National Heart Failure Audit 2011/12 Annual Report - UCL

Title
BRITISH SOCIETY FOR HEART FAILURE
NATIONAL
HEART
FAILURE
AUDIT
APRIL 2011 - MARCH 2012
National Heart Failure Audit April 2011-March 2012
1

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.
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.
Authors
Report 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)
Data cleaning and analysis
Emmanuel Lazaridis (NICOR)
Darragh O’Neill (NICOR)
Acknowledgments
The 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
National Heart Failure Audit
National Institute for Cardiovascular Outcomes Research (NICOR)
Institute of Cardiovascular Science, University College London
3rd floor, 170 Tottenham Court Road, London W1T 7HA
Tel: 0203 108 3927
Email: polly.mitchell@ucl.ac.uk
2Published National 27th Heart November Failure Audit 2012. April The 2011-March contents 2012 of this report may not be published or used commercially without permission

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.
National Heart Failure Audit April 2011-March 2012
3

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
4 National Heart Failure Audit April 2011-March 2012

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)
National Heart Failure Audit April 2011-March 2012
5

Foreword
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
6 National Heart Failure Audit April 2011-March 2012

1 Executive Summary
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 Audit
The 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.
National Heart Failure Audit April 2011-March 2012
7

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 followup
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 Recommendations
The 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
8 National Heart Failure Audit April 2011-March 2012

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 angiotensinconverting
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.
National Heart Failure Audit April 2011-March 2012
9

2 Introduction
2.1 Heart Failure
Heart 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
treatments 3 . In 2007 it was estimated that 1.81% of the
population aged 45 years or older suffered from heart failure 4 .
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 condition 5 . 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 admissions 6 .
Survival rates for heart failure patients who receive suboptimal
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 audit
National 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 data
In 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
10 National Heart Failure Audit April 2011-March 2012

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 audit
The 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 database
In 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 IT
User 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.
National Heart Failure Audit April 2011-March 2012
11

2.8 Improving our IT platform
Earlier 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 analysis
The 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.
12 National Heart Failure Audit April 2011-March 2012

3 Findings
3.1 Data cleaning and data quality
As 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
14204 (3952) Admission/
Readmission
1174 (286) 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 MRIS ii 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.
National Heart Failure Audit April 2011-March 2012
13

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.
Fig 1: Age at first admission by sex
Number of patients
8000
6000
4000
2000
0
433
219
18-44 45-54 55-64 65-74 75-84 85+
Men
Women
862
371
2072
862
4051
Age group
2127
6505
3.3.3 Age and Index of Multiple Deprivation
5304
4243
5836
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
14 National Heart Failure Audit April 2011-March 2012

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.
Fig 2: The effect of deprivation on age of first admission
Mean age at first admission
in audit period 2011/12
80
79
78
77
76
75
74
73
72
71
70
79.6
79.1
1 2 3 4 5
Index of multiple deprivation
3.4 Hospitalisation
78.3
76.9
1= least deprived 5= most deprived
74.5
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 3: Mean length of stay by hospital
Hospitals
0 5 10 15 20 25
Length of stay (mean) in days
Fig 4: Median length of stay by hospital
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.
Hospitals
0 5 10 15 20
Length of stay (median) in days
National Heart Failure Audit April 2011-March 2012
15

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.
Fig 5: Number of readmissions in 2011/12
81.2% 1 readmission
2 readmissions
3 readmissions
4+ readmissions
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
14.4%
3%
1.4%
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).
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
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
16 National Heart Failure Audit April 2011-March 2012

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 leftventricular
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 LVSD
All 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
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).
As with ACEI/ARB prescription, patients treated in a cardiology
ward, men, and younger patients were all more likely to be
National Heart Failure Audit April 2011-March 2012
17

Fig 6: Treatment for LVSD on discharge by age
% of patients key heart failure drugs
100
90
80
70
60
50
40
30
20
10
0
18-44 45-54 55-64 65-74 75-84 85+
Age group
ACEI
Loop diuretic
Beta blocker MRA
3.8 Monitoring heart failure patients
3.8.1 Follow-up services
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 followup,
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.
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.
18 National Heart Failure Audit April 2011-March 2012

3.9 Analysis by hospital
For the first time since it was established, the National Heart Failure Audit is publishing a series of analyses at a hospital level. All hospitals are included that submitted over 100 records or
over 70% of their HES/PEDW figures. There is significant variation across hospitals, but this is to some extent down to hospitals including unrepresentative patient populations in the audit.
3.9.1 Participation and case ascertainment
Tables 4 and 5 compare the number of patient records submitted to the audit (after data cleaning) to the number of inpatients discharged with a primary diagnosis of heart failure, as
recorded by HES for English Trusts and PEDW for Welsh Health Boards. iiiv The number of patients with a secondary and tertiary diagnosis of heart failure are also included. Participation
is defined as a Trust or Health Board submitting either 20 cases per calendar month, or greater than 70% of their HES/PEDW recorded figures.
Table 4: Participation and case ascertainment in England
Trust name Trust
records
submitted
% HES
submitted
Participation
status
Primary
HES heart
failure
discharges
Secondary
HES heart
failure
discharges
Tertiary HES
heart failure
discharges
NICOR
hospital
code
Hospital name Hospital
records
submitted
England 36559 61.9% 59083 52471 50315 36559
Aintree University Hospital NHS Foundation
Trust
296 110.9% Yes 267 221 218 FAZ University Hospital
Aintree
296
Airedale NHS Foundation Trust 0 0.0% No 245 242 172 AIR Airedale General Hospital 0
Ashford and St Peter's Hospitals NHS Trust 296 90.2% Yes 328 305 299 SPH St Peter's Hospital 296
Barking, Havering and Redbridge University
Hospitals NHS Trust
719 113.1% Yes 636 492 500
OLD Queen's Hospital
(Romford)
424
KGG King George Hospital 295
Barnet and Chase Farm Hospitals NHS Trust 519 106.1% Yes 489 391 406
BNT Barnet General Hospital 294
CHS Chase Farm Hospital 225
Barnsley Hospital NHS Foundation Trust 201 72.6% Yes 277 256 211 BAR Barnsley Hospital 201
Barts and the London
155 39.9% Partial 388 478 613 BAL The London Chest
Hospital/The Royal
London Hospital
155
Basildon and Thurrock University Hospitals
NHS Foundation Trust
35 9.7% Partial 362 339 480 BAS Basildon University
Hospital
35
Bedford Hospital NHS Trust 220 75.6% Yes 291 229 244 BED Bedford Hospital 220
Blackpool Teaching Hospitals NHS
Foundation Trust
903 243.4% Yes 371 363 375 VIC Blackpool Victoria
Hospital
903
Bolton NHS Foundation Trust 8 1.9% Partial 423 327 261 BOL Royal Bolton Hospital 8
iv. HES data is from 2010/11, and PEDW data from 2011/12, due to availability.
National Heart Failure Audit April 2011-March 2012
19

Trust name Trust
records
submitted
% HES
submitted
Participation
status
Primary
HES heart
failure
discharges
Secondary
HES heart
failure
discharges
Tertiary HES
heart failure
discharges
NICOR
hospital
code
Hospital name Hospital
records
submitted
Bradford Teaching Hospitals NHS Foundation
Trust
170 32.3% Partial 527 429 403 BRD Bradford Royal Infirmary 170
Brighton and Sussex University Hospitals
NHS Trust
628 114.8% Yes 547 513 447
RSC Royal Sussex County
Hospital
PRH Princess Royal Hospital
(Haywards Heath)
406
222
Buckinghamshire Healthcare NHS Trust 220 94.0% Yes 234 205 161
AMG Wycombe General
Hospital
220
SMV Stoke Mandeville Hospital 0
Burton Hospitals NHS Foundation Trust 239 91.6% Yes 261 234 166 BRT Queen's Hospital (Burton) 239
Calderdale and Huddersfield NHS
Foundation Trust
367 71.7% Yes 512 444 452
RHI Calderdale Royal Hospital 185
HUD Huddersfield Royal
Infirmary
182
Cambridge University Hospitals NHS
Foundation Trust
22 4.7% Partial 467 362 304 ADD Addenbrooke's Hospital 22
Central Manchester University Hospitals
NHS Foundation Trust
221 71.1% Yes 311 327 436 MRI Manchester Royal
Infirmary
221
Chelsea and Westminster Hospital NHS
Foundation Trust
84 46.4% Partial 181 107 112 WES Chelsea and Westminster
Hospital
84
Chesterfield Royal Hospital NHS Foundation
Trust
178 63.1% Partial 282 269 257 CHE Chesterfield Royal
Hospital
178
City Hospitals Sunderland NHS Foundation
Trust
245 67.7% Yes 362 436 475 SUN Sunderland Royal
Hospital
245
Colchester Hospital University NHS
Foundation Trust
381 86.8% Yes 439 362 310 COL Colchester General
Hospital
381
Countess of Chester Hospital NHS
Foundation Trust
341 132.2% Yes 258 215 208 COC Countess of Chester
Hospital
341
County Durham and Darlington NHS
Foundation Trust
325 58.9% Yes 552 529 558
DRY University Hospital of
North Durham
DAR Darlington Memorial
Hospital
180
145
Croydon Health Services NHS Trust 223 75.6% Yes 295 232 205 MAY Croydon University
Hospital
223
20 National Heart Failure Audit April 2011-March 2012

