ImportanceA composite score for guideline-directed medical therapy (GDMT) for patients with heart failure (HF) is associated with increased survival. Whether hospital performance according to a GDMT score is associated with a broader array of clinical outcomes at lower costs is unknown.ObjectivesTo evaluate hospital variability in GDMT score at discharge, 90-day risk-standardized clinical outcomes and costs, and associations between hospital GDMT score and clinical outcomes and costs.Design, Setting, and ParticipantsThis was a retrospective cohort study conducted from January 2015 to September 2019. Included for analysis were patients hospitalized for HF with reduced ejection fraction (HFrEF) in the Get With the Guidelines–Heart Failure Registry, a national hospital-based quality improvement registry. Study data were analyzed from July 2022 to April 2023.ExposuresGDMT score at discharge.Main Outcomes and MeasuresHospital variability in GDMT score, a weighted index from 0 to 1 of GDMT prescribed divided by the number of medications eligible, at discharge was evaluated using a generalized linear mixed model using the hospital as a random effect and quantified with the adjusted median odds ratio (AMOR). Parallel analyses centering on 90-day mortality, HF rehospitalization, mortality or HF rehospitalization, home time, and costs were performed. Costs were assessed from the perspective of the Centers of Medicare & Medicaid Services. Associations between hospital GDMT score and clinical outcomes and costs were evaluated using Spearman coefficients.ResultsAmong 41 161 patients (median [IQR] age, 78 [71-85] years; 25 546 male [62.1%]) across 360 hospitals, there was significant hospital variability in GDMT score at discharge (AMOR, 1.23; 95% CI, 1.21-1.26), clinical outcomes (mortality AMOR, 1.17; 95% CI, 1.14-1.24; HF rehospitalization AMOR, 1.22; 95% CI, 1.18-1.27; mortality or HF rehospitalization AMOR, 1.21; 95% CI, 1.18-1.26; home time AMOR, 1.07; 95% CI, 1.06-1.10) and costs (AMOR, 1.23; 95% CI, 1.21-1.26). Higher hospital GDMT score was associated with lower hospital mortality (Spearman ρ, −0.22; 95% CI, −0.32 to −0.12; P < .001), lower mortality or HF rehospitalization (Spearman ρ, −0.17; 95% CI, −0.26 to −0.06; P = .002), more home time (Spearman ρ, 0.14; 95% CI, 0.03-0.24; P = .01), and lower cost (Spearman ρ, −0.11; 95% CI, −0.21 to 0; P = .047) but not with HF rehospitalization (Spearman ρ, −0.10; 95% CI, −0.20 to 0; P = .06).Conclusions and RelevanceResults of this cohort study reveal that hospital variability in GDMT score, clinical outcomes, and costs was significant. Higher GDMT score at discharge was associated with lower mortality, lower mortality or hospitalization, more home time, and lower cost. Efforts to increase health care value should include GDMT optimization.

中文翻译：

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医院心力衰竭药物治疗评分及相关临床结果和费用


重要性心力衰竭 （HF） 患者指南指导药物治疗 （GDMT） 的综合评分与生存率增加相关。根据 GDMT 评分的医院绩效是否与以较低成本获得的更广泛的临床结果相关尚不清楚。目的评估出院时 GDMT 评分的医院变异性、90 天风险标准化临床结局和成本，以及医院 GDMT 评分与临床结局和成本之间的关联。设计、设置和参与者这是一项回顾性队列研究，于 2015 年 1 月至 2019 年 9 月进行。分析包括射血分数降低 （HFrEF） 的 HF 住院患者，该登记处是一个以国家医院为基础的质量改进登记处。分析了 2022 年 7 月至 2023 年 4 月的研究数据。主要结局和措施出院时 GDMT 评分的医院变异性，即从 0 到 1 的 GDMT 处方加权指数除以符合条件的药物数量，使用医院作为随机效应，并用调整后的中位比值比 （AMOR） 量化。以 90 天死亡率、 HF 再住院、死亡率或 HF 再住院、家庭时间和费用为中心进行平行分析。从 Medicare 和医疗补助服务。使用 Spearman 系数评估医院 GDMT 评分与临床结果和成本之间的关联。结果在 360 家医院的 41 161 名患者 （中位 [IQR] 年龄，78 [71-85] 岁;25 546 名男性 [62.1%]）中，出院时 GDMT 评分存在显著的医院差异 （AMOR， 1.23;95% CI， 1.21-1.26）、临床结局 （死亡率 AMOR，1.17;95% CI，1.14-1.24;HF 再住院 AMOR，1.22;95% CI，1.18-1.27;死亡率或 HF 再住院 AMOR，1.21;95% CI，1.18-1.26;家乡时间 AMOR，1.07;95% CI，1.06-1.10）和成本（AMOR，1.23;95% CI，1.21-1.26）。较高的医院 GDMT 评分与较低的住院死亡率相关（Spearman ρ，-0.22;95% CI，-0.32 至 -0.12;P < .001）、死亡率或 HF 再住院率较低（Spearman ρ，-0.17;95% CI，-0.26 至 -0.06;P = .002），更多的家庭时间 （Spearman ρ，0.14;95% CI，0.03-0.24;P = .01）和较低的成本（Spearman ρ，-0.11;95% CI，-0.21 至 0;P = .047），但 HF 再住院时没有 （Spearman ρ，-0.10;95% CI，-0.20 至 0;P = .06）。结论和相关性该队列研究的结果表明，医院在 GDMT 评分、临床结果和成本方面的差异很大。出院时 GDMT 评分越高，死亡率越低，死亡率或住院率越高，在家时间越长，成本越低。提高医疗保健价值的努力应包括 GDMT 优化。