Age- and sex-related differences in use of guideline-recommended care and mortality among patients with incident heart failure in Denmark.

BACKGROUND: data are sparse on age- and sex-related differences in use of guideline-recommended care and subsequent mortality among patients with heart failure (HF). METHODS: we identified 24,308 incident patients with a verified primary diagnosis of HF recorded during 2003-2010 in the Danish Heart Failure Registry. The registry monitors guideline-recommended processes of care: echocardiography, New York Heart Association Classification, treatment with angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, betablockers, physical training and patient education. RESULTS: older age was associated with lower use of recommended processes of care. Relative risk (RR) for receiving processes of care varied for men >80 years from 0.52 to 0.91 compared with men ≤65 years. Corresponding RRs among women >80 years varied from 0.55 to 0.89 compared with women ≤65 years. Older age was as expected associated with higher 1 year mortality (32.6% among men >80 years versus 5.4% among men ≤65 years and 33.8% among women >80 years versus 6.6% among women ≤65 years). The corresponding hazard ratios (HRs) were 4.54 (95% CI 3.93-5.25) and 4.08 (95% CI 3.51-4.75) for the oldest versus youngest men and women, after adjustment for patient characteristics. Adjustment for differences in care lowered HRs among the oldest age groups (adjusted HR 3.87 for men and 3.48 for women, respectively). The findings were also confirmed when stratifying the patients according to left ventricular ejection fraction ≤40% and >40%. CONCLUSION: older patients with HF were less likely to receive guideline-recommended processes of care, irrespective of sex. Lower level of care may contribute to an excess mortality observed among the older patients.

Socio-economic position, multimorbidity, and health care utilization among Danish left ventricular assist device patients.

AIMS: Increasing numbers of patients with advanced heart failure and significant comorbidity and social barriers are considered for left ventricular assist devices (LVADs). We sought to examine health care utilization post-LVAD implantation, including the influence of individual-level socio-economic position and multimorbidity. METHODS AND RESULTS: We conducted a Danish nationwide cohort study linking individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish national medical and administrative registries. Socio-economic position included cohabitation status, educational level, and employment status. Multimorbidity was defined as two or more chronic conditions from at least two chronic disease groups. Health care utilization (hospital activity, general practice activity, and redeemed medical prescriptions) within 2 years post-discharge after LVAD implantation was evaluated using descriptive statistics at 0.5 year intervals. We identified 119 patients discharged alive with first-time LVAD implanted between 2006 and 2018. The median age of the patients was 56.1 years, and 88.2% were male. Patients were followed until heart transplantation, LVAD explantation, death, 31 December 2018, or for 2 years. The median follow-up was 0.8 years. The highest median use of health care services was observed 0-0.5 years post-LVAD discharge compared with the subsequent follow-up intervals: 0.5-1, 1-1.5, and 1.5-2 years, respectively. The median (interquartile range) number of hospitalizations was 10 (7-14), bed days 14 (9-28), outpatient visits 8 (5-12), telephone contacts with a general practitioner 4 (2-8), and total redeemed medical prescriptions 26 (19-37) within 0-0.5 years post-LVAD discharge compared with the median utilization within the consecutive follow-up periods [e.g. within 0.5-1 year: hospitalizations 5 (3-8), bed days 8 (4-14), outpatient visits 5 (3-8), telephone contacts 2 (0-5), and redeemed medical prescriptions 24 (18-30)]. The median use of health care services was stable from 0.5 years onwards. The median number of hospitalizations and bed days was slightly higher in patients living alone with a low educational level or low employment status within 0-0.5 years post-LVAD implantation. Finally, the median number of in-hospital days and redeemed prescriptions was higher among patients with pre-existing multimorbidity. CONCLUSIONS: Among patients who underwent LVAD implantation, health care utilization was high in the early post-LVAD discharge phase and was influenced by socio-economic position. Multimorbidity influenced the number of in-hospital days and redeemed prescriptions during the 2 year follow-up.

Trends in quality of care among patients with incident heart failure in Denmark 2003-2010: a nationwide cohort study.