Dartford and Gravesham NHS Trust 73 23.7% Partial 308 228 191 DVH Darent Valley Hospital 73
Derby Hospitals NHS Foundation Trust 196 38.4% Partial 510 418 380 DER Royal Derby Hospital 196
Doncaster and Bassetlaw Hospitals NHS
Foundation Trust
197 37.4% Partial 527 446 441
DID Doncaster Royal Infirmary 128
BSL Bassetlaw Hospital 69
Dorset County Hospital NHS Foundation
Trust
176 89.8% Yes 196 201 179 WDH Dorset County Hospital 176
Ealing Hospital NHS Trust 262 118.0% Yes 222 158 181 EAL Ealing Hospital 262
East and North Hertfordshire NHS Trust 481 134.7% Yes 357 305 253
LIS Lister Hospital 267
QEW Queen Elizabeth II
Hospital
214
East Cheshire NHS Trust 167 64.0% Partial 261 152 171 MAC Macclesfield District
General Hospital
167
East Kent Hospitals University NHS
Foundation Trust
0 0.0% No 833 661 636
KCC Kent and Canterbury
Hospital
QEQ Queen Elizabeth The
Queen Mother Hospital
0
0
WHH William Harvey Hospital 0
East Lancashire Hospitals NHS Trust 234 47.4% Partial 494 515 536 BLA Royal Blackburn Hospital 234
East Sussex Healthcare NHS Trust 424 69.3% Yes 612 476 338
CGH Conquest Hospital 218
DGE Eastbourne District
General Hospital
206
Epsom and St Helier University Hospitals
NHS Trust
210 57.9% Partial 363 349 319
SHC St Helier Hospital 110
EPS Epsom Hospital 100
Frimley Park Hospital NHS Foundation Trust 287 121.6% Yes 236 236 257 FRM Frimley Park Hospital 287
Gateshead Health NHS Foundation Trust 128 56.6% Partial 226 262 249 QEG Queen Elizabeth Hospital
(Gateshead)
128
George Eliot Hospital NHS Trust 261 133.2% Yes 196 217 191 NUN George Eliot Hospital 261
Gloucestershire Hospitals NHS Foundation
Trust
121 23.9% Partial 507 467 412
GLO Gloucestershire Royal
Hospital
CHG Cheltenham General
Hospital
67
54
Great Western Hospitals NHS Foundation
Trust
212 83.8% Yes 253 275 276 PMS The Great Western
Hospital
212
National Heart Failure Audit April 2011-March 2012
21

Trust name Trust
records
submitted
% HES
submitted
Participation
status
Primary
HES heart
failure
discharges
Secondary
HES heart
failure
discharges
Tertiary HES
heart failure
discharges
NICOR
hospital
code
Hospital name Hospital
records
submitted
Guy's and St Thomas' NHS Foundation Trust 229 56.4% Partial 406 368 351 STH St Thomas' Hospital 229
Hampshire Hospitals NHS Foundation Trust 128 38.4% Partial 333 265 295
NHH Basingstoke and North
Hampshire Hospital
RHC Royal Hampshire County
Hospital
128
0
Harrogate and District NHS Foundation Trust 130 60.5% Partial 215 153 162 HAR Harrogate District
Hospital
130
Heart of England NHS Foundation Trust 368 32.8% Yes 1122 740 757
EBH Birmingham Heartlands
Hospital
207
SOL Solihull Hospital 161
GHS Good Hope Hospital 0
Heatherwood and Wexham Park Hospitals
NHS Foundation Trust
71 18.3% Partial 388 292 279 WEX Wexham Park Hospital 71
Hinchingbrooke Health Care NHS Trust 38 22.5% Partial 169 151 111 HIN Hinchingbrooke Hospital 38
Homerton University Hospital NHS
Foundation Trust
212 86.5% Yes 245 144 154 HOM Homerton University
Hospital
212
Hull and East Yorkshire Hospitals NHS Trust 737 171.0% Yes 431 411 464 CHH Castle Hill Hospital 627
Hull and East Yorkshire Hospitals NHS Trust HRI Hull Royal Infirmary 110
Imperial College Healthcare NHS Trust 491 79.1% Yes 621 594 621 STM St Mary's Hospital
Paddington
241
Imperial College Healthcare NHS Trust HAM Hammersmith Hospital 151
Imperial College Healthcare NHS Trust CCH Charing Cross Hospital 99
Isle of Wight NHS PCT 173 88.3% Yes 196 148 118 IOW St Mary's Hospital,
Newport
173
James Paget University Hospitals NHS
Foundation Trust
114 34.7% Partial 329 292 310 JPH James Paget University
Hospital
114
Kettering General Hospital NHS Foundation
Trust
239 79.1% Yes 302 230 252 KGH Kettering General
Hospital
239
King's College Hospital NHS Foundation
Trust
245 61.7% Yes 397 332 362 KCH King's College Hospital 245
Kingston Hospital NHS Trust 309 94.5% Yes 327 264 204 KTH Kingston Hospital 309
22 National Heart Failure Audit April 2011-March 2012

Lancashire Teaching Hospitals NHS
Foundation Trust
566 123.3% Yes 459 581 469
RPH Royal Preston Hospital 334
CHO Chorley and South Ribble
Hospital
232
Leeds Teaching Hospitals NHS Trust 248 30.4% Yes 815 719 704 LGI Leeds General Infirmary 248
Lewisham Healthcare NHS Trust 117 40.5% Partial 289 181 175 LEW University Hospital
Lewisham
117
Liverpool Heart and Chest Hospital NHS
Foundation Trust
136 64.5% Partial 211 118 150 BHL Liverpool Heart and Chest
Hospital
136
Luton and Dunstable Hospital NHS
Foundation Trust
346 121.8% Yes 284 271 255 LDH Luton and Dunstable
Hospital
346
Maidstone and Tunbridge Wells NHS Trust 404 90.2% Yes 448 448 336 MAI Maidstone Hospital 226
KSX Tunbridge Wells Hospital 178
Medway NHS Foundation Trust 0 0.0% No 300 241 256 MDW Medway Maritime
Hospital
0
Mid Cheshire Hospitals NHS Foundation
Trust
263 126.4% Yes 208 228 216 LGH Leighton Hospital 263
Mid Essex Hospital Services NHS Trust 136 34.7% Partial 392 211 201 BFH Broomfield Hospital 136
Mid Staffordshire NHS Foundation Trust 74 25.2% Partial 294 227 187 SDG Stafford Hospital 74
Mid Yorkshire Hospitals NHS Trust 420 64.9% Yes 647 491 393
PIN Pinderfields Hospital 301
DEW Dewsbury and District
Hospital
119
Milton Keynes Hospital NHS Foundation
Trust
154 75.9% Yes 203 164 129 MKH Milton Keynes General
Hospital
154
Newham University Hospital NHS Trust 2 0.8% Partial 242 169 169 NWG Newham University
Hospital
2
Norfolk and Norwich University Hospitals
NHS Foundation Trust
374 51.4% Yes 728 696 746 NOR Norfolk and Norwich
University Hospital
374
North Bristol NHS Trust 484 126.7% Yes 382 373 324
FRY Frenchay Hospital 279
BSM Southmead Hospital 205
North Cumbria University Hospitals NHS
Trust
78 22.3% Partial 350 372 310
CMI Cumberland Infirmary 46
WCI West Cumberland
Hospital
32
North Middlesex University Hospital NHS
Trust
171 55.3% Partial 309 176 156 NMH North Middlesex
University Hospital
171
National Heart Failure Audit April 2011-March 2012
23

Trust name Trust
records
submitted
% HES
submitted
Participation
status
Primary
HES heart
failure
discharges
Secondary
HES heart
failure
discharges
Tertiary HES
heart failure
discharges
NICOR
hospital
code
Hospital name Hospital
records
submitted
North Tees and Hartlepool NHS Foundation
Trust
383 140.3% Yes 273 329 316
NTG University Hospital of
North Tees
HGH University Hospital of
Hartlepool
234
149
Northampton General Hospital NHS Trust 217 77.0% Yes 282 290 227 NTH Northampton General
Hospital
217
Northern Devon Healthcare NHS Trust 212 74.9% Yes 283 231 219 NDD North Devon District
Hospital
212
Northern Lincolnshire and Goole Hospitals
NHS Foundation Trust
256 75.5% Yes 339 278 311
GGH Diana Princess of Wales
Hospital
SCU Scunthorpe General
Hospital
161
95
NTY North Tyneside Hospital 219
Northumbria Healthcare NHS Foundation Trust 400 60.6% Yes 660 530 503
ASH Wansbeck General
Hospital
125
HEX Hexham General Hospital 56
Nottingham University Hospitals NHS Trust 203 25.5% Partial 797 722 719
UHN Queen's Medical Centre 159
CHN Nottingham City Hospital 44
Oxford Radcliffe Hospitals NHS Trust 736 102.5% Yes 718 615 534
RAD John Radcliffe Hospital 624
HOR Horton General Hospital 112
Papworth Hospital NHS Foundation Trust 0 0.0% No 274 282 227 PAP Papworth Hospital 0
BRY Fairfield General Hospital 205
Pennine Acute Hospitals NHS Trust 645 88.5% Yes 729 929 881
OHM Royal Oldham Hospital 204
NMG North Manchester
General Hospital
183
BHH Rochdale Infirmary 53
Peterborough and Stamford Hospitals NHS
Foundation Trust
296 89.4% Yes 331 280 251 PET Peterborough City
Hospital
296
Plymouth Hospitals NHS Trust 0 0.0% No 635 525 498 PLY Derriford Hospital 0
Poole Hospital NHS Foundation Trust 307 146.2% Yes 210 237 198 PGH Poole General Hospital 307
24 National Heart Failure Audit April 2011-March 2012

