.5%

Par

tial

289

181

175

LEW

Uni

vers

ity H

ospi

tal

Lew

isha

m11

7

Live

rpoo

l Hea

rt a

nd C

hest

Hos

pita

l NH

S Fo

unda

tion

Trus

t13

664

.5%

Par

tial

211

118

150

BH

LLi

verp

ool H

eart

and

Che

st

Hos

pita

l13

6

Luto

n an

d D

unst

able

Hos

pita

l NH

S Fo

unda

tion

Trus

t34

612

1.8%

Yes

284

271

255

LDH

Luto

n an

d D

unst

able

H

ospi

tal

346

Mai

dsto

ne a

nd T

unbr

idge

Wel

ls N

HS

Trus

t40

490

.2%

Yes

448

448

336

MA

IM

aids

tone

Hos

pita

l22

6

KSX

Tunb

ridg

e W

ells

Hos

pita

l17

8

Med

way

NH

S Fo

unda

tion

Trus

t0

0.0%

No

300

241

256

MD

WM

edw

ay M

ariti

me

Hos

pita

l0

Mid

Che

shir

e H

ospi

tals

NH

S Fo

unda

tion

Trus

t26

312

6.4%

Yes

208

228

216

LGH

Leig

hton

Hos

pita

l26

3

Mid

Ess

ex H

ospi

tal S

ervi

ces

NH

S Tr

ust

136

34.7

%P

artia

l39

221

120

1B

FHB

room

field

Hos

pita

l13

6

Mid

Sta

ffor

dshi

re N

HS

Foun

datio

n Tr

ust

7425

.2%

Par

tial

294

227

187

SDG

Staf

ford

Hos

pita

l74

Mid

Yor

kshi

re H

ospi

tals

NH

S Tr

ust

420

64.9

%Ye

s64

749

139

3

PIN

Pin

derfi

elds

Hos

pita

l30

1

DEW

Dew

sbur

y an

d D

istr

ict

Hos

pita

l11

9

Milt

on K

eyne

s H

ospi

tal N

HS

Foun

datio

n Tr

ust

154

75.9

%Ye

s20

316

412

9M

KH

Milt

on K

eyne

s G

ener

al

Hos

pita

l15

4

New

ham

Uni

vers

ity H

ospi

tal N

HS

Trus

t2

0.8%

Par

tial

242

169

169

NW

GN

ewha

m U

nive

rsity

H

ospi

tal

2

Nor

folk

and

Nor

wic

h U

nive

rsity

Hos

pita

ls

NH

S Fo

unda

tion

Trus

t37

451

.4%

Yes

728

696

746

NO

RN

orfo

lk a

nd N

orw

ich

Uni

vers

ity H

ospi

tal

374

Nor

th B

rist

ol N

HS

Trus

t48

412

6.7%

Yes

382

373

324

FRY

Fren

chay

Hos

pita

l27

9

BSM

Sout

hmea

d H

ospi

tal

205

Nor

th C

umbr

ia U

nive

rsity

Hos

pita

ls N

HS

Trus

t78

22.3

%P

artia

l35

037

231

0

CM

IC

umbe

rlan

d In

firm

ary

46

WC

IW

est C

umbe

rlan

d H

ospi

tal

32

Nor

th M

iddl

esex

Uni

vers

ity H

ospi

tal N

HS

Trus

t17

155

.3%

Par

tial

309

176

156

NM

HN

orth

Mid

dles

ex

Uni

vers

ity H

ospi

tal

171



Trus

t nam

eTr

ust

reco

rds

subm

itte

d

% H

ES

subm

itte

dPa

rtic

ipat

ion

stat

usP

rim

ary

HES

hea

rt

failu

re

disc

harg

es

Seco

ndar

y H

ES h

eart

fa

ilure

di

scha

rges

Tert

iary

HES

he

art f

ailu

re

disc

harg

es

NIC

OR

ho

spit

al

code

Hos

pita

l nam

eH

ospi

tal

reco

rds

subm

itte

d

Nor

th T

ees

and

Har

tlepo

ol N

HS

Foun

datio

n Tr

ust

383

140.

3%Ye

s27

332

931

6

NTG

Uni

vers

ity H

ospi

tal o

f N

orth

Tee

s23

4

HG

HU

nive

rsity

Hos

pita

l of

Har

tlepo

ol14

9

Nor

tham

pton

Gen

eral

Hos

pita

l NH

S Tr

ust

217

77.0

%Ye

s28

229

022

7N

THN

orth

ampt

on G

ener

al

Hos

pita

l21

7

Nor

ther

n D

evon

Hea

lthc

are

NH

S Tr

ust

212

74.9

%Ye

s28

323

121

9N

DD

Nor

th D

evon

Dis

tric

t H

ospi

tal

212

Nor

ther

n Li

ncol

nshi

re a

nd G

oole

Hos

pita

ls

NH

S Fo

unda

tion

Trus

t25

675

.5%

Yes

339

278

311

GG

HD

iana

Pri

nces

s of

Wal

es

Hos

pita

l16

1

SCU

Scun

thor

pe G

ener

al

Hos

pita

l95

Nor

thum

bria

Hea

lthca

re N

HS

Foun

datio

n Tr

ust

400

60.6

%Ye

s66

053

050

3

NTY

Nor

th T

ynes

ide

Hos

pita

l21

9

ASH

Wan

sbec

k G

ener

al

Hos

pita

l12

5

HEX

Hex

ham

Gen

eral

Hos

pita

l56

Not

tingh

am U

nive

rsity

Hos

pita

ls N

HS

Trus

t20

325

.5%

Par

tial

797

722

719

UH

NQ

ueen

's M

edic

al C

entr

e15

9

CH

NN

ottin

gham

City

Hos

pita

l44

Oxf

ord

Rad

cliff

e H

ospi

tals

NH

S Tr

ust

736

102.

5%Ye

s71

861

553

4R

AD

John

Rad

cliff

e H

ospi

tal

624

HO

RH

orto

n G

ener

al H

ospi

tal

112

Pap

wor

th H

ospi

tal N

HS

Foun

datio

n Tr

ust

00.

0%N

o27

428

222

7PA

PP

apw

orth

Hos

pita

l0

Pen

nine

Acu

te H

ospi

tals

NH

S Tr

ust

645

88.5

%Ye

s72

992

988

1

BR

YFa

irfie

ld G

ener

al H

ospi

tal

205

OH

MR

oyal

Old

ham

Hos

pita

l20

4

NM

GN

orth

Man

ches

ter

Gen

eral

Hos

pita

l18

3

BH

HR

ochd

ale

Infir

mar

y53

Pet

erbo

roug

h an

d St

amfo

rd H

ospi

tals

NH

S Fo

unda

tion

Trus

t29

689

.4%

Yes

331

280

251

PET

Pet

erbo

roug

h C

ity

Hos

pita

l29

6

Ply

mou

th H

ospi

tals

NH

S Tr

ust

00.

0%N

o63

552

549

8P

LYD

erri

ford

Hos

pita

l0

Poo

le H

ospi

tal N

HS

Foun

datio

n Tr

ust

307

146.

2%Ye

s21

023

719

8P

GH

Poo

le G

ener

al H

ospi

tal

307



Por

tsm

outh

Hos

pita

ls N

HS

Trus

t31

959

.5%

Yes

536

543

509

QA

PQ

ueen

Ale

xand

ra H

ospi

tal

319

Rot

herh

am N

HS

Foun

datio

n Tr

ust

227

78.8

%Ye

s28

832

325

0R

OT

Rot

herh

am H

ospi

tal

227

Roy

al B

erks

hire

NH

S Fo

unda

tion

Trus

t44

911

1.4%

Yes

403

305

261

BH

RR

oyal

Ber

kshi

re H

ospi

tal

449

Roy

al B

rom

pton

and

Har

efiel

d N

HS

Foun

datio

n Tr

ust

234

46.7

%P

artia

l50

151

237

5N

HB

Roy

al B

rom

pton

Hos

pita

l21

0

HH

Har

efiel

d H

ospi

tal

24

Roy

al C

ornw

all H

ospi

tals

NH

S Tr

ust

155

32.2

%P

artia

l48

142

839

5R

CH

Roy

al C

ornw

all H

ospi

tal

155

Roy

al D

evon

and

Exe

ter

NH

S Fo

unda

tion

Trus

t22

571

.9%

Yes

313

389

620

RD

ER

oyal

Dev

on &

Exe

ter

Hos

pita

l22

5

Roy

al F

ree

Lond

on N

HS

Trus

t22

384

.8%

Yes

263

229

224

RFH

Roy

al F

ree

Hos

pita

l22

3

Roy

al L

iver

pool

and

Bro

adgr

een

Uni

vers

ity

Hos

pita

ls N

HS

Trus

t33

014

8.6%

Yes

222

237

272

RLU

Roy

al L

iver

pool

Uni

vers

ity

Hos

pita

l33

0

Roy

al S

urre

y C

ount

y H

ospi

tal N

HS

Foun

datio

n Tr

ust

144

81.8

%Ye

s17

614

114

4R

SUR

oyal

Sur

rey

Cou

nty

Hos

pita

l14

4

Roy

al U

nite

d H

ospi

tal B

ath

NH

S Tr

ust

00.

0%N

o45

539

543

4B

ATR

oyal

Uni

ted

Hos

pita

l Bat

h0

Salfo

rd R

oyal

NH

S Fo

unda

tion

Trus

t24

194

.1%

Yes

256

331

301

SLF

Salfo

rd R

oyal

241

Salis

bury

NH

S Fo

unda

tion

Trus

t34

220

9.8%

Yes

163

139

150

SAL

Salis

bury

Dis

tric

t Hos

pita

l34

2

Sand

wel

l and

Wes

t Bir

min

gham

Hos

pita

ls

NH

S Tr

ust

345

48.8

%Ye

s70

761

460

8

DU

DB

irm

ingh

am C

ity H

ospi

tal

190

SAN

Sand

wel

l Gen

eral

H

ospi

tal

155

Scar

boro

ugh

and

Nor

th E

ast Y

orks

hire

NH

S Tr

ust

72.

7%P

artia

l25

825

621

2SC

ASc

arbo

roug

h G

ener

al

Hos

pita

l7

Shef

field

Tea

chin

g H

ospi

tals

NH

S Fo

unda

tion

Trus

t45

251

.3%

Yes

881

905

736

NG

SN

orth

ern

Gen

eral

H

ospi

tal

442

RH

AR

oyal

Hal

lam

shir

e H

ospi

tal

10

Sher

woo

d Fo

rest

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

315

72.2

%Ye

s43

626

922

1K

MH

Kin

g's

Mill

Hos

pita

l30

2

NH

NN

ewar

k H

ospi

tal

13

Shre

wsb

ury

and

Telfo

rd H

ospi

tals

NH

S Tr

ust

8519

.5%

Par

tial

437

331

304

TLF

Pri

nces

s R

oyal

Hos

pita

l (T

elfo

rd)

48

RSS

Roy

al S

hrew

sbur

y H

ospi

tal

37

Sout

h D

evon

Hea

lthc

are

NH

S Fo

unda

tion

Trus

t35

987

.1%

Yes

412

236

243

TOR

Torb

ay H

ospi

tal

359



Trus

t nam

eTr

ust

reco

rds

subm

itte

d

% H

ES

subm

itte

dPa

rtic

ipat

ion

stat

usP

rim

ary

HES

hea

rt

failu

re

disc

harg

es

Seco

ndar

y H

ES h

eart

fa

ilure

di

scha

rges

Tert

iary

HES

he

art f

ailu

re

disc

harg

es

NIC

OR

ho

spit

al

code

Hos

pita

l nam

eH

ospi

tal

reco

rds

subm

itte

d

Sout

h Lo

ndon

Hea

lthc

are

NH

S Tr

ust

262

34.7

%Ye

s75

655

052

6

GW

HQ

ueen

Eliz

abet

h H

ospi

tal

(Woo

lwic

h)23

7

BR

OP

rinc

ess

Roy

al U

nive

rsity

H

ospi

tal (

Bro

mle

y)24

QM

HQ

ueen

Mar

y's

Hos

pita

l (S

idcu

p)1

Sout

h Te

es H

ospi

tals

NH

S Fo

unda

tion

Trus

t20

943

.1%

Par

tial

485

563

817

SCM

Jam

es C

ook

Uni

vers

ity

Hos

pita

l20

9

FRH

Fria

rage

Hos

pita

l0

Sout

h Ty

nesi

de N

HS

Foun

datio

n Tr

ust

267

147.

5%Ye

s18

114

011

2ST

DSo

uth

Tyne

side

Dis

tric

t H

ospi

tal

267

Sout

h W

arw

icks

hire

NH

S Fo

unda

tion

Trus

t 0

0.0%

No

126

232

180

WA

RW

arw

ick

Hos

pita

l0

Sout

hend

Uni

vers

ity H

ospi

tal N

HS

Foun

datio

n Tr

ust

555

165.

2%Ye

s33

624

126

8SE

HSo

uthe

nd H

ospi

tal

555

Sout

hpor

t and

Orm

skir

k H

ospi

tal N

HS

Trus

t20

374

.6%

Yes

272

224

191

SOU

Sout

hpor

t and

For

mby

D

istr

ict G

ener

al H

ospi

tal

203

St G

eorg

e's

Hea

lthc

are

NH

S Tr

ust

229

43.3

%P

artia

l52

950

660

8G

EOSt

Geo

rge'

s H

ospi

tal

229

St H

elen

s an

d K

now

sley

Tea

chin

g H

ospi

tals

N

HS

Trus

t22

668

.5%

Par

tial

330

390

354

WH

IW

hist

on H

ospi

tal

226

Stoc

kpor

t NH

S Fo

unda

tion

Trus

t17

550

.0%

Par

tial

350

399

358

SHH

Step

ping

Hill

Hos

pita

l17

5

Surr

ey a

nd S

usse

x H

ealt

hcar

e N

HS

Trus

t30

290

.7%

Yes

333

302

242

ESU

East

Sur

rey

Hos

pita

l30

2

Tam

esid

e H

ospi

tal N

HS

Foun

datio

n Tr

ust

178

73.0

%Ye

s24

428

622

3TG

ATa

mes

ide

Gen

eral

H

ospi

tal

178

Taun

ton

and

Som

erse

t NH

S Fo

unda

tion

Trus

t30

087

.2%

Yes

344

343

292

MP

HM

usgr

ove

Par

k H

ospi

tal

300

The

Dud

ley

Gro

up N

HS

Foun

datio

n Tr

ust

180

38.7

%P

artia

l46

537

537

9R

US

Rus

sells

Hal

l Hos

pita

l18

0

The

Hill

ingd

on H

ospi

tals

NH

S Fo

unda

tion

Trus

t19

786

.8%

Yes

227

171

155

HIL

Hill

ingd

on H

ospi

tal

197

The

Ipsw

ich

Hos

pita

l NH

S Tr

ust

203

53.0

%P

artia

l38

341

842

9IP

STh

e Ip

swic

h H

ospi

tal

203

The

New

cast

le U

pon

Tyne

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

170

24.1

%P

artia

l70

468

055

9FR

EFr

eem

an H

ospi

tal

170

RVN

Roy

al V

icto

ria

Infir

mar

y0



The

Nor

th W

est L

ondo

n H

ospi

tals

NH

S Tr

ust

360

77.9

%Ye

s46

236

133

5

NP

HN

orth

wic

k P

ark

Hos

pita

l34

6

CM

HC

entr

al M

iddl

esex

H

ospi

tal

14

The

Pri

nces

s A

lexa

ndra

Hos

pita

l NH

S Tr

ust

00.

0%N

o29

021

823

8PA

HP

rinc

ess

Ale

xand

ra

Hos

pita

l0

The

Que

en E

lizab

eth

Hos

pita

l Kin

g's

Lynn

N

HS

Foun

datio

n Tr

ust

201

66.3

%P

artia

l30

329

131

6Q

KL

Que

en E

lizab

eth

Hos

pita

l (K

ing'

s Ly

nn)

201

The

Roy

al B

ourn

emou

th a

nd C

hris

tchu

rch

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

00.

