Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey

Chronic care for heart failure patients: Who to refer back to the general practitioner?-Experiences of the Dutch integrated heart failure care model

OBJECTIVE

The number of patients with heart failure (HF) and corresponding burden of the healthcare system will increase significantly. The Dutch integrated model, 'Transmural care of HF Patients' was based on the European Society of Cardiology (ESC) guidelines and initiated to manage the increasing prevalence of HF patients in primary and secondary care and stimulate integrated care. It is unknown how many HF patients are eligible for back-referral to general practitioners (GPs), which is important information for the management of chronic HF care. This study aims to evaluate clinical practice of patients for whom chronic HF care can be referred from the cardiologist to the GP based on the aforementioned chronic HF care model.

DESIGN AND METHODS

A retrospective case record-based study was conducted, which included all chronic HF patients registered in the cardiology information systems of two different hospitals. Subsequently, 200 patients were randomly selected for evaluation. The following patients were considered eligible for referral to the GP: 1/Stable HF patients with reduced left ventricular ejection fraction (LVEF), 2/Stable HF patients with a recovered LVEF and 3/Stable HF patients with a preserved LVEF, 4/HF, palliative setting.

RESULTS

Of the 200 patients, 17% was considered eligible for referral to the GP. This group consisted of 5% patients with a reduced LVEF, 10.5% patients with recovered LVEF and 1.5% patients with a preserved LVEF. Main indicators for HF care by cardiologists were active cardiac disease other than HF (39.5%), recent admission for HF (29.5%) or a recent adjustment in HF medication (7.5%).

CONCLUSION

Applying the chronic HF care model of the 'Transmural care of HF patients' and the ESC-guidelines, results in an important opportunity to further optimise HF integrated care and to deal with the increasing number of HF patients referred to the hospital.

Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease

BACKGROUND

Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered.

OBJECTIVE

Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension.

DESIGN

Retrospective cohort study.

PATIENTS

Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years.

MAIN MEASURES

The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering.

KEY RESULTS

Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06).

CONCLUSIONS

Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

Primary care Adherence To Heart Failure guidelines IN Diagnosis, Evaluation and Routine management (PATHFINDER): a randomised controlled trial protocol

INTRODUCTION

General practitioners (GPs) routinely provide care for patients with heart failure (HF); however, adherence to management guidelines, including titrating medication to optimal dose, can be challenging in this setting. This study will evaluate the effectiveness of a multifaceted intervention to support adherence to HF management guidelines in primary care.

METHODS AND ANALYSIS

We will undertake a multicentre, parallel-group, randomised controlled trial of 200 participants with HF with reduced ejection fraction. Participants will be recruited during a hospital admission due to HF. Following hospital discharge, the intervention group will have follow-up with their GP scheduled at 1 week, 4 weeks and 3 months with the provision of a medication titration plan approved by a specialist HF cardiologist. The control group will receive usual care. The primary endpoint, assessed at 6 months, will be the difference between groups in the proportion of participants being prescribed five guideline-recommended treatments; (1) ACE inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor at least 50% of target dose, (2) beta-blocker at least 50% of target dose, (3) mineralocorticoid receptor antagonist at any dose, (4) anticoagulation for patients diagnosed with atrial fibrillation, (5) referral to cardiac rehabilitation. Secondary outcomes will include functional capacity (6-minute walk test); quality of life (Kansas City Cardiomyopathy Questionnaire); depressive symptoms (Patient Health Questionnaire-2); self-care behaviour (Self-Care of Heart Failure Index). Resource utilisation will also be assessed.

ETHICS AND DISSEMINATION

Ethical approval was granted by the South Metropolitan Health Service Ethics Committee (RGS3531), with reciprocal approval at Curtin University (HRE2020-0322). Results will be disseminated via peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12620001069943.

Developing an Interpretable Machine Learning Model to Predict in-Hospital Mortality in Sepsis Patients: A Retrospective Temporal Validation Study

BACKGROUND

Risk stratification plays an essential role in the decision making for sepsis management, as existing approaches can hardly satisfy the need to assess this heterogeneous population. We aimed to develop and validate a machine learning model to predict in-hospital mortality in critically ill patients with sepsis.

METHODS

Adult patients fulfilling the definition of Sepsis-3 were included at a large tertiary medical center. Relevant clinical features were extracted within the first 24 h in ICU, re-classified into different genres, and utilized for model development under three strategies: "Basic + Lab", "Basic + Intervention", and "Whole" feature sets. Extreme gradient boosting (XGBoost) was compared with logistic regression (LR) and established severity scores. Temporal validation was conducted using admissions from 2017 to 2019.

RESULTS

The final cohort included 24,272 patients, of which 4013 patients formed the test cohort for temporal validation. The trained and fine-tuned XGBoost model with the whole feature set showed the best discriminatory ability in the test cohort with AUROC as 0.85, significantly higher than the XGBoost "Basic + Lab" model (0.83), the LR "Whole" model (0.82), SOFA (0.63), SAPS-II (0.73), and LODS score (0.74). The performance in varying subgroups remained robust, and predictors, such as increased urine output and supplemental oxygen therapy, were crucially correlated with improved survival when interpretability was explored.

CONCLUSIONS

We developed and validated a novel XGBoost-based model and demonstrated significantly improved performance to LR and other scores in predicting the mortality risks of sepsis patients in the hospital using features in the first 24 h.

Sustainable adoption of noninvasive telemonitoring for chronic heart failure: A qualitative study in the Netherlands

Objective

Noninvasive telemonitoring aims to improve healthcare for patients with chronic heart failure (HF) by reducing hospitalizations and improving patient experiences. Yet, sustainable adoption seems to be limited. Therefore, the goal of our study is to gain insight in the processes that support sustainable adoption of telemonitoring for patients with HF.

Methods

We conducted semi-structured interviews with 25 stakeholders that were involved with the adoption of telemonitoring, such as healthcare professionals, policymakers and healthcare insurers. We analyzed the interviews by using a combination of open-coding and the themes of the Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability framework.

Results

We found that telemonitoring projects have moved beyond initial pilot phases despite a high level of complexity on multiple topics. The patient selection, the business case, the evidence, the aims of telemonitoring, integration of telemonitoring in the care pathway, reimbursement, and future centralization were items that yielded different and sometimes contradictory opinions.

Conclusions

This study showed that the sustainable adoption of telemonitoring for HF is a complex endeavor. Different aims and perspectives play an important role in the patient selection, design, evaluations and envisioned futures of telemonitoring. High conviction among participants of the added value that telemonitoring may support further adoption of telemonitoring. Structural evaluations will be needed to guide cyclical improvement and adapt programs to employ telemonitoring in such a manner that it contributes to collectively supported aims.

Risk prediction of mortality for patients with heart failure in England: observational study in primary care

AIMS

Many risk prediction models have been proposed for heart failure (HF), but few studies have used only information available to general practitioners (GPs) in primary care electronic health records (EHRs). We describe the predictors and performance of models built from GP-based EHRs in two cohorts of patients 10 years apart.

METHODS AND RESULTS

Linked primary and secondary care data for incident HF cases in England were extracted from the Clinical Practice Research Datalink for 2001-02 and 2011-12. Time-to-event models for all-cause mortality were developed using a long list of potential baseline predictors. Discrimination and calibration were calculated. A total of 5966 patients in 156 general practices were diagnosed in 2001-02, and 12 827 patients in 331 practices were diagnosed in 2011-12. The 5-year survival rate was 40.0% in 2001-02 and 40.2% in 2011-12, though the latter population were older, frailer, and more comorbid; for 2001-02, the 10-year survival was 20.8% and 15-year survival 11.1%. Consistent predictors included age, male sex, systolic blood pressure, body mass index, GP domiciliary visits before diagnosis, and some comorbidities. Model performance for both time windows was modest (c = 0.70), but calibration was generally excellent in both time periods.

CONCLUSIONS

Information routinely available to UK GPs at the time of diagnosis of HF gives only modest predictive accuracy of all-cause mortality, making it hard to decide on the type, place, and urgency of follow-up. More consistent recording of data relevant to HF (such as echocardiography and natriuretic peptide results) in GP EHRs is needed to support accurate prediction of healthcare needs in individuals with HF.

Moving the Paradigm Forward for Prediction and Risk-Based Primary Prevention of Heart Failure in Special Populations

PURPOSE OF REVIEW

Heart failure (HF) treatment paradigms increasingly recognize the importance of primary prevention. This review explores factors that enhance HF risk, summarizes evidence supporting the pharmacologic primary prevention of HF, and notes barriers to the implementation of primary prevention of HF with a focus on female and sexual and gender minority patients.

RECENT FINDINGS

HF has pathophysiologic sex-specific distinctions, suggesting that sex-specific preventive strategies may be beneficial. Pharmacologic agents that have shown benefit in reducing the risk of HF address the pathobiology underpinning these sex-specific risk factors. The implementation of pharmacologic therapies for primary prevention of HF needs to consider a risk-based model. Current pharmacotherapies hold mechanistic promise for the primary prevention of HF in females and gender and sexual minorities, although research is needed to understand the specific populations most likely to benefit. There are significant systemic barriers to the equitable provision of HF primary prevention.