Portsmouth Hospitals NHS Trust 319 59.5% Yes 536 543 509 QAP Queen Alexandra Hospital 319
Rotherham NHS Foundation Trust 227 78.8% Yes 288 323 250 ROT Rotherham Hospital 227
Royal Berkshire NHS Foundation Trust 449 111.4% Yes 403 305 261 BHR Royal Berkshire Hospital 449
Royal Brompton and Harefield NHS
Foundation Trust
234 46.7% Partial 501 512 375
NHB Royal Brompton Hospital 210
HH Harefield Hospital 24
Royal Cornwall Hospitals NHS Trust 155 32.2% Partial 481 428 395 RCH Royal Cornwall Hospital 155
Royal Devon and Exeter NHS Foundation
Trust
225 71.9% Yes 313 389 620 RDE Royal Devon & Exeter
Hospital
225
Royal Free London NHS Trust 223 84.8% Yes 263 229 224 RFH Royal Free Hospital 223
Royal Liverpool and Broadgreen University
Hospitals NHS Trust
330 148.6% Yes 222 237 272 RLU Royal Liverpool University
Hospital
330
Royal Surrey County Hospital NHS
Foundation Trust
144 81.8% Yes 176 141 144 RSU Royal Surrey County
Hospital
144
Royal United Hospital Bath NHS Trust 0 0.0% No 455 395 434 BAT Royal United Hospital Bath 0
Salford Royal NHS Foundation Trust 241 94.1% Yes 256 331 301 SLF Salford Royal 241
Salisbury NHS Foundation Trust 342 209.8% Yes 163 139 150 SAL Salisbury District Hospital 342
Sandwell and West Birmingham Hospitals
NHS Trust
345 48.8% Yes 707 614 608
DUD Birmingham City Hospital 190
SAN Sandwell General
Hospital
155
Scarborough and North East Yorkshire NHS
Trust
7 2.7% Partial 258 256 212 SCA Scarborough General
Hospital
7
Sheffield Teaching Hospitals NHS Foundation
Trust
452 51.3% Yes 881 905 736
NGS Northern General
Hospital
RHA Royal Hallamshire
Hospital
442
10
Sherwood Forest Hospitals NHS Foundation
Trust
315 72.2% Yes 436 269 221
KMH King's Mill Hospital 302
NHN Newark Hospital 13
Shrewsbury and Telford Hospitals NHS Trust 85 19.5% Partial 437 331 304
TLF Princess Royal Hospital
(Telford)
RSS Royal Shrewsbury
Hospital
48
37
South Devon Healthcare NHS Foundation
Trust
359 87.1% Yes 412 236 243 TOR Torbay Hospital 359
National Heart Failure Audit April 2011-March 2012
25

Trust name Trust
records
submitted
% HES
submitted
Participation
status
Primary
HES heart
failure
discharges
Secondary
HES heart
failure
discharges
Tertiary HES
heart failure
discharges
NICOR
hospital
code
Hospital name Hospital
records
submitted
GWH Queen Elizabeth Hospital
(Woolwich)
237
South London Healthcare NHS Trust 262 34.7% Yes 756 550 526
BRO Princess Royal University
Hospital (Bromley)
24
QMH Queen Mary's Hospital
(Sidcup)
1
South Tees Hospitals NHS Foundation Trust 209 43.1% Partial 485 563 817
SCM James Cook University
Hospital
209
FRH Friarage Hospital 0
South Tyneside NHS Foundation Trust 267 147.5% Yes 181 140 112 STD South Tyneside District
Hospital
267
South Warwickshire NHS Foundation Trust 0 0.0% No 126 232 180 WAR Warwick Hospital 0
Southend University Hospital NHS
Foundation Trust
555 165.2% Yes 336 241 268 SEH Southend Hospital 555
Southport and Ormskirk Hospital NHS Trust 203 74.6% Yes 272 224 191 SOU Southport and Formby
District General Hospital
203
St George's Healthcare NHS Trust 229 43.3% Partial 529 506 608 GEO St George's Hospital 229
St Helens and Knowsley Teaching Hospitals
NHS Trust
226 68.5% Partial 330 390 354 WHI Whiston Hospital 226
Stockport NHS Foundation Trust 175 50.0% Partial 350 399 358 SHH Stepping Hill Hospital 175
Surrey and Sussex Healthcare NHS Trust 302 90.7% Yes 333 302 242 ESU East Surrey Hospital 302
Tameside Hospital NHS Foundation Trust 178 73.0% Yes 244 286 223 TGA Tameside General
Hospital
178
Taunton and Somerset NHS Foundation Trust 300 87.2% Yes 344 343 292 MPH Musgrove Park Hospital 300
The Dudley Group NHS Foundation Trust 180 38.7% Partial 465 375 379 RUS Russells Hall Hospital 180
The Hillingdon Hospitals NHS Foundation
Trust
197 86.8% Yes 227 171 155 HIL Hillingdon Hospital 197
The Ipswich Hospital NHS Trust 203 53.0% Partial 383 418 429 IPS The Ipswich Hospital 203
The Newcastle Upon Tyne Hospitals NHS
Foundation Trust
170 24.1% Partial 704 680 559
FRE Freeman Hospital 170
RVN Royal Victoria Infirmary 0
26 National Heart Failure Audit April 2011-March 2012

The North West London Hospitals NHS Trust 360 77.9% Yes 462 361 335
NPH Northwick Park Hospital 346
CMH Central Middlesex
Hospital
14
The Princess Alexandra Hospital NHS Trust 0 0.0% No 290 218 238 PAH Princess Alexandra
Hospital
0
The Queen Elizabeth Hospital King's Lynn
NHS Foundation Trust
201 66.3% Partial 303 291 316 QKL Queen Elizabeth Hospital
(King's Lynn)
201
The Royal Bournemouth and Christchurch
Hospitals NHS Foundation Trust
0 0.0% No 584 662 615 BOU Royal Bournemouth
General Hospital
0
The Royal Wolverhampton Hospitals NHS
Trust
181 41.0% Partial 442 317 304 NCR New Cross Hospital 181
The Whittington Hospital NHS Trust 137 53.9% Partial 254 160 165 WHT Whittington Hospital 137
Trafford Healthcare NHS Trust 0 0.0% No 96 104 83 TRA Trafford General Hospital 0
PIL Pilgrim Hospital 106
United Lincolnshire Hospitals NHS Trust 253 32.0% Yes 790 748 693
LIN Lincoln County Hospital 101
GRA Grantham and District
Hospital
46
University College London Hospitals NHS
Foundation Trust
335 129.3% Yes 259 272 298 UCL University College
Hospital
335
University Hospital of North Staffordshire
NHS Trust
209 28.1% Partial 743 483 461 STO University Hospital of
North Staffordshire
209
University Hospital of South Manchester NHS
Foundation Trust
304 88.6% Yes 343 473 444 WYT Wythenshawe Hospital 304
University Hospital Southampton NHS Trust 142 27.3% Partial 521 464 443 SGH Southampton General
Hospital
142
University Hospitals Birmingham NHS
Foundation Trust
292 44.0% Yes 663 382 357 QEB Queen Elizabeth Hospital
(Edgbaston)
292
University Hospitals Bristol NHS Foundation
Trust
384 94.6% Yes 406 423 458 BRI Bristol Royal Infirmary 384
University Hospitals Coventry and
Warwickshire NHS Trust
309 60.7% Yes 509 577 671
WAL University Hospital
Coventry
281
RUG Hospital of St Cross 28
University Hospitals of Leicester NHS Trust 0 0.0% No 1169 741 658
GRL Glenfield Hospital 0
LER Leicester Royal Infirmary 0
University Hospitals of Morecambe Bay NHS
Foundation Trust
0 0.0% No 449 351 281
FGH Furness General Hospital 0
RLI Royal Lancaster Infirmary 0
National Heart Failure Audit April 2011-March 2012
27

Trust name Trust
records
submitted
% HES
submitted
Participation
status
Primary
HES heart
failure
discharges
Secondary
HES heart
failure
discharges
Tertiary HES
heart failure
discharges
NICOR
hospital
code
Hospital name Hospital
records
submitted
Walsall Healthcare NHS Trust 241 72.4% Yes 333 345 297 WMH Manor Hospital 241
Warrington and Halton Hospitals NHS
Foundation Trust
145 66.8% Partial 217 265 218 WDG Warrington Hospital 145
West Hertfordshire Hospitals NHS Trust 245 74.7% Yes 328 287 220 WAT Watford General Hospital 245
West Middlesex University Hospital NHS
Trust
212 101.0% Yes 210 181 216 WMU West Middlesex University
Hospital
212
West Suffolk NHS Foundation Trust 218 84.5% Yes 258 229 225 WSH West Suffolk Hospital 218
Western Sussex Hospitals NHS Trust 639 86.8% Yes 736 561 495
WRG Worthing Hospital 363
STR St Richard's Hospital 276
Weston Area Health NHS Trust 116 59.2% Partial 196 144 133 WGH Weston General Hospital 116
Whipps Cross University Hospital NHS Trust 206 66.9% Partial 308 268 266 WHC Whipps Cross University
Hospital
206
Wirral University Teaching Hospital NHS
Foundation Trust
219 44.2% Partial 496 383 303 WIR Arrowe Park Hospital 219
Worcestershire Acute Hospitals NHS Trust 392 71.9% Yes 545 454 500
RED Alexandra Hospital 227
WRC Worcestershire Royal
Hospital
165
Wrightington, Wigan and Leigh NHS
Foundation Trust
513 181.3% Yes 283 334 348 AEI Royal Albert Edward
Infirmary
513
Wye Valley NHS Trust 188 92.6% Yes 203 180 181 HCH County Hospital Hereford 188
Yeovil District Hospital NHS Foundation Trust 253 128.4% Yes 197 163 132 YEO Yeovil District Hospital 253
York Teaching Hospital NHS Foundation Trust 220 85.3% Yes 258 276 226 YDH York District Hospital 220
28 National Heart Failure Audit April 2011-March 2012