BACKGROUND: The treatment of heart failure (HF) is complex and the prognosis remains serious. A range of strategies is used across health care systems to improve the quality of care for HF patients. We present results from a nationwide multidisciplinary initiative to monitor and improve the quality of care and clinical outcome of HF patients using indicator monitoring combined with systematic auditing. METHODS: We conducted a nationwide, population-based prospective study using data from the Danish Heart Failure Registry. The registry systematically monitors and audits the use of guideline recommended processes of care at Danish hospital departments treating incident HF patients. We identified patients registered between 2003 and 2010 (n = 24,504) and examined changes in use of recommended processes of care and 1-year mortality. RESULTS: The use of the majority of the recommended processes of care increased substantially from 2003 to 2010: echocardiography (from 62.7% to 90.5%; Relative Risk (RR) 1.45 (95% CI, 1.39-1.50)), New York Heart Association classification (from 29.4% to 85.5%; RR 2.91 (95% CI, 2.69-3.14)), betablockers (from 72.6% to 88.3%; RR 1.23 (95% CI, 1.15-1.29)), physical training (from 5.6% to 22.8%; RR 4.04 (95% CI, 2.96-4.52)), and patient education (from 49.3% to 81.4%; RR 1.65 (95% CI, 1.52-1.80)). Use of ACE/ATII inhibitors remained stable (from 92.0% to 93.2%; RR 1.01 (95% CI, 0.99-1.04)). During the same period, 1-year mortality dropped from 20.5% to 12.8% (adjusted Hazard Ratio 0.79 (95% CI, 0.65-0.96). CONCLUSIONS: Use of guideline recommended processes of care has improved among patients with incident HF included in the Danish Heart Failure Registry between 2003 and 2010. During the same period, a decrease in mortality was observed.

Long-Term Medical Treatment and Adherence in Patients With Left Ventricular Assist Devices: A Danish Nationwide Cohort Study.

The use of a left ventricular assist device (LVAD) in treating advanced heart failure has increased. However, data regarding medical treatment and adherence following LVAD implantation is sparse, particularly whether socioeconomic factors (cohabitation status, educational level, employment status, and income) and multimorbidity influence these aspects, which are known to impact adherence in heart failure patients. We performed a nationwide cohort study of 119 patients with LVAD implanted between January 1, 2006, and December 31, 2018, who were discharged alive with LVAD therapy. We linked individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish medical and administrative registers. Medical treatment 90-day pre-LVAD and 720-day post-LVAD were assessed using descriptive statistics in 90-day intervals. Medication adherence (proportion of days covered ≥80%) was assessed 181- to 720-day post-LVAD. The proportions of patients using angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (88.7%), beta-blockers (67.0%), mineralocorticoid receptor antagonists (62.9%), warfarin (87.6%), and aspirin (55.7%) within 90-day post-LVAD were higher than pre-LVAD and were stable during follow-up. Medication adherence ranged from 86.7% (aspirin) to 97.8% (warfarin). Socioeconomic factors and multimorbidity did not influence medical medication use and adherence. Among LVAD patients, medical treatment and adherence are at high levels, regardless of socioeconomic background and multimorbidity.

Evidence-Based Process Performance Measures and Clinical Outcomes in Patients With Incident Heart Failure With Reduced Ejection Fraction: A Danish Nationwide Cohort Study.

BACKGROUND: Data on the association between quality of heart failure (HF) care and outcomes among patients with incident HF are sparse. We examined the association between process performance measures and clinical outcomes in patients with incident HF with reduced ejection fraction. METHODS: Patients with incident HF with reduced ejection fraction (n=10 966) between January 2008 and October 2015 were identified from the Danish HF Registry. Data from public registries were linked. Multivariable regression analyses were used to assess the association between 6 guideline-recommended HF care processes (New York Heart Association assessment, use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists, exercise training, and patient education) and all-cause and HF readmission, all-cause and HF hospital days, and mortality within 3 to 12 months after HF diagnosis. The associations were analyzed according to the percentages of all relevant performance measures fulfilled for the individual patient (0%-50% [reference group], >50%-75%, and >75%-100%) and for the individual performance measures. RESULTS: Fulfilling >75% to 100% of the performance measures (n=5341 [48.7%]) was associated with lower risk of all-cause readmission (adjusted hazard ratio, 0.78 [95% CI, 0.68-0.89]) and HF readmission (adjusted hazard ratio, 0.71 [95% CI, 0.54-0.92]), lower use of all-cause hospital days (adjusted mean ratio, 0.73 [95% CI, 0.70-0.76]) and HF hospital days (adjusted mean ratio, 0.79 [95% CI, 0.70-0.89]), and lower mortality (adjusted hazard ratio, 0.42 [95% CI, 0.32-0.53]). A dose-response relationship was observed between fulfilling more performance measures and mortality (adjusted hazard ratio, 0.62 [95% CI, 0.49-0.77] fulfilling >50%-75% of the measures). Fulfilling individual performance measures, except mineralocorticoid receptor antagonist therapy, was associated with lower adjusted all-cause readmission, lower adjusted use of all-cause and HF hospital days, and lower adjusted mortality. CONCLUSIONS: Fulfilling more process performance measures was associated with better clinical outcomes in patients with incident HF with reduced ejection fraction.