Changes in heart failure management and long-term mortality over 10 years: observational study

OBJECTIVES

To estimate the long-term survival of two cohorts of people diagnosed with heart failure 10 years apart and to assess differences in patient characteristics, clinical guideline compliance and survival by diagnosis setting.

METHODS

Data for patients aged 18 and over with a new diagnosis of heart failure in the Clinical Practice Research Datalink in 2001-2002 (5966 patients in 156 practices) and 2011-2012 (12 827 patients in 331 practices). Survival rates since diagnosis were described using Kaplan-Meier plots. Compliance with national guidelines was summarised.

RESULTS

2011/2012 patients were older than those diagnosed a decade before, with lower blood pressure and cholesterol but more comorbidity and healthcare contacts. For those diagnosed in 2001/2002, the 5-year survival was 40.0% (40.2% in the 2011/2012 cohort), 10-year survival was 20.8%, and 15-year survival 11.1%. Improvement in survival between the two time periods was seen only in those diagnosed in primary care (5-year survival 46.0% vs 57.4%, compared with 33.9% and 32.6% for hospital-diagnosed patients).Beta-blocker use rose from 24.3% to 39.1%; renin-angiotensin system blockers rose from 31.8% to 54.3% (both p<0.001). There was little change for loop diuretics and none for thiazide diuretics. For the 9963 patients with symptoms recorded by their general practitioner before diagnosis, brain natriuretic peptide (BNP) testing was low, but echocardiogram use rose from 8.3% to 19.3%, and specialist referral rose from 7.2% to 24.6% (all p<0.001).

CONCLUSIONS

The 10 years saw some long-term survival gains but only modest improvement in national clinical guideline compliance, from a low baseline, despite the introduction of national initiatives.

Analysis of canine cardiovascular therapeutic agent prescriptions using electronic health records in primary care veterinary practices in the United Kingdom

INTRODUCTION/OBJECTIVES

Canine cardiovascular (CV) diseases are often managed in primary care settings. The objectives were to describe CV therapeutic agent (CVTA) prescribing patterns in primary care practices in the United Kingdom (UK) and to evaluate recorded clinical signs, diagnostic tests and justifications for use of torasemide, a recently marketed and authorised loop-diuretic in the UK.

ANIMALS, MATERIALS AND METHODS

Electronic health records (EHRs) describing 3,579,420 consultations (1,043,042 unique dogs) were collated (1 April 2014 and 31 December 2018) by the Small Animal Veterinary Surveillance Network from 270 veterinary practices. Consultations prescribing at least one CVTA were identified. Annual variation in individual CVTA prescriptions was analysed using mixed-effects binomial regression models. Free-text clinical narratives were manually read to determine the first-prescribing event for torasemide.

RESULTS

Twenty-nine thousand and seven consultations (0.81% of all consultations, 95% confidence interval [CI], 0.76-0.86) prescribed CVTA in 14,148 (1.36%) dogs. Furosemide (52.8% of CV-prescribing consultations, 95% CI 50.7-54.9) and pimobendan (51.9%, 95% CI 50.1-53.7) were most prescribed. Longitudinal analysis (2014-2018) showed a significant negative temporal trend for angiotensin-converting enzyme inhibitors (p < 0.001), and furosemide (p = 0.003) and a positive temporal trend for pimobendan (p = 0.020) and torasemide (p < 0.001). First prescriptions of torasemide were identified in 16.5% of torasemide-prescribing consultations. Where justification for prescription of torasemide was identified (32.5%), furosemide resistance was the most common (92.0%).

CONCLUSIONS

EHRs can be used to temporally monitor prescribing habits, including responses to market authorisations. Despite authorisation in the UK for torasemide use as a first-line diuretic, it was most commonly prescribed after furosemide resistance.

PRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic heart failure in primary care (PREFER): a real-world study

Objective

To assess current management practice of heart failure with reduced ejection fraction (HFrEF) in multinational primary care (PC) and determine whether N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP)-guided referral of HFrEF patients from PC to a cardiologist could improve care, defined as adherence to European Society of Cardiology (ESC) guideline-recommended pharmacotherapy.

Methods

PRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic HF in PC (PREFER) study enrolled HFrEF patients from PC considered clinically stable and those with NT-pro-BNP ≥600 pg/mL were referred to a cardiologist for optimisation of HF treatment. The primary outcome of adherence to ESC HF guidelines after referral to specialist was assessed at the second visit within 4 weeks of cardiologist’s referral and no later than 6 months after the baseline visit. Based on futility interim analysis, the study was terminated early.

Results

In total, 1415 HFrEF patients from 223 PCs from 18 countries in Europe were enrolled. Of these, 1324 (96.9%) were considered clinically stable and 920 (65.0%) had NT-pro-BNP ≥600 pg/mL (mean: 2631 pg/mL). In total, 861 (60.8%) patients fulfilled both criteria and were referred to a cardiologist. Before cardiologist consultation, 10.1% of patients were on ESC guideline-recommended HFrEF medications and 2.7% were on recommended dosages of HFrEF medication (defined as ≥50% of ESC guideline-recommended dose). Postreferral, prescribed HFrEF drugs remained largely unchanged except for an increase in diuretics (+4.6%) and mineralocorticoid receptor antagonists (+7.9%). No significant increase in patients’ adherence to guideline-defined drug combinations (11.2% post-referral vs 10.1% baseline) or drug combinations and dosages (3.3% postreferral vs 2.7% baseline) was observed after cardiologist consultation.

Conclusions

PREFER demonstrates substantial suboptimal treatment of HFrEF patients in the real world. Referral of patients with elevated NT-pro-BNP levels from PC to cardiologist did not result in meaningful treatment optimisation for treatments with known mortality and morbidity benefit.

Sex-specific pattern of left ventricular hypertrophy and diastolic function in patients with type 2 diabetes mellitus

AIMS

Few prospective studies have evaluated sex-specific pattern, natural progression of left ventricular (LV) remodelling, and diastolic dysfunction in patients with type 2 diabetes (T2DM). The aim of this study was to study the sex-specific prevalence, longitudinal changes of LV remodelling, and diastolic dysfunction in patients with T2DM. Further, the prognostic value of diastolic function in women and men was also evaluated.

METHODS AND RESULTS

A total of 350 patients with T2DM (mean age 61 ± 11 years; women, 48.3%) was recruited. Detailed echocardiography was performed at baseline and after 25 months. A major adverse cardiovascular event (MACE) was defined as cardiovascular death, heart failure hospitalization, or myocardial infarction. Despite a similar age, prevalence of hypertension and body mass index, women had a higher prevalence of LV hypertrophy and diastolic dysfunction at baseline and follow-up compared with men. A total of 21 patients developed MACE (5 cardiovascular death, 9 hospitalization for heart failure, and 7 myocardial infarction) during a median follow-up of 56 months. Women with diastolic dysfunction had a higher incidence of MACE than those with normal diastolic function but this association was neutral in men. Multivariable Cox-regression analysis indicated that diastolic dysfunction was associated with MACE in women [hazard ratio = 6.30; 95% confidence interval (CI) = 1.06-37.54; P < 0.05] but not men (hazard ratio = 2.29, 95% CI = 0.67-7.89; P = 0.19).

CONCLUSION

LV hypertrophy and diastolic dysfunction, both at baseline and follow-up, were more common in women than men. Pre-clinical diastolic dysfunction was independently associated with MACE only in women with T2DM but was neutral in men.

Impact of stroke work on the ability of left ventricular mass to account for pressure effects on function in a community with prevalent systemic flow-dependent hypertension

AIMS

To determine whether the confounding influence of stroke work on left ventricular mass (LVM) limits the ability of LVM to detect hypertensive LV dysfunction in systemic flow-dependent hypertension.

METHODS

In a community with prevalent systemic flow-dependent hypertension (n = 709), arterial haemodynamics, LVM and LV function were determined using central arterial pressure, aortic velocity and diameter measurements in the outflow tract, and echocardiography with tissue Doppler imaging.

RESULTS

In multivariate models, stroke work showed markedly stronger relations with LVM index (LVMI) than blood pressure load [central arterial SBP (SBPc), backward wave pressure (Pb), 24-h SBP] (P < 0.0001 for comparisons). In contrast, although SBPc, Pb, and 24-h SBP were inversely associated with myocardial tissue shortening (s') and lengthening (e') velocity, stroke work was not. With adjustments for stroke work, positive relationships between SBPc, Pb, or 24-h SBP and LVMI were eliminated (P = 0.20 to P = 0.89), but strong relations between BP and s', e' or E/e' (P = 0.009 to P < 0.0001) remained. In mediation analysis, stroke work fully accounted for BP effects on LVMI, but explained none of the effects of BP on LV function. Hence LVMI accounted for little of the impact of BP load on LV function. Although LVMI beyond stroke work (inappropriate LVM) improved on relations between LVMI and s', it failed to improve on relations with e' or E/e' and contributed little beyond LVMI to the impact of BP on LV function.