0%N

o58

466

261

5B

OU

Roy

al B

ourn

emou

th

Gen

eral

Hos

pita

l0

The

Roy

al W

olve

rham

pton

Hos

pita

ls N

HS

Trus

t18

141

.0%

Par

tial

442

317

304

NC

RN

ew C

ross

Hos

pita

l18

1

The

Whi

ttin

gton

Hos

pita

l NH

S Tr

ust

137

53.9

%P

artia

l25

416

016

5W

HT

Whi

ttin

gton

Hos

pita

l13

7

Traf

ford

Hea

lthc

are

NH

S Tr

ust

00.

0%N

o96

104

83TR

ATr

affo

rd G

ener

al H

ospi

tal

0

Uni

ted

Linc

olns

hire

Hos

pita

ls N

HS

Trus

t25

332

.0%

Yes

790

748

693

PIL

Pilg

rim

Hos

pita

l10

6

LIN

Linc

oln

Cou

nty

Hos

pita

l10

1

GR

AG

rant

ham

and

Dis

tric

t H

ospi

tal

46

Uni

vers

ity C

olle

ge L

ondo

n H

ospi

tals

NH

S Fo

unda

tion

Trus

t33

512

9.3%

Yes

259

272

298

UC

LU

nive

rsity

Col

lege

H

ospi

tal

335

Uni

vers

ity H

ospi

tal o

f Nor

th S

taff

ords

hire

N

HS

Trus

t20

928

.1%

Par

tial

743

483

461

STO

Uni

vers

ity H

ospi

tal o

f N

orth

Sta

ffor

dshi

re20

9

Uni

vers

ity H

ospi

tal o

f Sou

th M

anch

este

r N

HS

Foun

datio

n Tr

ust

304

88.6

%Ye

s34

347

344

4W

YTW

ythe

nsha

we

Hos

pita

l30

4

Uni

vers

ity H

ospi

tal S

outh

ampt

on N

HS

Trus

t14

227

.3%

Par

tial

521

464

443

SGH

Sout

ham

pton

Gen

eral

H

ospi

tal

142

Uni

vers

ity H

ospi

tals

Bir

min

gham

NH

S Fo

unda

tion

Trus

t29

244

.0%

Yes

663

382

357

QEB

Que

en E

lizab

eth

Hos

pita

l (E

dgba

ston

)29

2

Uni

vers

ity H

ospi

tals

Bri

stol

NH

S Fo

unda

tion

Trus

t38

494

.6%

Yes

406

423

458

BR

IB

rist

ol R

oyal

Infir

mar

y38

4

Uni

vers

ity H

ospi

tals

Cov

entr

y an

d W

arw

icks

hire

NH

S Tr

ust

309

60.7

%Ye

s50

957

767

1

WA

LU

nive

rsity

Hos

pita

l C

oven

try

281

RU

GH

ospi

tal o

f St C

ross

28

Uni

vers

ity H

ospi

tals

of L

eice

ster

NH

S Tr

ust

00.

0%N

o11

6974

165

8G

RL

Gle

nfiel

d H

ospi

tal

0

LER

Leic

este

r R

oyal

Infir

mar

y0

Uni

vers

ity H

ospi

tals

of M

orec

ambe

Bay

NH

S Fo

unda

tion

Trus

t0

0.0%

No

449

351

281

FGH

Furn

ess

Gen

eral

Hos

pita

l0

RLI

Roy

al L

anca

ster

Infir

mar

y0



Trus

t nam

eTr

ust

reco

rds

subm

itte

d

% H

ES

subm

itte

dPa

rtic

ipat

ion

stat

usP

rim

ary

HES

hea

rt

failu

re

disc

harg

es

Seco

ndar

y H

ES h

eart

fa

ilure

di

scha

rges

Tert

iary

HES

he

art f

ailu

re

disc

harg

es

NIC

OR

ho

spit

al

code

Hos

pita

l nam

eH

ospi

tal

reco

rds

subm

itte

d

Wal

sall

Hea

lthc

are

NH

S Tr

ust

241

72.4

%Ye

s33

334

529

7W

MH

Man

or H

ospi

tal

241

War

ring

ton

and

Hal

ton

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

145

66.8

%P

artia

l21

726

521

8W

DG

War

ring

ton

Hos

pita

l14

5

Wes

t Her

tfor

dshi

re H

ospi

tals

NH

S Tr

ust

245

74.7

%Ye

s32

828

722

0W

ATW

atfo

rd G

ener

al H

ospi

tal

245

Wes

t Mid

dles

ex U

nive

rsity

Hos

pita

l NH

S Tr

ust

212

101.

0%Ye

s21

018

121

6W

MU

Wes

t Mid

dles

ex U

nive

rsity

H

ospi

tal

212

Wes

t Suf

folk

NH

S Fo

unda

tion

Trus

t21

884

.5%

Yes

258

229

225

WSH

Wes

t Suf

folk

Hos

pita

l21

8

Wes

tern

Sus

sex

Hos

pita

ls N

HS

Trus

t63

986

.8%

Yes

736

561

495

WR

GW

orth

ing

Hos

pita

l36

3

STR

St R

icha

rd's

Hos

pita

l27

6

Wes

ton

Are

a H

ealt

h N

HS

Trus

t11

659

.2%

Par

tial

196

144

133

WG

HW

esto

n G

ener

al H

ospi

tal

116

Whi

pps

Cro

ss U

nive

rsity

Hos

pita

l NH

S Tr

ust

206

66.9

%P

artia

l30

826

826

6W

HC

Whi

pps

Cro

ss U

nive

rsity

H

ospi

tal

206

Wir

ral U

nive

rsity

Tea

chin

g H

ospi

tal N

HS

Foun

datio

n Tr

ust

219

44.2

%P

artia

l49

638

330

3W

IRA

rrow

e P

ark

Hos

pita

l21

9

Wor

cest

ersh

ire

Acu

te H

ospi

tals

NH

S Tr

ust

392

71.9

%Ye

s54

545

450

0

RED

Ale

xand

ra H

ospi

tal

227

WR

CW

orce

ster

shir

e R

oyal

H

ospi

tal

165

Wri

ghtin

gton

, Wig

an a

nd L

eigh

NH

S Fo

unda

tion

Trus

t51

318

1.3%

Yes

283

334

348

AEI

Roy

al A

lber

t Edw

ard

Infir

mar

y51

3

Wye

Val

ley

NH

S Tr

ust

188

92.6

%Ye

s20

318

018

1H

CH

Cou

nty

Hos

pita

l Her

efor

d18

8

Yeov

il D

istr

ict H

ospi

tal N

HS

Foun

datio

n Tr

ust

253

128.

4%Ye

s19

716

313

2YE

OYe

ovil

Dis

tric

t Hos

pita

l25

3

York

Tea

chin

g H

ospi

tal N

HS

Foun

datio

n Tr

ust

220

85.3

%Ye

s25

827

622

6YD

HYo

rk D

istr

ict H

ospi

tal

220



Tabl

e 5:

Par

tici

pati

on a

nd c

ase

asce

rtai

nmen

t in

Wal

es

Trus

t nam

eTr

ust

reco

rds

subm

itte

d

% P

EDW

su

bmit

ted

Part

icip

atio

n st

atus

Pri

mar

y P

EDW

hea

rt

failu

re

disc

harg

es

Seco

ndar

y P

EDW

hea

rt

failu

re

disc

harg

es

Tert

iary

P

EDW

hea

rt

failu

re

disc

harg

es

NIC

OR

ho

spit

al

code

Hos

pita

l nam

eH

ospi

tal

reco

rds

subm

itte

d

Wal

es51

711

.9%

4348

3303

3380

517

Abe

rtaw

e B

ro M

orga

nnw

g U

nive

rsity

Hea

lth

Boa

rd7

0.9%

Par

tial

823

804

929

MO

RM

orri

ston

Hos

pita

l0

NG

HN

eath

Por

t Tal

bot H

ospi

tal

0

PO

WP

rinc

ess

Of W

ales

H

ospi

tal

7

SIN

Sing

leto

n H

ospi

tal

0

Ane

urin

Bev

an H

ealt

h B

oard

175

19.4

%P

artia

l90

171

364

7

GW

ER

oyal

Gw

ent H

ospi

tal

0

NEV

Nev

ill H

all H

ospi

tal

175

YYF

Cae

rphi

lly D

istr

ict M

iner

s H

ospi

tal/

Ysby

ty Y

stra

d Fa

wr

0

Bet

si C

adw

alad

r U

nive

rsity

Hea

lth

Boa

rd17

218

.5%

Par

tial

928

478

719

CLW

Gla

n C

lwyd

Hos

pita

l0

GW

YYs

byty

Gw

yned

d0

LLA

Llan

dudn

o G

ener

al

Hos

pita

l0

WR

XW

rexh

am M

aelo

r H

ospi

tal

172

Car

diff

& V

ale

Uni

vers

ity H

ealt

h B

oard

00.

0%N

o54

149

743

2

LLD

Llan

doug

h H

ospi

tal

0

UH

WU

nive

rsity

Hos

pita

l of

Wal

es0

Cw

m T

af H

ealt

h B

oard

20.

4%P

artia

l46

733

223

6P

CH

Pri

nce

Cha

rles

Hos

pita

l1

RG

HR

oyal

Gla

mor

gan

1

Hyw

el D

da H

ealt

h B

oard

161

23.4

%P

artia

l68

847

941

7

BR

GB

rong

lais

Gen

eral

H

ospi

tal

146

PP

HP

rinc

e P

hilip

Hos

pita

l6

WW

GW

est W

ales

Gen

eral

5

WYB

With

ybus

h G

ener

al

Hos

pita

l4



3.9.

2 C

linic

al p

ract

ice

Tabl

es 6

and

7 s

how

the

perc

enta

ges

of c

ases

at e

ach

hosp

ital r

ecei

ving

key

dia

gnos

tic te

sts,

ther

apie

s an

d re

ferr

al to

follo

w-u

p se

rvic

es a

t hos

pita

ls in

Eng

land

and

Wal

es. H

ospi

tal-

leve

l dat

a on

clin

ical

pra

ctic

e ha

s on

ly b

een

publ

ishe

d if

a ho

spita

l sub

mitt

ed m

ore

than

100

rec

ords

to th

e au

dit,

or g

reat

er th

an 7

0% o

f the

ir H

ES r

ecor

ded

figur

es. A

n as

teri

sk (*

) in

a ce

ll in

dica

tes

that

too

few

rec

ords

wer

e su

bmitt

ed fo

r a

perc

enta

ge to

be

publ

ishe

d.

Ple

ase

note

that

thes

e ou

tput

s ha

ve n

ot b

een

risk

adj

uste

d, b

ut th

e de

nom

inat

ors

used

for

each

ana

lysi

s ha

ve b

een

chos

en to

ens

ure

that

the

outc

omes

are

as

repr

esen

tativ

e as

po

ssib

le. T

he a

udit

Pro

ject

Boa

rd h

as d

ecid

ed to

ref

rain

from

pub

lishi

ng o

utco

mes

dat

a (e

.g. r

eadm

issi

on a

nd m

orta

lity

rate

s) a

t a h

ospi

tal l

evel

unt

il a

satis

fact

ory

risk

adj

ustm

ent

mod

el h

as b

een

deve

lope

d. H

owev

er, s

ince

Apr

il 20

12 th

e N

atio

nal H

eart

Fai

lure

Aud

it ha

s in

clud

ed a

ser

ies

of n

ew m

anda

tory

dat

a ite

ms,

whi

ch w

ill e

nabl

e a

soph

istic

ated

ris

k ad

just

men

t of t

he d

ata

to a

ccou

nt fo

r kn

own

conf

ound

ers.

Thi

s w

ill e

nabl

e th

e au

dit t

o pu

blis

h ou

tcom

e da

ta a

t a h

ospi

tal l

evel

in th

e ne

ar fu

ture

.

Tabl

e 6:

Clin

ical

pra

ctic

e in

Eng

land

(201

1/12

)

Den

omin

ator

s fo

r ta

bles

6 a

nd 7

as

foll

ows:

• %

rec

eive

d ec

ho: a

ll re

cord

s.•

% c

ardi

olog

y in

patie

nt: a

ll re

cord

s.•

% A

CE

I/A

RB

on

disc

harg

e: a

ll re

cord

s w

here

pat

ient

had

LVS

D a

nd s

urvi

ved

to d

isch

arge

.•

% b

eta

bloc

ker

on d

isch

arge

: all

reco

rds

whe

re p

atie

nt h

ad L

VSD

and

sur

vive

d to

dis

char

ge.

• %

ref

erre

d to

HF

liais

on s

ervi

ce: a

ll re

cord

s w

here

pat

ient

had

LVS

D a

nd s

urvi

ved

to d

isch

arge

.•

% r

efer

red

to c

ardi

olog

y fo

llow

-up:

all

reco

rds

whe

re p

atie

nt s

urvi

ved

to d

isch

arge

.

Trus

t nam

eN

ICO

R

hosp

ital

code

Hos

pita

l nam

eR

ecor

ds

subm

itted

% r

ecei

ved

echo

%

car

diol

ogy

inpa

tien

t %

AC

EI/A

RB

on

dis

char

ge

% b

eta

bloc

ker

on

disc

harg

e

% r

efer

red

to H

F lia

ison

se

rvic

e

% re

ferr

ed

to c

ardi

olog

y fo

llow

-up

Engl

and

and

Wal

es37

076

85.9

%47

.1%

82.7

%76

.4%

63.2

%51

.1%

Engl

and

3655

985

.9%

47.0

%82

.7%

76.3

%63

.2%

51.5

%

Ain

tree

Uni

vers

ity H

ospi

tal N

HS

Foun

datio

n Tr

ust

FAZ

Uni

vers

ity H

ospi

tal A

intr

ee29

698

.3%

83.4

%65

.6%

75.1

%97

.7%

91.2

%

Air

edal

e N

HS

Foun

datio

n Tr

ust

AIR

Air

edal

e G

ener

al H

ospi

tal

0

Ash

ford

and

St P

eter

's H

ospi

tals

N

HS

Trus

tSP

HSt

Pet

er's

Hos

pita

l29

684

.8%

49.3

%59

.0%

56.4

%51

.4%

50.6

%

Bar

king

, Hav

erin

g an

d R

edbr

idge

U

nive

rsity

Hos

pita

ls N

HS

Trus

tK

GG

Kin

g G

eorg

e H

ospi

tal

295

98.6

%21

.0%

72.0

%70

.8%

73.1

%55

.5%

Bar

king

, Hav

erin

g an

d R

edbr

idge

U

nive

rsity

Hos

pita

ls N

HS

Trus

tO

LDQ

ueen

's H

ospi

tal (

Rom

ford

)42

498

.6%

19.6

%79

.0%

78.3

%82

.0%

55.5

%

Bar

net a

nd C

hase

Far

m H

ospi

tals

N

HS

Trus

tB

NT

Bar

net G

ener

al H

ospi

tal

294

91.8

%59

.5%

97.2

%86

.2%

63.4

%50

.6%

Bar

net a

nd C

hase

Far

m H

ospi

tals

N

HS

Trus

tC

HS

Cha

se F

arm

Hos

pita

l22

586

.2%

37.8

%81

.5%

80.6

%71

.9%

58.3

%

Bar

nsle

y H

ospi

tal N

HS

Foun

datio

n Tr

ust

BA

RB

arns

ley

Hos

pita

l20

184

.1%

20.4

%92

.9%

82.1

%24

.6%

43.2

%

Denominators for tables 6 and 7 as follows:

• % received echo: all records.

• % cardiology inpatient: all records.

• % ACEI/ARB on discharge: all records where patient had LVSD and survived to discharge.

• % beta blocker on discharge: all records where patient had LVSD and survived to discharge.

• % referred to HF liaison service: all records where patient had LVSD and survived to discharge.

• % referred to cardiology follow-up: all records where patient survived to discharge.