The Danish Heart Failure Registry: A Validation Study of Content.

Background: The Danish Heart Failure Registry (DHFR) is a clinical quality database established to monitor and improve the quality of heart failure (HF) care in Denmark. Objective: We examined the validity of the content of the DHFR. Methods: In a random sample of patients registered in DHFR between the 1st of January 2016 to the 31st of December 2018, we determined the agreement between the information entered in the database and information in the medical records regarding 1) content; 2) sensitivity; 3) specificity; 4) positive predictive values (PPV) as well as negative predictive values (NPV) of all patient characteristics and performance measures obtained in the DHFR. Results: The study population included 453 patients. In general, the content of the DHFR was accurate. Patient characteristics showed high PPV between 93.0% and 99.5% for all variables. Sensitivity ranged from 81.0% to 95.2%, specificity from 79.8% to 99.5% and NPV ranged from 81.4% to 99.0%. The pharmacological performance measures showed high agreement regarding sensitivity (77.4% to 98.6%) and PPV (84.0% to 94.0%). Further, the specificity ranged from 66.7% to 98.0% and NPP ranged from 90.1% to 96.5%. For the non-pharmacological performance measures, patient education showed high sensitivity (98.0%, 95% CI 96.1-99.1) and PPV (94.9% CI: 93.0-96.3), whereas referral to exercise training had a lower sensitivity of 77.8% (CI: 71.6-83.1) and a PPV of 74.5% (CI: 69.6-78.6). Conclusion: Overall, the Danish Heart Failure Registry have a high degree of completeness and validity, making it a valuable tool for clinical epidemiological research in HF.

The heart & mind trial: intervention with cognitive-behavioural therapy in patients with cardiac disease and anxiety: randomised controlled trial protocol.

INTRODUCTION: Patients with cardiac disease often experience anxiety (prevalence about 20%-25%) and have a doubled mortality risk when suffering from anxiety compared with patients without anxiety. This calls for interventions aiming to reduce anxiety. METHODS AND ANALYSIS: The Heart & Mind Trial consists of three parts: (1) screening of all hospitalised and outpatient cardiac patients with arrhythmia, heart failure or ischaemic heart disease at four university hospitals in Denmark using the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A); Patients scoring ≥8 is invited to participate; (2) Assessment of the type of anxiety by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders and (3) Randomised clinical superiority trial with blinded outcome assessment, with 1:1 randomisation to cognitive-behavioural therapy (CBT) performed by a CBT-trained cardiac nurse plus usual care or, usual care alone. The primary outcome is anxiety measured with HADS-A at 5 months. Secondary outcomes include anxiety symptoms measured with Becks Anxiety Inventory and heart rate variability. Exploratory outcomes measured at 12 months include blood cortisol (stress response), blood C reactive protein (stress response), health-related quality of life, readmission, mortality and attributable direct costs. A total of 336 patients will be included. The primary analyses are based on the intention-to-treat principle. For the primary outcome, we will use a linear regression model. For the long-term outcomes, mixed regression models will be used including repeated measurements. ETHICS AND DISSEMINATION: The trial is performed in accordance with the Declaration of Helsinki. All patients must give informed consent prior to participation and the trial is initiated after approval by the Danish Data Protection Agency (P-2020-894) and the National Committee on Health Research Ethics (H-20066739). Positive, neutral and negative results of the trial will be published. TRIAL REGISTRATION NUMBER: NCT04582734.

Risk factors for hospital readmission in adult patients with heart failure with reduced ejection fraction: a systematic review.

