Trajectories of care in patients with heart failure: a longitudinal analysis of diagnostic tests, drug prescriptions and follow-up patterns in 93,000 individuals
Authors: Canoy Dexter., K Rahimi, F Hobbs, N Conrad
Journal: PLoS Medicine (2019)

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 UK 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) post-hospitalisation 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 (RR) or adjusted differences and 95% confidence intervals, 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-I) or angiotensin receptor blockers (ARB) both increased significantly (37% vs 82%, RR 2.24 [2.15, 2.34]; 18% vs 63%, RR 3.48 [2.72, 4.43], respectively). Yet, the average daily dose prescribed remained below guideline recommendations (42% for ACE-I or ARB, 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, nor information about follow-up in community heart failure clinics.   Conclusions: Management 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 incentives schemes confined to individual clinical settings have been insufficient to identify these gaps and address patients’ long-term care needs.