Table 5: Participation and case ascertainment in Wales
Trust name Trust
records
submitted
% PEDW
submitted
Participation
status
Primary
PEDW heart
failure
discharges
Secondary
PEDW heart
failure
discharges
Tertiary
PEDW heart
failure
discharges
NICOR
hospital
code
Hospital name Hospital
records
submitted
Wales 517 11.9% 4348 3303 3380 517
MOR Morriston Hospital 0
Abertawe Bro Morgannwg University Health
Board
7 0.9% Partial 823 804 929
NGH Neath Port Talbot Hospital 0
POW Princess Of Wales
Hospital
7
SIN Singleton Hospital 0
GWE Royal Gwent Hospital 0
Aneurin Bevan Health Board 175 19.4% Partial 901 713 647
NEV Nevill Hall Hospital 175
YYF Caerphilly District Miners
Hospital/Ysbyty Ystrad
Fawr
0
CLW Glan Clwyd Hospital 0
Betsi Cadwaladr University Health Board 172 18.5% Partial 928 478 719
GWY Ysbyty Gwynedd 0
LLA Llandudno General
Hospital
0
WRX Wrexham Maelor Hospital 172
Cardiff & Vale University Health Board 0 0.0% No 541 497 432
LLD Llandough Hospital 0
UHW University Hospital of
Wales
0
Cwm Taf Health Board 2 0.4% Partial 467 332 236
PCH Prince Charles Hospital 1
RGH Royal Glamorgan 1
BRG Bronglais General
Hospital
146
Hywel Dda Health Board 161 23.4% Partial 688 479 417
PPH Prince Philip Hospital 6
WWG West Wales General 5
WYB Withybush General
Hospital
4
National Heart Failure Audit April 2011-March 2012
29

3.9.2 Clinical practice
Tables 6 and 7 show the percentages of cases at each hospital receiving key diagnostic tests, therapies and referral to follow-up services at hospitals in England and Wales. Hospitallevel
data on clinical practice has only been published if a hospital submitted more than 100 records to the audit, or greater than 70% of their HES recorded figures. An asterisk (*) in a
cell indicates that too few records were submitted for a percentage to be published.
Please note that these outputs have not been risk adjusted, but the denominators used for each analysis have been chosen to ensure that the outcomes are as representative as
possible. The audit Project Board has decided to refrain from publishing outcomes data (e.g. readmission and mortality rates) at a hospital level until a satisfactory risk adjustment
model has been developed. However, since April 2012 the National Heart Failure Audit has included a series of new mandatory data items, which will enable a sophisticated risk
adjustment of the data to account for known confounders. This will enable the audit to publish outcome data at a hospital level in the near future.
Table 6: Clinical practice in England (2011/12)
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.
Trust name NICOR
hospital
code
Hospital name Records
submitted
% received
echo
% cardiology
inpatient
% ACEI/ARB
on discharge
% beta
blocker on
discharge
% referred
to HF liaison
service
% referred
to cardiology
follow-up
England and Wales 37076 85.9% 47.1% 82.7% 76.4% 63.2% 51.1%
England 36559 85.9% 47.0% 82.7% 76.3% 63.2% 51.5%
Aintree University Hospital NHS
Foundation Trust
FAZ University Hospital Aintree 296 98.3% 83.4% 65.6% 75.1% 97.7% 91.2%
Airedale NHS Foundation Trust AIR Airedale General Hospital 0
Ashford and St Peter's Hospitals
NHS Trust
SPH St Peter's Hospital 296 84.8% 49.3% 59.0% 56.4% 51.4% 50.6%
Barking, Havering and Redbridge
University Hospitals NHS Trust
KGG King George Hospital 295 98.6% 21.0% 72.0% 70.8% 73.1% 55.5%
Barking, Havering and Redbridge
University Hospitals NHS Trust
OLD Queen's Hospital (Romford) 424 98.6% 19.6% 79.0% 78.3% 82.0% 55.5%
Barnet and Chase Farm Hospitals
NHS Trust
BNT Barnet General Hospital 294 91.8% 59.5% 97.2% 86.2% 63.4% 50.6%
Barnet and Chase Farm Hospitals
NHS Trust
CHS Chase Farm Hospital 225 86.2% 37.8% 81.5% 80.6% 71.9% 58.3%
Barnsley Hospital NHS Foundation
Trust
BAR Barnsley Hospital 201 84.1% 20.4% 92.9% 82.1% 24.6% 43.2%
30 National Heart Failure Audit April 2011-March 2012

Barts and the London BAL The London Chest Hospital/The Royal
London Hospital
155 89.7% 69.7% 78.8% 83.5% 86.4% 85.7%
Basildon and Thurrock University
Hospitals NHS Foundation Trust
BAS Basildon University Hospital 35 * * * * * *
Bedford Hospital NHS Trust BED Bedford Hospital 220 90.0% 38.6% 64.3% 74.1% 29.1% 55.1%
Blackpool Teaching Hospitals NHS
Foundation Trust
VIC Blackpool Victoria Hospital 903 91.4% 60.3% 85.1% 83.8% 70.9% 21.8%
Bolton NHS Foundation Trust BOL Royal Bolton Hospital 8 * * * * * *
Bradford Teaching Hospitals NHS
Foundation Trust
BRD Bradford Royal Infirmary 170 82.4% 46.5% 79.5% 70.5% 59.0% 63.2%
Brighton and Sussex University
Hospitals NHS Trust
PRH Princess Royal Hospital (Haywards
Heath)
222 68.0% 6.8% 89.4% 84.6% 34.2% 33.5%
Brighton and Sussex University
Hospitals NHS Trust
RSC Royal Sussex County Hospital 406 82.3% 50.0% 86.5% 74.5% 75.0% 55.4%
Buckinghamshire Healthcare NHS
Trust
SMV Stoke Mandeville Hospital 0
Buckinghamshire Healthcare NHS
Trust
AMG Wycombe General Hospital 220 97.7% 70.5% 90.9% 81.3% 62.7% 79.1%
Burton Hospitals NHS Foundation
Trust
BRT Queen's Hospital (Burton) 239 72.4% 43.9% 90.4% 92.2% 43.2% 51.5%
Calderdale and Huddersfield NHS
Foundation Trust
RHI Calderdale Royal Hospital 185 94.1% 62.2% 93.0% 69.6% 58.2% 55.2%
Calderdale and Huddersfield NHS
Foundation Trust
HUD Huddersfield Royal Infirmary 182 91.8% 50.5% 95.6% 73.2% 53.2% 42.7%
Cambridge University Hospitals
NHS Foundation Trust
ADD Addenbrooke's Hospital 22 * * * * * *
Central Manchester University
Hospitals NHS Foundation Trust
MRI Manchester Royal Infirmary 221 88.2% 47.0% 89.0% 90.6% 77.8% 72.9%
Chelsea and Westminster Hospital
NHS Foundation Trust
WES Chelsea and Westminster Hospital 84 * * * * * *
Chesterfield Royal Hospital NHS
Foundation Trust
CHE Chesterfield Royal Hospital 178 75.3% 44.9% 91.5% 86.4% 48.8% 28.6%
City Hospitals Sunderland NHS
Foundation Trust
SUN Sunderland Royal Hospital 245 85.7% 24.5% 81.8% 77.4% 31.3% 50.7%
Colchester Hospital University NHS
Foundation Trust
COL Colchester General Hospital 381 99.5% 50.5% 81.4% 80.0% 94.6% 39.5%
Countess of Chester Hospital NHS
Foundation Trust
COC Countess of Chester Hospital 341 99.1% 68.0% 95.7% 92.0% 90.6% 51.9%
National Heart Failure Audit April 2011-March 2012
31

Trust name NICOR
hospital
code
Hospital name Records
submitted
% received
echo
% cardiology
inpatient
% ACEI/ARB
on discharge
% beta
blocker on
discharge
% referred
to HF liaison
service
% referred
to cardiology
follow-up
County Durham and Darlington
NHS Foundation Trust
DAR Darlington Memorial Hospital 145 93.1% 47.6% 86.5% 73.7% 50.8% 42.0%
County Durham and Darlington
NHS Foundation Trust
DRY University Hospital of North Durham 180 97.8% 53.9% 69.4% 71.7% 46.6% 48.5%
Croydon Health Services NHS Trust MAY Croydon University Hospital 223 79.8% 30.5% 63.3% 67.2% 31.8% 33.9%
Dartford and Gravesham NHS Trust DVH Darent Valley Hospital 73 * * * * * *
Derby Hospitals NHS Foundation
Trust
DER Royal Derby Hospital 196 89.80% 51.03% 81.11% 67.78% 98.94% 76.74%
Doncaster and Bassetlaw Hospitals
NHS Foundation Trust
BSL Bassetlaw Hospital 69 * * * * * *
Doncaster and Bassetlaw Hospitals
NHS Foundation Trust
DID Doncaster Royal Infirmary 128 85.9% 17.3% 95.0% 75.6% 52.2% 53.6%
Dorset County Hospital NHS
Foundation Trust
WDH Dorset County Hospital 176 71.0% 21.0% 68.9% 80.5% 47.3% 29.5%
Ealing Hospital NHS Trust EAL Ealing Hospital 262 93.9% 37.0% 72.5% 90.8% 11.5% 82.0%
East and North Hertfordshire NHS
Trust
LIS Lister Hospital 267 62.9% 57.7% 87.0% 82.4% 78.4% 74.2%
East and North Hertfordshire NHS
Trust
QEW Queen Elizabeth II Hospital 214 84.6% 16.4% 62.6% 66.1% 25.2% 30.1%
East Cheshire NHS Trust MAC Macclesfield District General Hospital 167 75.4% 56.3% 89.7% 86.5% 50.0% 62.9%
East Kent Hospitals University NHS
Foundation Trust
KCC Kent and Canterbury Hospital 0
East Kent Hospitals University NHS
Foundation Trust
QEQ Queen Elizabeth The Queen Mother
Hospital
0
East Kent Hospitals University NHS
Foundation Trust
WHH William Harvey Hospital 0
East Lancashire Hospitals NHS
Trust
BLA Royal Blackburn Hospital 234 76.1% 61.5% 82.0% 85.7% 89.5% 75.9%
East Sussex Healthcare NHS Trust CGH Conquest Hospital 218 88.1% 53.2% 64.0% 57.0% 63.2% 44.9%
East Sussex Healthcare NHS Trust DGE Eastbourne District General Hospital 206 89.3% 56.3% 73.2% 62.6% 70.3% 53.6%
Epsom and St Helier University
Hospitals NHS Trust
EPS Epsom Hospital 100 49.0% 43.0% 80.0% 40.0% 63.6% 35.6%
32 National Heart Failure Audit April 2011-March 2012

