Association between heart failure quality of care and mortality: a population‐based cohort study using nationwide registries

AIMS: To evaluate the quality of heart failure (HF) care using the European Society of Cardiology (ESC) quality indicators (QIs) for HF and to assess whether better quality of care is associated with improved outcomes. METHODS AND RESULTS: We performed a nationwide cohort study using the Swedish HF registry, consisting of patients with any type of HF at their first outpatient visit or hospitalization. Independent participant data for quality of HF care was evaluated against the ESC QIs for HF, and association with mortality estimated using multivariable Cox regression. In total, 43 704 patients from 80 hospitals across Sweden enrolled between 2013–2019 were included, with median follow‐up 23.6 months. Of the 16 QIs for HF, 13 could be measured and 5 were inversely associated with all‐cause mortality during follow‐up. Higher attainment (≥50% vs. <50% attainment) of the composite opportunity‐based score (combination of QIs into a single score) for patients with reduced ejection fraction was associated with lower all‐cause mortality (adjusted hazard ratio 0.81; 95% confidence interval 0.72–0.91). Attainment of the composite score was less in the outpatient than inpatient setting (adjusted odds ratio 0.85; 95% confidence interval 0.72–0.99). Quality of care varied across hospitals, with assessment of health‐related quality of life being the indicator with the widest variation in attainment (interquartile range 61.7%). CONCLUSION: Quality of HF care may be measured using the ESC HF QIs. In Sweden, attainment of HF care evaluated using the QIs demonstrated between and within hospital variation, and many QIs were inversely associated with mortality.