Why do we need NICE Quality Standards for chronic heart failure?

Heart failure is a complex syndrome in which cardiac insufficiency leads to shortness of breath, fatigue, and fluid retention, which can impact hugely on quality of life. It is a chronic condition with a significant mortality and it imposes a huge burden on patients, society and the NHS.

The quality standards build on the NICE guideline on chronic heart failure (NG106) and recent technology appraisals. They provide “concise, measurable statements” that healthcare personnel can use to audit and assess their services, says Dr Khatib.

What are the implications of the NICE Quality Standards?

The NICE quality standards set out what each quality statement means for different audiences such as commissioners, GPs and service providers. For example, according to Quality Statement number 3, clinical pharmacists with an interest in heart failure should ensure that patients receive appropriate, personalised medication, explains Dr Khatib.

In addition, early diagnosis of heart failure could be improved through the use of a blood test for NT Pro BMP (N-terminal pro-B-type natriuretic peptide) and the provision of cardiac rehabilitation for patients with heart failure should be enhanced.

About Dr Rani Khatib

Dr Rani Khatib is a Consultant Cardiology Pharmacist at Leeds Teaching Hospitals NHS Trust and Associate Professor at the Leeds Institute for Cardiometabolic Medicine (LICaM), University of Leeds. He served on the Guideline Development Group and the Quality Standards Committee for heart failure. In addition, he is Co-chair of UKCPA Cardiovascular Group, National Clinical Champion for Lipid Optimisation, AHSN, NHSE and is a member of the ESC Task Force on Cardiology Allied Professionals.

Read and watch the full series on our website or on YouTube.

The NICE quality standards set out what each quality statement means for different audiences such as commissioners, GPs and service providers. For example, in Quality Statement number 3, clinical pharmacists with an interest in heart failure are clearly identified as one of the groups of healthcare professionals who have a role to play. This quality standard relates to medicines and is concerned with auditing prescribed therapies. Part of this would, of course, be ensuring that patients receive appropriate, personalised treatment, explains Dr Khatib.

Taking a wider perspective, Dr Khatib would like to see the quality statements being used to assess how well services are performing in all settings – “each ICB, each surgery, each ICS, each hospital”.

“Each one of these statements [should be] assessed and audited to see how well are we doing with the diagnosis, how we are we’re doing with access to specialist services, how well are we doing in medications, how we are we doing with our reviews, and how are we doing with access to cardiac rehab. …..  we would like to see people auditing the quality of their service against these quality standards and putting plans in place in order to enhance the provisions to meet these standards”, he says.

Dr Khatib emphasises that the diagnosis of heart failure could be improved. “We need to think more heart failure we need to think about access to diagnostics such as a simple blood test – NT Pro BMP (N-terminal pro-B-type natriuretic peptide).  People who present with symptoms suggestive of heart failure should be tested because this would increase the chances of early diagnosis. “The earlier we detect heart failure the better”, he says. There is now a range of pharmacological and non-pharmacological treatment options and prompt intervention can give people better quality f life and reduce mortality, he adds.

Another area which is really important is cardiac rehabilitation.  “We’re a little bit more familiar with cardiac rehab post heart attack, post MI but I think the kind that we have for patients with heart failure has got a significant importance and benefits.  It’s something that we ought to focus on and work with commissioners and service providers in order to enhance the provision for it. It’s an area that’s not as good as we want it to be and the more we can invest in it the better, definitely”, says Dr Khatib.

About Dr Rani Khatib

Dr Rani Khatib is a Consultant Cardiology Pharmacist at Leeds Teaching Hospitals NHS Trust and Associate Professor at the Leeds Institute for Cardiometabolic Medicine (LICaM), University of Leeds. He served on the Guideline Development Group and the Quality Standards Committee for heart failure. In addition, he is Co-chair of UKCPA Cardiovascular Group, National Clinical Champion for Lipid Optimisation, AHSN, NHSE and is a member of the ESC Task Force on Cardiology Allied Professionals.

Read and watch the full series on our website or on YouTube.

As a frontline clinician Dr Khatib is responsible for running a number of clinical services including some innovative cardiology outpatient clinics focussing on risks and medicines optimisation.  He also contributes to a variety of projects in primary care.  In addition, he is actively involved in research concerned with evaluation of person-centred care, adherence and multi-disciplinary care in the cardiovascular arena.  Recently he has developed a particular interest in cardiorenal metabolic services and promises that we will hear more about a “proper multidisciplinary, one-stop approach” designed to deliver holistic care for people with this complex set of inter-related conditions.

Heart failure is a complex syndrome in which cardiac insufficiency “leads to symptoms which can impact hugely on quality of life, including shortness of breath, fatigue, and fluid retention”. It is a chronic condition with a significant mortality and it imposes a huge burden on patients, society and the NHS, he adds.

Guidelines and quality standards   

The NICE guideline on chronic heart failure (NG106) was published in 2018. The guideline contains multiple recommendations about different aspects of the diagnosis and management of chronic heart failure whereas the quality standards (QS 9) are focused on priority areas. The quality standards are built on the both the guideline and some of the NICE technology appraisals that have been published since 2018, explains Dr Khatib. Importantly, the quality standards focus on quality improvement areas and offer “concise, measurable statements” that healthcare personnel can use to audit and assess their services, he says.

Quality standards are limited to a few areas where there is a need for further enhancement or improvement.  Dr Khatib cites Quality Standard number three, as an example:

‘Adults with chronic heart failure who have reduced ejection fraction receive all appropriate medication at target or optimal tolerated doses.’

The quality standard is a simple statement but the rationale is set out next in the document. “I would advise that when you read the quality statement, don’t leave it at that ……. go and read a little bit of the detail around it, which is actually in the quality statement document, and it will tell you a little bit more about what do we mean by ‘appropriate medications’ [and] what do we mean by ‘optimal tolerated doses’, what’s the rationale behind identifying this quality statement and ….. what you should be auditing if you were to look at that”, says Dr Khatib.

About Dr Rani Khatib

Dr Rani Khatib is a Consultant Cardiology Pharmacist at Leeds Teaching Hospitals NHS Trust and Associate Professor at the Leeds Institute for Cardiometabolic Medicine (LICaM), University of Leeds. He served on the Guideline Development Group and the Quality Standards Committee for heart failure. In addition, he is Co-chair of UKCPA Cardiovascular Group, National Clinical Champion for Lipid Optimisation, AHSN, NHSE and is a member of the ESC Task Force on Cardiology Allied Professionals.

Read and watch the full series on our website or on YouTube.