Diagnostic tests, drug prescriptions, and follow-up patterns after incident heart failure: a cohort study of 93,000 UK patients

Conrad, N. et al. (2019) Diagnostic tests, drug prescriptions, and follow-up patterns after incident heart failure: a cohort study of 93,000 UK patients. PLoS Medicine, 16(5), e1002805. (doi: 10.1371/journal.pmed.1002805) (PMID:31112552) (PMCID:PMC6528949)

Abstract

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 United Kingdom 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) posthospitalisation 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 (RRs) or adjusted differences and 95% confidence intervals (CIs), 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-Is) or angiotensin receptor blockers (ARBs) both increased significantly (37% versus 82%, RR 2.24 [2.15, 2.34] and 18% versus 63%, RR 3.48 [2.72, 4.43], respectively). Yet, the average daily dose prescribed remained below guideline recommendations (42% for ACE-Is or ARBs, 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, or 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 incentive schemes confined to individual clinical settings have been insufficient to identify these gaps and address patients’ long-term care needs.

• Item Type: Articles
• Additional Information: 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.
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: McMurray, Professor John and Cleland, Professor John

Creator Roles

Cleland, J. G.: Investigation, Methodology, Writing – review and editing
McMurray, J. J.V.: Conceptualization, Investigation, Methodology, Writing – review and editing

• Authors: Conrad, N., Judge, A., Canoy, D., Tran, J., O’Donnell, J., Nazarzadeh, M., Salimi-Khorshidi, G., Hobbs, F.D. R., Cleland, J. G., McMurray, J. J.V., and Rahimi, K.
• College/School: College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health; College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Robertson Centre
• Journal Name: PLoS Medicine
• Publisher: Public Library of Science
• ISSN: 1549-1277
• ISSN (Online): 1549-1676
• Published Online: 21 May 2019
• Copyright Holders: Copyright © 2019 Conrad et al.
• First Published: First published in PLoS Medicine 16(5): e1002805
• Publisher Policy: Reproduced under a Creative Commons License