Epsom and St Helier University
Hospitals NHS Trust
SHC St Helier Hospital 110 69.1% 40.9% 83.3% 81.8% 70.3% 37.8%
Frimley Park Hospital NHS
Foundation Trust
FRM Frimley Park Hospital 287 87.5% 72.1% 84.8% 65.2% 84.8% 60.2%
Gateshead Health NHS Foundation
Trust
QEG Queen Elizabeth Hospital (Gateshead) 128 78.1% 30.8% 65.1% 55.5% 65.1% 46.8%
George Eliot Hospital NHS Trust NUN George Eliot Hospital 261 87.4% 34.1% 77.3% 85.0% 0.0% 50.7%
Gloucestershire Hospitals NHS
Foundation Trust
CHG Cheltenham General Hospital 54 * * * * * *
Gloucestershire Hospitals NHS
Foundation Trust
GLO Gloucestershire Royal Hospital 67 * * * * * *
Great Western Hospitals NHS
Foundation Trust
PMS The Great Western Hospital 212 85.4% 55.9% 95.4% 84.8% 89.1% 70.1%
Guy's and St Thomas' NHS
Foundation Trust
STH St Thomas' Hospital 229 98.7% 60.3% 82.2% 77.8% 92.3% 80.3%
Hampshire Hospitals NHS
Foundation Trust
NHH Basingstoke and North Hampshire
Hospital
128 85.9% 69.5% 92.6% 63.0% 83.3% 19.5%
Hampshire Hospitals NHS
Foundation Trust
RHC Royal Hampshire County Hospital 0
Harrogate and District NHS
Foundation Trust
HAR Harrogate District Hospital 130 81.5% 51.5% 90.0% 90.2% 66.7% 44.4%
Heart of England NHS Foundation
Trust
EBH Birmingham Heartlands Hospital 207 97.1% 50.0% 84.5% 66.1% 68.3% 55.6%
Heart of England NHS Foundation
Trust
GHS Good Hope Hospital 0
Heart of England NHS Foundation
Trust
SOL Solihull Hospital 161 97.5% 78.0% 88.2% 75.6% 82.1% 40.1%
Heatherwood and Wexham Park
Hospitals NHS Foundation Trust
WEX Wexham Park Hospital 71 * * * * * *
Hinchingbrooke Health Care NHS
Trust
HIN Hinchingbrooke Hospital 38 * * * * * *
Homerton University Hospital NHS
Foundation Trust
HOM Homerton University Hospital 212 84.0% 50.0% 82.7% 89.6% 72.6% 60.5%
Hull and East Yorkshire Hospitals
NHS Trust
CHH Castle Hill Hospital 627 89.0% 75.8% 86.8% 83.8% 66.8% 84.6%
Hull and East Yorkshire Hospitals
NHS Trust
HRI Hull Royal Infirmary 110 64.5% 0.9% 77.3% 68.2% 60.9% 39.0%
National Heart Failure Audit April 2011-March 2012
33

Trust name NICOR
hospital
code
Hospital name Records
submitted
% received
echo
% cardiology
inpatient
% ACEI/ARB
on discharge
% beta
blocker on
discharge
% referred
to HF liaison
service
% referred
to cardiology
follow-up
Imperial College Healthcare NHS
Trust
CCH Charing Cross Hospital 99 91.9% 43.4% 100.0% 64.0% 60.7% 35.8%
Imperial College Healthcare NHS
Trust
HAM Hammersmith Hospital 151 85.4% 47.0% 89.4% 86.5% 48.2% 76.2%
Imperial College Healthcare NHS
Trust
STM St Mary's Hospital Paddington 241 99.2% 26.1% 88.2% 81.0% 30.3% 53.9%
Isle of Wight NHS PCT IOW St Mary's Hospital, Newport 173 73.4% 26.0% 71.4% 42.0% 93.5% 48.3%
James Paget University Hospitals
NHS Foundation Trust
JPH James Paget University Hospital 114 83.3% 40.4% 89.6% 82.2% 12.8% 27.1%
Kettering General Hospital NHS
Foundation Trust
KGH Kettering General Hospital 239 87.0% 74.9% 83.0% 85.7% 93.3% 53.3%
King's College Hospital NHS
Foundation Trust
KCH King's College Hospital 245 95.1% 44.0% 89.0% 85.6% 49.2% 36.2%
Kingston Hospital NHS Trust KTH Kingston Hospital 309 60.2% 34.6% 80.0% 48.5% 0.0% 44.7%
Lancashire Teaching Hospitals NHS
Foundation Trust
CHO Chorley and South Ribble Hospital 232 100.0% 50.4% 97.1% 84.7% 96.6% 78.4%
Lancashire Teaching Hospitals NHS
Foundation Trust
RPH Royal Preston Hospital 334 98.8% 37.7% 80.0% 81.6% 98.8% 86.4%
Leeds Teaching Hospitals NHS
Trust
LGI Leeds General Infirmary 248 98.8% 94.4% 81.5% 82.6% 98.7% 88.6%
Lewisham Healthcare NHS Trust LEW University Hospital Lewisham 117 99.1% 45.3% 86.7% 92.9% 88.6% 96.7%
Liverpool Heart and Chest Hospital
NHS Foundation Trust
BHL Liverpool Heart and Chest Hospital 136 95.6% 97.8% 72.9% 79.8% 76.2% 99.1%
Luton and Dunstable Hospital NHS
Foundation Trust
LDH Luton and Dunstable Hospital 346 90.5% 26.3% 92.3% 71.4% 69.0% 47.1%
Maidstone and Tunbridge Wells
NHS Trust
MAI Maidstone Hospital 226 93.8% 64.4% 90.9% 78.0% 89.2% 74.7%
Maidstone and Tunbridge Wells
NHS Trust
KSX Tunbridge Wells Hospital 178 82.0% 43.8% 97.7% 55.7% 80.9% 60.7%
Medway NHS Foundation Trust MDW Medway Maritime Hospital 0
Mid Cheshire Hospitals NHS
Foundation Trust
LGH Leighton Hospital 263 100.0% 82.9% 90.4% 89.2% 69.7% 46.5%
34 National Heart Failure Audit April 2011-March 2012

Mid Essex Hospital Services NHS
Trust
BFH Broomfield Hospital 136 99.3% 30.1% 97.0% 95.9% 78.0% 63.8%
Mid Staffordshire NHS Foundation
Trust
SDG Stafford Hospital 74 * * * * * *
Mid Yorkshire Hospitals NHS Trust DEW Dewsbury and District Hospital 119 79.8% 31.1% 90.4% 77.1% 92.7% 61.3%
Mid Yorkshire Hospitals NHS Trust PIN Pinderfields Hospital 301 94.0% 53.5% 84.9% 87.6% 69.7% 60.4%
Milton Keynes Hospital NHS
Foundation Trust
MKH Milton Keynes General Hospital 154 76.6% 48.7% 76.0% 68.0% 75.9% 46.2%
Newham University Hospital NHS
Trust
NWG Newham University Hospital 2 * * * * * *
Norfolk and Norwich University
Hospitals NHS Foundation Trust
NOR Norfolk and Norwich University
Hospital
374 80.5% 100.0% 84.0% 79.0% 33.2% 68.5%
North Bristol NHS Trust FRY Frenchay Hospital 279 93.2% 34.4% 80.2% 72.4% 1.9% 21.0%
North Bristol NHS Trust BSM Southmead Hospital 205 94.6% 55.1% 58.5% 71.8% 13.7% 45.6%
North Cumbria University Hospitals
NHS Trust
CMI Cumberland Infirmary 46 * * * * * *
North Cumbria University Hospitals
NHS Trust
WCI West Cumberland Hospital 32 * * * * * *
North Middlesex University Hospital
NHS Trust
NMH North Middlesex University Hospital 171 83.0% 7.6% 92.9% 79.3% 86.2% 36.0%
North Tees and Hartlepool NHS
Foundation Trust
HGH University Hospital of Hartlepool 149 96.0% 64.4% 100.0% 98.0% 63.6% 32.8%
North Tees and Hartlepool NHS
Foundation Trust
NTG University Hospital of North Tees 234 78.2% 58.5% 97.7% 93.2% 75.6% 30.4%
Northampton General Hospital NHS
Trust
NTH Northampton General Hospital 217 86.6% 49.3% 100.0% 98.7% 99.0% 29.0%
Northern Devon Healthcare NHS
Trust
NDD North Devon District Hospital 212 84.9% 50.2% 74.0% 54.3% 71.3% 30.1%
Northern Lincolnshire and Goole
Hospitals NHS Foundation Trust
GGH Diana Princess of Wales Hospital 161 22.4% 31.7% 78.3% 69.6% 0.0% 43.5%
Northern Lincolnshire and Goole
Hospitals NHS Foundation Trust
SCU Scunthorpe General Hospital 95 * * * * * *
Northumbria Healthcare NHS
Foundation Trust
HEX Hexham General Hospital 56 * * * * * *
Northumbria Healthcare NHS
Foundation Trust
NTY North Tyneside Hospital 219 90.9% 45.7% 60.5% 79.3% 47.1% 29.6%
National Heart Failure Audit April 2011-March 2012
35