OBJECTIVE: The objective of this review was to identify and synthesize evidence on risk factors associated with hospital readmission within the first year after heart failure hospitalization among patients with heart failure with reduced left ventricular ejection fraction. INTRODUCTION: Heart failure is associated with a high risk of hospital readmission. Readmissions are associated with higher mortality and health care costs. It is a high health care priority to identify vulnerable patients with heart failure who may potentially benefit from targeted personalized care interventions aiming to reduce readmissions. INCLUSION CRITERIA: This review considered studies including adult patients who had heart failure with a reduced left ventricular ejection fraction ≤ 40% who were discharged after a heart failure hospitalization. The authors included studies with experimental and observational designs evaluating risk factors for i) all-cause hospital readmission, ii) heart failure hospital readmission, and iii) composite outcomes within seven, 15, 30, 60, 90, 180, and 365 days after hospital discharge. Composite outcomes included end points where all-cause readmission and/or heart failure readmission were part of a defined end point (i.e. all-cause readmission or mortality; heart failure readmission or mortality; cardiovascular readmission; cardiovascular readmission or mortality; and readmission, mortality, or cardiac transplant). Studies reporting all-cause readmission and/or heart failure readmission as a primary outcome, secondary outcome, or part of a composite outcome were included. METHODS: PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, OpenGrey, MedNar, DART-Europe, ProQuest Dissertations and Theses, and the Grey Literature Report in Public Health were searched to find both published and unpublished studies in English, Swedish, Norwegian, or Danish from 2000 to June 2018. Study selection, critical appraisal, data extraction, and data synthesis followed the JBI approach for systematic reviews. Statistical pooling was not possible due to clinical and methodological heterogeneity of the studies included and the lack of risk factors reported more than once. A narrative summary of the findings was performed. RESULTS: Fifty-two studies, including one randomized controlled trial and 51 cohort studies with a total of 128,186 participants, were included. Risk factors for readmission were reported for 30-day outcome in 16 studies, 60-day in three studies, 90-day in 15 studies, 180-day in 12 studies, and 365-day outcome in 15 studies. Based on multivariable analyses from 43 cohort studies and results from one randomized controlled trial, the authors identified several factors associated with higher risk of all-cause readmission, heart failure readmission, and composite outcomes (e.g. readmission or death) within 30, 60, 90, 180, and 365 days after discharge for a heart failure hospitalization. CONCLUSIONS: This review provides a comprehensive overview of factors associated with a clinical outcome after a heart failure hospitalization in patients with heart failure with left ventricular ejection fraction ≤ 40%. Owing to the heterogeneity of variables investigated and the lack of comparability of findings, the clinical impact of the identified risk factors remains uncertain. This review highlights research gaps and the need for a standardized way to define and measure all-cause readmission, heart failure readmission, and composite end points in clinical research to improve study quality and enable comparison of findings between studies.

Inequalities in heart failure care in a tax-financed universal healthcare system: a nationwide population-based cohort study.

AIMS: Data on socioeconomic-related differences in heart failure (HF) care are sparse. Inequality in care may potentially contribute to a poor clinical outcome. We examined socioeconomic-related differences in quality of HF care among patients with incident HF with reduced ejection fraction (EF) (HFrEF). METHODS AND RESULTS: We conducted a nationwide population-based cohort study among patients with HFrEF (EF ≤40%) registered from January 2008 to October 2015 in the Danish Heart Failure Registry, a nationwide registry of patients with a first-time primary HF diagnosis. Associations between individual-level socioeconomic factors (cohabitation status, education, and family income) and the quality of HF care defined by six guideline-recommended process performance measures [New York Heart Association (NYHA) classification, treatment with angiotensin-converting-enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB), beta-blockers and mineralocorticoid receptor antagonists, exercise training, and patient education] were assessed using multiple imputation and multivariable logistic regression controlling for potential confounders. Among 17 122 HFrEF patients included, 15 290 patients had data on all six process performance measures. Living alone was associated with lower odds of NYHA classification [adjusted OR (aOR) 0.81; 95% confidence interval (CI): 0.72-0.90], prescription of ACEI/ARB (aOR 0.76; 95% CI: 0.68-0.88) and beta-blockers (aOR 0.84; 95% CI: 0.76-0.93), referral to exercise training (aOR 0.75; 95% CI: 0.69-0.81), and patient education (aOR 0.73; 95% CI: 0.67-0.80). Compared with high-level education, low-level education was associated with lower odds of NYHA classification (aOR 0.93; 95% CI: 0.79-1.11), treatment with ACEI/ARB (aOR 0.99; 95% CI: 0.81-1.20) and beta-blockers (aOR 0.93; 95% CI: 0.79-1.09), referral to exercise training (aOR 0.73; 95% CI: 0.65-0.82), and patient education (aOR 0.86, 95% CI: 0.75-0.98). An income in the lowest tertile was associated with lower odds of NYHA classification (aOR 0.67; 95% CI: 0.58-0.79), prescription of ACEI/ARB (aOR 0.80, 95% CI: 0.67-0.95) and beta-blockers (aOR 0.88, 95% CI: 0.86-1.01), referral to exercise training (aOR 0.59, 95% CI: 0.53-0.64), and patient education (aOR 0.66; 95% CI: 0.59-0.74) compared with an income in the highest tertile. Overall, no systematic differences were seen when the analyses were stratified by sex and age groups. CONCLUSIONS: Living alone, low-level education, and income in the lowest tertile were associated with reduced use of recommended processes of HF care among Danish HFrEF patients with a first-time primary HF diagnosis. Efforts are warranted to ensure guideline-recommended HF care to all HFrEF patients, irrespective of socioeconomic background.