Bar

ts a

nd th

e Lo

ndon

BA

LTh

e Lo

ndon

Che

st H

ospi

tal/

The

Roy

al

Lond

on H

ospi

tal

155

89.7

%69

.7%

78.8

%83

.5%

86.4

%85

.7%

Bas

ildon

and

Thu

rroc

k U

nive

rsity

H

ospi

tals

NH

S Fo

unda

tion

Trus

tB

AS

Bas

ildon

Uni

vers

ity H

ospi

tal

35*

**

**

*

Bed

ford

Hos

pita

l NH

S Tr

ust

BED

Bed

ford

Hos

pita

l22

090

.0%

38.6

%64

.3%

74.1

%29

.1%

55.1

%

Bla

ckpo

ol T

each

ing

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

VIC

Bla

ckpo

ol V

icto

ria

Hos

pita

l90

391

.4%

60.3

%85

.1%

83.8

%70

.9%

21.8

%

Bol

ton

NH

S Fo

unda

tion

Trus

tB

OL

Roy

al B

olto

n H

ospi

tal

8*

**

**

*

Bra

dfor

d Te

achi

ng H

ospi

tals

NH

S Fo

unda

tion

Trus

tB

RD

Bra

dfor

d R

oyal

Infir

mar

y17

082

.4%

46.5

%79

.5%

70.5

%59

.0%

63.2

%

Bri

ghto

n an

d Su

ssex

Uni

vers

ity

Hos

pita

ls N

HS

Trus

tP

RH

Pri

nces

s R

oyal

Hos

pita

l (H

ayw

ards

H

eath

)22

268

.0%

6.8%

89.4

%84

.6%

34.2

%33

.5%

Bri

ghto

n an

d Su

ssex

Uni

vers

ity

Hos

pita

ls N

HS

Trus

tR

SCR

oyal

Sus

sex

Cou

nty

Hos

pita

l40

682

.3%

50.0

%86

.5%

74.5

%75

.0%

55.4

%

Buc

king

ham

shir

e H

ealt

hcar

e N

HS

Trus

tSM

VSt

oke

Man

devi

lle H

ospi

tal

0

Buc

king

ham

shir

e H

ealt

hcar

e N

HS

Trus

tA

MG

Wyc

ombe

Gen

eral

Hos

pita

l22

097

.7%

70.5

%90

.9%

81.3

%62

.7%

79.1

%

Bur

ton

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

BR

TQ

ueen

's H

ospi

tal (

Bur

ton)

239

72.4

%43

.9%

90.4

%92

.2%

43.2

%51

.5%

Cal

derd

ale

and

Hud

ders

field

NH

S Fo

unda

tion

Trus

tR

HI

Cal

derd

ale

Roy

al H

ospi

tal

185

94.1

%62

.2%

93.0

%69

.6%

58.2

%55

.2%

Cal

derd

ale

and

Hud

ders

field

NH

S Fo

unda

tion

Trus

tH

UD

Hud

ders

field

Roy

al In

firm

ary

182

91.8

%50

.5%

95.6

%73

.2%

53.2

%42

.7%

Cam

brid

ge U

nive

rsity

Hos

pita

ls

NH

S Fo

unda

tion

Trus

tA

DD

Add

enbr

ooke

's H

ospi

tal

22*

**

**

*

Cen

tral

Man

ches

ter

Uni

vers

ity

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

MR

IM

anch

este

r R

oyal

Infir

mar

y22

188

.2%

47.0

%89

.0%

90.6

%77

.8%

72.9

%

Che

lsea

and

Wes

tmin

ster

Hos

pita

l N

HS

Foun

datio

n Tr

ust

WES

Che

lsea

and

Wes

tmin

ster

Hos

pita

l84

**

**

**

Che

ster

field

Roy

al H

ospi

tal N

HS

Foun

datio

n Tr

ust

CH

EC

hest

erfie

ld R

oyal

Hos

pita

l17

875

.3%

44.9

%91

.5%

86.4

%48

.8%

28.6

%

City

Hos

pita

ls S

unde

rlan

d N

HS

Foun

datio

n Tr

ust

SUN

Sund

erla

nd R

oyal

Hos

pita

l24

585

.7%

24.5

%81

.8%

77.4

%31

.3%

50.7

%

Col

ches

ter

Hos

pita

l Uni

vers

ity N

HS

Foun

datio

n Tr

ust

CO

LC

olch

este

r G

ener

al H

ospi

tal

381

99.5

%50

.5%

81.4

%80

.0%

94.6

%39

.5%

Cou

ntes

s of

Che

ster

Hos

pita

l NH

S Fo

unda

tion

Trus

tC

OC

Cou

ntes

s of

Che

ster

Hos

pita

l34

199

.1%

68.0

%95

.7%

92.0

%90

.6%

51.9

%



Trus

t nam

eN

ICO

R

hosp

ital

code

Hos

pita

l nam

eR

ecor

ds

subm

itted

% r

ecei

ved

echo

% c

ardi

olog

y in

pati

ent

% A

CEI

/AR

B

on d

isch

arge

% b

eta

bloc

ker

on

disc

harg

e

% r

efer

red

to H

F lia

ison

se

rvic

e

% re

ferr

ed

to c

ardi

olog

y fo

llow

-up

Cou

nty

Dur

ham

and

Dar

lingt

on

NH

S Fo

unda

tion

Trus

tD

AR

Dar

lingt

on M

emor

ial H

ospi

tal

145

93.1

%47

.6%

86.5

%73

.7%

50.8

%42

.0%

Cou

nty

Dur

ham

and

Dar

lingt

on

NH

S Fo

unda

tion

Trus

tD

RY

Uni

vers

ity H

ospi

tal o

f Nor

th D

urha

m18

097

.8%

53.9

%69

.4%

71.7

%46

.6%

48.5

%

Cro

ydon

Hea

lth

Serv

ices

NH

S Tr

ust

MAY

Cro

ydon

Uni

vers

ity H

ospi

tal

223

79.8

%30

.5%

63.3

%67

.2%

31.8

%33

.9%

Dar

tfor

d an

d G

rave

sham

NH

S Tr

ust

DVH

Dar

ent V

alle

y H

ospi

tal

73*

**

**

*

Der

by H

ospi

tals

NH

S Fo

unda

tion

Trus

tD

ERR

oyal

Der

by H

ospi

tal

196

89.8

0%51

.03%

81.1

1%67

.78%

98.9

4%76

.74%

Don

cast

er a

nd B

asse

tlaw

Hos

pita

ls

NH

S Fo

unda

tion

Trus

tB

SLB

asse

tlaw

Hos

pita

l69

**

**

**

Don

cast

er a

nd B

asse

tlaw

Hos

pita

ls

NH

S Fo

unda

tion

Trus

tD

IDD

onca

ster

Roy

al In

firm

ary

128

85.9

%17

.3%

95.0

%75

.6%

52.2

%53

.6%

Dor

set C

ount

y H

ospi

tal N

HS

Foun

datio

n Tr

ust

WD

HD

orse

t Cou

nty

Hos

pita

l17

671

.0%

21.0

%68

.9%

80.5

%47

.3%

29.5

%

Ealin

g H

ospi

tal N

HS

Trus

tEA

LEa

ling

Hos

pita

l26

293

.9%

37.0

%72

.5%

90.8

%11

.5%

82.0

%

East

and

Nor

th H

ertf

ords

hire

NH

S Tr

ust

LIS

List

er H

ospi

tal

267

62.9

%57

.7%

87.0

%82

.4%

78.4

%74

.2%

East

and

Nor

th H

ertf

ords

hire

NH

S Tr

ust

QEW

Que

en E

lizab

eth

II H

ospi

tal

214

84.6

%16

.4%

62.6

%66

.1%

25.2

%30

.1%

East

Che

shir

e N

HS

Trus

tM

ACM

accl

esfie

ld D

istr

ict G

ener

al H

ospi

tal

167

75.4

%56

.3%

89.7

%86

.5%

50.0

%62

.9%

East

Ken

t Hos

pita

ls U

nive

rsity

NH

S Fo

unda

tion

Trus

tK

CC

Ken

t and

Can

terb

ury

Hos

pita

l0

East

Ken

t Hos

pita

ls U

nive

rsity

NH

S Fo

unda

tion

Trus

tQ

EQQ

ueen

Eliz

abet

h Th

e Q

ueen

Mot

her

Hos

pita

l0

East

Ken

t Hos

pita

ls U

nive

rsity

NH

S Fo

unda

tion

Trus

tW

HH

Will

iam

Har

vey

Hos

pita

l0

East

Lan

cash

ire

Hos

pita

ls N

HS

Trus

tB

LAR

oyal

Bla

ckbu

rn H

ospi

tal

234

76.1

%61

.5%

82.0

%85

.7%

89.5

%75

.9%

East

Sus

sex

Hea

lthc

are

NH

S Tr

ust

CG

HC

onqu

est H

ospi

tal

218

88.1

%53

.2%

64.0

%57

.0%

63.2

%44

.9%

East

Sus

sex

Hea

lthc

are

NH

S Tr

ust

DG

EEa

stbo

urne

Dis

tric

t Gen

eral

Hos

pita

l20

689

.3%

56.3

%73

.2%

62.6

%70

.3%

53.6

%

Epso

m a

nd S

t Hel

ier

Uni

vers

ity

Hos

pita

ls N

HS

Trus

tEP

SEp

som

Hos

pita

l10

049

.0%

43.0

%80

.0%

40.0

%63

.6%

35.6

%



Epso

m a

nd S

t Hel

ier

Uni

vers

ity

Hos

pita

ls N

HS

Trus

tSH

CSt

Hel

ier

Hos

pita

l11

069

.1%

40.9

%83

.3%

81.8

%70

.3%

37.8

%

Frim

ley

Par

k H

ospi

tal N

HS

Foun

datio

n Tr

ust

FRM

Frim

ley

Par

k H

ospi

tal

287

87.5

%72

.1%

84.8

%65

.2%

84.8

%60

.2%

Gat

eshe

ad H

ealt

h N

HS

Foun

datio

n Tr

ust

QEG

Que

en E

lizab

eth

Hos

pita

l (G

ates

head

)12

878

.1%

30.8

%65

.1%

55.5

%65

.1%

46.8

%

Geo

rge

Elio

t Hos

pita

l NH

S Tr

ust

NU

NG

eorg

e El

iot H

ospi

tal

261

87.4

%34

.1%

77.3

%85

.0%

0.0%

50.7

%

Glo

uces

ters

hire

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

CH

GC

helt

enha

m G

ener

al H

ospi

tal

54*

**

**

*

Glo

uces

ters

hire

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

GLO

Glo

uces

ters

hire

Roy

al H

ospi

tal

67*

**

**

*

Gre

at W

este

rn H

ospi

tals

NH

S Fo

unda

tion

Trus

tP

MS

The

Gre

at W

este

rn H

ospi

tal

212

85.4

%55

.9%

95.4

%84

.8%

89.1

%70

.1%

Guy

's a

nd S

t Tho

mas

' NH

S Fo

unda

tion

Trus

tST

HSt

Tho

mas

' Hos

pita

l22

998

.7%

60.3

%82

.2%

77.8

%92

.3%

80.3

%

Ham

pshi

re H

ospi

tals

NH

S Fo

unda

tion

Trus

tN

HH

Bas

ings

toke

and

Nor

th H

amps

hire

H

ospi

tal

128

85.9

%69

.5%

92.6

%63

.0%

83.3

%19

.5%

Ham

pshi

re H

ospi

tals

NH

S Fo

unda

tion

Trus

tR

HC

Roy

al H

amps

hire

Cou

nty

Hos

pita

l0

Har

roga

te a

nd D

istr

ict N

HS

Foun

datio

n Tr

ust

HA

RH

arro

gate

Dis

tric

t Hos

pita

l13

081

.5%

51.5

%90

.0%

90.2

%66

.7%

44.4

%

Hea

rt o

f Eng

land

NH

S Fo

unda

tion

Trus

tEB

HB

irm

ingh

am H

eart

land

s H

ospi

tal

207

97.1

%50

.0%

84.5

%66

.1%

68.3

%55

.6%

Hea

rt o

f Eng

land

NH

S Fo

unda

tion

Trus

tG

HS

Goo

d H

ope

Hos

pita

l0

Hea

rt o

f Eng

land

NH

S Fo

unda

tion

Trus

tSO

LSo

lihul

l Hos

pita

l16

197

.5%

78.0

%88

.2%

75.6

%82

.1%

40.1

%

Hea

ther

woo

d an

d W

exha

m P

ark

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

WEX

Wex

ham

Par

k H

ospi

tal

71*

**

**

*

Hin

chin

gbro

oke

Hea

lth

Car

e N

HS

Trus

tH

INH

inch

ingb

rook

e H

ospi

tal

38*

**

**

*

Hom

erto

n U

nive

rsity

Hos

pita

l NH

S Fo

unda

tion

Trus

tH

OM

Hom

erto

n U

nive

rsity

Hos

pita

l21

284

.0%

50.0

%82

.7%

89.6

%72

.6%

60.5

%

Hul

l and

Eas

t Yor

kshi

re H

ospi

tals

N

HS

Trus

tC

HH

Cas

tle H

ill H

ospi

tal

627

89.0

%75

.8%

86.8

%83

.8%

66.8

%84

.6%

Hul

l and

Eas

t Yor

kshi

re H

ospi

tals

N

HS

Trus

tH

RI

Hul

l Roy

al In

firm

ary

110

64.5

%0.

9%77

.3%

68.2

%60

.9%

39.0

%



Trus

t nam

eN

ICO

R

hosp

ital

code

Hos

pita

l nam

eR

ecor

ds

subm

itted

% r

ecei

ved

echo

% c

ardi

olog

y in

pati

ent

% A

CEI

/AR

B

on d

isch

arge

% b

eta

bloc

ker

on

disc

harg

e

% r

efer

red

to H

F lia

ison

se

rvic

e

% re

ferr

ed

to c

ardi

olog

y fo

llow

-up

Impe

rial

Col

lege

Hea

lthc

are

NH

S Tr

ust

CC

HC

hari

ng C

ross

Hos

pita

l99

91.9

%43

.4%

100.

0%64

.0%

60.7

%35

.8%

Impe

rial

Col

lege

Hea

lthc

are

NH

S Tr

ust

HA

MH

amm

ersm

ith H

ospi

tal

151

85.4

%47

.0%

89.4

%86

.5%

48.2

%76

.2%

Impe

rial

Col

lege

Hea

lthc

are

NH

S Tr

ust

STM

St M

ary'

s H

ospi

tal P

addi

ngto

n24

199

.2%

26.1

%88

.2%

81.0

%30

.3%

53.9

%

Isle

of W

ight

NH

S P

CT

IOW

St M

ary'

s H

ospi

tal,

New

port

173

73.4

%26

.0%

71.4

%42

.0%

93.5

%48

.3%

Jam

es P

aget

Uni

vers

ity H

ospi

tals

N

HS

Foun

datio

n Tr

ust

JPH

Jam

es P

aget

Uni

vers

ity H

ospi

tal

114

83.3

%40

.4%

89.6

%82

.2%

12.8

%27

.1%

Ket

teri

ng G

ener

al H

ospi

tal N

HS

Foun

datio

n Tr

ust

KG

HK

ette

ring

Gen

eral

Hos

pita

l23

987

.0%

74.9

%83

.0%

85.7

%93

.3%

53.3

%

Kin

g's

Col

lege

Hos

pita

l NH

S Fo

unda

tion

Trus

tK

CH

Kin

g's

Col

lege

Hos

pita

l24

595

.1%

44.0

%89

.0%

85.6

%49

.2%

36.2

%

Kin

gsto

n H

ospi

tal N

HS

Trus

tK

THK

ings

ton

Hos

pita

l30

960

.2%

34.6

%80

.0%

48.5

%0.