Trust name NICOR
hospital
code
Hospital name Records
submitted
% received
echo
% cardiology
inpatient
% ACEI/ARB
on discharge
% beta
blocker on
discharge
% referred
to HF liaison
service
% referred
to cardiology
follow-up
Northumbria Healthcare NHS
Foundation Trust
ASH Wansbeck General Hospital 125 93.6% 49.6% 81.1% 67.6% 69.3% 12.0%
Nottingham University Hospitals
NHS Trust
CHN Nottingham City Hospital 44 * * * * * *
Nottingham University Hospitals
NHS Trust
UHN Queen's Medical Centre 159 88.7% 18.9% 75.8% 67.4% 70.0% 31.9%
Oxford Radcliffe Hospitals NHS
Trust
HOR Horton General Hospital 112 96.4% 17.9% 100.0% 97.1% 93.0% 17.3%
Oxford Radcliffe Hospitals NHS
Trust
RAD John Radcliffe Hospital 624 95.7% 22.8% 99.6% 98.7% 91.7% 54.1%
Papworth Hospital NHS Foundation
Trust
PAP Papworth Hospital 0
Pennine Acute Hospitals NHS Trust BRY Fairfield General Hospital 205 80.0% 63.4% 86.0% 80.4% 93.9% 31.9%
Pennine Acute Hospitals NHS Trust NMG North Manchester General Hospital 183 95.1% 40.4% 83.0% 82.5% 91.2% 55.3%
Pennine Acute Hospitals NHS Trust BHH Rochdale Infirmary 53 * * * * * *
Pennine Acute Hospitals NHS Trust OHM Royal Oldham Hospital 204 90.7% 4.4% 87.8% 63.4% 97.1% 83.3%
Peterborough and Stamford
Hospitals NHS Foundation Trust
PET Peterborough City Hospital 296 87.5% 71.6% 75.4% 65.7% 51.7% 59.6%
Plymouth Hospitals NHS Trust PLY Derriford Hospital 0
Poole Hospital NHS Foundation
Trust
PGH Poole General Hospital 307 70.7% 23.1% 70.5% 67.0% 20.0% 28.0%
Portsmouth Hospitals NHS Trust QAP Queen Alexandra Hospital 319 96.6% 94.0% 79.9% 74.8% 77.9% 43.7%
Rotherham NHS Foundation Trust ROT Rotherham Hospital 227 83.3% 32.6% 80.4% 81.9% 69.5% 37.1%
Royal Berkshire NHS Foundation
Trust
BHR Royal Berkshire Hospital 449 88.2% 46.1% 83.3% 83.4% 72.9% 28.2%
Royal Brompton and Harefield NHS
Foundation Trust
HH Harefield Hospital 24 * * * * * *
Royal Brompton and Harefield NHS
Foundation Trust
NHB Royal Brompton Hospital 210 100.00% 98.50% 92.00% 87.84% 52.27% 97.52%
Royal Cornwall Hospitals NHS Trust RCH Royal Cornwall Hospital 155 84.52% 43.23% 81.08% 70.54% 61.86% 37.14%
Royal Devon and Exeter NHS
Foundation Trust
RDE Royal Devon & Exeter Hospital 225 77.78% 52.89% 100.00% 100.00% 75.00% 40.21%
36 National Heart Failure Audit April 2011-March 2012

Royal Free London NHS Trust RFH Royal Free Hospital 223 93.27% 45.29% 97.47% 95.18% 64.55% 58.51%
Royal Liverpool and Broadgreen
University Hospitals NHS Trust
RLU Royal Liverpool University Hospital 330 83.3% 56.4% 75.5% 87.6% 92.0% 42.8%
Royal Surrey County Hospital NHS
Foundation Trust
RSU Royal Surrey County Hospital 144 72.9% 26.4% 86.7% 65.2% 8.9% 38.9%
Royal United Hospital Bath NHS
Trust
BAT Royal United Hospital Bath 0
Salford Royal NHS Foundation Trust SLF Salford Royal 241 90.0% 30.7% 65.0% 74.3% 91.8% 46.3%
Salisbury NHS Foundation Trust SAL Salisbury District Hospital 342 95.0% 61.7% 87.2% 76.1% 31.3% 46.8%
Sandwell and West Birmingham
Hospitals NHS Trust
DUD Birmingham City Hospital 190 88.4% 56.3% 67.7% 54.0% 64.9% 76.7%
Sandwell and West Birmingham
Hospitals NHS Trust
SAN Sandwell General Hospital 155 94.2% 69.0% 88.6% 62.4% 98.9% 84.3%
Scarborough and North East
Yorkshire NHS Trust
SCA Scarborough General Hospital 7 * * * * * *
Sheffield Teaching Hospitals NHS
Foundation Trust
NGS Northern General Hospital 442 100.0% 26.9% 78.6% 72.3% 0.0% 29.0%
Sheffield Teaching Hospitals NHS
Foundation Trust
RHA Royal Hallamshire Hospital 10 * * * * * *
Sherwood Forest Hospitals NHS
Foundation Trust
KMH King's Mill Hospital 302 78.1% 49.3% 79.8% 81.4% 65.0% 51.5%
Sherwood Forest Hospitals NHS
Foundation Trust
NHN Newark Hospital 13 * * * * * *
Shrewsbury and Telford Hospitals
NHS Trust
TLF Princess Royal Hospital (Telford) 48 * * * * * *
Shrewsbury and Telford Hospitals
NHS Trust
RSS Royal Shrewsbury Hospital 37 * * * * * *
South Devon Healthcare NHS
Foundation Trust
TOR Torbay Hospital 359 63.0% 31.8% 60.0% 47.0% 20.2% 33.1%
South London Healthcare NHS
Trust
BRO Princess Royal University Hospital
(Bromley)
24 * * * * * *
South London Healthcare NHS
Trust
GWH Queen Elizabeth Hospital (Woolwich) 237 92.4% 61.2% 89.2% 93.8% 82.9% 63.6%
South London Healthcare NHS
Trust
QMH Queen Mary's Hospital (Sidcup) 1 * * * * * *
South Tees Hospitals NHS
Foundation Trust
FRH Friarage Hospital 0
National Heart Failure Audit April 2011-March 2012
37

Trust name NICOR
hospital
code
Hospital name Records
submitted
% received
echo
% cardiology
inpatient
% ACEI/ARB
on discharge
% beta
blocker on
discharge
% referred
to HF liaison
service
% referred
to cardiology
follow-up
South Tees Hospitals NHS
Foundation Trust
SCM James Cook University Hospital 209 95.7% 87.1% 90.1% 77.5% 93.3% 63.6%
South Tyneside NHS Foundation
Trust
STD South Tyneside District Hospital 267 91.8% 64.0% 94.4% 80.3% 93.8% 73.7%
South Warwickshire NHS
Foundation Trust
WAR Warwick Hospital 0
Southend University Hospital NHS
Foundation Trust
SEH Southend Hospital 555 87.2% 39.1% 70.8% 77.4% 85.3% 38.7%
Southport and Ormskirk Hospital
NHS Trust
SOU Southport and Formby District General
Hospital
203 96.1% 18.3% 67.5% 42.7% 70.9% 70.8%
St George's Healthcare NHS Trust GEO St George's Hospital 229 99.1% 13.1% 87.3% 84.9% 94.9% 48.7%
St Helens and Knowsley Teaching
Hospitals NHS Trust
WHI Whiston Hospital 226 92.5% 77.0% 78.7% 72.1% 95.6% 34.6%
Stockport NHS Foundation Trust SHH Stepping Hill Hospital 175 95.4% 16.6% 92.7% 87.5% 32.2% 42.2%
Surrey and Sussex Healthcare NHS
Trust
ESU East Surrey Hospital 302 76.2% 54.4% 81.5% 63.7% 57.7% 52.5%
Tameside Hospital NHS Foundation
Trust
TGA Tameside General Hospital 178 71.9% 34.8% 80.8% 76.7% 72.6% 50.4%
Taunton and Somerset NHS
Foundation Trust
MPH Musgrove Park Hospital 300 80.3% 52.7% 83.7% 73.1% 0.0% 37.2%
The Dudley Group NHS Foundation
Trust
RUS Russells Hall Hospital 180 96.1% 65.6% 77.8% 74.7% 72.5% 68.6%
The Hillingdon Hospitals NHS
Foundation Trust
HIL Hillingdon Hospital 197 91.9% 52.8% 80.2% 60.2% 70.5% 29.0%
The Ipswich Hospital NHS Trust IPS The Ipswich Hospital 203 63.5% 25.6% 86.8% 81.3% 46.1% 22.3%
The Newcastle Upon Tyne Hospitals
NHS Foundation Trust
FRE Freeman Hospital 170 58.2% 68.8% 85.7% 72.3% 52.8% 93.1%
The Newcastle Upon Tyne Hospitals
NHS Foundation Trust
RVN Royal Victoria Infirmary 0
The North West London Hospitals
NHS Trust
CMH Central Middlesex Hospital 14 * * * * * *
The North West London Hospitals
NHS Trust
NPH Northwick Park Hospital 346 96.5% 84.7% 77.0% 71.9% 72.4% 47.7%
38 National Heart Failure Audit April 2011-March 2012

The Princess Alexandra Hospital
NHS Trust
PAH Princess Alexandra Hospital 0
The Queen Elizabeth Hospital
King's Lynn NHS Foundation Trust
QKL Queen Elizabeth Hospital (King's Lynn) 201 94.5% 67.2% 93.9% 87.1% 84.6% 31.8%
The Royal Bournemouth and
Christchurch Hospitals NHS
Foundation Trust
BOU Royal Bournemouth General Hospital 0
The Royal Wolverhampton Hospitals
NHS Trust
NCR New Cross Hospital 181 75.1% 11.6% 78.5% 67.2% 65.1% 30.7%
The Whittington Hospital NHS Trust WHT Whittington Hospital 137 99.3% 61.3% 97.0% 93.7% 85.3% 78.3%
Trafford Healthcare NHS Trust TRA Trafford General Hospital 0
United Lincolnshire Hospitals NHS
Trust
GRA Grantham and District Hospital 46 * * * * * *
United Lincolnshire Hospitals NHS
Trust
LIN Lincoln County Hospital 101 62.4% 30.7% 60.7% 69.0% 47.1% 53.8%
United Lincolnshire Hospitals NHS
Trust
PIL Pilgrim Hospital 106 59.4% 27.4% 73.7% 76.3% 28.2% 50.0%
University College London Hospitals
NHS Foundation Trust
UCL University College Hospital 335 99.1% 55.8% 99.4% 95.0% 83.3% 90.2%
University Hospital of North
Staffordshire NHS Trust
STO University Hospital of North
Staffordshire
209 81.6% 31.1% 71.9% 56.1% 82.9% 60.1%
University Hospital of South
Manchester NHS Foundation Trust
WYT Wythenshawe Hospital 304 75.0% 49.3% 94.9% 90.4% 57.4% 38.3%
University Hospital Southampton
NHS Trust
SGH Southampton General Hospital 142 100.0% 39.4% 0.0% 0.0% 0.0% 49.2%
University Hospitals Birmingham
NHS Foundation Trust
QEB Queen Elizabeth Hospital (Edgbaston) 292 55.7% 17.4% 91.1% 82.9% 30.8% 32.2%
University Hospitals Bristol NHS
Foundation Trust
BRI Bristol Royal Infirmary 384 93.8% 89.3% 80.8% 78.7% 64.4% 80.4%
University Hospitals Coventry and
Warwickshire NHS Trust
RUG Hospital of St Cross 28 * * * * * *
University Hospitals Coventry and
Warwickshire NHS Trust
WAL University Hospital Coventry 281 95.0% 74.6% 86.1% 76.3% 94.2% 51.7%
University Hospitals of Leicester
NHS Trust
GRL Glenfield Hospital 0
University Hospitals of Leicester
NHS Trust
LER Leicester Royal Infirmary 0
National Heart Failure Audit April 2011-March 2012
39

