Performance measures recommend the initiation of β-blocker therapy prior to hospital discharge in patients hospitalized for left ventricular systolic dysfunction and heart failure. However, according to the guidelines set out by a consortium of prominent cardiology organizations, administration of β-blockers in these patients comes with a number of caveats—the therapy should not be initiated in patients receiving intravenous diuretics or inotropes during hospitalization, nor while the patient is in an intensive care unit. Despite these clear guidelines, findings from a retrospective cohort study suggest that, in the race to meet performance measures, not all patients with heart failure who are administered β-blockers prior to hospital discharge should have received them.

The investigators used the Perspective database, which contains data for approximately 20% of all annual acute-care hospitalizations in the USA, to identify a cohort of 217,550 patients discharged after treatment for heart failure, and calculated the percentage of patients who received β-blocker therapy. “Currently, approximately 40% of patients in whom a β-blocker is started during hospitalization have at least one potential contraindication to treatment,” explains one of the investigators, Kumar Dharmarajan of Yale-New Haven Hospital, CT, USA. This proportion was evident even in an age-restricted cohort (patients aged between 18 and 49 years) and those hospitalized with acute myocardial infarction, indicating that this misadministration is widespread.

“Our concern is that this proportion may further rise now that inpatient β-blocker initiation is considered a performance measure that is being closely monitored by accrediting bodies and payers,” adds Dharmarajan. “To avoid unintended consequences from the unselected application of the new heart failure performance measure, it may be prudent to use metrics that assess medication overuse in addition to underuse”.

In an editorial note accompanying the study report in JAMA Internal Medicine, Rita Redberg highlights that “the purpose of performance measures is to improve patient care, not to get high grades. Too much focus on meeting a target can distract us from the care of the whole patient.”