Management of people with heart failure in the UK has shortcomings in screening, continuity of care, and medication doses, which disproportionally impact women and older people, according to a study led by Nathalie Conrad and Kazem Rahimi of The George Institute for Global Health at the University of Oxford, UK, published May 21 in PLOS Medicine. Findings suggest that screening and follow-up are sub-optimal, and these problems could be due, at least in part, to poor record-keeping in primary care and inadequate information exchange between hospitals and primary care.
Heart failure is common--affecting about 2% of the population in high-income countries--and can lead to disability and death. Effective treatment usually involves a complex process of investigations, step-wise initiation of medicines, and dose-adjustments, which can sometimes be challenging to follow. In the past decade, the UK has introduced programs to evaluate and improve heart failure management in primary and secondary care, but patients' care trajectories across different healthcare settings have not been studied. In this retrospective study, Rahimi and colleagues used electronic health records from 93,074 people who were diagnosed with heart failure in the UK between 2002 and 2014 to investigate the medical care they received from diagnosis to 1 year later. The authors examined five indicators of care: (i) diagnosis setting (inpatient or outpatient), (ii) post-hospitalization follow-up in primary care, (iii) diagnostic investigations, (iv) prescription of essential drugs, and (v) drug treatment doses.
The study suggests that patients were more likely to be diagnosed with heart failure in hospital than by their general practitioner, received insufficient follow-up after hospital discharge, and were prescribed medications at insufficient doses. The average daily dose prescribed was below guideline recommendations (42% for ACE-I or ARB, 29% for beta-blockers in 2014) and remained largely unchanged beyond the first 30 days after diagnosis, despite guideline recommendations to regularly up-titrate doses. Rates of outpatient diagnoses and follow-up in primary care were low, and even declined over time (from 56% in 2002 to 36% in 2014, RR 0.64 [0.62, 0.67] and from 20% to 14%, RR 0.73 [0.65, 0.82], respectively). Gaps in care were more common in women, individuals older than 75 years, and to some extent in socioeconomically deprived individuals. The authors call for additional research to explore the reasons behind these disparities, saying that further improvements are likely to require broader approaches to health services design that support appropriate care at every level of the patient journey.
In an accompanying Perspective, Nicholas Mills and colleagues at the University of Edinburgh, UK, discuss the need for high-quality implementation science (the study of strategies to integrate and embed research advances into clinical practice) and large-scale analysis of routinely-collected healthcare data. They argue that real-time collation of healthcare data across primary and secondary care, and robust methodologies to evaluate changes in clinical practice and policy, are essential to successfully overcome these disparities and gaps in care. To ensure the highest standards of patient-centered care and best resource allocation, Mills and colleagues argue for a linked, anonymized healthcare informatics platform for sharing data between care settings that is granular enough to facilitate meaningful evaluation of current practice.
NC is supported by the British Heart Foundation. KR, DC, and FDRH are supported by the National Institute of Health Research (NIHR) Oxford Biomedical Research Centre. KR further receives grants from the Oxford Martin School, as well as the PEAK Urban programme from the UKRI's Global Challenge Research Fund - Grant Ref: ES/P011055/1. AJ is supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol. FDRH further acknowledges support from the NIHR School for Primary Care Research (SPCR), and the NIHR Collaboration for Leadership in Applied Research in Health and Care (CLARHC) Oxford. JOD acknowledges the support of the RCUK Digital Economy Programme. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
I have read the journal's policy and the authors of this manuscript have the following competing interests: NC's work is funded by a research grant from the British Heart Foundation. AJ has received consultancy fees from Freshfields Bruckhaus Deringer and has held advisory board positions (which involved receipt of fees) from Anthera Pharmaceuticals, Inc., outside of the submitted work. JT declared funding for scholarships and grants from Rhodes Trust, Clarendon Fund, and British Research Council. JGFC has received honoraria or research support from Amgen, Bayer, Medtronic, Novartis, and Servier. FDRH has received occasional funding from Novartis in relation to speaking or consultancy on heart failure in the past 3 years. KR receives a stipend as a Speciality Consulting Editor for PLOS Medicine and serves on the journal's Editorial Board.
Conrad N, Judge A, Canoy D, Tran J, O'Donnell J, Nazarzadeh M, et al. (2019) Diagnostic tests, drug prescriptions, and follow-up patterns after incident heart failure: A cohort study of 93,000 UK patients. PLoS Med 16(5): e1002805. https://doi.org/10.1371/journal.pmed.1002805
Image Credit: sbtlneet, Pixabay
The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
Bristol National Institute for Health Research Biomedical Research Centre, Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, United Kingdom 4National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
Deep Medicine, Oxford Martin School, University of Oxford, Oxford, United Kingdom
Collaboration Center of Meta-Analysis Research, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, United Kingdom 4Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow and National Heart & Lung Institute, Imperial College London, London, United Kingdom
Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
In your coverage please use this URL to provide access to the freely available paper: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002805
NLM is supported by the Butler Senior Clinical Research Fellowship from the British Heart Foundation (FS/16/14/32023). AGJ is supported by a National Research Scotland Clinician Scientist Award. MSA and AGJ are supported by a Catalytic Grant from the Chief Scientist Office of the Scottish Government Health and Social Care Directorate (CGA/19/01). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
I have read the journal's policy and the authors of this manuscript have the following competing interests: NLM has received honoraria and the University of Edinburgh has received research grants from Abbott Diagnostics and Siemens Healthineers, who manufacture diagnostic tests for heart failure. MSA and AGJ have no competing interests.
Anwar MS, Japp AG, Mills NL (2019) Heart failure and healthcare informatics. PLoS Med 16(5): e1002806. https://doi.org/10.1371/journal.pmed.1002806
BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
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