0%44

.7%

Lanc

ashi

re T

each

ing

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

CH

OC

horl

ey a

nd S

outh

Rib

ble

Hos

pita

l23

210

0.0%

50.4

%97

.1%

84.7

%96

.6%

78.4

%

Lanc

ashi

re T

each

ing

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

RP

HR

oyal

Pre

ston

Hos

pita

l33

498

.8%

37.7

%80

.0%

81.6

%98

.8%

86.4

%

Leed

s Te

achi

ng H

ospi

tals

NH

S Tr

ust

LGI

Leed

s G

ener

al In

firm

ary

248

98.8

%94

.4%

81.5

%82

.6%

98.7

%88

.6%

Lew

isha

m H

ealt

hcar

e N

HS

Trus

tLE

WU

nive

rsity

Hos

pita

l Lew

isha

m11

799

.1%

45.3

%86

.7%

92.9

%88

.6%

96.7

%

Live

rpoo

l Hea

rt a

nd C

hest

Hos

pita

l N

HS

Foun

datio

n Tr

ust

BH

LLi

verp

ool H

eart

and

Che

st H

ospi

tal

136

95.6

%97

.8%

72.9

%79

.8%

76.2

%99

.1%

Luto

n an

d D

unst

able

Hos

pita

l NH

S Fo

unda

tion

Trus

tLD

HLu

ton

and

Dun

stab

le H

ospi

tal

346

90.5

%26

.3%

92.3

%71

.4%

69.0

%47

.1%

Mai

dsto

ne a

nd T

unbr

idge

Wel

ls

NH

S Tr

ust

MA

IM

aids

tone

Hos

pita

l22

693

.8%

64.4

%90

.9%

78.0

%89

.2%

74.7

%

Mai

dsto

ne a

nd T

unbr

idge

Wel

ls

NH

S Tr

ust

KSX

Tunb

ridg

e W

ells

Hos

pita

l17

882

.0%

43.8

%97

.7%

55.7

%80

.9%

60.7

%

Med

way

NH

S Fo

unda

tion

Trus

tM

DW

Med

way

Mar

itim

e H

ospi

tal

0

Mid

Che

shir

e H

ospi

tals

NH

S Fo

unda

tion

Trus

tLG

HLe

ight

on H

ospi

tal

263

100.

0%82

.9%

90.4

%89

.2%

69.7

%46

.5%



Mid

Ess

ex H

ospi

tal S

ervi

ces

NH

S Tr

ust

BFH

Bro

omfie

ld H

ospi

tal

136

99.3

%30

.1%

97.0

%95

.9%

78.0

%63

.8%

Mid

Sta

ffor

dshi

re N

HS

Foun

datio

n Tr

ust

SDG

Staf

ford

Hos

pita

l74

**

**

**

Mid

Yor

kshi

re H

ospi

tals

NH

S Tr

ust

DEW

Dew

sbur

y an

d D

istr

ict H

ospi

tal

119

79.8

%31

.1%

90.4

%77

.1%

92.7

%61

.3%

Mid

Yor

kshi

re H

ospi

tals

NH

S Tr

ust

PIN

Pin

derfi

elds

Hos

pita

l30

194

.0%

53.5

%84

.9%

87.6

%69

.7%

60.4

%

Milt

on K

eyne

s H

ospi

tal N

HS

Foun

datio

n Tr

ust

MK

HM

ilton

Key

nes

Gen

eral

Hos

pita

l15

476

.6%

48.7

%76

.0%

68.0

%75

.9%

46.2

%

New

ham

Uni

vers

ity H

ospi

tal N

HS

Trus

tN

WG

New

ham

Uni

vers

ity H

ospi

tal

2*

**

**

*

Nor

folk

and

Nor

wic

h U

nive

rsity

H

ospi

tals

NH

S Fo

unda

tion

Trus

tN

OR

Nor

folk

and

Nor

wic

h U

nive

rsity

H

ospi

tal

374

80.5

%10

0.0%

84.0

%79

.0%

33.2

%68

.5%

Nor

th B

rist

ol N

HS

Trus

tFR

YFr

ench

ay H

ospi

tal

279

93.2

%34

.4%

80.2

%72

.4%

1.9%

21.0

%

Nor

th B

rist

ol N

HS

Trus

tB

SMSo

uthm

ead

Hos

pita

l20

594

.6%

55.1

%58

.5%

71.8

%13

.7%

45.6

%

Nor

th C

umbr

ia U

nive

rsity

Hos

pita

ls

NH

S Tr

ust

CM

IC

umbe

rlan

d In

firm

ary

46*

**

**

*

Nor

th C

umbr

ia U

nive

rsity

Hos

pita

ls

NH

S Tr

ust

WC

IW

est C

umbe

rlan

d H

ospi

tal

32*

**

**

*

Nor

th M

iddl

esex

Uni

vers

ity H

ospi

tal

NH

S Tr

ust

NM

HN

orth

Mid

dles

ex U

nive

rsity

Hos

pita

l17

183

.0%

7.6%

92.9

%79

.3%

86.2

%36

.0%

Nor

th T

ees

and

Har

tlepo

ol N

HS

Foun

datio

n Tr

ust

HG

HU

nive

rsity

Hos

pita

l of H

artle

pool

149

96.0

%64

.4%

100.

0%98

.0%

63.6

%32

.8%

Nor

th T

ees

and

Har

tlepo

ol N

HS

Foun

datio

n Tr

ust

NTG

Uni

vers

ity H

ospi

tal o

f Nor

th T

ees

234

78.2

%58

.5%

97.7

%93

.2%

75.6

%30

.4%

Nor

tham

pton

Gen

eral

Hos

pita

l NH

S Tr

ust

NTH

Nor

tham

pton

Gen

eral

Hos

pita

l21

786

.6%

49.3

%10

0.0%

98.7

%99

.0%

29.0

%

Nor

ther

n D

evon

Hea

lthc

are

NH

S Tr

ust

ND

DN

orth

Dev

on D

istr

ict H

ospi

tal

212

84.9

%50

.2%

74.0

%54

.3%

71.3

%30

.1%

Nor

ther

n Li

ncol

nshi

re a

nd G

oole

H

ospi

tals

NH

S Fo

unda

tion

Trus

tG

GH

Dia

na P

rinc

ess

of W

ales

Hos

pita

l16

122

.4%

31.7

%78

.3%

69.6

%0.

0%43

.5%

Nor

ther

n Li

ncol

nshi

re a

nd G

oole

H

ospi

tals

NH

S Fo

unda

tion

Trus

tSC

USc

unth

orpe

Gen

eral

Hos

pita

l95

**

**

**

Nor

thum

bria

Hea

lthc

are

NH

S Fo

unda

tion

Trus

tH

EXH

exha

m G

ener

al H

ospi

tal

56*

**

**

*

Nor

thum

bria

Hea

lthc

are

NH

S Fo

unda

tion

Trus

tN

TYN

orth

Tyn

esid

e H

ospi

tal

219

90.9

%45

.7%

60.5

%79

.3%

47.1

%29

.6%



Trus

t nam

eN

ICO

R

hosp

ital

code

Hos

pita

l nam

eR

ecor

ds

subm

itted

% r

ecei

ved

echo

% c

ardi

olog

y in

pati

ent

% A

CEI

/AR

B

on d

isch

arge

% b

eta

bloc

ker

on

disc

harg

e

% r

efer

red

to H

F lia

ison

se

rvic

e

% re

ferr

ed

to c

ardi

olog

y fo

llow

-up

Nor

thum

bria

Hea

lthc

are

NH

S Fo

unda

tion

Trus

tA

SHW

ansb

eck

Gen

eral

Hos

pita

l12

593

.6%

49.6

%81

.1%

67.6

%69

.3%

12.0

%

Not

tingh

am U

nive

rsity

Hos

pita

ls

NH

S Tr

ust

CH

NN

ottin

gham

City

Hos

pita

l44

**

**

**

Not

tingh

am U

nive

rsity

Hos

pita

ls

NH

S Tr

ust

UH

NQ

ueen

's M

edic

al C

entr

e15

988

.7%

18.9

%75

.8%

67.4

%70

.0%

31.9

%

Oxf

ord

Rad

cliff

e H

ospi

tals

NH

S Tr

ust

HO

RH

orto

n G

ener

al H

ospi

tal

112

96.4

%17

.9%

100.

0%97

.1%

93.0

%17

.3%

Oxf

ord

Rad

cliff

e H

ospi

tals

NH

S Tr

ust

RA

DJo

hn R

adcl

iffe

Hos

pita

l62

495

.7%

22.8

%99

.6%

98.7

%91

.7%

54.1

%

Pap

wor

th H

ospi

tal N

HS

Foun

datio

n Tr

ust

PAP

Pap

wor

th H

ospi

tal

0

Pen

nine

Acu

te H

ospi

tals

NH

S Tr

ust

BR

YFa

irfie

ld G

ener

al H

ospi

tal

205

80.0

%63

.4%

86.0

%80

.4%

93.9

%31

.9%

Pen

nine

Acu

te H

ospi

tals

NH

S Tr

ust

NM

GN

orth

Man

ches

ter

Gen

eral

Hos

pita

l18

395

.1%

40.4

%83

.0%

82.5

%91

.2%

55.3

%

Pen

nine

Acu

te H

ospi

tals

NH

S Tr

ust

BH

HR

ochd

ale

Infir

mar

y53

**

**

**

Pen

nine

Acu

te H

ospi

tals

NH

S Tr

ust

OH

MR

oyal

Old

ham

Hos

pita

l20

490

.7%

4.4%

87.8

%63

.4%

97.1

%83

.3%

Pet

erbo

roug

h an

d St

amfo

rd

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

PET

Pet

erbo

roug

h C

ity H

ospi

tal

296

87.5

%71

.6%

75.4

%65

.7%

51.7

%59

.6%

Ply

mou

th H

ospi

tals

NH

S Tr

ust

PLY

Der

rifo

rd H

ospi

tal

0

Poo

le H

ospi

tal N

HS

Foun

datio

n Tr

ust

PG

HP

oole

Gen

eral

Hos

pita

l30

770

.7%

23.1

%70

.5%

67.0

%20

.0%

28.0

%

Por

tsm

outh

Hos

pita

ls N

HS

Trus

tQ

AP

Que

en A

lexa

ndra

Hos

pita

l31

996

.6%

94.0

%79

.9%

74.8

%77

.9%

43.7

%

Rot

herh

am N

HS

Foun

datio

n Tr

ust

RO

TR

othe

rham

Hos

pita

l22

783

.3%

32.6

%80

.4%

81.9

%69

.5%

37.1

%

Roy

al B

erks

hire

NH

S Fo

unda

tion

Trus

tB

HR

Roy

al B

erks

hire

Hos

pita

l44

988

.2%

46.1

%83

.3%

83.4

%72

.9%

28.2

%

Roy

al B

rom

pton

and

Har

efiel

d N

HS

Foun

datio

n Tr

ust

HH

Har

efiel

d H

ospi

tal

24*

**

**

*

Roy

al B

rom

pton

and

Har

efiel

d N

HS

Foun

datio

n Tr

ust

NH

BR

oyal

Bro

mpt

on H

ospi

tal

210

100.

00%

98.5

0%92

.00%

87.8

4%52

.27%

97.5

2%

Roy

al C

ornw

all H

ospi

tals

NH

S Tr

ust

RC

HR

oyal

Cor

nwal

l Hos

pita

l15

584

.52%

43.2

3%81

.08%

70.5

4%61

.86%

37.1

4%

Roy

al D

evon

and

Exe

ter

NH

S Fo

unda

tion

Trus

tR

DE

Roy

al D

evon

& E

xete

r H

ospi

tal

225

77.7

8%52

.89%

100.

00%

100.

00%

75.0

0%40

.21%



Roy

al F

ree

Lond

on N

HS

Trus

tR

FHR

oyal

Fre

e H

ospi

tal

223

93.2

7%45

.29%

97.4

7%95

.18%

64.5

5%58

.51%

Roy

al L

iver

pool

and

Bro

adgr

een

Uni

vers

ity H

ospi

tals

NH

S Tr

ust

RLU

Roy

al L

iver

pool

Uni

vers

ity H

ospi

tal

330

83.3

%56

.4%

75.5

%87

.6%

92.0

%42

.8%

Roy

al S

urre

y C

ount

y H

ospi

tal N

HS

Foun

datio

n Tr

ust

RSU

Roy

al S

urre

y C

ount

y H

ospi

tal

144

72.9

%26

.4%

86.7

%65

.2%

8.9%

38.9

%

Roy

al U

nite

d H

ospi

tal B

ath

NH

S Tr

ust

BAT

Roy

al U

nite

d H

ospi

tal B

ath

0

Salfo

rd R

oyal

NH

S Fo

unda

tion

Trus

tSL

FSa

lford

Roy

al24

190

.0%

30.7

%65

.0%

74.3

%91

.8%

46.3

%

Salis

bury

NH

S Fo

unda

tion

Trus

tSA

LSa

lisbu

ry D

istr

ict H

ospi

tal

342

95.0

%61

.7%

87.2

%76

.1%

31.3

%46

.8%

Sand

wel

l and

Wes

t Bir

min

gham

H

ospi

tals

NH

S Tr

ust

DU

DB

irm

ingh

am C

ity H

ospi

tal

190

88.4

%56

.3%

67.7

%54

.0%

64.9

%76

.7%

Sand

wel

l and

Wes

t Bir

min

gham

H

ospi

tals

NH

S Tr

ust

SAN

Sand

wel

l Gen

eral

Hos

pita

l15

594

.2%

69.0

%88

.6%

62.4

%98

.9%

84.3

%

Scar

boro

ugh

and

Nor

th E

ast

York

shir

e N

HS

Trus

tSC

ASc

arbo

roug

h G

ener

al H

ospi

tal

7*

**

**

*

Shef

field

Tea

chin

g H

ospi

tals

NH

S Fo

unda

tion

Trus

tN

GS

Nor

ther

n G

ener

al H

ospi

tal

442

100.