CONCLUSION

In systemic flow-dependent hypertension, the impact of stroke work markedly limits the ability of LVM to account for adverse effects of hypertension on LV function.

Exploring the opinion of stakeholders about self-care, home care and hospital management of heart failure patients: A qualitative study

Introduction

Heart failure is a widespread chronic cardiac illness with varying etiologies. If the HF patients manage themselves at home by following the appropriate advice by healthcare professionals, they tend to have better quality of life and less readmissions. This study was aimed to identify and explore practices of self-management by heart failure patients, home management of heart failure by their family caregivers and hospital management by healthcare providers.

Methods

A qualitative study was conducted in a tertiary care center in Northern India on participants (patients, their family caregivers, doctors and nurses) who were recruited purposively and interviewed individually by principle investigator using semi-structured questionnaires. Interviews were audio recorded and transcribed after taking informed consent. Iterative process including coding, reviewing and analyzing was done by four researchers and themes were finalized.

Results

Total 41 participants (15 patients, 12 family caregivers, 4 doctors and 10 nurses) completed the interviews. It was observed that patients and family caregivers were not able to manage heart failure efficiently. Nurses and doctors reported many barriers to provide specialized care to these patients.

Discussion

There were definite barriers and challenges in the management of heart failure symptoms by the stakeholders. For the patients and family members who suffer this debilitating illness, managing heroically is a challenge. It is important to develop self-care management protocol for the heart failure patients. Healthcare professionals must overcome the barriers to train patients and family caregivers. Multidisciplinary integration can fulfill the gap in providing care to such patients.

Diagnosis, treatment, and follow-up of heart failure patients by general practitioners: A Delphi consensus statement

Aims

Creation of an algorithm that includes the most important parameters (history, clinical parameters, and anamnesis) that can be linked to heart failure, helping general practitioners in recognizing heart failure in an early stage and in a better follow-up of the patients.

Methods and results

The algorithm was created using a consensus-based Delphi panel technique with fifteen general practitioners and seven cardiologists from Belgium. The method comprises three iterations with general statements on diagnosis, referral and treatment, and follow-up. Consensus was obtained for the majority of statements related to diagnosis, referral, and follow-up, whereas a lack of consensus was seen for treatment statements. Based on the statements with good and perfect consensus, an algorithm for general practitioners was assembled, helping them in diagnoses and follow-up of heart failure patients. The diagnosis should be based on three essential pillars, i.e. medical history, anamnesis and clinical examination. In case of suspected heart failure, blood analysis, including the measurement of NT-proBNP levels, can already be performed by the general practitioner followed by referral to the cardiologist who is then responsible for proper diagnosis and initiation of treatment. Afterwards, a multidisciplinary health care process between the cardiologist and the general practitioner is crucial with an important role for the general practitioner who has a key role in the up-titration of heart failure medication, down-titration of the dose of diuretics and to assure drug compliance.

Conclusions

Based on the consensus levels of statements in a Delphi panel setting, an algorithm is created to help general practitioners in the diagnosis and follow-up of heart failure patients.

Drug-Therapy Problems and Predictors among Hospitalized Heart-Failure Patients: A Prospective Observational Study

BACKGROUND

Heart-failure patients are at high risk of experiencing drug-therapy problems, owing to polypharmacy, comorbidities, and usually advanced age. Drug-therapy problems can lead to poor clinical outcomes, increased health-care costs and decreased quality of life, and thus strategies for identifying, resolving, and preventing them are urgently needed. Therefore, this study aimed at investigating the incidence and predictors of drug-therapy problems among hospitalized heart-failure patients.

METHODS

This hospital-based prospective observational study was conducted from February 1 to May 31, 2014 at Jimma University Specialized Hospital. Patients of either sex aged 18 years and above with chronic heart failure and complete medical records were enrolled. Patients with high-output heart failure, <1 day of hospital stay, unwilling to give written informed consent, and unconscious without caregivers were excluded. Data were collected from medication charts, laboratory reports, patients/caregivers, morning multidisciplinary meetings, and ward rounds. Multivariate binary logistic regression analysis was done to identify independent predictors of drug-therapy problems.

RESULTS

A total of 104 heart-failure patients (mean age 51.20±15.66 years, females 51.9%) were consecutively enrolled, and 95 (91.3%) had experienced at least one drug-therapy problem (total 268, mean 2.82±1.39 encounters per patient). Of these problems, 45.5% were the need for additional drugs, followed by noncompliance (22.0%), inappropriate dosing (9.3%), unnecessary drugs (9.0%), ineffective drugs (8.2%), and adverse drug reactions (6.0%). None of the independent variables was found to be an independent predictor of having at least one drug-therapy problem. However, the number of clinical/pharmacological risk factors (AOR 7.93), female sex (AOR 3.24), and length of hospital stay (AOR 12.98) were predictors of noncompliance.

CONCLUSION

Patients suffered from a large number of drug-therapy problems. Drugs with survival benefit were underused. Noncompliance and the need for additional drug therapy were the most frequently identified drug-therapy problems. Numbers of clinical/pharmacological risk factors, length of hospital stay, and female sex were identified as predictors for noncompliance.

Heart failure epidemiology and treatment in primary care: a retrospective cross-sectional study

Aims

Heart failure is one of the leading causes of morbidity and mortality worldwide, but little is known on heart failure epidemiology and treatment in primary care. This study described patients with heart failure treated by general practitioners, with focus on drug prescriptions and especially on the only specific treatment for heart failure with reduced ejection fraction, namely sacubitril/valsartan.

Methods and results

This was a retrospective cross‐sectional study using data from an electronic medical record database of Swiss general practitioners from 2016 to 2019. Multilevel logistic regression was used to find determinants of sacubitril/valsartan prescription; odds ratios (ORs) and 95% confidence intervals (CIs) were reported. We identified 1288 heart failure patients (48.5% women; age: median 85 years, interquartile range 77–90 years) by means of diagnosis code, representing 0.5% of patients consulting a general practitioner during the observation period. About 73.6% received a renin–angiotensin–aldosterone system inhibitor, 67.8% a beta‐blocker, 34.6% a calcium channel blocker, 86.1% a diuretic, and 40.1% another cardiac drug. Sacubitril/valsartan was prescribed in 6% predominantly male patients (OR 2.10, CI 1.25–3.84), of younger age (OR 0.59 per increase in 10 years, CI 0.49–0.71), with diabetes mellitus (OR 1.76, CI 1.07–2.90). The recommended starting dose for sacubitril/valsartan was achieved in 67.1% and the target dose in 28.6% of patients.

Conclusions

Prevalence of heart failure among patients treated by general practitioners was low. Considering the disease burden and association with multimorbidity, awareness of heart failure in primary care should be increased, with the aim to optimize heart failure therapy.

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR-HF pilot study

Aims

Identifying heart failure (HF) patients in general practice is challenging, and little is known about the current quality of care. We implemented an extended audit from the electronic health records (EHRs) of general practitioners (GPs) to identify HF patients and investigate patient characteristics and quality of care.

Methods and results

This study describes the baseline results of the OSCAR‐HF pilot study in eight general practices (51 GPs) in Flanders, Belgium. This prospective trial ran for 6 months. Interventions included an extended audit, an N‐terminal pro‐B‐type natriuretic peptide point‐of‐care test, and assistance of a specialist HF nurse. The extended audit searched on risk factors for HF, HF symptoms, signs, and medication in the GPs' EHR to generate a list of possible HF patients. GPs determined which patients had HF. Those HF patients constituted the OSCAR‐HF study population. Each patient file was manually revised to extract biomarker measurements, echocardiography data, and quality indicators. An independent panel of experts assessed the validity of GPs' HF diagnoses. Feedback about the validity of the HF diagnosis was given to the GP. Out of 18 011 patients ≥ 40 years, we identified 310 patients with a registered HF diagnosis before the study start (HF prevalence: 1.7%). The extended audit led to a 74% increase in identified HF patients (n = 538, HF prevalence: 3.0%) with a mean age of 79 ± 11 years. The prevalence of HF with reduced ejection fraction (HFrEF) was 20% (n = 110). A high proportion of patients underwent echocardiography in the past 5 years (86%, n = 462). Natriuretic peptides were rarely available in patients' files (19%, n = 100). Medical specialists should improve communication about the HF diagnosis because a specialist diagnosis was present in only 225 patients (42%) while 67% (n = 359) of the HF diagnoses were judged objectified by a panel of experts. Assigning a diagnosis of HF was particularly difficult in HF patients with preserved EF (HFpEF). HFrEF treatment rates with renin–angiotensin–aldosterone system blockers (84%, n = 92) and beta‐blockers (86%, n = 94) were very good; however, target doses were hardly reached (34% and 14%, respectively).

