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De Clercq L, Himmelreich JCL, Harskamp RE. Quality of heart failure registration in primary care: observations from 1 million electronic health records in the Amsterdam Metropolitan Area. Diagnosis (Berl) 2024; 0:dx-2024-0009. [PMID: 38741552 DOI: 10.1515/dx-2024-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVES Proper coding of heart failure (HF) in electronic health records (EHRs) is an important prerequisite for adequate care and research towards this vulnerable patient population. We set out to evaluate the accuracy of registration of HF diagnoses in primary care EHRs. METHODS In a routine primary care database covering the Amsterdam Metropolitan Area, we identified all episodes of care with International Classification of Primary Care (ICPC) codes K77 (decompensatio cordis) or K84.03 (cardiomyopathy) up to 31/12/2021. We also performed two text-based searches to identify HF episodes without an appropriate ICPC-code. An expert panel evaluated all ICPC and text matches for congruence between the assigned codes and notes. RESULTS From a database of 968,433 records we identified 19,106 patients (2.0 %) with a total of 24,011 ICPC-coded HF episodes. Removal of 1,324 episodes found to concern other or uncertain diagnoses and inclusion of 4,582 validated HF episodes identified through text search led to exclusion of 909 (overregistration: 4.8 %) and inclusion of 2,266 additional patients (underregistration: 11.1 %). The inclusion of miscoded HF episodes advanced the first known date of HF diagnosis in 3.9 % of records, with a median shift of 3.45 years. Episode-level underregistration decreased significantly over time, from 23.8 % in 2006 to 10.0 % in 2021. CONCLUSIONS While there is improvement over time, there are still substantial levels of over- and underregistration of HF, emphasizing the need for cautious interpretation of ICPC-coded data. The findings contribute to the understanding of HF registration issues in primary care and provide insights for improving registration practices.
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Affiliation(s)
- Lukas De Clercq
- Department of General Practice, 26066 Amsterdam UMC location, University of Amsterdam , Amsterdam, The Netherlands
- Personalized Medicine and Digital Health, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Jelle C L Himmelreich
- Department of General Practice, 26066 Amsterdam UMC location, University of Amsterdam , Amsterdam, The Netherlands
- Personalized Medicine, Amsterdam Public Health, Amsterdam, The Netherlands
- Heart Failure & Arrhythmias and Atherosclerosis & Ischemic Syndromes, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ralf E Harskamp
- Department of General Practice, 26066 Amsterdam UMC location, University of Amsterdam , Amsterdam, The Netherlands
- Personalized Medicine, Amsterdam Public Health, Amsterdam, The Netherlands
- Heart Failure & Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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2
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Loke I, Antoniou S, Boramakot R, Walters D, Fuat A. Demystifying heart failure with a preserved ejection fraction: what you need to know. Br J Gen Pract 2024; 74:103-105. [PMID: 39222434 PMCID: PMC10904139 DOI: 10.3399/bjgp24x736396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Affiliation(s)
- Ian Loke
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Leicester
| | - Sotiris Antoniou
- Cardiovascular Medicine, St Bartholomew's Hospital, Barts Health NHS Trust, London
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Wan Ahmad WA, Mohd Ghazi A, Abdul Ghapar AK, Muthusamy TS, Liew HB, Zainal Abidin I, Ong ML, Ross NT, Cham YL, Ho WS, Fegade M, Chew DSP. From Primary to Tertiary Care: Expert Position Statements to Guide Heart Failure with Preserved Ejection Fraction Diagnosis. Malays J Med Sci 2023; 30:49-66. [PMID: 36875198 PMCID: PMC9984115 DOI: 10.21315/mjms2023.30.1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/31/2022] [Indexed: 03/05/2023] Open
Abstract
Globally, heart failure with preserved ejection fraction (HFpEF) is quickly becoming the dominant form of heart failure (HF) in ageing populations. However, there are still multiple gaps and challenges in making a firm diagnosis of HFpEF in many low-to-middle income Asian countries. In response to this unmet need, the Malaysian HFpEF Working Group (MY-HPWG) gathered and reviewed evidence surrounding the use of different diagnostic modalities indicated for patients with HFpEF to identify diagnostic tools that could be conveniently accessed across different healthcare settings. As a result, five recommendation statements were proposed and an accompanying algorithm was developed, with the aim of improving the diagnostic rate of HFpEF. The MY-HPWG recommends using more easily accessible and non-invasive tools, such as natriuretic peptide (NP) biomarkers and basic echocardiogram (ECHO), to ensure timely HFpEF diagnosis in the primary and secondary care settings, and prompt referral to a tertiary care centre for more comprehensive assessments in uncertain cases.