0%26

.9%

78.6

%72

.3%

0.0%

29.0

%

Shef

field

Tea

chin

g H

ospi

tals

NH

S Fo

unda

tion

Trus

tR

HA

Roy

al H

alla

msh

ire

Hos

pita

l10

**

**

**

Sher

woo

d Fo

rest

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

KM

HK

ing'

s M

ill H

ospi

tal

302

78.1

%49

.3%

79.8

%81

.4%

65.0

%51

.5%

Sher

woo

d Fo

rest

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

NH

NN

ewar

k H

ospi

tal

13*

**

**

*

Shre

wsb

ury

and

Telfo

rd H

ospi

tals

N

HS

Trus

tTL

FP

rinc

ess

Roy

al H

ospi

tal (

Telfo

rd)

48*

**

**

*

Shre

wsb

ury

and

Telfo

rd H

ospi

tals

N

HS

Trus

tR

SSR

oyal

Shr

ewsb

ury

Hos

pita

l37

**

**

**

Sout

h D

evon

Hea

lthc

are

NH

S Fo

unda

tion

Trus

tTO

RTo

rbay

Hos

pita

l35

963

.0%

31.8

%60

.0%

47.0

%20

.2%

33.1

%

Sout

h Lo

ndon

Hea

lthc

are

NH

S Tr

ust

BR

OP

rinc

ess

Roy

al U

nive

rsity

Hos

pita

l (B

rom

ley)

24*

**

**

*

Sout

h Lo

ndon

Hea

lthc

are

NH

S Tr

ust

GW

HQ

ueen

Eliz

abet

h H

ospi

tal (

Woo

lwic

h)23

792

.4%

61.2

%89

.2%

93.8

%82

.9%

63.6

%

Sout

h Lo

ndon

Hea

lthc

are

NH

S Tr

ust

QM

HQ

ueen

Mar

y's

Hos

pita

l (Si

dcup

)1

**

**

**

Sout

h Te

es H

ospi

tals

NH

S Fo

unda

tion

Trus

tFR

HFr

iara

ge H

ospi

tal

0



Trus

t nam

eN

ICO

R

hosp

ital

code

Hos

pita

l nam

eR

ecor

ds

subm

itted

% r

ecei

ved

echo

% c

ardi

olog

y in

pati

ent

% A

CEI

/AR

B

on d

isch

arge

% b

eta

bloc

ker

on

disc

harg

e

% r

efer

red

to H

F lia

ison

se

rvic

e

% re

ferr

ed

to c

ardi

olog

y fo

llow

-up

Sout

h Te

es H

ospi

tals

NH

S Fo

unda

tion

Trus

tSC

MJa

mes

Coo

k U

nive

rsity

Hos

pita

l20

995

.7%

87.1

%90

.1%

77.5

%93

.3%

63.6

%

Sout

h Ty

nesi

de N

HS

Foun

datio

n Tr

ust

STD

Sout

h Ty

nesi

de D

istr

ict H

ospi

tal

267

91.8

%64

.0%

94.4

%80

.3%

93.8

%73

.7%

Sout

h W

arw

icks

hire

NH

S Fo

unda

tion

Trus

t W

AR

War

wic

k H

ospi

tal

0

Sout

hend

Uni

vers

ity H

ospi

tal N

HS

Foun

datio

n Tr

ust

SEH

Sout

hend

Hos

pita

l55

587

.2%

39.1

%70

.8%

77.4

%85

.3%

38.7

%

Sout

hpor

t and

Orm

skir

k H

ospi

tal

NH

S Tr

ust

SOU

Sout

hpor

t and

For

mby

Dis

tric

t Gen

eral

H

ospi

tal

203

96.1

%18

.3%

67.5

%42

.7%

70.9

%70

.8%

St G

eorg

e's

Hea

lthc

are

NH

S Tr

ust

GEO

St G

eorg

e's

Hos

pita

l22

999

.1%

13.1

%87

.3%

84.9

%94

.9%

48.7

%

St H

elen

s an

d K

now

sley

Tea

chin

g H

ospi

tals

NH

S Tr

ust

WH

IW

hist

on H

ospi

tal

226

92.5

%77

.0%

78.7

%72

.1%

95.6

%34

.6%

Stoc

kpor

t NH

S Fo

unda

tion

Trus

tSH

HSt

eppi

ng H

ill H

ospi

tal

175

95.4

%16

.6%

92.7

%87

.5%

32.2

%42

.2%

Surr

ey a

nd S

usse

x H

ealt

hcar

e N

HS

Trus

tES

UEa

st S

urre

y H

ospi

tal

302

76.2

%54

.4%

81.5

%63

.7%

57.7

%52

.5%

Tam

esid

e H

ospi

tal N

HS

Foun

datio

n Tr

ust

TGA

Tam

esid

e G

ener

al H

ospi

tal

178

71.9

%34

.8%

80.8

%76

.7%

72.6

%50

.4%

Taun

ton

and

Som

erse

t NH

S Fo

unda

tion

Trus

tM

PH

Mus

grov

e P

ark

Hos

pita

l30

080

.3%

52.7

%83

.7%

73.1

%0.

0%37

.2%

The

Dud

ley

Gro

up N

HS

Foun

datio

n Tr

ust

RU

SR

usse

lls H

all H

ospi

tal

180

96.1

%65

.6%

77.8

%74

.7%

72.5

%68

.6%

The

Hill

ingd

on H

ospi

tals

NH

S Fo

unda

tion

Trus

tH

ILH

illin

gdon

Hos

pita

l19

791

.9%

52.8

%80

.2%

60.2

%70

.5%

29.0

%

The

Ipsw

ich

Hos

pita

l NH

S Tr

ust

IPS

The

Ipsw

ich

Hos

pita

l20

363

.5%

25.6

%86

.8%

81.3

%46

.1%

22.3

%

The

New

cast

le U

pon

Tyne

Hos

pita

ls

NH

S Fo

unda

tion

Trus

tFR

EFr

eem

an H

ospi

tal

170

58.2

%68

.8%

85.7

%72

.3%

52.8

%93

.1%

The

New

cast

le U

pon

Tyne

Hos

pita

ls

NH

S Fo

unda

tion

Trus

tR

VNR

oyal

Vic

tori

a In

firm

ary

0

The

Nor

th W

est L

ondo

n H

ospi

tals

N

HS

Trus

tC

MH

Cen

tral

Mid

dles

ex H

ospi

tal

14*

**

**

*

The

Nor

th W

est L

ondo

n H

ospi

tals

N

HS

Trus

tN

PH

Nor

thw

ick

Par

k H

ospi

tal

346

96.5

%84

.7%

77.0

%71

.9%

72.4

%47

.7%



The

Pri

nces

s A

lexa

ndra

Hos

pita

l N

HS

Trus

tPA

HP

rinc

ess

Ale

xand

ra H

ospi

tal

0

The

Que

en E

lizab

eth

Hos

pita

l K

ing'

s Ly

nn N

HS

Foun

datio

n Tr

ust

QK

LQ

ueen

Eliz

abet

h H

ospi

tal (

Kin

g's

Lynn

)20

194

.5%

67.2

%93

.9%

87.1

%84

.6%

31.8

%

The

Roy

al B

ourn

emou

th a

nd

Chr

istc

hurc

h H

ospi

tals

NH

S Fo

unda

tion

Trus

t

BO

UR

oyal

Bou

rnem

outh

Gen

eral

Hos

pita

l0

The

Roy

al W

olve

rham

pton

Hos

pita

ls

NH

S Tr

ust

NC

RN

ew C

ross

Hos

pita

l18

175

.1%

11.6

%78

.5%

67.2

%65

.1%

30.7

%

The

Whi

ttin

gton

Hos

pita

l NH

S Tr

ust

WH

TW

hitt

ingt

on H

ospi

tal

137

99.3

%61

.3%

97.0

%93

.7%

85.3

%78

.3%

Traf

ford

Hea

lthc

are

NH

S Tr

ust

TRA

Traf

ford

Gen

eral

Hos

pita

l0

Uni

ted

Linc

olns

hire

Hos

pita

ls N

HS

Trus

tG

RA

Gra

ntha

m a

nd D

istr

ict H

ospi

tal

46*

**

**

*

Uni

ted

Linc

olns

hire

Hos

pita

ls N

HS

Trus

tLI

NLi

ncol

n C

ount

y H

ospi

tal

101

62.4

%30

.7%

60.7

%69

.0%

47.1

%53

.8%

Uni

ted

Linc

olns

hire

Hos

pita

ls N

HS

Trus

tP

ILP

ilgri

m H

ospi

tal

106

59.4

%27

.4%

73.7

%76

.3%

28.2

%50

.0%

Uni

vers

ity C

olle

ge L

ondo

n H

ospi

tals

N

HS

Foun

datio

n Tr

ust

UC

LU

nive

rsity

Col

lege

Hos

pita

l33

599

.1%

55.8

%99

.4%

95.0

%83

.3%

90.2

%

Uni

vers

ity H

ospi

tal o

f Nor

th

Staf

ford

shir

e N

HS

Trus

tST

OU

nive

rsity

Hos

pita

l of N

orth

St

affo

rdsh

ire

209

81.6

%31

.1%

71.9

%56

.1%

82.9

%60

.1%

Uni

vers

ity H

ospi

tal o

f Sou

th

Man

ches

ter

NH

S Fo

unda

tion

Trus

tW

YTW

ythe

nsha

we

Hos

pita

l30

475

.0%

49.3

%94

.9%

90.4

%57

.4%

38.3

%

Uni

vers

ity H

ospi

tal S

outh

ampt

on

NH

S Tr

ust

SGH

Sout

ham

pton

Gen

eral

Hos

pita

l14

210

0.0%

39.4

%0.

0%0.

0%0.

0%49

.2%

Uni

vers

ity H

ospi

tals

Bir

min

gham

N

HS

Foun

datio

n Tr

ust

QEB

Que

en E

lizab

eth

Hos

pita

l (Ed

gbas

ton)

292

55.7

%17

.4%

91.1

%82

.9%

30.8

%32

.2%

Uni

vers

ity H

ospi

tals

Bri

stol

NH

S Fo

unda

tion

Trus

tB

RI

Bri

stol

Roy

al In

firm

ary

384

93.8

%89

.3%

80.8

%78

.7%

64.4

%80

.4%

Uni

vers

ity H

ospi

tals

Cov

entr

y an

d W

arw

icks

hire

NH

S Tr

ust

RU

GH

ospi

tal o

f St C

ross

28*

**

**

*

Uni

vers

ity H

ospi

tals

Cov

entr

y an

d W

arw

icks

hire

NH

S Tr

ust

WA

LU

nive

rsity

Hos

pita

l Cov

entr

y28

195

.0%

74.6

%86

.1%

76.3

%94

.2%

51.7

%

Uni

vers

ity H

ospi

tals

of L

eice

ster

N

HS

Trus

tG

RL

Gle

nfiel

d H

ospi

tal

0

Uni

vers

ity H

ospi

tals

of L

eice

ster

N

HS

Trus

tLE

RLe

ices

ter

Roy

al In

firm

ary

0



Trus

t nam

eN

ICO

R

hosp

ital

code

Hos

pita

l nam

eR

ecor

ds

subm

itted

% r

ecei

ved

echo

% c

ardi

olog

y in

pati

ent

% A

CEI

/AR

B

on d

isch

arge

% b

eta

bloc

ker

on

disc

harg

e

% r

efer

red

to H

F lia

ison

se

rvic

e

% re

ferr

ed

to c

ardi

olog

y fo

llow

-up

Uni

vers

ity H

ospi

tals

of M

orec

ambe

B

ay N

HS

Foun

datio

n Tr

ust

FGH

Furn

ess

Gen

eral

Hos

pita

l0

Uni

vers

ity H

ospi

tals

of M

orec

ambe

B

ay N

HS

Foun

datio

n Tr

ust

RLI

Roy

al L

anca

ster

Infir

mar

y0

Wal

sall

Hea

lthc

are

NH

S Tr

ust

WM

HM

anor

Hos

pita

l24

110

0.0%

52.3

%10

0.0%

100.

0%90

.4%

78.0

%

War

ring

ton

and

Hal

ton

Hos

pita

ls

NH

S Fo

unda

tion

Trus

tW

DG

War

ring

ton

Hos

pita

l14

510

0.0%

67.6

%94

.1%

85.7

%98

.9%

69.7

%

Wes

t Her

tfor

dshi

re H

ospi

tals

NH

S Tr

ust

WAT

Wat

ford

Gen

eral

Hos

pita

l24

594

.7%

50.6

%10

0.0%

99.1

%81

.6%

92.1

%

Wes

t Mid

dles

ex U

nive

rsity

Hos

pita

l N

HS

Trus

tW

MU

Wes

t Mid

dles

ex U

nive

rsity

Hos

pita

l21

283

.5%

23.1

%71

.8%

77.9

%76

.8%

30.7

%

Wes

t Suf

folk

NH

S Fo

unda

tion

Trus

tW

SHW

est S

uffo

lk H

ospi

tal

218

69.3

%33

.0%

83.6

%68

.0%

12.8

%34

.2%

Wes

tern

Sus

sex

Hos

pita

ls N

HS

Trus

tST

RSt

Ric

hard

's H

ospi

tal

276

84.8

%48

.9%

76.8

%72

.5%

53.7

%46

.1%

Wes

tern

Sus

sex

Hos

pita

ls N

HS

Trus

tW

RG

Wor

thin

g H

ospi

tal

363

75.5

%40

.5%

75.9

%72

.4%

59.0

%47

.1%

Wes

ton

Are

a H

ealt

h N

HS

Trus

tW

GH

Wes

ton

Gen

eral

Hos

pita

l11

678

.4%

25.9

%69

.8%

65.1

%0.

0%20

.6%

Whi

pps

Cro

ss U

nive

rsity

Hos

pita

l N

HS

Trus

tW

HC

Whi

pps

Cro

ss U

nive

rsity

Hos

pita

l20

683

.0%

33.0

%84

.8%

77.3

%75

.0%

47.4

%

Wir

ral U

nive

rsity

Tea

chin

g H

ospi

tal

NH

S Fo

unda

tion

Trus

tW

IRA

rrow

e P

ark

Hos

pita

l21

995

.0%

43.8

%98

.7%

85.9

%97

.4%

40.9

%

Wor

cest

ersh

ire

Acu

te H

ospi

tals

N

HS

Trus

tR

EDA

lexa

ndra

Hos

pita

l22

787

.7%

35.9

%71

.1%

79.8

%42

.2%

53.3

%

Wor

cest

ersh

ire

Acu

te H

ospi

tals

N

HS

Trus

tW

RC

Wor

cest

ersh

ire

Roy

al H

ospi

tal

165

44.8

%53

.9%

83.0

%61

.5%

18.2

%39

.6%

Wri

ghtin

gton

, Wig

an a

nd L

eigh

NH

S Fo

unda

tion

Trus

tA

EIR

oyal

Alb

ert E

dwar

d In

firm

ary

513

97.3

%62

.0%

88.0

%87

.7%

68.2

%66

.0%

Wye

Val

ley

NH

S Tr

ust

HC

HC

ount

y H

ospi

tal H

eref

ord

188

80.9

%25

.0%

77.4

%58

.1%

58.1

%30

.4%

Yeov

il D

istr

ict H

ospi

tal N

HS

Foun

datio

n Tr

ust

YEO

Yeov

il D

istr

ict H

ospi

tal

253

92.1

%55

.6%

92.3

%85

.3%

100.

0%40

.5%

York

Tea

chin

g H

ospi

tal N

HS

Foun

datio

n Tr

ust

YDH

York

Dis

tric

t Hos

pita

l22

072

.3%

9.5%

84.0

%80

.0%

28.6

%32

.2%



Tabl

e 7:

Clin

ical

pra

ctic

e in

Wal

es (2

011/

12)

Hea

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3.10 MortalityMortality in the National Heart Failure Audit database is determined by linking audit data with mortality data from the Office of National Statistics (ONS) via NHS number, and other patient identifiable data collected by the audit. The total number of patients in the audit database who could be assigned a mortality status by MRIS was 24,744. The follow-up period refers to the period from date of discharge to date of death for those patients who died, and date of discharge to date of census for those who survived.

Currently the audit uses all-cause mortality as the basis for all mortality analysis, but NICOR has now been granted permission by the National Information Governance Board (NIGB) to obtain cause of death for patients included in its audits and registers.v This will allow for a more accurate representation of the number of deaths caused by heart failure, as an elderly patient group with high levels of comorbidity is guaranteed to register a significant number of non-cardiovascular deaths.

3.10.1 2011/12 in-hospital mortalityvi

Overall 11.1% of patients died in hospital but in-hospital mortality rates varied depending on the ward on which the patient was treated: 7.8% of those on cardiology ward died in hospital, compared with 13.2% of patients treated on general medicine and 17.4% of those on other wards.

In-hospital mortality stood at 10.2% for men and 12.1% for women, and, predictably, was much higher for older patients: only 2.5% of patients in the 16-44 age group died in hospital, compared with 10.9% of patients who were aged 75-84 at admission, and 16.8% of patients over 85 years of age.

Following adjustment for confounding factors (age >75 years; NYHA class III/IV; previous AMI), a significant association remained between not being treated on a cardiology ward and worse survival outcomes (HR=1.66, 95% CI 1.52 to 1.81, p<0.001.

3.10.2 2011/12 post-discharge mortality

Overall mortality for those patients who survived to discharge stood at 26.2% for the audit year. Median follow-up was 211 days for all patients, 281 days for those who survived to the end of the follow-up period and 39 days for patients who deceased (figure 7).

Sex: Mortality rates were similar for men and women who survived to discharge, with 26.6% of women and 25.9% of men dying within the follow-up period (median follow-up of 231 days for both men and women) (figure 8).

Age: Predictably, mortality increased significantly with age, 7.4% of those aged 16-44 died (301 days median follow-up), compared with 26.9% of patients the 75-84 age group (229 days median follow-up) and 37.2% of those over 85 years (median follow-up of 200 days) (figure 9).

Place of care: Patients treated on a cardiology ward had better outcomes than those treated on general medical or other wards, with 21.8% of patients treated on cardiology wards dying (242 day median follow-up), compared with 29.8% on general medicine (225 day median follow-up), and 33.4% on other wards (215 day median follow-up) (figure 10).