Conclusions

This study highlighted the need to improve case finding for HF in general practice and showed that an extended audit in the GPs' EHR was a successful strategy to do so. To improve the quality of HF care in general practice, specific strategies are needed to diagnose HFpEF and to reach target doses of disease‐modifying drugs in HFrEF patients.

Hospitalization outcome of heart diseases between patients who received medical care by cardiologists and non-cardiologist physicians: A propensity-score matched study

Background and aims

The effects of physician specialty on the outcome of heart disease remains incompletely understood because of inconsistent findings from some previous studies. Our purpose is to compare the admission outcomes of heart disease in patients receiving care by cardiologists and noncardiologist (NC) physicians.

Methods

Using reimbursement claims data of Taiwan’s National Health Insurance from 2008–2013, we conducted a matched study of 6264 patients aged ≥20 years who received a cardiologist’s care during admission for heart disease. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, and type of heart disease, 6264 controls who received an NC physician’s care were selected. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for complications and mortality during admission for heart disease associated with a cardiologist’s care.

Results

Patients who received a cardiologist’s care had a lower risk of pneumonia (OR = 0.61; 95% CI, 0.53–0.70), septicemia (OR = 0.49; 95% CI, 0.39–0.61), urinary tract infection (OR = 0.76; 95% CI, 0.66–0.88), and in-hospital mortality (OR = 0.37; 95% CI, 0.29–0.47) than did patients who received an NC physician’s care. The association between a cardiologist’s care and reduced adverse events following admission was significant in both sexes and in patients aged ≥40 years.

Conclusion

We raised the possibility that cardiologist care was associated with reduced infectious complications and mortality among patients who were admitted due to heart disease.

The epidemiology of heart failure in the general Australian community - study of heart failure in the Australian primary carE setting (SHAPE): methods

BACKGROUND

There is a paucity of information on the epidemiology of heart failure (HF) in Australia. The Study of Heart failure in the Australian Primary carE setting (SHAPE) study aims to estimate the prevalence and annual incidence of HF in the general Australian community and to describe the demographic and key clinical profile of Australians with HF.

METHODS

We undertook a retrospective cohort study based on analysis of non-identifiable medical records of adult patients cared for at 43 general practices between 1 July 2013 and 30 June 2018. Data were extracted from coded (diagnosis, pathology and prescription fields) and uncoded fields (clinical notes) in the medical records. The latter searches of free text looked for common synonyms relevant to HF. The population was stratified into three groups based on a hierarchy of selection criteria: (1) definite HF, (2) probable HF and (3) possible HF. The prevalence and annual incidence of HF were calculated, along with 95% confidence intervals.

RESULTS

The practices provided care to 2.3 million individual patients over the five-year study period, of whom 1.93 million were adults and 1.12 million were regular patients. Of these patients 15,468 were classified as having 'definite HF', 4751 as having 'probable HF' and 33,556 as having 'possible HF'. A further 39,247 were identified as having an aetiological condition associated with HF. A formal HF diagnosis, HF terms recorded as text in the notes and HF-specific medication were the most common methods to identify 'definite' HF patients. Typical signs and symptoms in combination with a diuretic prescription was the most common method to identify 'probable HF' patients. The majority of 'possible' HF patients were identified by the presence of 2 or more of the typical signs or symptoms. Dyspnoea was the commonest recorded symptom and an elevated jugular venous pressure the commonest recorded sign.

CONCLUSIONS

This novel approach to undertaking retrospective research of primary care data successfully analysed a combination of coded and uncoded data from the electronic medical records of patients routinely managed in the GP setting. SHAPE is the first real-world study of the epidemiology of HF in the general Australian community setting.

Changes over time in attitudes towards the management of older patients with heart failure by general practitioners: a qualitative study

BACKGROUND

Underdiagnosis and undertreatment of chronic heart failure (CHF) are common in older patients, who are usually treated by general practitioners (GPs). In 2007, the French ICAGE study explored GPs' attitudes to the management of this condition in older patients.

OBJECTIVES

To explore changes over time in GPs' attitudes towards the management of CHF in patients aged ≥75 and to identify barriers to optimal management.

METHODS

In 2015, we performed a qualitative study of 20 French GPs via semi-structured interviews and a thematic content analysis. The results were compared with the findings of a 2007 study.

RESULTS

In 2015, the perceived barriers to diagnosis were the same as in 2007. Echocardiography was still the preferred diagnostic method but the GPs relied on the cardiologist to confirm the diagnosis. Many GPs were still unaware of the different types of CHF. In contrast, they reported greater knowledge of decompensation factors and the ultrasound criteria for CHF. They also prescribed a brain natriuretic peptide assay more frequently. Angiotensin-converting enzyme inhibitors and beta blockers were more strongly perceived to be core treatments. Few GPs initiated drug treatments and optimized dosages. Although patient education was never mentioned, the importance of multidisciplinary care was emphasized.

CONCLUSION

Our results evidenced a small recent improvement in the management of older patients with CHF. Appropriate guidelines and training for GPs, patient education and multidisciplinary collaboration might further improve the care given to this population.

Optimising standards of care of heart failure in general practice the OSCAR-HF pilot study protocol

Background: Heart failure (HF) imposes a burden for patients and health economics. General practitioners (GPs) are confronted with the broadest range of HF management. Although guidelines exist, they are not fully implemented in the Belgian health care system. Methods: We will conduct a non-randomised, non-controlled prospective observational trial (six months follow-up) to implement a multifaceted intervention in Belgian general practice to support GPs in the implementation of evidence-based HF guidelines. The multifaceted intervention consists of an audit and feedback method to detect previously unrecognised patients with HF and to increase awareness for proactive HF management, an NT-proBNP point-of-care test to improve detection and adequate diagnosis of patients with HF and a specialist HF nurse to assist GPs in the education of patients, optimisation of treatment and follow-up after hospitalisation. All patients aged 40 years and older with a confirmed diagnosis of HF by their GP based on the clinical audit are eligible for participation. The main objective of this pilot study is to evaluate the feasibility of this multifaceted intervention and the evolution of predefined quality indicators. We will measure the impact on HF diagnosis, medication optimisation, multidisciplinary follow-up and patients' quality of life after six months. Additionally, the experiences of GPs and investigators will be studied. Conclusions: Heart failure is an important health problem in which GPs play a key role. Therefore, we will evaluate the feasibility of a multifaceted intervention to optimise diagnosis as well as implement the guideline recommended therapies in patients with HF in general practice.

[Optimization of systolic heart failure treatment by general practitioners after hospital discharge: Are guidelines applied?]

Heart failure is a common and serious disease, with constantly increasing incidence. General practitioners have an essential role in its management.

AIM OF THE STUDY

Describe general practitioner's practice in optimizing heart failure treatment after hospital discharge.

PATIENTS AND METHOD

All patients admitted for heart failure with altered ejection fraction in Nanterre's hospital cardiology department between February 2014 and January 2015 and having a general practitioner were included. Demographic, clinical, biological, ultrasound data and treatments were collected. A questionnaire was submitted to general practitioners two months after discharge.

RESULTS

A total of 82 patients (age 76±12years, left ventricular ejection fraction 36±8%) were included. The target dose of angiotensin-converting-enzyme inhibitors and beta-blockers was reached for 18% of patients during hospitalization. Forty-two general practitioners answered the questionnaire, which concerned 60% of patients (n=49). None of them modified angiotensin-converting-enzyme inhibitors nor beta-blockers. The reasons were the lack of patient consultation (43%), the good tolerance (43%), the absence of habit (24%), and the attribution of this role to the cardiologist (41%). Possible improvements are: more precise hospitalization reports, alternating consultations and educational sessions.

CONCLUSION

Patients with heart failure are under-treated at discharge and general practitioners do not optimize the treatment after hospital discharge. The main axis of improvement is to establish a better defined care pathway.

Survival of patients with chronic heart failure in the community: a systematic review and meta-analysis

Aim

To provide reliable survival estimates for people with chronic heart failure and explain variation in survival by key factors including age at diagnosis, left ventricular ejection fraction, decade of diagnosis, and study setting.

Methods and results

We searched in relevant databases from inception to August 2018 for non‐interventional studies reporting survival rates for patients with chronic or stable heart failure in any ambulatory setting. Across the 60 included studies, there was survival data for 1.5 million people with heart failure. In our random effects meta‐analyses the pooled survival rates at 1 month, 1, 2, 5 and 10 years were 95.7% (95% confidence interval 94.3–96.9), 86.5% (85.4–87.6), 72.6% (67.0–76.6), 56.7% (54.0–59.4) and 34.9% (24.0–46.8), respectively. The 5‐year survival rates improved between 1970–1979 and 2000–2009 across healthcare settings, from 29.1% (25.5–32.7) to 59.7% (54.7–64.6). Increasing age at diagnosis was significantly associated with a reduced survival time. Mortality was lowest in studies conducted in secondary care, where there were higher reported prescribing rates of key heart failure medications. There was significant heterogeneity among the included studies in terms of heart failure diagnostic criteria, participant co‐morbidities, and treatment rates.