Socioeconomic Factors and Clinical Outcomes Among Patients With Heart Failure in a Universal Health Care System.

OBJECTIVES: This study examined the associations between socioeconomic factors (SEF), readmission, and mortality in patients with incident heart failure (HF) with reduced ejection fraction (HFrEF) in a tax-financed universal health care system. BACKGROUND: Lack of health insurance is considered a key factor in health inequality, leading to poor clinical outcomes. However, data are sparse for the association between SEF and clinical outcomes among patients with HF in countries with tax-financed health care systems. METHODS: A nationwide population-based cohort study of 17,122 patients with incident HFrEF was carried out. Associations were assessed between individual-level SEF (cohabitation status, education, and income) and all-cause, HF, and non-HF readmission and mortality within 1 to 30, 31 to 90, and 91 to 365 days, as well as hospital bed days within 1 year after HF diagnosis. RESULTS: Low income was associated with a higher risk of all-cause readmission (adjusted hazard ratio [HR]: 1.24; 95% confidence interval [CI]: 1.08 to 1.43) and non-HF readmission (HR: 1.36; 95% CI: 1.17 to 1.58) within days 31 to 90 as well as with a higher risk of all-cause (HR: 1.27; 95% CI: 1.14 to 1.41), HF (HR: 1.26; 95% CI: 1.02 to 1.55) and non-HF readmission (HR: 1.25; 95% CI: 1.12 to 1.39) within days 91 to 365. Low-income patients also had a higher use of hospital bed days and risk of mortality during follow-up. CONCLUSIONS: In a tax-financed universal health care system, low income was associated with a higher risk of all-cause and non-HF readmission within 1 to 12 months after HF diagnosis and with HF readmission within 3 to 12 months among patients with incident HFrEF. Low-income patients also had a higher number of hospital bed days and a higher rate of mortality during follow-up.

Association between process performance measures and 1-year mortality among patients with incident heart failure: a Danish nationwide study.

Aims: To examine the association between fulfilment of performance measures supported by clinical guidelines recommendations and 1-year mortality among patients with incident heart failure (HF) in Denmark. Methods and results: A nationwide population-based follow-up study based on the Danish Heart Failure Registry. All Danish hospital departments caring for patients with HF. We identified 24 308 in- and outpatients diagnosed with HF from 2003 to 2010. Quality of care was defined as receiving the guideline recommended processes of care: use of echocardiography, New York Heart Association classification, treatment with angiotensin-converting-enzyme inhibitors/angiotensin-II-receptor blocker, beta blockers, physical training, and patient education. Main outcome measure is 1-year mortality. We used multiple imputation and multivariable Cox proportional hazard regression to compute hazard ratios (HRs) for 1-year mortality adjusted for potential confounding factors. Within 1 year, 17.1% of the patients died and the adjusted HRs ranged from 0.61 [95% confidence interval (CI) 0.55-0.67] for patient education to 0.99 (95% CI 0.90-1.10) for beta blocker therapy. The association between meeting more performance measures and 1-year mortality appeared to follow a dose-response pattern: using 0-25% of fulfilled measures as reference, patients who fulfilled 76-100% of the performance measures had an adjusted HR of 0.43 (95% CI 0.38-0.48), while the adjusted HR was 0.96 (95% CI 0.86-1.07) for patients who fulfilled between 26% and 50% of the performance measures. Conclusion: Meeting process performance measures, which reflect care in concordance with clinical guideline recommendations, was associated with substantially lower 1-year mortality among patients with incident HF.