Diagnosis of LVSD: Of patients without LVSD 28.3% died during the follow-up period, compared to 24.8% of those with LVSD (median follow-up time of 227 days for those without LVSD and 236 days for those with LVSD) (figure 11).

ACE inhibitor and/or ARB on discharge: For those patients with an echo diagnosis of LVSD, 38.8% of those who were not discharged on an ACE inhibitor and/or ARB died, with a median follow-up of 201 days. Only 20.2% of patients with LVSD who were discharged on ACE inhibitor and/or ARB died within the follow-up period (median follow-up of 249 days) (figure 12).

Mortality rates by ACEI/ARB prescription showed similar patterns when all patients were considered, rather than just those with a diagnosis of LVSD: 36.7% of patients who were discharged without ACE inhibitors and/or ARBs died, with a median follow-up period of 207 days, compared with 21.0% of patients discharged on the drugs (median follow-up of 247 days) (figure 13).

Beta blocker on discharge: 33.0% of patients with LVSD who were not discharged on beta blockers died within the follow-up period (median 220 day follow-up), compared with only 21.1% of patients who were prescribed the treatment on discharge (median follow-up of 245 days) (figure 14).

Irrespective of echo diagnosis, 32.1% of those discharged on no beta blocker died (227 median follow-up), compared with 22.2% of patients discharged on beta blockers (242 day median follow-up) (figure 15).

Loop diuretic on discharge: 17.0% of patients with a diagnosis of LVSD who were discharged in 2011/12 without a prescription of loop diuretics died within the follow-up period, with a median 262 day follow-up, compared with 25.6% of patients who were discharged on loop diuretics (median follow-up period of 235 days) (figure 16).

For all patients, including those without LVSD, 20.6% of patients discharged without loop diuretics died within the follow-up period (median 250 days), compared with 26.5% of patients discharged on a loop (231 day median follow-up) (figure 17).

v. The NIGB monitors NHS and health-related information governance.

vi. Data for the 2011/2012 mortality analysis can be found in appendix 3 at the end of this report.



Additive drug treatment: The number of recommended disease modifying drugs a patient was prescribed on discharge had a significant impact on survival: 45.8% of patients with LVSD discharged without a prescription for an ACEI/ARB, beta blocker or MRA died (median follow-up of 183 days), compared with 27.1% of those discharged on ACEI/ARB only (median follow-up 242 days) and 18.4% of patients discharged on an ACEI/ARB and a beta blocker (median follow-up 251 days). Mortality was 16.8% for patients discharged on ACEI/ARB, beta blocker and an MRA (257 days median follow-up) (figure 18).

Referral to follow-up services: 20.1% of patients who were referred to cardiology follow-up in 2011/12 died (median follow-up 249 days), compared to 32.1% of patients who did not receive a cardiology referral (median follow-up of 216 days) (figure 19).

Mortality was 24.8% for patients who were referred to a heart failure liaison service on discharge (median follow-up 232 days), compared to 27.9% for patients not referred to heart failure nurse led follow-up (median follow-up period of 231 days) (figure 20).

Predictors of mortality for survivors to discharge

A Cox proportional hazards model appears to show that for patients who survived to discharge, even with adjustment for age, severity of symptoms and history of AMI, those not prescribed ACE inhibitors/ARBs and beta blockers on discharge had higher mortality rates. Patients prescribed loop diuretics on discharge also had increased mortality rates following adjustment for these confounding factors. Patients who were not cardiology inpatients and those who did not receive cardiology follow-up also had increased mortality rates when the confounding patient characteristics were taken into account (table 8).

Table 8: Cox proportional hazards model for post-discharge mortality (2011/12)

Predictor Hazard ratio

Lower .95

Upper .95

p-value

Previous AMI 1.28 1.20 1.36 < 0.001

Age > 75 1.77 1.65 1.90 < 0.001

NYHA class III/IV 1.22 1.13 1.31 < 0.001

No ACEI/ARB on discharge

1.69 1.59 1.81 < 0.001

No beta blocker on discharge

1.26 1.19 1.35 < 0.001

Loop diuretic on discharge

1.16 1.04 1.29 0.006

No cardiology follow-up

1.36 1.28 1.45 < 0.001

Not a cardiology inpatient

1.10 1.03 1.17 0.003

Days after discharge

% s

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 7: Overall post-discharge survival


% s

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 8: Post-discharge survival by sex

Women

Men




% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 9: Post-discharge survival by age at admission

16-44

45-54

55-64

65-74

75-84

85+


% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 11: Post-discharge survival by presence or absence of LVSD

Diagnosis of LVSD

No diagnosis of LVSD


% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 12: Post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge for patients with LVSD

ACE inhibitor/ARB

No ACE inhibitor/ARB


% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 10: Post-discharge survival by place of care

Cardiology

General Medicine

Other




% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 13: Post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge (all patients)

ACE inhibitor/ARB



% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 15: Post-discharge survival by prescription of beta blockers on discharge (all patients)

Beta blocker

No beta blocker


% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 16: Post-discharge survival by prescription of loopdiuretics on discharge for patients with LVSD

No loop diuretic

Loop diuretic


% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 14: Post-discharge survival by prescription of beta blockers on discharge for patients with LVSD

Beta blocker

No beta blocker




% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 17: Post-discharge survival by prescription of loop diuretics on discharge (all patients)

No loop diuretic

Loop diuretic


% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 19: Post-discharge survival by referral to cardiology follow-up services

Referred to cardiology follow-up

Not referred to cardiology follow-up


% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 20: Post-discharge survival by referral to heart failure liason follow-up services

Referred to heart failure liaison follow-up

Not referred to heart failure liaison follow-up


% S

urvi

ved

100

90

80

70

60

50

40

30

20

10

0

0 100 200 300 400

Fig 18: Post-discharge survival by additive drug treatment on discharge for patients with a diagnosis of LVSD

ACE inhibitor/ARB

ACEI inhibitor/ARB and beta blocker

ACEI inhibitor/ARB, beta blocker and MRA

No ACEI inhibitor/ARB, beta blocker or MRA



3.11 Three-year trends

3.11.1 Three-year in-hospital mortalityvii

Over the three years from April 2009 to March 2012, 12.1% of patients died in hospital. Only 8.2% of patients treated on a cardiology ward died, compared with 14.7% of patient treated on general medical wards, and 18.5% of patients on other wards. 11.2% of men died in hospital, compared with 13.1% of women, in the three-year period.

3.11.2 Three-year post-discharge mortality

Over the three years from 2009-2012, out of 66,249 patients, 24,590 (37.1%) died, with a median follow-up period between discharge and death/censoring of 331 days. Median follow-up was 504 days for patients who survived, and 89 days for patients who died (figure 21). The audit is not yet in a position to report place or cause of death for the majority of patients but hopes to do so in future reports.

Sex: Long term mortality was broadly similar for men and women: 37.8% of women discharged alive within the three years died, with a 375 day follow-up period, compared to 36.6% of men (median follow-up 376 days) (figure 22).

Age: Unsurprisingly age had a major impact on mortality, with 52.0% of patients over the age of 85 (median follow-up of 281 days) and 38.4% of patients between 75 and 84 (median follow-up of 369 days), dying within the follow-up period, compared with only 10.8% of the youngest patients, aged 16-44 (538 day median follow-up period) (figure 23).

Place of care: Heart failure patients’ main place of care continued to have an impact on mortality long after discharge, with 31.1% of cardiology patients dying (404 day follow-up), compared with 42.4% of general medical patients (355 day follow-up) and 45.0% of patients on other wards (323 day follow-up) (figure 24).

Diagnosis of LVSD: 40.7% of patients diagnosed with heart failure without LVSD admitted between 2009 and 2012 died, compared with 34.7% of patients diagnosed with LVSD (Median follow-up period of 362 days for no LVSD and 384 days for LVSD) (figure 25).

ACE inhibitor and/or ARB on discharge: Of those patients discharged in 2009-12 diagnosed with LVSD, 50.1% of those who did not receive an ACE inhibitor or ARB on discharge died (median follow-up of 285 days), whereas only 30.2% of those who were prescribed an ACE inhibitor and/or ARB died (median follow-up of 417 days) (figure 26).

Beta blocker on discharge: Of those patients discharged with a diagnosis of LVSD between 2009 and 2012, 45.9% of those not discharged on beta blockers died, compared with 29.4% of patients prescribed a beta blocker (median follow-up period of

361 days for those discharged on no beta blocker and 403 days for patients discharged on a beta blocker) (figure 27).

Loop diuretic on discharge: Of patients diagnosed with LVSD discharged between 2009 and 2012, 25.0% died within the follow-up period if they were not discharged on loop diuretics, compared with 35.8% of patients discharged on loop diuretics (follow-up 423 days for patients without loop diuretics, and 384 days for patients with loop diuretics) (figure 28).

Additive drug treatment: Patients with a diagnosis of LVSD discharged on all three of ACEI/ARBs, beta blockers and MRAs had mortality rates of 25.0% over three years (median follow-up of 419 days). 26.9% of patients discharged on ACEI/ARBs and beta blockers in 2009-12 died (427 days median follow-up), compared with 40.6% for those discharged on an ACEI/ARB alone (412 days median follow-up). 56.7% of patients who left hospital on none of the three NICE recommended treatments in 2009-12 died (median follow-up of 257 days) (figure 29).

Referral to follow-up services on discharge: Patients referred for cardiology follow-up had far better outcomes than those not referred for follow-up with a cardiologist, with mortality of 29.3% (422 days median follow-up) for the former, compared with 44.6% for the latter (327 days median follow-up) (figure 30).

Those referred to heart failure liaison follow-up services had lower mortality (34.7%) than those not referred to nurse led follow-up (39.4%) across the three year audit period (median follow-up of 363 for those not referred to HF liaison service follow-up, and 384 days for patients referred to nurse led services on discharge) (figure 31).

Three-year predictors of mortality for survivors to discharge

Similar to the findings of the 2011/12 survival analyses, a Cox proportional hazards model shows that in 2009-12, even when accounting for age, severity of symptoms on admission and previous AMI, those patients who were not prescribed an ACE inhibitor/ARB and those not prescribed a beta blocker on discharge were more likely to die during the follow-up period than those given these therapies on discharge. The mortality rate also remained higher for patients discharged on a loop diuretic, those not referred to cardiology follow-up, and those who were not treated on a cardiology ward (table 9).

vii. Data for the 2009-12 mortality analysis can be found in appendix 4 at the end of this report.



Table 9: Cox proportional hazards model for post-discharge mortality (2009-12)

Predictor Hazard ratio

Lower .95

Upper .95

p value

Previous AMI 1.26 1.22 1.31 < 0.001

Age > 75 1.82 1.75 1.89 < 0.001

NYHA class III/IV 1.15 1.11 1.19 < 0.001

No ACEI/ARB on discharge

1.58 1.52 1.63 < 0.001

No beta blocker on discharge

1.29 1.25 1.33 < 0.001

Loop diuretic on discharge

1.21 1.14 1.28 < 0.001

No cardiology follow-up

1.34 1.30 1.39 < 0.001

Not a cardiology inpatient

1.11 1.08 1.15 < 0.001


% S

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Fig 21: Three-year post-discharge survival (2009-12)


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Fig 22: Three-year post-discharge survival by sex (2009-12)

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Fig 23: Three-year post-discharge survival by age (2009-12)

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Fig 24: Three-year post-discharge survival by place ofcare (2009-12)

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Other

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Fig 26: Three-year post-discharge survival by prescription of ACE inhibitor and/or ARB on discharge in patients with LVSD (2009-12)

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ACE inhibitor/ARB



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Fig 27: Three-year post-discharge survival by prescription of beta blockers on discharge in patients with LVSD (2009-12)

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Fig 25: Three-year post-discharge survival by presence or absence of LVSD (2009-12)

0 200 400 600 800 1000 1200

Diagnosis of LVSD

No diagnosis of LVSD




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Fig 28: Three-year post-discharge survival by prescription of loop diuretics on discharge in patients with LVSD (2009-12)

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No beta blocker


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Fig 30: Three-year post-discharge survival by referral to cardiology follow-up services (2009-12)

0 200 400 600 800 1000 1200

Referred to cardiology follow-up

Not referred to cardiology follow-up


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Fig 31: Three-year post-discharge survival by referral to heart failure liaison follow-up services (2009-12)

0 200 400 600 800 1000 1200

Referred to heart failure liaison services

Not referred to heart failure liaison services


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Fig 29: Three-year post-discharge survival by additive drug treatment on discharge in patients with LVSD (2009-12)

0 200 400 600 800 1000 1200

ACE inhibitor/ARB

ACEI inhibitor/ARB and beta blocker

ACEI inhibitor/ARB, beta blocker and MRA

No ACEI inhibitor/ARB, beta blocker or MRA



4 Case studies

4.1 Improving clinical practice and patient outcomesLee Taaffe, North Central London Cardiovascular and Stroke Network

In North Central London, data from the National Heart Failure Audit is used to measure and improve the heart failure services across the six hospitals in the North Central London Cardiovascular and Stroke Network. The North Central London Heart Failure Task Group, which is hosted by the Network, devised a suite of local measures covering activity, admissions, diagnostics, prescribing, length of stay, and mortality. The data from the National Heart Failure Audit, along with HES data, is analysed quarterly and presented at the Heart Failure Task Group for discussion and learning. At the end of the financial year an annual report is produced that details the outcomes for each hospital across the year and benchmarks performance against local and national report findings. Furthermore, the report benchmarks against previous years’ findings to show how each hospital is progressing in its delivery of services to patients.

4.2 Using data to drive improvement

Pauline Wortman, Enhancing Quality & Recovery

Enhancing Quality & Recovery (EQ&R) is an innovative and award winning clinician-led quality improvement programme across Kent, Surrey and Sussex. The programme works with teams in 10 Acute Trusts, six Community Providers and three Mental Health Trusts and spans 10 clinical pathways. Clinicians identify between four and seven evidence-based measures, aligned wherever possible to NICE guidance, in order to benchmark performance and drive forward quality improvement focussed on improving patient outcomes and reducing variation in care.

Quality improvement that is clinically-led, data driven and focussed on patient outcomes is a very, very potent cocktail.

Professor Sir Bruce Keogh, NHS Medical Director, EQ&R What a difference a year makes conference, Gatwick 25th

January 2012.

EQ&R is the inaugural winner of the Cardiac care category of the Health Service Journal & Nursing Times 2012 Integration Award. This achievement reflects the success of clinical teams across the region in introducing quality improvement metrics for the full heart failure pathway as well as collaborative working that has led to action to improve quality of patient care with reduced variation and improved patient outcomes across the region.

EQ&R has recognised that when clinicians take ownership of their data and believe and trust it, this provides a very strong motivation to improve against it. Making this happen requires a clear focus on data quality: the need for a tightly defined population and clinical criteria so that ”apples are being compared with apples” and for a high level of data completeness (all patients, not just patients on the cardiology ward, for example). Improvement builds on clinicians “knowing where they are”, not just “where they think they are”. It also depends on clinical leadership and the development of wider teams, including coders and data analysts, for example, and truly collaborative working focussed on sharing of best practice and using the skills and knowledge of multi-disciplinary teams. At the core of the EQ&R approach is a focus on producing transparent measurement which is hard to ignore for accountability and improvement, rather than judgement.

Collecting timely and relevant data on every patient, every time can appear to be a chore especially before the value of the information being produced is realised. EQ&R has found engagement needs to encompass all those involved in the audit loop with active sharing of results within teams. Action against the data is more likely if analysis is available as soon as is practicable. In this way quality data can be reflected upon and action taken harnessing and maintaining the momentum and enthusiasm for improvement in patient care. This immediacy and impetus for service improvement can be lost where data is not fed back in a timely and consistent way.

Collaboration between EQ&R and MINAP and the National Heart Failure Audit is securing advantages for all parties. By sharing data, the duplication of data input is avoided. By capturing the full population rather than a sample population, data completeness is improved and the discipline of a monthly rather than yearly data deadline feeds into a faster service improvement cycle.