Conclusion

These results can inform health policy and individual patient advanced care planning. Mortality associated with chronic heart failure remains high despite steady improvements in survival. There remains significant scope to improve prognosis through greater implementation of evidence‐based treatments. Further research exploring the barriers and facilitators to treatment is recommended.

Evaluating Pharmacist Impact on Guideline-Directed Medical Therapy in Patients With Reduced Ejection Fraction Heart Failure

BACKGROUND

Limited literature exists evaluating the ability of a pharmacist to quickly and effectively initiate and manage dose titrations of guideline-directed medication therapy (GDMT) in an outpatient setting.

METHODS

This pilot study aimed to investigate the impact of pharmacist-managed, outpatient heart failure management on patients' heart failure outcomes, and health-care-related costs. Retrospective chart review performed on patients referred to pharmacist practicing under collaborative practice agreement. End points included time to achieve individualized target doses of GDMT; beta-blocker dose tolerance; and the clinic's impact on left ventricular ejection fraction (LVEF), hospital admission, and emergency department encounter rates. Descriptive statistics were used to report nominal data. Wilcoxon signed-rank test was used to evaluate continuous variables.

RESULTS

Thirty-six patients completed full titration utilizing an average of 4.9 visits over 12.7 weeks. Seventy-eight percent (n = 28) achieved full beta-blocker titration. Seventy-six percent of patients had LVEF >35% after titration versus 43% at baseline. A significant reduction in all-cause hospital admissions was seen during both 13-week and 12-month comparison periods (P < .05). We estimated >US$50 000 annual revenue generation from 0.2 full-time equivalent pharmacist.

CONCLUSIONS

Although hypothesis generating, our results support the idea that pharmacist-managed medication titration clinics are effective at completing titration, improving LVEF, and generating revenue.

General practitioners' perceptions about their role in current and future heart failure care: an exploratory qualitative study

Background

A comprehensive disease management programme (DMP) with a central role for general practitioners (GPs) is needed to improve heart failure (HF) care. However, previous research has shown that GPs have mixed experiences with multidisciplinary HF care. Therefore, in this study, we explore the perceptions that GPs have regarding their role in current and future HF care, prior to the design of an HF disease management programme.

Methods

This was a qualitative semi-structured interview study with Belgian GPs until data saturation was reached. The QUAGOL method was used for data analysis.

Results

In general, GPs wanted to assume a central role in HF care. Current interdisciplinary collaboration with cardiologists was perceived as smooth, partly because of the ease of access. In contrast, due to less well-established communication and the variable knowledge of nurses regarding HF care, collaboration with home care nurses was perceived as suboptimal. With regard to the future organization of HF care, all GPs confirmed the need for a structured chronic care approach and envisioned this as a multidisciplinary care pathway: flexible, patient-centred, without additional administration and with appropriate delegation of some critical tasks, including education and monitoring. GPs considered all-round general practice nurses as the preferred partner to delegate tasks to in HF care and reported limited experience in collaborating with specialist HF nurses.

Conclusion

GPs expressed the need for a protocol-driven care pathway in chronic HF care. However, in contrast to the existing care trajectories, this pathway should be flexible, without additional administrative burdens and with a central role for GPs.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4271-2) contains supplementary material, which is available to authorized users.

Common risk factors for heart failure and cancer

Cardiovascular (CV) disease and cancer are the leading causes of death.1,2 Over the last decades, it has been appreciated that both CV disease and cancer are more common in individuals in whom risk factors for disease development accumulate, and preventative measures have been extremely important in driving down the incidence of disease.3-6 In general, the field of epidemiology, risk reduction, and preventative trials is divided into health care professionals who have an interest in either CV disease or cancer. As a result, the medical literature and medical practice has largely focused on the one disease, or the other. However, human individuals do not behave according to this dogma. Emerging data clearly suggest that identical risk factors may lead to CV disease in the one individual, but may cause cancer in another, or even both diseases in the same individual. This overlap exists between risk factors that are historically classified as 'CV risk factors' as these factors do equally strong predict cancer development. Therefore, we propose that a holistic approach might better estimate actual risks for CV disease and cancer. In this review, we summarize current insights in common behavioural risk factors for heart failure, being the most progressed and lethal form of CV disease, and cancer.

Think-aloud study about the diagnosis of chronic heart failure in Belgian general practice

OBJECTIVES

Diagnosing chronic heart failure (CHF) in general practice is challenging. Our aim was to investigate how general practitioners (GPs) diagnose CHF in real-world patients.

DESIGN

Think-aloud study.

METHODS

Fourteen GPs were asked to reason about four real-world CHF cases from their own practices. The cases were selected through a clinical audit. This was followed by an interview to get a deeper insight in their reasoning. The Qualitative Analysis Guide of Leuven was used as a guide in data analysis.

RESULTS

We developed a conceptual diagnostic model based on three important reasoning steps. First, GPs assessed the likelihood of CHF based on the presence or absence of HF signs and symptoms. However, this approach had serious limitations since GPs experienced many barriers in their clinical assessment, especially in comorbid elderly. Second, if CHF was considered based on step 1, the main influencing factor to take further diagnostic steps was the GPs' perception of the added value of a validated CHF diagnosis in that specific case. Third, the choice and implications of these further diagnostic steps (N-terminal pro B-type natriuretic peptide, ECG and/or cardiac ultrasound) were influenced by the GPs' knowledge about these tests and the quality of the cardiologists' reports.

CONCLUSION

This think-aloud study identified the factors that influenced the diagnostic reasoning about CHF in general practice. As a consequence, targets to improve this diagnostic reasoning were withheld: a paradigm shift towards an earlier and more comprehensive risk assessment with, among others, access to natriuretic peptide testing and convincing GPs of the added value of a validated HF diagnosis.

Prescribing patterns of evidence-based heart failure pharmacotherapy and outcomes in the ASIAN-HF registry: a cohort study

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), β blockers, and mineralocorticoid receptor antagonists (MRAs) are of proven benefit and are recommended by guidelines for management of patients with heart failure and reduced ejection fraction (HFrEF). We aimed to examine the first prospective multinational data from Asia on prescribing patterns of guideline-directed medical therapies and analyse its effect on outcomes.

METHODS

In the prospective multinational ASIAN-HF registry (with enrolment from 46 centres in 11 countries in Asia), we enrolled patients aged 18 years or older, with symptomatic heart failure (stage C, with at least one episode of decompensated heart failure in the past 6 months that resulted in admission to hospital or was treated in an outpatient clinic) and left ventricular systolic dysfunction (ejection fraction ≤40% on baseline echocardiography, consistent with 2016 European Society of Cardiology guidelines). We excluded patients with heart failure caused by severe valvular heart disease, life-threatening comorbidity with a life expectancy of less than 1 year, who were unable or unwilling to give consent, or who had concurrent participation in a clinical trial. Patients were followed up for 3 years for the outcomes of death and cause-specific admittance to hospital. Primary outcomes were uptake of guideline-directed medical therapies (as proportions) by therapeutic class, achieved doses as proportions of guideline-recommended doses, and their association with 1-year composite outcome of all-cause death or admittance to hospital because of heart failure. This study is registered with ClinicalTrials.gov, number NCT01633398.

FINDINGS

Between Oct 1, 2012, and Dec 31, 2015, we enrolled 5276 patients with HFrEF (mean age 59·6 years [SD 13·2], 77% men, body-mass index 24·9 kg/m² [5·1], 33% New York Heart Association class III or IV). Follow-up data were available for 4544 (90%) of 5061 eligible patients taking medication for heart failure, with median follow-up of 417 days (IQR 214-735). ACE inhibitors or ARBs were prescribed to 3868 (77%) of 5005 patients, β blockers to 3975 (79%) of 5061, and MRAs to 2998 (58%) of 5205, with substantial regional variation. Guideline-recommended dose was achieved in only 17% of cases for ACE inhibitors or ARB, 13% for β blockers, and 29% for MRAs. Country (all three drug classes), increasing body-mass index (ACE inhibitors or ARBs and MRAs), and in-patient recruitment (ACE inhibitors or ARBs and β blockers) were associated with attainment of guideline-recommended dose (all p<0·05). When adjusted for indication bias, increasing drug doses, from low dose (1-<25% of guideline-recommended dose) upwards were associated with lower hazards of a 1-year composite outcome for ACE inhibitors or ARBs and β blockers compared with non-users. The lowest adjusted hazards were in the group that attained guideline-recommended doses above 50% (hazard ratio [HR] 0·54, 95% CI 0·50-0·58 for ACE inhibitors or ARBs [50-99·9%]; HR 0·47, 0·46-0·50 for β blockers, and HR 0·77, 0·72-0·81 for MRAs [≥100%]).

INTERPRETATION

Guideline-directed medical therapies at recommended doses are underutilised in patients with HFrEF. Improved uptake and uptitration of guideline-directed medical therapies are needed for better patient outcomes.

