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

Abstract

Background Effective 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 findings For 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...

Temporal Trends and Patterns in Mortality After Incident Heart Failure

“… 7 , 8 Randomized clinical trials have demonstrated the effectiveness of these treatments in reducing mortality and hospitalizations, and observational studies have shown that they are increasingly being used worldwide. 9 , 10 , 11 Despite this, several recent studies have reported that the decline in mortality rates among patients with heart failure has been stalling since the mid-2000s. 12 , 13 , 14 To our knowledge, the reasons underlying this apparent paradox are unknown.…”

Heart failure and healthcare informatics

“…In PLOS Medicine , Rahimi and colleagues report the results of a longitudinal analysis of diagnostic tests, drug prescriptions, and follow-up patterns in 93,000 individuals with heart failure in the UK [11]. The authors show convincingly that some aspects of care, such as the use of diagnostic testing and initiation of evidence-based therapies, have improved over time.…”

“…It is clear how such findings, if sufficiently robust, could be used to inform future targeted interventions. The study certainly provides us valuable retrospective insights into two major policy initiatives designed to improve standards in heart failure treatment focused on primary and secondary care [11]. The data show persuasively that both the ‘quality and outcomes framework’, a primary care reporting and incentives scheme, and the ‘national heart failure audit’ initiative, a secondary care reporting programme, changed behaviour, but that the outcomes were tied too tightly to specific measures and may have led to unintended consequences.…”

Survival rates in elderly patients with heart failure: reply

“…Secondly, prescribing of medications with proven prognostic benefit in heart failure remains suboptimal across all age groups, although treatment rates are improving over time . Many patients also do not receive the recommended combination or optimal dose of medications .…”

“…Secondly, prescribing of medications with proven prognostic benefit in heart failure remains suboptimal across all age groups, although treatment rates are improving over time . Many patients also do not receive the recommended combination or optimal dose of medications . Older people may be at particular risk of not receiving these medications due to individual patient factors such as treatment intolerance, impaired renal function, or medication interactions.…”