Trust name NICOR
hospital
code
Hospital name Records
submitted
% received
echo
% cardiology
inpatient
% ACEI/ARB
on discharge
% beta
blocker on
discharge
% referred
to HF liaison
service
% referred
to cardiology
follow-up
University Hospitals of Morecambe
Bay NHS Foundation Trust
FGH Furness General Hospital 0
University Hospitals of Morecambe
Bay NHS Foundation Trust
RLI Royal Lancaster Infirmary 0
Walsall Healthcare NHS Trust WMH Manor Hospital 241 100.0% 52.3% 100.0% 100.0% 90.4% 78.0%
Warrington and Halton Hospitals
NHS Foundation Trust
WDG Warrington Hospital 145 100.0% 67.6% 94.1% 85.7% 98.9% 69.7%
West Hertfordshire Hospitals NHS
Trust
WAT Watford General Hospital 245 94.7% 50.6% 100.0% 99.1% 81.6% 92.1%
West Middlesex University Hospital
NHS Trust
WMU West Middlesex University Hospital 212 83.5% 23.1% 71.8% 77.9% 76.8% 30.7%
West Suffolk NHS Foundation Trust WSH West Suffolk Hospital 218 69.3% 33.0% 83.6% 68.0% 12.8% 34.2%
Western Sussex Hospitals NHS
Trust
STR St Richard's Hospital 276 84.8% 48.9% 76.8% 72.5% 53.7% 46.1%
Western Sussex Hospitals NHS
Trust
WRG Worthing Hospital 363 75.5% 40.5% 75.9% 72.4% 59.0% 47.1%
Weston Area Health NHS Trust WGH Weston General Hospital 116 78.4% 25.9% 69.8% 65.1% 0.0% 20.6%
Whipps Cross University Hospital
NHS Trust
WHC Whipps Cross University Hospital 206 83.0% 33.0% 84.8% 77.3% 75.0% 47.4%
Wirral University Teaching Hospital
NHS Foundation Trust
WIR Arrowe Park Hospital 219 95.0% 43.8% 98.7% 85.9% 97.4% 40.9%
Worcestershire Acute Hospitals
NHS Trust
RED Alexandra Hospital 227 87.7% 35.9% 71.1% 79.8% 42.2% 53.3%
Worcestershire Acute Hospitals
NHS Trust
WRC Worcestershire Royal Hospital 165 44.8% 53.9% 83.0% 61.5% 18.2% 39.6%
Wrightington, Wigan and Leigh NHS
Foundation Trust
AEI Royal Albert Edward Infirmary 513 97.3% 62.0% 88.0% 87.7% 68.2% 66.0%
Wye Valley NHS Trust HCH County Hospital Hereford 188 80.9% 25.0% 77.4% 58.1% 58.1% 30.4%
Yeovil District Hospital NHS
Foundation Trust
YEO Yeovil District Hospital 253 92.1% 55.6% 92.3% 85.3% 100.0% 40.5%
York Teaching Hospital NHS
Foundation Trust
YDH York District Hospital 220 72.3% 9.5% 84.0% 80.0% 28.6% 32.2%
40 National Heart Failure Audit April 2011-March 2012

Table 7: Clinical practice in Wales (2011/12)
Health Board name NICOR
hospital
code
Hospital name Records
submitted
% received
echo
% cardiology
inpatient
% ACEI/ARB
on discharge
% beta
blocker on
discharge
% referred
to HF liaison
service
% referred
to cardiology
follow-up
England and Wales 37076 85.9% 47.1% 82.7% 76.4% 63.2% 51.1%
Wales 517 87.0% 52.9% 81.6% 79.3% 64.5% 29.2%
Abertawe Bro Morgannwg
University Health Board
MOR Morriston Hospital 0
Abertawe Bro Morgannwg
University Health Board
NGH Neath Port Talbot Hospital 0
Abertawe Bro Morgannwg
University Health Board
POW Princess of Wales Hospital 7 * * * * * *
Abertawe Bro Morgannwg
University Health Board
SIN Singleton Hospital 0
Aneurin Bevan Health Board YYF Caerphilly District Miners Hospital/Ysbyty
Ystrad Fawr
0
Aneurin Bevan Health Board NEV Nevill Hall Hospital 175 87.4% 39.4% 92.3% 92.9% 48.4% 19.5%
Aneurin Bevan Health Board GWE Royal Gwent Hospital 0
Betsi Cadwaladr University Health
Board
CLW Glan Clwyd Hospital 0
Betsi Cadwaladr University Health
Board
LLA Llandudno General Hospital 0
Betsi Cadwaladr University Health
Board
WRX Wrexham Maelor Hospital 172 79.1% 37.2% 64.2% 74.7% 78.9% 33.9%
Betsi Cadwaladr University Health
Board
GWY Ysbyty Gwynedd 0
Cardiff & Vale University Health
Board
LLD Llandough Hospital 0
Cardiff & Vale University Health Board UHW University Hospital of Wales 0
Cwm Taf Health Board PCH Prince Charles Hospital 1 * * * * * *
Cwm Taf Health Board RGH Royal Glamorgan 1 * * * * * *
Hywel Dda Health Board BRG Bronglais General Hospital 146 94.5% 82.2% 88.2% 70.2% 66.2% 34.2%
Hywel Dda Health Board PPH Prince Philip Hospital 6 * * * * * *
Hywel Dda Health Board WWG West Wales General 5 * * * * * *
Hywel Dda Health Board WYB Withybush General Hospital 4 * * * * * *
National Heart Failure Audit April 2011-March 2012
41

3.10 Mortality
Mortality 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 followup
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 mortality vi
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

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 postdischarge
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
No beta blocker
on discharge
Loop diuretic on
discharge
No cardiology
follow-up
Not a cardiology
inpatient
1.69 1.59 1.81 < 0.001
1.26 1.19 1.35 < 0.001
1.16 1.04 1.29 0.006
1.36 1.28 1.45 < 0.001
1.10 1.03 1.17 0.003
Fig 7: Overall post-discharge survival
100
% survived
% survived
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Days after discharge
Fig 8: Post-discharge survival by sex
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Days after discharge
Women
Men
National Heart Failure Audit April 2011-March 2012
43

Fig 9: Post-discharge survival by age at admission
100
% Survived
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Days after discharge
16-44
55-64
75-84
45-54
65-74
85+
Fig 11: Post-discharge survival by presence or
absence of LVSD
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Diagnosis of LVSD
No diagnosis of LVSD
Days after discharge
Fig 10: Post-discharge survival by place of care
100
% Survived
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Days after discharge
Fig 12: Post-discharge survival by prescription of ACE
inhibitor and/or ARB on discharge for patients with LVSD
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Days after discharge
Cardiology
General Medicine
Other
ACE inhibitor/ARB
No ACE inhibitor/ARB
44 National Heart Failure Audit April 2011-March 2012

Fig 13: Post-discharge survival by prescription of ACE
inhibitor and/or ARB on discharge (all patients)
Fig 15: Post-discharge survival by prescription of
beta blockers on discharge (all patients)
100
90
80
70
100
90
80
70
% Survived
60
50
40
% Survived
60
50
40
30
20
10
0
30
20
10
0
0 100 200 300 400
Days after discharge
0 100 200 300 400
Days after discharge
ACE inhibitor/ARB
No ACE inhibitor/ARB
Fig 14: Post-discharge survival by prescription of beta
blockers on discharge for patients with LVSD
Beta blocker
No beta blocker
Fig 16: Post-discharge survival by prescription of loop
diuretics on discharge for patients with LVSD
100
90
80
70
100
90
80
70
% Survived
60
50
40
% Survived
60
50
40
30
20
10
0
0 100 200 300 400
Days after discharge
Beta blocker
No beta blocker
30
20
10
0
0 100 200 300 400
Days after discharge
No loop diuretic
Loop diuretic
National Heart Failure Audit April 2011-March 2012
45

Fig 17: Post-discharge survival by prescription of loop
diuretics on discharge (all patients)
Fig 19: Post-discharge survival by referral to
cardiology follow-up services
100
90
80
70
100
90
80
70
% Survived
60
50
40
% Survived
60
50
40
30
20
10
0
0 100 200 300 400
Days after discharge
No loop diuretic
Loop diuretic
30
20
10
0
0 100 200 300 400
Days after discharge
Referred to cardiology follow-up
Not referred to cardiology follow-up
Fig 18: Post-discharge survival by additive drug
treatment on discharge for patients with a
diagnosis of LVSD
Fig 20: Post-discharge survival by referral to heart
failure liason follow-up services
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 100 200 300 400
Days after discharge
ACEI inhibitor/ARB, beta blocker and MRA
ACEI inhibitor/ARB and beta blocker
ACE inhibitor/ARB
No ACEI inhibitor/ARB, beta blocker or MRA
Days after discharge
Referred to heart failure liaison follow-up
Not referred to heart failure liaison follow-up
46 National Heart Failure Audit April 2011-March 2012

