P1489An audit of 215,000 patients on primary care registers using novel electronic searches to identify patients with heart failure requiring treatment optimisation and complex device therapies
Authors: Chaggar P , Grayson A D , Connor N , Hughes C 
Published: June 2020

INTRODUCTION

 Patients with heart failure (HF) may not routinely receive review from a HF specialist and understanding of which patients may benefit from specialist therapies is not widely appreciated by non-specialists.  Therefore, there may be frequent missed opportunities for patients under non-specialist care to access prognostically important therapies. 

PURPOSE

To identify high-risk patients in primary care with HF and left ventricular systolic dysfunction (LVSD) that require optimisation and consideration for complex device therapy.

METHODS

15 general practitioner (GP) practices across Cornwall were audited between between July 2018 and August 2019 with a total population of 215,114 patients. The total combined HF register in these practices was 2,925. A further 2,238 patients were identified using the case finder element of GRASP-HF, an electronic search tool, to identify patients with HF +/- LVSD not coded correctly in GP records. Electronic records were manually reviewed and selected patients, potentially benefitting from further optimisation, were electronically reviewed by a Consultant Cardiologists for final screening before being invited into a specialist HF clinic at their local GP practice. All patients received an up to date ECG prior to specialist review. Outcomes of each patient clinical review were followed-up for a minimum of 1 month.

RESULTS

From 5,163 patients audited, 157 underwent clinic review with a Consultant Cardiologist at their local GP practice and are described below.

Patient characteristics

Mean age was 75 years, 78% were male, 51% had ischaemic cardiomyopathy and 27% had AF. 66% had severe LVSD (EF &lt;35%), 48% had broad QRS (&gt;120ms) and only 44% were deemed to be on optimal medical therapy. Of 88 patients not fully optimised, the proportion requiring optimisation of ACEi/ARB, beta-blocker, MRA, sacubitril-valsartan and ivabradine were 57%, 30%, 36%, 7% and 1%, respectively.  

Patient outcomes

Median follow up period was 7 months (range 2-15).  65% of all patients required further imaging of LV function to help determine onward management.  48% were potential candidates for device therapy and 3 patients (2%) were listed directly for device therapy while 5 patients (3%) declined.  In total, following complete assessment, 18 patients (11%) received device implantation (12 CRT-P, 2 CRT-D, 2 ICD and 1 loop recorder) and 25 patients (16%) received sacubitril-valsartan.  A change in patient clinical management was instituted in 64% of patients following specialist review.

CONCLUSION

This comprehensive audit of GP registers demonstrates a significant burden of patients with HF and LVSD who are not appropriately coded.  This audit also identifies frequent opportunities to intensify 1st and 2nd line medical therapies and patients that may benefit from specialist therapies including complex devices.  Primary care teams would benefit from regular review of their HF registers and from specialist outreach initiatives.