Introduction

This quality standard covers the assessment, diagnosis and management of chronic heart failure in adults (18 and older). The diagnosis and management of acute heart failure is covered by NICE's quality standard on acute heart failure in adults. For more information see the chronic heart failure topic overview.

This quality standard has been updated. The topic was identified for update following the annual review of quality standards in 2014. The review identified that there had been changes in the areas for improvement for chronic heart failure in adults. For further information about the update, see update information. Statements from the 2011 quality standard that are no longer national priorities for improvement but are still underpinned by current accredited guidance are included after the updated statements in the list of quality statements.

This quality standard should be considered alongside other relevant NICE quality standards, such as the NICE quality standard on end of life care in adults, which covers care provided by health and social care staff for adults approaching the end of life. It should also be read alongside the NICE technology appraisal guidance for implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure. Additional quality standards relevant to this topic are listed in related NICE quality standards.

Why this quality standard is needed

Chronic heart failure is a complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired. It is caused by structural or functional abnormalities of the heart. Some people have heart failure due to left ventricular systolic dysfunction that is associated with a reduced left ventricular ejection fraction, some have heart failure with a preserved ejection fraction and others have a combination of valve disease, arrhythmia and ventricular dysfunction. Most of the evidence about treatment is for heart failure due to left ventricular systolic dysfunction. The most common cause of heart failure in the UK is coronary heart disease, and many people with heart failure have had a myocardial infarction in the past. The quality statements in this quality standard relate to all causes of chronic heart failure unless stated otherwise.

For people with chronic heart failure and their family members and carers, the condition can have adverse effects on their quality of life and be a financial burden. People with chronic heart failure often experience poor quality of life; symptoms include breathlessness, fatigue and ankle swelling, and over one‑third of people experience severe and prolonged depressive illness.

The British Heart Foundation's 2014 report Cardiovascular disease statistics estimated that around 550,000 people in the UK were living with heart failure in 2013. Both the incidence and the prevalence of heart failure increase with age, with an average age at first diagnosis of 76 years[1].

The prevalence of heart failure is expected to rise in the future as a result of an ageing population, improved survival of people with ischaemic heart disease and more effective treatments for heart failure.

Heart failure has a poor prognosis: 30–40% of people diagnosed with heart failure die within 1 year, but thereafter the mortality is less than 10% per year. Patients on GP heart failure registers, representing prevalent cases of heart failure, have a 5‑year survival rate of 58%, compared with 93% in the general population[2][3].

The quality standard is expected to contribute to improvements in the following outcomes:

  • mortality due to heart failure

  • hospital admissions

  • ability to manage a long‑term condition

  • quality of life

  • medication safety.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1, 2 and 3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults

1b Life expectancy at 75

i Males ii Females

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease*

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Improving functional ability in people with long‑term conditions

2.2 Employment of people with long‑term conditions*, **

Enhancing quality of life for carers

2.4 Health-related quality of life for carers**

Improving quality of life for people with multiple long‑term conditions

2.7 Health‑related quality of life for people with three or more long‑term conditions**

3 Helping people to recover from episodes of ill health or following injury

Overarching indicators

3b Emergency readmissions within 30 days of discharge from hospital*

Improvement areas

Improving outcomes from planned treatments

3.1 Total health gain as assessed by patients for elective procedures

i Physical health-related procedures

Helping older people to recover their independence after illness or injury

3.6 i Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation service*

ii Proportion offered rehabilitation following discharge from acute or community hospital*

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i GP services

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

i Primary care

ii Hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to inpatients' personal needs

Improving people's experience of accident and emergency services

4.3 Patient experience of A&E services

Improving people's experience of integrated care

4.9 People's experience of integrated care**

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics are in development

Table 2 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

Indicators

1.8 Employment for those with long‑term health conditions including adults with a learning disability or who are in contact with secondary mental health services*,**

1.9 Sickness absence rate

4. Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.4 Under 75 mortality rate from all cardiovascular diseases (including heart disease and stroke)*

4.11 Emergency readmissions within 30 days of discharge from hospital*

4.13 Health-related quality of life for older people

Alignment with Adult Social Care Outcomes Framework and/or NHS Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 3 The Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life**

Outcome measures

Carers can balance their caring roles and maintain their desired quality of life

1D Carer‑reported quality of life**

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation

1E Proportion of adults with a learning disability in paid employment**

2 Delaying and reducing the need for care and support

Overarching measure

2A Permanent admissions to residential and nursing care homes, per 100,000 population

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help them manage their care needs

Earlier diagnosis, intervention and reablement means that people and their carers are less dependent on intensive services

2B Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services*

Alignment with NHS Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to chronic heart failure.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for chronic heart failure specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole chronic heart failure care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with chronic heart failure.

Multidisciplinary teams have a pivotal role in the ongoing management of heart failure. NICE's guideline on chronic heart failure in adults recommends that heart failure care should be delivered by a multidisciplinary team with an integrated approach across the healthcare community. This team comprises professionals with appropriate competencies from primary and secondary care, and typically includes doctors with a subspecialty interest in heart failure, GPs and heart failure specialist nurses. The team can also involve other services, such as palliative care and rehabilitation, in the care of individual patients.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating adults with chronic heart failure should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with chronic heart failure. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.



[1] Cowie MR, Wood DA, Coats AJ et al. (1999) Incidence and aetiology of heart failure; a population-based study. European Heart Journal 20: 421–8

[2] Cowie MR, Wood DA, Coats AJ et al. (2000) Survival of patients with a new diagnosis of heart failure: a population based study. Heart 83: 505–10

[3] Hobbs FD, Roalfe AK, Davis RC et al. (2007) Prognosis of all-cause heart failure and borderline left ventricular systolic dysfunction: 5 year mortality follow-up of the Echocardiographic Heart of England Screening Study (ECHOES). European Heart Journal 28: 1128–34