Quality standard
Quality statement 2: Specialist assessment
Quality statement 2: Specialist assessment
Quality statement
Adults with suspected heart failure have specialist assessment and transthoracic echocardiography within 2 weeks of referral if they have a very high N‑terminal pro‑B‑type natriuretic peptide (NT‑proBNP) level, or 6 weeks if they have a high NT‑proBNP level. [2011, updated 2023]
Rationale
Adults who have high (between 400 and 2,000 ng/litre) or very high levels (over 2,000 ng/litre) of NT‑proBNP have a higher likelihood of heart failure and a poorer prognosis. Having transthoracic echocardiography concurrently with specialist assessment to confirm heart failure classification within 2 or 6 weeks of referral can help to ensure that the person is started on appropriate treatment to manage their condition.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local service pathways and written clinical protocols to ensure that adults with suspected heart failure who have been referred for diagnosis have transthoracic echocardiography and specialist assessment within 2 or 6 weeks based on their NT‑proBNP level.
Data source: No routinely collected data for this measure has been identified. Data can be collected from information recorded locally by healthcare provider organisations, for example from service pathways or protocols.
Process
a) Proportion of adults with very high levels of NT‑proBNP, who have been referred for diagnosis, who have transthoracic echocardiography and specialist assessment within 2 weeks of referral.
Numerator – the number in the denominator who have transthoracic echocardiography and specialist assessment within 2 weeks of referral.
Denominator – the number of adults with very high levels of NT‑proBNP who have been referred for diagnosis.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
b) Proportion of adults with high levels of NT‑proBNP, who have been referred for diagnosis, who have transthoracic echocardiography and specialist assessment within 6 weeks of referral.
Numerator – the number in the denominator who have transthoracic echocardiography and specialist assessment within 6 weeks of referral.
Denominator – the number of adults with high levels of NT‑proBNP who have been referred for diagnosis.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
Outcome
Hospital admissions due to heart failure.
Data source: The National Heart Failure Audit contains data on hospital admission rates for heart failure.
What the quality statement means for different audiences
Service providers (such as secondary care) ensure that systems such as referral pathways, as well as appropriate equipment and staff training, are in place for adults with suspected heart failure to have an echocardiogram and be seen by a specialist concurrently within 2 or 6 weeks of referral based on their levels of NT‑proBNP.
Healthcare professionals (such as consultant cardiologists) ensure that adults with suspected heart failure have an echocardiogram and specialist assessment within 2 or 6 weeks of referral based on their levels of NT‑proBNP.
Commissioners (integrated care systems) ensure that they commission services in which adults with suspected heart failure have an echocardiogram and specialist assessment concurrently within 2 or 6 weeks of referral based on their levels of NT‑proBNP.
Adults with suspected heart failure who have been referred for diagnosis have a test called an echocardiogram and are seen by a heart specialist at the same time. This should happen within 2 weeks of being referred by their GP if a blood test shows very high levels of a substance (called an N‑terminal pro‑B‑type natriuretic peptide) that suggests they may have heart failure needing urgent treatment. It should happen within 6 weeks if those levels are high. An echocardiogram is a test to check the structure of the heart and how well it is working. The specialist will carry out an assessment and confirm whether they have chronic heart failure. If chronic heart failure is diagnosed, the specialist will try to find the cause, offer treatment and talk to the person about how to manage the condition.
Source guidance
Chronic heart failure in adults: diagnosis and management. NICE guideline NG106 (2018), recommendations 1.2.3 and 1.2.4
Definitions of terms used in this quality statement
Specialist assessment
Specialist assessment includes tests to evaluate for possible aggravating factors and to exclude other conditions with similar presentations, and confirm a diagnosis of heart failure, including the type of reduced or preserved ejection fraction. It also includes assessment for underlying causes where appropriate.
The assessment should be carried out by the core specialist heart failure multidisciplinary team which should include:
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a lead physician with subspecialty training in heart failure (usually a consultant cardiologist) who is responsible for making the clinical diagnosis
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a specialist heart failure nurse
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a healthcare professional with expertise in specialist prescribing for heart failure.
[Adapted from NICE's clinical knowledge summary on chronic heart failure and NICE's guideline on chronic heart failure in adults, recommendation 1.1.1]
Very high levels of NT-proBNP
Very high levels of NT‑proBNP are defined as above 2,000 ng/litre (236 pmol/litre). [Adapted from NICE's guideline on chronic heart failure in adults, recommendation 1.2.3]
High levels of NT-proBNP
High levels of NT‑proBNP are defined as between 400 and 2,000 ng/litre (47 to 236 pmol/litre). [Adapted from NICE's guideline on chronic heart failure in adults, recommendation 1.2.4]