Data collection and reporting provides the canvas on which to build service improvements, outcome improvements and variation reductions. The data collected within the EQ programme is specifically designed to monitor:

• That every heart failure patient in hospital has appropriate diagnosis, management and appropriate information provided to them about their condition prior to discharge.

• That every patient has a continuing plan.

• That the ‘transfer of care’ between sectors contains minimum information.

• Personalised care plans and patient held records meet ‘best practice’ standards and are completed with the patient within two weeks of discharge.

• That medical management is optimised in the community.



• That end-of-life care is planned.

• That there is a reduction in variations in clinical practice and outcomes.

• That the patient experience is improved.

Quality data provides the evidence that services are making improvements to reach the ultimate goal of delivering the care that each and every patient can expect: A quality of care delivered to every patient, every time, regardless of their local hospital or community provider, where they live, or who their GP is.

4.3 An example of local practice in conducting the National Heart Failure Audit

Rachel Kindred, Denise Hockey and Lynne Thomas, Aneurin Bevan Health Board, South Wales

Background

Participation in the National Heart Failure Audit began at Nevill Hall Hospital in 2008 with a small patient group, namely those patients referred to the Heart Failure Specialist Nurse team. In 2009 the Clinical Audit Department (now the Quality & Patient Safety Improvement & Measurement Department), became involved with the data input, also using the data for the All Wales 1000 Lives Campaign. The patient group was widened in 2010 to include all those with a coded diagnosis of heart failure on discharge. In 2012 data collection began at Royal Gwent Hospital, the Health Board’s other main acute hospital.

Process

Challenges

The biggest challenge has been to achieve collaboration between the three departments (Information, Quality & Patient Safety and the Heart Failure Specialist Nurse team). This has involved regular communication to refine the identification of cases and the obtaining of case notes for the audit. Obtaining case notes has proved time consuming and requires close communication to ensure the notes are available at the right time to be viewed by a busy clinical team, before being removed when required by other departments of the hospital.

Benefits

The biggest benefit to participation has been the ability to export and review the data regularly as a team, allowing the comparison of data over time in order to resolve areas of lower compliance.

Left to right: Lynne Thomas (Quality and Patient Safety Im-provement and Measurement Assistant), Denise Hockey (Heart Failure Nurse Specialist), Rachel Kindred (Quality and Patient Safety Improvement & Measurement Co-ordinator)

Cases are identified monthly by the Information Department based on discharge codes

Q&PS Improvement & Measurement Assistant obtains notes

Heart Failure Specialist Nurse team analyses notes and completes audit pro forma

Q&PS Improvement & Measurement Co-ordinator inputs data to the NICOR database, then exports data for analysis and feedback to Heart Failure clinical team meeting every two months.



4.4 The national perspective

Hugh F McIntyre, Chair NICE Heart Failure Quality Standard and Heart Failure Commissioning Outcome Framework/Quality Outcome Framework

The central purpose of improving the quality of care is to reduce variation and improve outcome. Improving the quality of care requires defined standards and the systematic measurement of care against those standards. These measurements must then be made available to those accountable for delivering care to allow them both to benchmark and where necessary improve care.

Based upon the heart failure guideline update (2010), measurable indicators of care - the heart failure quality standards - were published in 2011. These define the components of high quality care which services for patients with heart failure should seek to deliver and which commissioners will increasingly expect from any provider. Consistent delivery of improved standards of care should lead to better outcome. It is the role of the National Commissioning Board to deliver such improvement in outcomes - to do so will require a set of integrated indicators (currently under development) which will be delivered through the Commissioning Outcome Framework/Quality Outcome Framework process and will be used by the National Commissioning Board to hold Clinical Commissioning Groups to account.

With standards established, the second component of quality improvement - consistent reliable local data - is fundamental to enable clinical teams to understand the quality of local care they deliver. Now in its sixth year, the National Heart Failure Audit, which covers nearly all of England and Wales, provides a dataset that not only addresses the majority of the hospital-based quality standards but already indicates the potential link between better quality of care (for example place of care and optimal therapy) and better outcome. For the first time the introduction of hospital-level reporting provides specialist teams with measures of the inclusiveness and quality of the care which they deliver, and allows teams to compare their performance with that of local and national peers.

Looking to the future, two areas are likely to become increasingly important. The National Commissioning Board sets five domains of outcome, which can be summarised as enhanced survival; quality of life; recovery (including both hospital admission and long term conditions); patient experience and safety. These move beyond the traditional ‘medical’ outcomes of death and readmission and are particularly relevant to heart failure - especially in older populations. Secondly the local mechanisms that deliver comparative data reporting (which are under development) will need to address not only the organised delivery of comparative data through networks, but also the mechanisms whereby local variations in quality of care can be targeted and reduced.



5 Research use of National Heart Failure Audit data

Professor Henry Dargie, HALO Chair

The National Heart Failure Audit is in its sixth year of activity, and is now collecting data on 60% of all patients discharged from hospital with heart failure in England and Wales. With over 130,000 records in the database, the audit has become a valuable research resource, and as the size and representativeness of the audit increases, so too will its significance for research projects. In 2011 HALO – the Heart failure Audit anaLysis and Outcomes group - was established to handle applications for the use of National Heart Failure Audit data from external groups, and to manage internal research projects.

The National Heart Failure Audit has recently revised its dataset to include a series of new fields that will allow credible risk adjusted data to be produced. This data can be used for comparisons of outcomes among centres, and will allow the audit to start answering more sophisticated questions about variation in outcomes and to investigate the correlation between treatment and management, and outcomes for patients. We hope to start publishing risk adjusted data at a hospital level by 2013.

Of particular interest to HALO is the prospect of investigating the very high mortality recorded by the audit, which is highly variable between centres. In 2011/12 overall mortality during admission stood at 11.1%, with much lower mortality in cardiology wards (7.8%) compared to General Medical wards (13.2%) and other wards (17.4%). The one-year mortality for those surviving to discharge was also very high (26.2%) and it is quite possible that recorded mortality rates will continue to rise as a result of increasing representativeness of the audit. Much higher than reported from Europe and the US, these high mortality rates probably reflect the relatively unselective nature of the data.

The data seem to suggest that managing heart failure patients in a specialist setting has benefits beyond those conferred by higher prescription rates and optimal titration of evidence based drugs. This was shown dramatically for AMI when coronary care units (CCUs) were introduced by Desmond Julian in 1960s to provide early cardiopulmonary resuscitation (CPR), and mortality rates fell dramatically within a couple of years. Our hypothesis is that this was not due to CPR alone but to better management by cardiologists of the most common cause of death in CCUs which was then, and still remains, heart failure. However the extent to which the myriad factors affecting the outcomes for heart failure patients are managed better by specialists remains an unanswered and key research question, and one which HALO hopes to address.

Current HALO projects include a collaborative application for funding to the NIHR Health Technology Assessment (HTA) programme with Professor Barnaby Reeves of the University of Bristol and his team. The study has been commissioned by the HTA to determine the effect of BNP and NT-proBNP testing on outcomes for chronic heart failure patients, and to assess the cost-effectiveness of the technology. The HALO/University of Bristol application proposes to use audit data to supplement this systematic review, and to evaluate the efficacy of BNP testing in reducing mortality and readmission rates in heart failure patients.

HALO is also involved in a collaborative project with Professor Kazem Rahimi from the George Centre for Healthcare Innovation at the University of Oxford, which will investigate the diverse factors affecting outcomes for heart failure patients. The project, funded by an NIHR grant, will look into various aspects of the delivery of heart failure care, in an attempt to determine the percentage of variation in outcomes that is determined by hospital related factors. This project ties in closely with the ambition of the National Heart Failure Audit to deliver risk adjusted data, and will be extremely valuable towards the goal of generating and publishing risk adjusted, hospital level analysis.

Adam Timmis, Chair of MAG (MINAP academic group), has recently joined the group in order to develop a programme of research between MAG and HALO, looking at the incidence of heart failure and outcomes in post-infarction patients. This would involve linkage of MINAP and National Heart Failure Audit data, and tracking patients across multiple cardiovascular admissions to hospital. In addition to this, HALO is working with the European Society of Cardiology Heart Failure Association to produce an educational tool which incorporates the ESC guideline for the treatment and care of heart failure patients into the audit application. This will provide guidance on best practice and clinical standards alongside the data entry application, and will turn the audit database into a powerful tool for promoting and implementing optimal heart failure care.

As HALO moves from strength to strength, we welcome applications for use of National Heart Failure Audit data from hospitals, universities and research groups.



This audit confirms that patients admitted to hospital with a primary diagnosis of heart failure have a poor outcome despite contemporary pharmacological therapy, but that optimal treatment and management, which follows recommended clinical guidelines, is associated with improved outcomes. Patients are much more likely to receive this treatment if they are treated on a cardiology ward, and these patients consequently have lower mortality, both within hospital and following discharge.

Improving the outcome of patients with heart failure requires four major approaches:

• Improved case-ascertainment

• Better treatments

• Better implementation of existing treatment and management pathways

• Better recognition and management of the end of life

This cannot be achieved without better coordination and organisation of care across the spectrum of health and social care.

Future audits will provide more detailed information on risk factors and devices. Increased access to other datasets will provide comprehensive data on the rate, duration and reasons for re-hospitalisation, and information on the cause of death will allow for more sophisticated mortality analyses.

The audit group would like to thank all of the nurses, clinicians, clinical audit facilitators and all others involved in collecting and submitting data to the audit over the last five years. As the audit continues to grow it becomes more useful as a tool for monitoring the treatment and management of heart failure in England and Wales, both at a local and national level. The continued support and participation of hospitals, Trusts and Health Boards is essential for the success and development of the audit, and all of the work and input from individuals and hospitals across the U.K. is greatly appreciated.

6.1 Quality of care and patient outcomesThe 2011/12 report supports the findings of previous years in emphasising the benefits of specialist cardiology input in the management of acute heart failure patients. The National Heart Failure Audit strongly supports the NICE guidance relating to heart failure, and continues to encourage its implementation. NICE has produced both a clinical guideline (2010) and a quality standard (2011) for chronic heart failure, which outline evidence based clinical guidance as to the most effective treatment and management of heart failure patients.26

On the basis of the findings in this report, the National Heart Failure Audit group recommends that Trusts and Health Boards ensure that patients with heart failure have specialist input to their care and are managed on cardiology wards wherever

feasible. Access to specialist medical and nursing care is essential to optimal care for heart failure patients, so Trusts should ensure that key personnel are in place to deliver this care.

Key, evidence-based therapies should be initiated during a patient’s hospital admission. The use of ACE inhibitors/ARBs, beta blockers and MRAs for patients with left ventricular systolic dysfunction is associated with improved patient outcomes, and these treatments should be implemented wherever possible.

Furthermore, audit findings suggest that robust arrangements for optimisation of therapy for cardiac dysfunction via cardiology follow-up, nurse-led heart failure liaison services and primary care need to be firmly in place prior to discharge. The next phase of the audit will address this discharge planning phase more specifically, but 2011/12 findings clearly show that referral to specialist follow-up services on discharge has beneficial effects on outcomes for heart failure patients.

The audit showed in 2011/12 that outcomes for patients with heart failure without LVSD are poorer than for those with LVSD. This likely reflects the greater age of patients who do not have LVSD, but this aspect of heart failure care requires greater attention to identify other possible reasons for this difference and to determine improved management strategies. The continuing increase in case ascertainment coupled with data already accrued from previous audits will provide a robust basis for these aims and should be a focus of interest for subsequent audit reports.

6.2 Data completeness and participationThe National Heart Failure Audit is a key tool for gathering information to improve outcomes in acute heart failure. Even though considerable progress has been made in case ascertainment since the audit began, the data is still not fully representative of the population of heart failure patients in England and Wales. The aim now should be to strive for inclusion of all patients admitted to hospital with a primary diagnosis of heart failure to ensure a more representative dataset. As of April 2013 hospitals will be required to submit data pertaining to all acute admissions with a primary discharge diagnosis of heart failure.

By 2012/13, the audit aims to enrol 95% of eligible Trusts in England and Health Boards in Wales, and to capture 70% of all acute patients admitted to hospital with heart failure in England and Wales.

Following the deletion of several thousand 0 and 1 day admissions from the 2011/12 data, which were believed to be elective admissions for patients with heart failure, hospitals are reminded that only acute heart failure patients should be included in the National Heart Failure Audit. The inclusion of elective admissions has the potential to skew survival analysis and misrepresent the treatment and management of heart failure in England and Wales.

6 Conclusions



7 Appendices

Appendix 1: National Heart Failure Audit Project Board membershipName Representation

Jackie Austin Nurse Consultant (Aneurin Bevan Health Board) and Lead Nurse (South Wales Cardiac Network)

Gemma Baldock-Apps Cardiology Audit and Data Manager (East Sussex Healthcare NHS Trust)

Lailaa Carr Contract and Project Officer (HQIP)

John Cleland Professor of Cardiology (U. of Hull)

Henry Dargie Professor of Cardiology and Consultant Cardiologist (U. of Glasgow); Chair of the Heart Failure Academic Group

Nadeem Fazal National Clinical Audit Services Manager (NICOR)

Jules Grange Heart Failure Specialist Nurse (East Sussex Healthcare NHS Trust)

Suzanna Hardman Consultant Cardiologist (Whittington) and Chair of British Society for Heart Failure

Candy Jeffries Interim Director (Beds and Herts Heart and Stroke Network)

Helen Laing National Clinical Audit Lead (HQIP)

Theresa McDonagh (Chair) National Heart Failure Audit Clinical Lead; Consultant Cardiologist and Professor of Heart Failure (KCH/KCL)

Richard Mindham Heart failure patient representative

Polly Mitchell National Heart Failure Audit Project Manager (NICOR)

Marion Standing Developer (NICOR)

Lynne Walker NICOR Programme Manager (NICOR)

Appendix 2: HALO membershipName Representation

John Cleland Professor of Cardiology (U. of Hull)

Henry Dargie (Chair) Professor of Cardiology and Consultant Cardiologist (U. of Glasgow)

Suzanna Hardman Consultant Cardiologist (Whittington) and Chair of BSH

Theresa McDonagh National Heart Failure Audit Clinical Lead; Consultant Cardiologist and Professor of Heart Failure (KCL)

Polly Mitchell National Heart Failure Audit Project Manager (NICOR)

Appendix 3: Data for 2011/12 mortality analysisIn-hospital mortality

Analysis Variable Deaths Denominator Mortality (%)

Overall In hospital deaths 3420 30886 11.1%

Sex Men 1730 16969 10.2%

Sex Women 1690 13910 12.1%

Place of care Cardiology ward 1141 14635 7.8%

Place of care General medical ward 1691 12833 13.2%

Place of care Other ward 578 3316 17.4%

Age 16-44 15 594 2.5%

Age 45-54 29 1119 2.6%

Age 55-64 136 2704 5.0%

Age 65-74 416 5757 7.2%

Age 75-84 1207 11102 10.9%

Age ≥85 1617 9609 16.8%



Mortality for survivors to discharge


Overall All discharges 7182 27386 26.2%

Sex Men 3937 15186 25.9%

Sex Women 3244 12193 26.6%




Age 16-44 43 576 7.5%

Age 45-54 99 1086 9.1%

Age 55-64 346 2561 13.5%

Age 65-74 1068 5320 20.1%

Age 75-84 2654 9864 26.9%

Age ≥85 2972 7978 37.3%

Diagnosis LVSD Dx LVSD 4087 16460 24.8%

Diagnosis LVSD No Dx LVSD 3095 10926 28.3%

ACEI/ARB on discharge (LVSD) ACEI/ARB 2527 12470 20.2%

ACEI/ARB on discharge (LVSD) No ACEI/ARB 915 2361 38.8%

ACEI/ARB on discharge (all) ACEI/ARB 3977 18895 21.0%

ACEI/ARB on discharge (all) No ACEI/ARB 1995 5444 36.7%

Beta blocker on discharge (LVSD)

