A study of 93,000 UK adults with heart failure has revealed critical care shortcomings in diagnostic tests, drug prescriptions, and follow-up patterns, with women and those over 75 years of age disproportionately affected.
The George Institute for Global Health at the Nuffield Department of Women's and Reproductive Health (University of Oxford) investigated the medical care received by heart failure patients from the time of diagnosis up to a year later, examining variations over time based on patient characteristics such as age, sex, and socioeconomic status, as well as across outpatient and inpatient settings.
“Over the past 25 years, the UK has introduced several programmes to evaluate and improve the quality of care received by heart failure patients. However, little was known about patients’ journey of care across primary and secondary care services. This is a critical component of chronic disease management, so we set about addressing these knowledge gaps in order to provide evidence-based recommendations to strengthen health systems,” said Dr Nathalie Conrad who led the research using participants in the Clinical Practice Research Datalink.
The research team found that, overall, patients were more likely to be diagnosed with heart failure in hospital rather than by their general practitioner; received insufficient follow-up after hospitalisation; and doses of key medicines prescribed to patients were far below those recommended by clinical management guidelines, even a year after diagnosis. Critically, only 17% of patients diagnosed with heart failure in hospital had their diagnosis recorded by their general practitioner in the following 12 months.
Women and older patients were particularly disadvantaged across all these care dimensions. In particular, women were 13% less likely than men of the same age to receive a prescription for the two most important drugs in heart failure management within three months of diagnosis. Women were also 9% less likely than men of the same age and socioeconomic status to be first diagnosed with heart failure in a general practice.
“Heart failure is a severe condition and early diagnosis is crucial for doctors to rapidly initiate life-saving medications. Our findings suggest out-of-hospital screening for early signs of heart failure and follow-up are sub-optimal, and women and older patients are particularly vulnerable to these shortcomings in current heart failure care,” said Conrad.
“Health systems need to adopt a broader perspective of service design and recognise the patient journey as a care continuum to improve care quality, adhere to recommended treatment guidelines and provide more equitable access for all those at risk of, or living with, heart failure. Particular attention needs to be given to women and older patients to ensure they receive the treatment they need within the recommended timeframe,” added Conrad.
Heart failure affects about 2% of the population in high-income countries, with mortality rates comparable to the most severe cancers. Effective treatments exist but involve a complex process of investigation and step-wise initiation of medication and adjustment - care programmes that are often challenging to implement consistently.
The study was funded by the British Heart Foundation, the Oxford Martin School at the University of Oxford, and by the NIHR Oxford Biomedical Research Centre.
The paper is published in PLOS Medicine: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002805