3.11 Three-year trends
3.11.1 Three-year in-hospital mortality vii
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 followup
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 followup
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 followup
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.
National Heart Failure Audit April 2011-March 2012
47

Table 9: Cox proportional hazards model for postdischarge
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
No beta blocker
on discharge
Loop diuretic on
discharge
No cardiology
follow-up
Not a cardiology
inpatient
1.58 1.52 1.63 < 0.001
1.29 1.25 1.33 < 0.001
1.21 1.14 1.28 < 0.001
1.34 1.30 1.39 < 0.001
1.11 1.08 1.15 < 0.001
Fig 21: Three-year post-discharge survival (2009-12)
Fig 22: Three-year post-discharge survival by sex
(2009-12)
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 200 400 600 800 1000 1200
Days after discharge
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 200 400 600 800 1000 1200
Days after discharge
% Survived
100
90
80
70
60
50
40
30
20
Women
Men
Fig 23: Three-year post-discharge survival by age
(2009-12)
10
0
0 200 400 600 800 1000 1200
Days after discharge
16-44
45-54
55-64
65-74
75-84
85+
48 National Heart Failure Audit April 2011-March 2012

Fig 24: Three-year post-discharge survival by place of
care (2009-12)
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 200 400 600 800 1000 1200
Days after discharge
Fig 26: Three-year post-discharge survival by
prescription of ACE inhibitor and/or ARB on discharge
in patients with LVSD (2009-12)
% Survival post-discharge
100
90
80
70
60
50
40
30
20
10
0
0 200 400 600 800 1000 1200
Days
Cardiology
General Medicine
Other
ACE inhibitor/ARB
No ACE inhibitor/ARB
Fig 25: Three-year post-discharge survival by
presence or absence of LVSD (2009-12)
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 200 400 600 800 1000 1200
Diagnosis of LVSD
No diagnosis of LVSD
Days after discharge
Fig 27: Three-year post-discharge survival by
prescription of beta blockers on discharge in patients
with LVSD (2009-12)
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 200 400 600 800 1000 1200
Beta blocker
No beta blocker
Days after discharge
National Heart Failure Audit April 2011-March 2012
49

Fig 28: Three-year post-discharge survival by
prescription of loop diuretics on discharge in patients
with LVSD (2009-12)
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 200 400 600 800 1000 1200
Beta blocker
No beta blocker
Days after discharge
Fig 29: Three-year post-discharge survival by
additive drug treatment on discharge in patients
with LVSD (2009-12)
% Survived
100
90
80
70
60
50
40
30
20
10
0
0 200 400 600 800 1000 1200
Days after discharge
ACEI inhibitor/ARB, beta blocker and MRA
ACEI inhibitor/ARB and beta blocker
ACE inhibitor/ARB
No ACEI inhibitor/ARB, beta blocker or MRA
50 National Heart Failure Audit April 2011-March 2012
Fig 30: Three-year post-discharge survival by referral
to cardiology follow-up services (2009-12)
% Survived
% Survived
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
0 200 400 600 800 1000 1200
Days after discharge
Referred to cardiology follow-up
Not referred to cardiology follow-up
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
Days after discharge
Referred to heart failure liaison services
Not referred to heart failure liaison services

4 Case studies
4.1 Improving clinical practice and
patient outcomes
Lee 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.
National Heart Failure Audit April 2011-March 2012
51

• 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.
Process
Cases are identified monthly by the Information
Department based on discharge codes
Q&PS Improvement & Measurement Assistant
obtains notes
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
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.
Challenges
Left to right: Lynne Thomas (Quality and Patient Safety Improvement
and Measurement Assistant), Denise Hockey (Heart
Failure Nurse Specialist), Rachel Kindred (Quality and Patient
Safety Improvement & Measurement Co-ordinator)
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.
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.
52 National Heart Failure Audit April 2011-March 2012

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 hospitalbased
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.
National Heart Failure Audit April 2011-March 2012
53

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.
54 National Heart Failure Audit April 2011-March 2012

6 Conclusions
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 outcomes
The 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 participation
The 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.
National Heart Failure Audit April 2011-March 2012
55

7 Appendices
Appendix 1: National Heart Failure Audit Project Board membership
Name
Jackie Austin
Gemma Baldock-Apps
Lailaa Carr
John Cleland
Henry Dargie
Nadeem Fazal
Jules Grange
Suzanna Hardman
Candy Jeffries
Helen Laing
Theresa McDonagh (Chair)
Richard Mindham
Polly Mitchell
Marion Standing
Lynne Walker
Representation
Nurse Consultant (Aneurin Bevan Health Board) and Lead Nurse (South Wales Cardiac Network)
Cardiology Audit and Data Manager (East Sussex Healthcare NHS Trust)
Contract and Project Officer (HQIP)
Professor of Cardiology (U. of Hull)
Professor of Cardiology and Consultant Cardiologist (U. of Glasgow); Chair of the Heart Failure
Academic Group
National Clinical Audit Services Manager (NICOR)
Heart Failure Specialist Nurse (East Sussex Healthcare NHS Trust)
Consultant Cardiologist (Whittington) and Chair of British Society for Heart Failure
Interim Director (Beds and Herts Heart and Stroke Network)
National Clinical Audit Lead (HQIP)
National Heart Failure Audit Clinical Lead; Consultant Cardiologist and Professor of Heart Failure
(KCH/KCL)
Heart failure patient representative
National Heart Failure Audit Project Manager (NICOR)
Developer (NICOR)
NICOR Programme Manager (NICOR)
Appendix 2: HALO membership
Name
John Cleland
Henry Dargie (Chair)
Suzanna Hardman
Theresa McDonagh
Polly Mitchell
Representation
Professor of Cardiology (U. of Hull)
Professor of Cardiology and Consultant Cardiologist (U. of Glasgow)
Consultant Cardiologist (Whittington) and Chair of BSH
National Heart Failure Audit Clinical Lead; Consultant Cardiologist and Professor of Heart Failure
(KCL)
National Heart Failure Audit Project Manager (NICOR)
Appendix 3: Data for 2011/12 mortality analysis
In-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%
56 National Heart Failure Audit April 2011-March 2012

Mortality for survivors to discharge
Analysis Variable Deaths Denominator Mortality (%)
Overall All discharges 7182 27386 26.2%
Sex Men 3937 15186 25.9%
Sex Women 3244 12193 26.6%
Place of care Cardiology ward 2944 13463 21.9%
Place of care General medical ward 3308 11100 29.8%
Place of care Other ward 914 2734 33.4%
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 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 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)
Additive drug treatment (LVSD)
ACEI/ARB, beta blocker and MRA on
discharge
ACEI/ARB & beta blocker on
discharge
734 4367 16.8%
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%
National Heart Failure Audit April 2011-March 2012
57

Appendix 4: Data for 2009-12 mortality analysis
Three-year in-hospital mortality (2009-12)
Analysis Variable Deaths Denominator Mortality (%)
Overall In hospital deaths 9082 75331 12.1%
Sex Men 4605 41040 11.2%
Sex Women 4472 34263 13.1%
Place of care Cardiology ward 2872 34984 8.2%
Place of care General medical ward 4742 32351 14.7%
Place of care Other ward 1457 7888 18.5%
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)
Analysis Variable Deaths Denominator Mortality (%)
Overall All discharges 24572 66167 37.1%
Sex Men 13319 36380 36.6%
Sex Women 11247 29764 37.8%
Place of care Cardiology ward 9971 32074 31.1%
Place of care General medical ward 11692 27572 42.4%
Place of care Other ward 2889 6427 45.0%
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)
Beta blocker on discharge
(LVSD)
Loop diuretic on discharge
(LVSD)
Loop diuretic on discharge
(LVSD)
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%
58 National Heart Failure Audit April 2011-March 2012

Additive drug treatment (LVSD)
Additive drug treatment (LVSD)
ACEI/ARB, beta blocker and MRA on
discharge
ACEI/ARB & beta blocker on
discharge
2389 9577 25.0%
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
Acute Myocardial
Infarction
Angiotensin II
receptor antagonist/
angiotensin receptor
blocker
Angiotensinconverting
enzyme
inhibitor
Beta blocker
British Society for
Heart Failure
Cardiac
resynchronisation
therapy
Chronic obstructive
pulmonary disease
Contraindication
Diuretic
Acronym
AMI
ARB
ACE
inhibitor/
ACEI
BSH
CRT
COPD
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.
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.
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.
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.
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.
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.
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.
A factor serving as a reason to withhold medical treatment, due to its unsuitability.
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.
National Heart Failure Audit April 2011-March 2012
59

Heart failure
Hospital Episode
Statistics
Left ventricular
dysfunction
Left ventricular
ejection fraction
Left ventricular
systolic dysfunction
Medical Research
Information Service
Mineralocorticoid
receptor antagonist
National Clinical
Audit and Patient
Outcomes
Programme
National Institute
for Cardiovascular
Outcomes Research
National Institute for
Health and Clinical
Excellence
New York Heart
Association class
Oedema
Patient Episode
Database of Wales
HES
LVD
LVEF
LVSD
MRIS
MRA
NCAPOP
NICOR
NICE
NYHA class
PEDW
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.
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.
Any functional impairment of the left ventricle of the heart.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
60 National Heart Failure Audit April 2011-March 2012

8 References
1. For example: EuroHeart Failure Survey II reports inhospital
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Survey recorded in-hospital mortality of only 3.8%, with a
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(see Maggioni AP et al, ‘EURObservational Research
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26. National Institute for Health and Clinical Excellence (2010),
CG108 Chronic heart failure: Management of chronic heart
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publications.nice.org.uk/chronic-heart-failure-cg108;
National Institute for Health and Clinical Excellence (2011),
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org.uk/guidance/qualitystandards/chronicheartfailure/
home.jsp
62 National Heart Failure Audit April 2011-March 2012

National Heart Failure Audit April 2011-March 2012
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