FUNDING

National Medical Research Council (Singapore), A*STAR Biomedical Research Council ATTRaCT program, Boston Scientific Investigator Sponsored Research program, and Bayer.

Home monitoring with IT-supported specialist management versus home monitoring alone in patients with heart failure: Design and baseline results of the SUPPORT-HF 2 randomized trial

OBJECTIVES

SUPPORT-HF 2 tests the hypothesis that home monitoring with information technology-supported specialist management is more effective in optimizing medical therapy than is home monitoring alone for patients with heart failure.

METHODS AND RESULTS

The study was designed as a 2-armed partially blinded parallel randomized controlled trial. Seven sites in the United Kingdom (UK) recruited a total of 202 adults with heart failure at high risk of adverse outcomes and with potential to benefit from remote management (mean age 73 years, 28% female, median left ventricular ejection fraction 37%). Both arms are given a home monitoring and communication kit (Internet-enabled tablet computer, Bluetooth-enabled blood pressure and heart rate monitor, and weighing scale). For each participant, an individualized plan for treatment of heart failure and major comorbidities is developed before randomization. Participants randomized to intervention receive regular feedback to support self-management, and their physicians receive advice on blood investigations and pharmacological treatment from a central specialist heart failure team. Participants in the control arm use the same monitoring system but with no central medical management support. The primary outcome is the use of recommended medical therapy, defined as treatment consistent with the guidelines for management of patients with chronic heart failure, and will be measured as a composite opportunity score. The trial data collection ended in October 2017, and results will be reported in 2019.

TRIAL REGISTRATION

ISRCTN86212709.

CONCLUSIONS

Preliminary experience suggests that central provision of tailored specialist management using commercially available low-cost monitoring and computing devices, enhanced by customized applications, is feasible.

Burden of heart failure in Flemish general practices: a registry-based study in the Intego database

OBJECTIVES

To assess the prevalence and incidence of heart failure (HF) stages A to C/D and their evolution over a 16-year period. Additionally, trends in comorbidities and cardiovascular (CV) treatment in patients with HF were studied in the same period.

DESIGN

Registry-based study.

SETTING

Primary care, Flanders, Belgium.

PARTICIPANTS

Data were obtained from Intego, a morbidity registration network in which 111 general practitioners of 48 practices collaborate. In the study period between 2000 and 2015, data from 165 796 unique patients aged 45 years and older were available.

OUTCOME MEASURES

Prevalence and incidence were calculated for HF stage A, B and C/D by gender. Additionally, the trend in age-standardised prevalence and incidence rates between 2000 and 2015 was analysed with joint-point regression. The same model was used to study trends in comorbidity profiles in incident HF cases and trends in cardiovascular medication in prevalent HF cases.

RESULTS

We found a downward trend in the incidence and prevalence of HF stage C/D in Flemish general practice between 2000 and 2015, whereas the prevalence and incidence of stage A and B increased. The burden of comorbidities in incident HF cases increased during the study period, as shown by an increasing disease count (p<0.001). The prescription of cardiovascular medication such as renin-angiotensin-aldosterone system blockade, β-blockers and statins showed a sharp increase in the first part of the study period (2000-2008).

CONCLUSION

Age-standardised incidence and prevalence of HF stage C/D showed a slightly downward trend over the past 16 years, probably due to the sharp increase in cardiovascular treatment. However, the increasing age-standardised incidence and prevalence of stage A and B, as precursors of symptomatic HF, together with a rising comorbid burden, highlights the challenges we are still facing.

Real-world presentation with heart failure in primary care: do patients selected to follow diagnostic and management guidelines have better outcomes?

Objective

To describe associations between initial management of people presenting with heart failure (HF) symptoms in primary care, including compliance with the recommendations of the National Institute for Health and Care Excellence (NICE), and subsequent unplanned hospitalisation for HF and death.

Methods

This is a retrospective cohort study using data from general practices submitting records to the Clinical Practice Research Datalink. The cohort comprised patients diagnosed with HF during 2010–2013 and presenting to their general practitioners with breathlessness, fatigue or ankle swelling.

Results

13 897 patients were included in the study. Within the first 6 months, only 7% had completed the NICE-recommended pathway; another 18.6% had followed part of it (B-type natriuretic peptide testing and/or echocardiography, or specialist referral). Significant differences in hazards were seen in unadjusted analysis in favour of full or partial completion of the NICE-recommended pathway. Covariate adjustment attenuated the relations with death much more than those for HF admission. Compared with patients placed on the NICE pathway, treatment with HF medications had an HR of 1.16 (95% CI 1.05 to 1.28, p=0.003) for HF admission and 1.03 (95% CI 0.90 to 1.17, p= 0.674) for death. Patients who partially followed the NICE pathway had similar hazards to those who completed it. Patients on no pathway had the highest hazard for HF admission at 1.30 (95% 1.18 to 1.43, p<0.001) but similar hazard for death.

Conclusions

Patients not put on at least some elements of the NICE-recommended pathway had significantly higher risk of HF admission but non-significant higher risk of death than other patients had.

Survival of patients with chronic heart failure in the community: a systematic review and meta-analysis protocol

BACKGROUND

Heart failure (HF) is a common condition affecting more than 10% of those over 70 years of age. Reliable estimates of survival following a diagnosis of HF are important to guide management and facilitate advanced care planning. Most existing research has focused on survival rates for patients admitted to hospital with acute HF. However, the majority of patients with HF are diagnosed in the outpatient setting and can have periods of sustained symptom stability in the chronic phase of their illness. There has not been a systematic review of the literature to determine the prognosis of patients with chronic HF in the community.

METHODS

We will undertake a comprehensive search of the following databases: CINAHL, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and the Clinical Trials Register ( clinicaltrials.gov ). Two reviewers will independently complete screening, data extraction and quality appraisal with the option of input from a third reviewer to arbitrate. We will include data from observational or database studies conducted in either community or outpatient settings. Studies of acute HF or specific subgroups of patients will be excluded. There is no restriction by geographical setting, publication language or study date. We will complete QUIPS and GRADE assessments to systematically appraise the quality of evidence within and between studies. Where possible, we will seek to pool results to conduct a meta-analysis and undertake relevant subgroup analysis including by study setting, participant age and study decade. The primary outcome will be survival time from diagnosis. The secondary outcomes will be HF-related hospital admissions, symptom burden and measures of morbidity.

DISCUSSION

This systematic review will provide up to date evidence on the current survival rates and prognostic indicators for patients with chronic HF. We will put this into historical perspective, comparing outcomes across time to help understand the impact of advances in evidence-based treatment on average survival. This information is important in facilitating informed decision-making for patients and health professionals as well as highlighting areas to focus resources and improve public health planning.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2017 CRD42017075680.

Barriers to Beta-Blocker Use and Up-Titration Among Patients with Heart Failure with Reduced Ejection Fraction

PURPOSE

For patients with heart failure with reduced ejection fraction (HFrEF), guidelines recommend use of beta-blockers with gradual up-titration. However, many patients with HFrEF do not use beta-blockers and up-titration is rare. Our purpose was to identify and rank barriers to beta-blocker use and up-titration from the perspective of primary care physicians.

METHODS

We conducted 4 moderated, structured group discussions among 19 primary care physicians using the nominal group technique; 16 participants also completed a survey. Participants generated lists of barriers to beta-blocker use and up-titration among patients with HFrEF. Each participant had six votes with three votes assigned to the item ranked most important, two to the second most important item, and one to the third most important item. Investigators characterized items into themes. The percentage of available votes was calculated for each theme.

RESULTS

Fifteen of 16 participating primary care physicians who completed the survey reported that management of beta-blockers was their responsibility. Treatment/side effects, particularly hypotension, were identified as the most important barrier for beta-blocker use (72% of available votes) followed by polypharmacy (11%), healthcare system barriers (10%), and comorbidities (6%). Barriers to up-titration included treatment/side effects (49% of available votes), patient communication/buy-in (21%), polypharmacy (13%), and healthcare system barriers (8%).

CONCLUSIONS

Many barriers to guideline concordant use of beta-blockers among patients with HFrEF identified by primary care providers are not readily modifiable. Addressing these barriers may require development, testing, and dissemination of protocols for beta-blocker initiation and up-titration that are safe and appropriate in primary care.

Assessing Statewide All-Cause Future One-Year Mortality: Prospective Study With Implications for Quality of Life, Resource Utilization, and Medical Futility

Background

For many elderly patients, a disproportionate amount of health care resources and expenditures is spent during the last year of life, despite the discomfort and reduced quality of life associated with many aggressive medical approaches. However, few prognostic tools have focused on predicting all-cause 1-year mortality among elderly patients at a statewide level, an issue that has implications for improving quality of life while distributing scarce resources fairly.

Objective

Using data from a statewide elderly population (aged ≥65 years), we sought to prospectively validate an algorithm to identify patients at risk for dying in the next year for the purpose of minimizing decision uncertainty, improving quality of life, and reducing futile treatment.

