Heart failure labelled patients with missing ejection fraction in primary care: prognosis and determinants

Abstract

BackgroundIt is common to find a high variability in the accuracy of heart failure (HF) diagnosis in electronic primary care medical records (EMR). Our aims were to ascertain (i) whether the prognosis of HF labelled patients whose ejection fraction (EF) was missing in their EMR differed from those that had it registered, and (ii) the causes contributing to the differences in the availability of EF in EMR.MethodsRetrospective cohort analyses based on clinical records of HF and attended at 52 primary healthcare centres of Barcelona (Spain). Information of 8376 HF patients aged > 40 years followed during five years was analyzed.ResultsEF was available only in 8.5% of primary care medical records. Cumulate incidence for mortality and hospitalization from 1st January 2009 to 31th December 2012 was 37.6%. The highest rate was found in patients with missing EF (HR 1.84, 95% CI 1.68 -1.95) compared to those with preserved EF. Patients hospitalized the previous year and those requiring home healthcare (HR 1.81, 95% Confidence Interval 1.68-1.95 and HR 1.58, 95% CI 1.46-1.71, respectively) presented a higher risk of having an adverse outcome. Older patients, those more socio-economically disadvantaged, obese, requiring home healthcare, and taking loop diuretics were less likely to have an EF registered.ConclusionsEF is poorly recorded in primary care. HF patients with EF missing at medical records had the worst prognosis. They tended to be older, socio-economically disadvantaged, and more fragile.

<p>Risk Factors for Heart Failure with Preserved or Reduced Ejection Fraction Among Medicare Beneficiaries: Application of Competing Risks Analysis and Gradient Boosted Model</p>

“…Infrequent availability of EF values in investigations conducted using routine care heart failure populations has been noted in prior studies as well. 35,36 This limitation can impact our study in two important ways: 1) our inability to classify nearly 60% of the cases into their respective heart failure subtype can compromise statistical power in detecting heterogeneous effects of the predictors across heart failure subtypes; 2) we grouped all patients with unavailable EF into a single category with the assumption that the EF is randomly missing in our EHR across classes of heart failure. However, if availability of EF in our data is dependent upon the subtype of heart failure, then the outcome misclassification resulting from this approach of classifying all patients with unavailable EF into a single group could lead to imperfect effect estimates of association between risk factors and development of rEF and pEF.…”

The tip of the iceberg: finding patients with heart failure with preserved ejection fraction in primary care. An observational study

“…In a study of 683 patients with a heart failure diagnosis in 30 general practices, only 45.2% had undergone an echocardiogram at the start of the study in 2010–2011. 18 Munoz and colleagues 22 analysed records from 8376 patients with diagnoses of heart failure in 52 primary care practices in Barcelona 2009–2012. The majority of patients (91.5%) did not have an available EF.…”

Introducing nurse‐led heart failure clinics in Swedish primary care settings

“…HF patients with EF missing from their medical records are known to have poor outcomes regarding hospitalisation and survival, and tend to be older and more fragile. 16 Another reason could be that -due to a lack of time -the GP does not provide the patient with HF-specific education. 13 A considerable amount of the HF self-care is performed in the patient's home supported by family caregivers, and insufficient knowledge could lead to adverse outcomes for the patient.…”