Beta blocker 2447 11592 21.1%


No beta blocker 1079 3270 33.0%

Beta blocker on discharge (all) Beta blocker 3806 17134 22.2%

Beta blocker on discharge (all) No beta blocker 2350 7329 32.1%

Loop diuretic on discharge (LVSD)

Loop diuretic 3603 14075 25.6%


No loop diuretic 281 1658 17.0%

Loop diuretic on discharge (all) Loop diuretic 6300 23798 26.5%

Loop diuretic on discharge (all) No loop diuretic 521 2524 20.6%

Additive drug treatment (LVSD) ACEI/ARB, beta blocker and MRA on discharge

734 4367 16.8%

Additive drug treatment (LVSD) ACEI/ARB & beta blocker on discharge

809 4408 18.4%

Additive drug treatment (LVSD) ACEI/ARB on discharge 357 1316 27.1%

Additive drug treatment (LVSD) No ACEI/ARB, beta blocker or MRA on discharge

299 653 45.8%

Referral to cardiology follow-up Cardiology follow-up 2745 13615 20.2%

Referral to cardiology follow-up No cardiology follow-up 4082 12724 32.1%

Referral to nurse-led follow-up HF liaison follow-up 3453 13922 24.8%

Referral to nurse-led follow-up No HF liaison follow-up 3352 12000 27.9%



Appendix 4: Data for 2009-12 mortality analysisThree-year in-hospital mortality (2009-12)


Overall In hospital deaths 9082 75331 12.1%

Sex Men 4605 41040 11.2%

Sex Women 4472 34263 13.1%




Age 16-44 15 594 2.5%

Age 45-54 29 1119 2.6%

Age 55-64 136 2704 5.0%

Age 65-74 416 5757 7.2%

Age 75-84 1207 11102 10.9%

Age ≥85 1617 9609 16.8%

Three-year mortality for survivors to discharge (2009-12)


Overall All discharges 24572 66167 37.1%

Sex Men 13319 36380 36.6%

Sex Women 11247 29764 37.8%




Age 16-44 159 1469 10.8%

Age 45-54 384 2742 14.0%

Age 55-64 1276 6247 20.4%

Age 65-74 3868 13201 29.3%

Age 75-84 9083 23652 38.4%

Age ≥85 9799 18851 52.0%

Diagnosis LVSD Diagnosis of LVSD 13534 39028 34.7%

Diagnosis LVSD No Diagnosis of LVSD 11038 27139 40.7%

ACEI/ARB on discharge (LVSD) ACEI/ARB on discharge (LVSD) 9124 30166 30.32 %

ACEI/ARB on discharge (LVSD) No ACEI/ARB on discharge (LVSD) 2810 5604 50.1%


Beta blocker on discharge (LVSD) 7658 26054 29.4%


No beta blocker on discharge (LVSD) 4275 9317 45.9%


Loop diuretic on discharge (LVSD) 12002 33525 35.8%


No loop diuretic on discharge (LVSD) 1003 4005 25.0%



Additive drug treatment (LVSD) ACEI/ARB, beta blocker and MRA on discharge

2389 9577 25.0%

Additive drug treatment (LVSD) ACEI/ARB & beta blocker on discharge

2814 10470 26.9%

Additive drug treatment (LVSD) ACEI/ARB on discharge 1606 3959 40.6%

Additive drug treatment (LVSD) No ACEI/ARB, beta blocker or MRA on discharge

1013 1788 56.7%

Referral to cardiology follow-up Cardiology follow-up 9581 32714 29.3%

Referral to cardiology follow-up No cardiology follow-up 13652 30585 44.6%

Referral to nurse-led follow-up HF liaison follow-up 11164 32175 34.7%

Referral to nurse-led follow-up No HF liaison follow-up 11655 29575 39.4%

Appendix 5: Glossary

Term Acronym

Acute Myocardial Infarction

AMI Commonly known as a heart attack, a myocardial infarction results from the interruption of blood supply to part of the heart, which causes heart muscle cells to die. The damage to the heart muscle carries a risk of sudden death, but those who survive often go on to suffer from heart failure.

Angiotensin II receptor antagonist/angiotensin receptor blocker

ARB A group of drugs usually prescribed for those patients who are intolerant of ACE inhibitors. Rather than lowering levels of angiotensin II, they instead prevent the chemical from having any effect on blood vessels.

Angiotensin-converting enzyme inhibitor

ACE inhibitor/ACEI

A group of drugs used primarily for the treatment of high blood pressure and heart failure. They stop the body’s ability to produce angiotensin II, a hormone which causes blood vessels to contract, thus dilating blood vessels and increasing the supply of blood and oxygen to the heart.

Beta blocker A group of drugs which slow the heart rate, decrease cardiac output and lessen the force of heart muscle and blood vessel contractions. Used to treat abnormal or irregular heart rhythms, and abnormally fast heart rates.

British Society for Heart Failure

BSH The professional society for healthcare professionals involved in the care of heart failure patients. The BSH aims to improve care and outcomes for heart failure patients by increasing knowledge and promoting research about the diagnosis, causes and management of heart failure.

Cardiac resynchronisation therapy

CRT CRT, also known as biventricular pacing, aims to improve the heart’s pumping efficiency by making the chambers of the heart pump together. 25-50% of all heart failure patients have hearts whose walls do not contract simultaneously. CRT involves implanting a CRT pacemaker or ICD (implantable cardioverter-defibrillator) that has a lead positioned in each ventricle. Most devices also include a third lead which is positioned in the right atrium to ensure that the atria and ventricles contract together.

Chronic obstructive pulmonary disease

COPD The co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing lung diseases in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs, causing shortness of breath (dyspnoea). In contrast to asthma, this limitation is poorly reversible and usually gets progressively worse over time.

Contraindication A factor serving as a reason to withhold medical treatment, due to its unsuitability.

Diuretic A group of drugs which help to remove extra fluid from the body by increasing the amount of water passed through the kidneys. Loop diuretic

Echocardiography Echo A diagnostic test which uses ultrasound to create two-dimensional images of the heart. This allows clinicians to examine the size of the chambers of the heart and its pumping function in detail.

Electrocardiography ECG A diagnostic test which interprets the electrical activity of the heart, detected by electrode attached to the arms, legs and chest.



Heart failure A syndrome characterised by the reduced ability of the heart to pump blood around the body, caused by structural or functional cardiac abnormalities. The condition is characterised by symptoms such as shortness of breath and fatigue, and signs such as fluid retention.

Acute heart failure refers to the rapid onset of the symptoms and signs of heart failure, often resulting in a hospitalisation, whereas in chronic heart failure the symptoms develop more slowly.

Hospital Episode Statistics

HES The national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere. HES is the data source for a wide range of healthcare analysis for the NHS, government and many other organisations. The National Heart Failure Audit uses HES data to calculate case ascertainment.

Left ventricular dysfunction

LVD Any functional impairment of the left ventricle of the heart.

Left ventricular ejection fraction

LVEF A measurement of how much blood is pumped out of the left ventricle with each heartbeat. An ejection fraction of below 40% may be an indication of heart failure.

Left ventricular systolic dysfunction

LVSD A failure of the pumping function of the heart, characterized by a decreased ejection fraction and inadequate ventricular contraction. It is often caused by damage to the heart muscle, for example following a myocardial infarction (heart attack).

Medical Research Information Service

MRIS An NHS Information Centre service which links datasets at the level of individual patient records for medical research projects. NICOR uses MRIS to determine the life status of patients included in the audit, so as to calculate mortality rates.

Mineralocorticoid receptor antagonist

MRA A group of diuretic drugs, whose main action is to block the response to the hormone aldosterone, which promotes the retention of salt and the loss of potassium and magnesium. MRAs increase urination, reduce water and salt, and retain potassium. They help to lower blood pressure and increase the pumping ability of the heart.

National Clinical Audit and Patient Outcomes Programme

NCAPOP A group of 30 national clinical audits, funded by the Department of Health and overseen by HQIP that collect data on the implementation of evidence based clinical standard in U.K. Trusts, and report on patient outcomes.

National Institute for Cardiovascular Outcomes Research

NICOR Part of the National Centre for Cardiovascular Prevention and Outcomes, based in the Institute of Cardiovascular Science at University College London. NICOR manages six national clinical audits and three new technology registries.

National Institute for Health and Clinical Excellence

NICE A special health authority in England which provides guidance, sets quality standards and manages a national database to improve people’s health and prevent and treat ill health. NICE makes recommendations to the NHS on new and existing medicines, treatments and procedures, and on treating and caring for people with specific diseases and conditions.

New York Heart Association class

NYHA class NYHA classification is used to describe degrees of heart failure by placing patients in one of four categories based on how much they are limited during physical activity:Class I (Mild): No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea (shortness of breath).Class II (Mild): Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea.Class III (Moderate): Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnoea.Class IV (Severe): Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Oedema An excess build-up of fluid in the body, causing tissue to become swollen. Heart failure patients often suffer from peripheral oedema, affecting the feet and ankles, and pulmonary oedema, in which fluid collects around the lungs.

Patient Episode Database of Wales

PEDW The national statistics database for Wales, collecting data on all inpatient and outpatient activity undertaken in NHS hospitals in Wales, and on Welsh patients treated in English NHS Trusts.



8 References

1. For example: EuroHeart Failure Survey II reports in-

hospital mortality rates of 6.7%, but has a patient group

of only 3580 (see Nieminen MS et al (2006), ‘EuroHeart

Failure Survey II (EHFS II): a survey on hospitalized acute

heart failure patients: description of population’, European

Heart Journal 27(22):2725:36. http://www.ncbi.nlm.nih.

gov/pubmed/17000631), and the ESC Heart Failure Pilot

Survey recorded in-hospital mortality of only 3.8%, with a

patient population of 5118 (1892 with acute heart failure)

(see Maggioni AP et al, ‘EURObservational Research

Programme: the Heart Failure Pilot Survey (ESC-HF Pilot)’,

European Journal of Heart Failure 12(10):1076-84. http://

www.ncbi.nlm.nih.gov/pubmed/20805094). Also see the

EuroHeart Failure survey programme. This showed 9.1%

mortality for index hospitalisation in the U.K., compared to

an average of 6.9%, but exhibited lots of evidence of biased

reporting (Cleland JG, Swedberg K, Follath F, et al (2003),

‘The EuroHeart Failure survey programme- a survey on the

quality of care among patients with heart failure in Europe.

Part 1: patient characteristics and diagnosis’, European

Heart Journal 24 (5), 442-63, http://www.ncbi.nlm.nih.gov/

pubmed/12633546).

2. National Institute for Health and Clinical Excellence

(2011), QS9 Chronic heart failure quality standard, http://

publications.nice.org.uk/chronic-heart-failure-quality-

standard-qs9/list-of-statements.

3. National Institute for Health and Clinical Excellence (2010),

CG108 Chronic heart failure: Management of chronic heart

failure in adults in primary and secondary care, http://

publications.nice.org.uk/chronic-heart-failure-cg108.

4. Commission for Healthcare Audit and Inspection

(2007), Pushing the boundaries: Improving services for

people with heart failure, p.21, http://archive.cqc.org.

uk/_db/_documents/Pushing_the_boundaries_

Improving_services_for_patients_with_heart_

failure_200707020413.pdf.

5. Scarborough P, Bhatnagar P, Wickramasinghe K,

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Wislon P, Sutton G (2000), ‘Survival of patients with a new

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83, 505–510.

8. See National Heart Failure Audit annual reports from

2008/9, 2009/10 and 2010/11, www.ucl.ac.uk/nicor/audits/

heartfailure/additionalfiles.

9. Gibbs JSR, McCoy ASM, Gibbs LME, Rogers AE, Addington-

Hall JM (2002), ‘Living with and dying from heart failure: the

role of palliative care’, Heart 88, 36-39, http://heart.bmj.

com/content/88/suppl_2/ii36.full.

10. Jiang W, Alexander J et al (2001), ‘Relationship of Depression

to Increased Risk of Mortality and Rehospitalization in

Patients with Congestive Heart Failure’, Archives of Internal

Medicine 161(15), 1849-1856, http://www.ncbi.nlm.nih.gov/

pubmed/11493126.

11. NHS (2010), National Service Framework for Coronary

Heart Disease (Standard eleven: Heart failure), http://www.

dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@

dh/@en/documents/digitalasset/dh_4057526.pdf.






Chronic heart failure quality standard, http://www.nice.

org.uk/guidance/qualitystandards/chronicheartfailure/

home.jsp.

14. Mcdonagh TA, Blue, L, Clark AL, Dahlström U, Ekman I,

Lainscak M, McDonald K, Ryder M, Strömberg A, Jaarsma

T (2011), ‘European Society of Cardiology Heart Failure

Association Standards for Delivering Heart Failure Care’,

European Journal of Heart Failure 13(3), 235-241, http://

eurjhf.oxfordjournals.org/content/13/3/235.full.


http://www.ncbi.nlm.nih.gov/pubmed/17000631



http://publications.nice.org.uk/chronic-heart-failure-quality-standard-qs9/list-of-statements

http://publications.nice.org.uk/chronic-heart-failure-cg108

http://archive.cqc.org.uk/_db/_documents/Pushing_the_boundaries_Improving_services_for_patients_with_heart_failure_200707020413.pdf

www.bhf.org.uk/idoc.ashx?docid=9ef69170-3edf-4fbb-a202-a93955c1283d&version=-1


www.ucl.ac.uk/nicor/audits/heartfailure/additionalfiles

http://heart.bmj.com/content/88/suppl_2/ii36.full


http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4057526.pdf


http://www.nice.org.uk/guidance/qualitystandards/chronicheartfailure/home.jsp

http://eurjhf.oxfordjournals.org/content/13/3/235.full


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Heart Failure Audit (CV37), http://mqi.ic.nhs.uk/Search.as

px?query=heart%25failure&ref=1.05.27.

16. Care Quality Commission, Quality and Risk Profiles, http://

www.cqc.org.uk/organisations-we-regulate/registered-

services/quality-and-risk-profiles-qrps.

17. Number 10, Letter to Cabinet Ministers on transparency and

open data, http://www.number10.gov.uk/news/letter-to-

cabinet-ministers-on-transparency-and-open-data/.

18. Cleland JGF, Mcdonagh TA, Rigby AS, et al (2011), ‘The

national heart failure audit for England and Wales 2008-

2009’, Heart 97 (11), 876-86, http://www.ncbi.nlm.nih.gov/

pubmed/21173198.

19. HQIP, National Clinical Audits, http://www.hqip.org.uk/

national-clinical-audits-including-ncapop-and-corp/.

20. Department of Health, 2011/12 Standard terms and

conditions for acute hospital services (Gateway reference

15458), http://www.dh.gov.uk/prod_consum_dh/groups/

dh_digitalassets/documents/digitalasset/dh_124518.pdf.

21. Welsh Government, NHS Wales National Clinical Audit and

Outcomes Review Plan 2012/13, http://www.hqip.org.uk/

assets/Core-Team/NHS-Wales-NCAOR-Plan-2012-13.pdf.








home.jsp.

24. See www.ucl.ac.uk/nicor/audits/heartfailure/dataset.




publications.nice.org.uk/chronic-heart-failure-cg108,

clause 1.2.2.7.




publications.nice.org.uk/chronic-heart-failure-cg108;

National Institute for Health and Clinical Excellence (2011),



home.jsp


http://mqi.ic.nhs.uk/Search.aspx?query=heart%25failure&ref=1.05.27

http://www.cqc.org.uk/organisations-we-regulate/registered-services/quality-and-risk-profiles-qrps

http://www.number10.gov.uk/news/letter-to-cabinet-ministers-on-transparency-and-open-data/


http://www.hqip.org.uk/national-clinical-audits-including-ncapop-and-corp/

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124518.pdf

http://www.hqip.org.uk/assets/Core-Team/NHS-Wales-NCAOR-Plan-2012-13.pdf



www.ucl.ac.uk/nicor/audits/heartfailure/dataset




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