Research Article: Diagnostic tests, drug prescriptions, and follow-up patterns after incident heart failure: A cohort study of 93,000 UK patients

Date Published: May 21, 2019

Publisher: Public Library of Science

Author(s): Nathalie Conrad, Andrew Judge, Dexter Canoy, Jenny Tran, Johanna O’Donnell, Milad Nazarzadeh, Gholamreza Salimi-Khorshidi, F. D. Richard Hobbs, John G. Cleland, John J. V. McMurray, Kazem Rahimi, Aziz Sheikh

Abstract: BackgroundEffective management of heart failure is complex, and ensuring evidence-based practice presents a major challenge to health services worldwide. Over the past decade, the United Kingdom introduced a series of national initiatives to improve evidence-based heart failure management, including a landmark pay-for-performance scheme in primary care and a national audit in secondary care started in 2004 and 2007, respectively. Quality improvement efforts have been evaluated within individual clinical settings, but patterns of care across its continuum, although a critical component of chronic disease management, have not been studied. We have designed this study to investigate patients’ trajectories of care around the time of diagnosis and their variation over time by age, sex, and socioeconomic status.Methods and findingsFor this retrospective population-based study, we used linked primary and secondary health records from a representative sample of the UK population provided by the Clinical Practice Research Datalink (CPRD). We identified 93,074 individuals newly diagnosed with heart failure between 2002 and 2014, with a mean age of 76.7 years and of which 49% were women. We examined five indicators of care: (i) diagnosis care setting (inpatient or outpatient), (ii) posthospitalisation follow-up in primary care, (iii) diagnostic investigations, (iv) prescription of essential drugs, and (v) drug treatment dose. We used Poisson and linear regression models to calculate category-specific risk ratios (RRs) or adjusted differences and 95% confidence intervals (CIs), adjusting for year of diagnosis, age, sex, region, and socioeconomic status. From 2002 to 2014, indicators of care presented diverging trends. Outpatient diagnoses and follow-up after hospital discharge in primary care declined substantially (ranging from 56% in 2002 to 36% in 2014, RR 0.64 [0.62, 0.67] and 20% to 14%, RR 0.73 [0.65, 0.82], respectively). Primary care referral for diagnostic investigations and appropriate initiation of beta blockers and angiotensin-converting–enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) both increased significantly (37% versus 82%, RR 2.24 [2.15, 2.34] and 18% versus 63%, RR 3.48 [2.72, 4.43], respectively). Yet, the average daily dose prescribed remained below guideline recommendations (42% for ACE-Is or ARBs, 29% for beta blockers in 2014) and was largely unchanged beyond the first 30 days after diagnosis. Despite increasing rates of treatment initiation, the overall dose prescribed to patients in the 12 months following diagnosis improved little over the period of study (adjusted difference for the combined dose of beta blocker and ACE-I or ARB: +6% [+2%, +10%]). Women and patients aged over 75 years presented significant gaps across all five indicators of care. Our study was limited by the available clinical information, which did not include exact left ventricular ejection fraction values, investigations performed during hospital admissions, or information about follow-up in community heart failure clinics.ConclusionsManagement of heart failure patients in the UK presents important shortcomings that affect screening, continuity of care, and medication titration and disproportionally impact women and older people. National reporting and incentive schemes confined to individual clinical settings have been insufficient to identify these gaps and address patients’ long-term care needs.

Partial Text: Over the past 25 years, we have witnessed remarkable developments in clinical interventions that improve symptoms, quality of life, and prognosis in patients with heart failure. However, effective clinical care involves a complex process of investigations, stepwise initiation of medicines, and dose titration that often takes place in different care settings over several months and can be difficult to implement consistently. Although clinical guidelines provide a valuable tool to support physicians in the management of heart failure patients [1–7], ensuring optimal use of evidence-based therapies in routine clinical practice remains a major concern and challenge to health services worldwide [8,9].

A total of 93,074 patients newly diagnosed with heart failure between 2002 and 2014 were included in the study. Patient characteristics stratified by sex, socioeconomic status, and time period categories have been previously published [15]. Patient characteristics varied depending on where they were first diagnosed; those diagnosed in hospital were older, had more comorbidities, and were more likely to be women (Table 1). Patients with a record of reduced ejection fraction were more likely to be younger, be male, and present with fewer comorbidities than those for whom ejection fraction was preserved or unspecified (S6 Table).

This large-scale, population-based study provides important information on contemporary care of heart failure patients in routine clinical practice and insights into its variation over time by age, sex, and socioeconomic status. Our study confirms previous reports of high rates of guideline-indicated diagnostic investigations and treatment initiation in Western countries (S1 Table). However, further investigation of care across the continuum of primary and secondary services and from the prediagnosis stage to several months after incident diagnosis revealed important shortcomings in the management of patients. First, rates of outpatient diagnoses and follow-up in primary care after hospital discharge are low and have been declining over time. Second, doses of key medicines remain far below those recommended in guidelines in all groups of patients and for all three drug classes investigated, even a year after diagnosis. Finally, deficiencies in care were more common in women, older people, and, to some extent, socioeconomically deprived individuals.



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