Methods

Analysis was performed using electronic medical records from the Health Information Exchange in the state of Maine, which covered records of nearly 95% of the statewide population. The model was developed from 125,896 patients aged at least 65 years who were discharged from any care facility in the Health Information Exchange network from September 5, 2013, to September 4, 2015. Validation was conducted using 153,199 patients with same inclusion and exclusion criteria from September 5, 2014, to September 4, 2016. Patients were stratified into risk groups. The association between all-cause 1-year mortality and risk factors was screened by chi-squared test and manually reviewed by 2 clinicians. We calculated risk scores for individual patients using a gradient tree-based boost algorithm, which measured the probability of mortality within the next year based on the preceding 1-year clinical profile.

Results

The development sample included 125,896 patients (72,572 women, 57.64%; mean 74.2 [SD 7.7] years). The final validation cohort included 153,199 patients (88,177 women, 57.56%; mean 74.3 [SD 7.8] years). The c-statistic for discrimination was 0.96 (95% CI 0.93-0.98) in the development group and 0.91 (95% CI 0.90-0.94) in the validation cohort. The mortality was 0.99% in the low-risk group, 16.75% in the intermediate-risk group, and 72.12% in the high-risk group. A total of 99 independent risk factors (n=99) for mortality were identified (reported as odds ratios; 95% CI). Age was on the top of list (1.41; 1.06-1.48); congestive heart failure (20.90; 15.41-28.08) and different tumor sites were also recognized as driving risk factors, such as cancer of the ovaries (14.42; 2.24-53.04), colon (14.07; 10.08-19.08), and stomach (13.64; 3.26-86.57). Disparities were also found in patients’ social determinants like respiratory hazard index (1.24; 0.92-1.40) and unemployment rate (1.18; 0.98-1.24). Among high-risk patients who expired in our dataset, cerebrovascular accident, amputation, and type 1 diabetes were the top 3 diseases in terms of average cost in the last year of life.

Conclusions

Our study prospectively validated an accurate 1-year risk prediction model and stratification for the elderly population (≥65 years) at risk of mortality with statewide electronic medical record datasets. It should be a valuable adjunct for helping patients to make better quality-of-life choices and alerting care givers to target high-risk elderly for appropriate care and discussions, thus cutting back on futile treatment.

B-type natriuretic peptide may predict prognosis in older adults admitted with a diagnosis other than heart failure

BACKGROUND AND AIMS

The diagnosis of heart failure (HF) in elderly patients is often difficult, due to overlap of typical signs and symptoms with those of comorbidities. B-type Natriuretic Peptide (BNP) predicts diagnosis and prognosis of HF, but little is known on its predictive role of short-term prognosis when admission diagnosis is other than HF.

METHODS AND RESULTS

We prospectively recruited 404 consecutive patients (aged≥65 years) hospitalized in the Unit of Internal Medicine, University of Catania, Catania, Italy, with an admission diagnosis other than HF. Clinical examination, laboratory data and BNP were evaluated at the admission. The predictive value of BNP and other variables for in-hospital mortality, thirty-day mortality and three month re-hospitalization was assessed. During hospitalization 48 (12%) patients died; by logistic regression analysis, in-hospital mortality was not predicted by BNP>600 pg/ml (OR = 1.36; CI 95% = 0.60-2.80; p = 0.4), while it was by chronic kidney disease (CKD, p < 0.001), WBC count (p < 0.001), immobilization syndrome (p < 0.008) and age (p = 0.012). After discharge, 54 patients (15%) died within 30 days; in these patients thirty-day mortality was significantly predicted by BNP>600 pg/ml (OR = 2.70; CI 95% = 1.40-5.00; p = 0.001), CKD (p < 0.001), malnutrition (p = 0.029) and age (p = 0.033). Re-hospitalized patients were 97 (32%); three month re-hospitalization was predicted by BNP>600 pg/ml (OR = 12.28; CI 95% = 6.00-24.90; p < 0.001) and anamnestic HF (p = 0.002).

CONCLUSIONS

Our study shows that BNP>600 pg/ml, CKD, malnutrition and age predict thirty-day mortality after discharge in elderly patients with an admission diagnosis other than HF, while CKD, WBC count, immobilization syndrome and age predict in-hospital mortality. Three-month re-hospitalization was predicted by BNP>600 pg/ml and anamnestic HF.

Meta-Analysis Comparing Neurohumoral Antagonist Use in Patients ≥75 Years Versus <75 Years Receiving Cardiac Resynchronization Therapy

Neurohumoral antagonists are the foundation of heart failure therapy in patients with reduced left ventricular ejection fraction. Cardiac resynchronization therapy (CRT) has also been associated with improved outcomes in these patients. We aimed to evaluate the use of neurohumoral antagonists in patients ≥75 years compared with <75 years of age receiving CRT. We searched electronic databases, up to December 20, 2016 for all studies reporting medication use in patients ≥75 years and <75 years of age who received CRT. We used random-effects meta-analysis models to summarize the studies. We retained 12 studies (1 randomized trial and 11 observational studies) enrolling 5,728 ≥75 years old and 9,549 patients of <75 years old. There were lower use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers in patients ≥75 years compared with patients <75 years (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.47 to 0.74, p < 0.0001). In addition, there were lower use of mineralocorticoid receptor antagonists in patients ≥75 years compared with patients <75 years (OR 0.48, 95% CI 0.40 to 0.57, p < 0.0001). The use of β blockers was nonsignificantly lower in patients ≥75 years compared with patients <75 years (OR 0.70, 95% CI 0.47 to 1.03, p = 0.07). In conclusion, neurohumoral antagonists appeared to be underused in patients ≥75 years compared with patients <75 years receiving CRT. Consideration should be given to increase neurohumoral antagonism in patients ≥75 years referred for CRT.

Methods to identify heart failure patients in general practice and their impact on patient characteristics: A systematic review

BACKGROUND

Identifying patients with heart failure (HF) in general practice is challenging. Our aim was to provide an overview of methods used to identify patients with HF in general practice and to assess their impact on patient characteristics.

METHODS AND RESULTS

A systematic review was conducted using MEDLINE, EMBASE and CENTRAL. Taken together, 105 studies on HF in general practice were included, totalling 196,105 patients. Five main identification methods for HF were distinguished, including 1) echocardiographic assessments, 2) results of echocardiography in general practitioner (GP) charts, 3) GP judgment after chart review, 4) GP judgment of consecutive patients and 5) only chart review. Only 30% of studies used the results of echocardiography. Despite a large heterogeneity between studies the pooled data revealed a predominant phenotype of older women with hypertension rather than ischaemic heart disease. Linear regression analysis showed that the impact of the identification method on patient characteristics was limited. However, study design had a greater impact, with randomized-controlled trials (RCTs) including younger, male patients with ischaemic heart disease and higher HF drug prescription rates at baseline.

CONCLUSION

Pooled data of 196,105 patients with HF confirmed a phenotype of older women with hypertension rather than ischaemic heart disease as the predominant HF population in general practice. The lack of a gold standard definition of HF introduced a large heterogeneity in identification methods with remarkably limited impact on patient characteristics. However, RCTs did include patients with a different phenotype, emphasizing the need to promote inclusion of real-world HF patients.

Providers and Patients Caught Between Standardization and Individualization: Individualized Standardization as a Solution Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare"

In their 2017 article, Mannion and Exworthy provide a thoughtful and theory-based analysis of two parallel trends in modern healthcare systems and their competing and conflicting logics: standardization and customization. This commentary further discusses the challenge of treatment decision-making in times of evidence-based medicine (EBM), shared decision-making and personalized medicine. From the perspective of systems theory, we propose the concept of individualized standardization as a solution to the problem. According to this concept, standardization is conceptualized as a guiding framework leaving room for individualization in the patient physician interaction. The theoretical background is the concept of context management according to systems theory. Moreover, the comment suggests multidisciplinary teams as a possible solution for the integration of standardization and individualization, using the example of multidisciplinary tumor conferences and highlighting its limitations. The comment also supports the authors’ statement of the patient as co-producer and introduces the idea that the competing logics of standardization and individualization are a matter of perspective on macro, meso and micro levels.