Risk factors for readmission to hospital in adult patients with heart failure and reduced ejection fraction: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this systematic review is to identify and synthesize the best available evidence on risk factors associated with hospital readmission at different time points within the first year after heart failure (HF) hospitalization in patients suffering from HF with reduced ejection fraction (EF).More specifically, the question is: what are the risk factors for the prediction of hospital readmission within seven, 15, 30, 60, 90, 180 and 365 days of discharge in hospitalized patients with HF with reduced EF aged 18 years or older?

Patients with heart failure as co-designers of an educational website: implications for medical education.

OBJECTIVES: To identify the learning needs of patients with heart failure between outpatients follow-up visits from their perspective and to ascertain what they emphasize as being important in the design of an educational website for them. METHODS: We conducted a two-step qualitative study at Aarhus University Hospital, Denmark. Twenty patients with heart failure participated either in focus group interviews, diary writing, or video-recorded design sessions. Data on learning needs were collected in step 1 and analyses, therefore, helped develop the preliminary prototypes of a website. In step 2, patients worked on the prototypes in video-recorded design sessions, employing a think-aloud method. The interviews were transcribed and a content analysis was performed on the text and video data. RESULTS: Patients' learning needs were multifaceted, driven by anxiety, arising from, and often influenced by, such daily situations and contexts as the medical condition, medication, challenges in daily life, and where to get support and how to manage their self-care. They emphasized different ways of adapting the design to the patient group to enable interaction with peers and professionals and specific interface issues. CONCLUSIONS: This study provided insights into the different learning needs of patients with heart failure, how managing daily situations is the starting point for these needs and how emotions play a part in patients' learning. Moreover, it showed how patient co-designers proved to be useful for understanding how to design a website that supports patients' learning: insights, which may become important in designing online learning tools for patients.

The Danish Heart Failure Registry.

AIM OF DATABASE: The aim of the Danish Heart Failure Registry (DHFR) is to monitor and improve the care of patients with incident heart failure (HF) in Denmark. STUDY POPULATION: The DHFR includes inpatients and outpatients (≥18 years) with incident HF. Reporting to the DHFR is mandatory for the Danish hospital departments treating patients with incident HF. Final decision to register a patient in the DHFR is made by a cardiologist to ensure the validity of the diagnosis. Approximately 42,400 patients with incident HF were registered in the DHFR in July 2015. MAIN VARIABLES AND DESCRIPTIVE DATA: The main variables recorded in the DHFR are related to the indicators for quality of care in patients with incident HF: performance of echocardiography, functional capacity (New York Heart Association functional classification), pharmacological therapy (angiotensin converting enzyme/angiotensin II antagonist inhibitors, beta-blockers, and mineralocorticoid receptor antagonist), nonpharmacological therapy (physical training, patient education), 4-week readmission rate, and 1-year mortality. Furthermore, basic patient characteristics and prognostic factors (eg, smoking and alcohol) are recorded. At the annual national audit in the DHFR, the indicators and standards for good clinical quality of care for patients with HF are discussed, and recommendations are reported back to clinicians to promote quality improvement initiatives. Furthermore, results and recommendations are communicated to the public in an annual report. All standards for the quality indicators have been met at a national level since 2014. Indicators for treatment status 1 year after diagnosis are under consideration (now prevalent HF). CONCLUSION: The DHFR is a valuable tool for continuous improvement of quality of care in patients with incident HF in Denmark. Furthermore, it is an important resource for the Danish registry-based HF research.

[Use of elastic compression stockings]. / Anvendelse af kompressionsstrømper.

Post-thrombotic syndrome (PTS) is caused by venous insufficiency and is a frequent complication of deep venous thrombosis. Patients with PTS have reduced quality of life and an increased risk of recurrent deep venous thrombosis. Importantly, the risk of PTS is halved by the use of elastic compression stockings. This review outlines important practical aspects related to correct clinical use of these stockings.