Route to heart failure diagnosis in English primary care: a retrospective cohort study of variation

Abstract

BackgroundDespite the existence of evidence-based guidelines supporting the identification of heart failure (HF) in primary care, the proportion of patients diagnosed in this setting remains low. Understanding variation in patients’ routes to diagnosis will better inform HF management.AimTo identify the factors associated with variation in patients’ routes to HF diagnosis in primary care.Design and settingA retrospective cohort study of 13 897 patients diagnosed with HF between 1 January 2010 and 31 March 2013 in English primary care.MethodThis study used primary care electronic health records to identify routes to HF diagnosis, defined using the National Institute for Health and Care Excellence (NICE) guidelines, and adherence to the NICE-recommended guidelines. Multilevel logistic regression was used to investigate factors associated with the recommended route to HF diagnosis, and funnel plots were used to visualise variation between practices.ResultsFew patients (7%, n = 976) followed the recommended route to HF diagnosis. Adherence to guidelines was significantly associated with younger age (P = 0.001), lower deprivation level (P = 0.007), HF diagnosis source (P<0.001), not having chronic pulmonary disease (P<0.001), receiving further consultation for symptom(s) suggestive of HF (P<0.001), and presenting with breathlessness (P<0.001). Route to diagnosis also varied significantly between GP practices (P<0.001).ConclusionThe significant association of certain patient characteristics with route to HF diagnosis and the variation between GP practices raises concerns about equitable HF management. Further studies should investigate reasons for this variation to improve the diagnosis of HF in primary care. However, these must consider the complexities of a patient group often affected by frailty and multiple comorbidities.

Diagnostic delays for breathlessness in primary care: a qualitative study to investigate current care and inform future pathways

“…(13) Despite the impact breathlessness has on quality of life (14), sufferers may delay seeking help, normalising their symptoms, (15,16) and frequently experience significant delays in diagnosis and treatment after seeking help. (17,18) Evidence about patients' experiences whilst awaiting diagnosis and about clinicians' experiences of managing the diagnostic challenges of chronic breathlessness in primary care is lacking. Previous literature has described the experiences of patients living with breathlessness in specific disease conditions; commonly cancer or cardiorespiratory disease.…”

“…Despite the impact breathlessness has on quality of life, 14 people with the condition may delay seeking help, normalising their symptoms, 15 , 16 and frequently experience significant delays in diagnosis and treatment after seeking help. 17 , 18 …”

The year in cardiology 2019: heart failure

“…Analyses of the diagnostic pathway in primary care in the UK suggest that key investigations are often not done. [6][7][8] Similar data from other countries are urgently required. Several large epidemiological surveys 9,10 and analyses of large trials 11,12 have recently been published that allow the demographics, aetiology, and management of heart failure to be compared internationally.…”

Breathless and awaiting diagnosis in UK lockdown for COVID-19…We’re stuck

“…Breathlessness is common and surveys of the general population indicate the prevalence is around 9–11% 6 , 7 , but people often delay seeking help until everyday activities become significantly impaired. Adults presenting with chronic breathlessness frequently experience significant delays in diagnosis and therefore treatment 8 , 9 . The reasons are multi-factorial and include the complex multimorbidity of breathlessness 10 , 11 , accessibility of investigations 12 , and variable adherence to disease-specific diagnostic pathways 9 .…”

“…Long delays to diagnosis and therefore treatment is well documented in conditions associated with chronic breathlessness such as chronic obstructive pulmonary disease (COPD) 8 , heart failure 9 and pulmonary fibrosis 13 . Unfortunately, our data highlights further delays to a diagnosis for those with breathlessness during the COVID-19 pandemic due to both patient behaviours and the healthcare system.…”