Outcomes of a Pharmacist-Managed Heart Failure Medication Titration Assistance Clinic

Background: National guidelines recommend angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and β-blockers (BBs) at target doses for morbidity and mortality benefits in heart failure with reduced ejection fraction (HFrEF); regardless, titration of these therapies in practice remains suboptimal. We implemented an outpatient pharmacist-managed HFrEF medication titration assistance clinic (MTAC) at one institution to improve titration for general cardiology (GC) patients. Objective: To evaluate MTAC impact by determining the proportion of patients on target or maximum tolerated ACE inhibitor/ARB and BB doses. Methods: A retrospective chart review of adult patients with documented ejection fraction ≤40% managed in the MTAC or GC from 2011 to 2013 was conducted. HFrEF medication regimens were collected at initial visit and months 1, 2, 3, 6, 9, and 12 to assess titration. Target doses were defined per guideline or dose at which ejection fraction recovered during the study. Maximum tolerated doses were defined as the highest dose patients tolerated without physiological limitations. Results: Of 148 patients, the MTAC managed 51 and GC managed 97. At baseline, 90% of MTAC versus 82% of GC patients were prescribed ACE inhibitors/ARBs and BBs. In the MTAC, 4% were at target or maximum tolerated doses compared with 32% of GC patients ( P < 0.001). At 12 months, 95% of patients in the MTAC and 87% in GC were prescribed ACE inhibitors/ARBs and BBs. Of those prescribed ACE inhibitors/ARBs and BBs, 64% in the MTAC versus 40% in GC reached target or maximum tolerated doses ( P = 0.01). Conclusions: The pharmacist-managed MTAC increased the proportion of patients on optimal HFrEF therapies and are a resource for GC patients.

The treatment gap in patients with chronic systolic heart failure: a systematic review of evidence-based prescribing in practice

The extent and impact of under-prescribing of evidence-based pharmacological therapies among heart failure patients with reduced ejection fraction (HFREF) in contemporary practice is unclear. We sought to examine the prescribing patterns of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β-blockers (BBs) and mineralocorticoid receptor antagonists (MRAs), and to quantify the estimated 'treatment gap' among HFREF patients in the 'real-world' setting. The MEDLINE, PubMed, EMBASE, CINAHL and CENTRAL databases were searched for registry- or survey-based studies which examined the prescribing rates of ACE inhibitors, ARBs, BBs and MRAs among HFREF patients. Searches were limited to those published in the years 2000-2015. A total of 23 reports, including 83,605 patients, were evaluated. Overall, ACE inhibitors/ARBs, BBs and MRAs were prescribed to 79.8, 81.4 and 36.4 % of patients, respectively. The estimated treatment gaps in the overall population were 13.1 % for ACE inhibitors/ARBs, 3.9 % for BBs and 16.8 % for MRAs. The proportion of patients who received ≥50 % of the guideline-recommended target doses was 72 % for ACE inhibitors, 51 % for ARBs, 49 % for BBs, 53 % for the combination of ACE inhibitors/ARBs and BBs and 83 % for MRAs. Prescribing these drugs according to contemporary guidelines was associated with lower mortality risk. Patients who were elderly, female and with comorbidities were less likely to receive optimal treatment as recommended by the guidelines. ACE inhibitors, ARBs, BBs and MRAs are under-prescribed in eligible HFREF patients. Efforts should be made to improve approaches to closing the treatment gap at both systems of care and individual levels.

Evidence-Based Therapy and Its Association With Workforce Detachment After First Hospitalization for Heart Failure

OBJECTIVES

This study investigated the association between the use of evidence-based medicine (EBM) for heart failure (HF) and risk of workforce detachment.

BACKGROUND

The ability to work can be a marker of functional capacity and quality of life.

METHODS

We examined a nationwide cohort of patients in the workforce 1 year after first hospitalization for HF. EBM was defined as treatment with β-blockers and renin angiotensin system inhibitors. The fraction of target dose (0 TO 1) for each drug was calculated. The sum of the fractions gave each patient a score between 0 and 2. Patients were stratified into 4 groups according to this score: group 4 score = 2 (target dose of both drugs); group 3 score <2 to >1; group 2 score ≤1 to >0.5; and group 1 score ≤0.5. The risk of subsequent workforce detachment was estimated in cause specific Cox regression models.

RESULTS

One year after first HF hospitalization, 10,185 patients were part of the workforce, and 7,561 (74%) were in treatment with at least 1 of the components of EBM. During a median follow-up of 727 days, 2,698 individuals (36%) became detached from the workforce. Patients receiving more EBM had a significantly lower risk of workforce detachment compared with those receiving less EBM (group 4 hazard ratio [HR]: 0.87; 95% confidence interval [CI]: 0.77 to 0.98; group 3 HR: 0.85; 95% CI: 0.77 to 0.94; and group 2 HR 0.92; 95% CI: 0.83 to 1.02), all compared to group 1.

CONCLUSIONS

Patients in the workforce 1 year after first HF hospitalization and treated with target or near-target doses of EBM were associated with a significantly lower risk of subsequent workforce detachment.

Adherence to guidelines in patients with chronic heart failure in primary health care

OBJECTIVE

To describe adherence to international guidelines for chronic heart failure (CHF) management concerning diagnostics, pharmacological treatment and self-care behaviour in primary health care.

DESIGN

A cross-sectional descriptive study of patients with CHF, using data obtained from medical records and a postal questionnaire.

SETTING

Three primary health care centres in Sweden.

SUBJECTS

Patients with a CHF diagnosis registered in their medical record.

MAIN OUTCOME MEASURES

Adherence to recommended diagnostic tests and pharmacological treatment by the European Society of Cardiology guidelines and self-care behaviour, using the European Heart Failure Self-care Behaviour Scale (EHFScBS-9).

RESULTS

The 155 participating patients had a mean age of 79 (SD9) years and 89 (57%) were male. An ECG was performed in all participants, 135 (87%) had their NT-proBNP measured, and 127 (82%) had transthoracic echocardiography performed. An inhibitor of the renin angiotensin system (RAS) was prescribed in 120 (78%) patients, however only 45 (29%) in target dose. More men than women were prescribed RAS-inhibition. Beta blockers (BBs) were prescribed in 117 (76%) patients, with 28 (18%) at target dose. Mineralocorticoidreceptor antagonists were prescribed in 54 (35%) patients and daily diuretics in 96 (62%). The recommended combination of RAS-inhibitors and BBs was prescribed to 92 (59%), but only 14 (9%) at target dose. The mean score on the EHFScBS-9 was 29 (SD 6) with the lowest adherence to daily weighing and consulting behaviour.

CONCLUSION

Adherence to guidelines has improved since prior studies but is still suboptimal particularly with regards to medication dosage. There is also room for improvement in patient education and self-care behaviour.

Validation of heart failure diagnosis registered in primary care records in two primary care centres in Barcelona (Spain) and factors related. A cross-sectional study

BACKGROUND

Heart failure (HF) diagnosis as reported in primary care medical records is not always properly confirmed and could result in over-registration.

OBJECTIVES

To determine the proportion of registered HF that can be confirmed with information from primary care medical records and to analyse related factors.

METHODS

A cross-sectional study. The medical records of 595 HF patients attended in two primary healthcare centres in Barcelona (Spain) were revised and validated by a team of experts who classified diagnosis into confirmed, unconfirmed, and misdiagnosis. Variables potentially related to the confirmation of the diagnosis were analysed. The revision of medical records and data collection took place from 15 January to 31 March 2014.

RESULTS

Mean (standard deviation) age was 78 (10) years and 58% were women. The diagnosis could be confirmed in 53.6% of patients. Factors associated with a greater probability of having a confirmed diagnosis were age (yearly OR: 0.97, 95%CI: 0.95-0.99), cardiologist follow-up (OR: 3.66, 95%CI: 2.46-5.48), history of ischaemic heart disease (OR: 2.18, 95%CI: 1.36-2.48), atrial fibrillation (OR: 2.01, 95%CI: 1.34-3.03), and prescription of loop diuretics (OR: 3.24, 95%CI: 2.14-4.89).

CONCLUSION

Only in half of the patients labelled as HF in primary care medical records could this diagnosis be further confirmed. Variables regularly registered in clinical practice could help general practitioners identify those patients requiring a revision of their HF diagnosis.

Chronic heart failure management in primary healthcare in Poland: Results of a nationwide cross-sectional study

Background: Organizational and educational activities in primary care in Poland have been introduced to improve the chronic heart failure (CHF) management.

Objectives: To assess the use of diagnostic procedures, pharmacotherapy and referrals of CHF in primary care in Poland.

Methods: The cross-sectional survey was conducted in 2013, involving 390 primary care centres randomly selected from a national database. Trained nurses contacted primary care physicians who retrospectively filled out the study questionnaires on the previous year’s CHF management in the last five patients who had recently visited their office. The data on diagnostic and treatment procedures were collected.

Results: The mean age ± SD of the 2006 patients was 72 ± 11 years, 45% were female, and 56% had left ventricular ejection fraction <50%. The percentage of the CHF patients diagnosed based on echocardiography was 67% and significantly increased during the last decade. Echocardiography was still less frequently performed in older patients (≥80 years) than in the younger ones (respectively 50% versus 72%, Ρ <0.001) and in women than in men (62% versus 71%, P <0.001). The percentage of the patients treated with β-blocker alone was 88%, but those with a combination of angiotensin inhibition 71%. The decade before, these percentages were 68% and 57%, respectively. Moreover, an age-related gap observed in the use of the above-mentioned therapy has disappeared.

Conclusion: The use of echocardiography in CHF diagnostics has significantly improved in primary care in Poland but a noticeable inequality in the geriatric patients and women remains. Most CHF patients received drug classes in accordance with guidelines.