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Affiliation(s)
- Wan Azman Wan Ahmad
- Division of Cardiology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Azmee Mohd Ghazi
- Cardiology Department, The National Heart Institute of Malaysia, Kuala Lumpur, Malaysia
| | | | | | - Houng Bang Liew
- Cardiology Department, Queen Elizabeth Hospital II, Sabah, Malaysia
| | - Imran Zainal Abidin
- Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mei Lin Ong
- Cardiology Department, Gleneagles Hospital Penang, Pulau Pinang, Malaysia
| | - Noel Thomas Ross
- Medical Department, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Yee Ling Cham
- Cardiology Department, Sarawak Heart Centre, Sarawak, Malaysia
| | - Wing Sze Ho
- Novartis Corporation (Malaysia) Sdn. Bhd., Selangor, Malaysia
| | - Mayuresh Fegade
- Novartis Corporation (Malaysia) Sdn. Bhd., Selangor, Malaysia
| | - David Soon Ping Chew
- Cardiology Department, Cardiac Vascular Sentral Kuala Lumpur, Kuala Lumpur, Malaysia
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4
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Smeets M, Raat W, Aertgeerts B, Penders J, Vercammen J, Droogne W, Mullens W, Janssens S, Vaes B. Mixed‐methods evaluation of a multifaceted heart failure intervention in general practice: the OSCAR‐HF pilot study. ESC Heart Fail 2022; 10:907-916. [PMID: 36461750 PMCID: PMC10053264 DOI: 10.1002/ehf2.14251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/06/2022] [Accepted: 11/08/2022] [Indexed: 12/05/2022] Open
Abstract
AIMS Heart failure (HF) is an important health problem for which multidisciplinary care is recommended, yet few studies involve primary care practitioners in the multidisciplinary management of HF. We set up a multifaceted prospective observational trial, OSCAR-HF, piloting audit and feedback, natriuretic peptide testing at the point of care, and the assistance of a specialist HF nurse in primary care. The aim was to optimize HF care in general practice. METHODS AND RESULTS This is an analysis at 6 month follow-up of the study interventions of the OSCAR-HF pilot study, a nonrandomized, noncontrolled prospective observational trial conducted in eight Belgian general practices [51 general practitioners (GPs)]. Patients who were assessed by their GP to have HF constituted the OSCAR-HF study population. We used descriptive statistics and mixed-effects modelling for the quantitative analysis and thematic analysis of the focus group interviews. There was a 10.2% increase in the registered HF population after 6 months of follow-up (n = 593) compared with baseline (n = 538) and a 27% increase in objectified HF diagnoses (baseline n = 359 to 456 at T6 M). Natriuretic peptide testing (with or without referral) accounted for 54% (n = 60/111) of the newly registered HF diagnoses. There was no difference in the proportion of patients with HF with reduced ejection fraction who received their target dosage of renin-angiotensin-aldosterone system inhibitors or beta-blockers at 6 months compared with baseline (P = 0.9). Patients who received an HF nurse intervention (n = 53) had significantly worse quality of life at baseline [difference in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score 9.2 points; 95% confidence interval (CI) 4.0, 14] and had a significantly greater improvement in quality-of-life scores at the 6 month follow-up [change in MLHFQ score -9.8 points; 95% CI -15, -4.5] than patients without an HF nurse intervention. GPs found audit and feedback valuable but time intensive. Natriuretic peptides were useful, but the point-of-care test was impractical, and the assistance of an HF nurse was a useful addition to routine HF care. CONCLUSIONS The use of audit and feedback combined with natriuretic peptide testing was a successful strategy to increase the number of registered and objectified HF diagnoses at 6 months. GPs and HF nurses selected patients with worse quality-of-life scores at baseline for the HF nurse intervention, which led to a significantly greater improvement in quality-of-life scores at the 6 month follow-up compared with patients without an HF nurse intervention. The interventions were deemed feasible and useful by the participating GPs with some specific remarks that can be used for optimization. TRIAL REGISTRATION ClinicalTrials.gov (NCT02905786), registered on 14 September 2016 at https://clinicaltrials.gov/.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care KU Leuven Kapucijnenvoer 7, blok D bus 7001 3000 Leuven Belgium
| | - Willem Raat
- Department of Public Health and Primary Care KU Leuven Kapucijnenvoer 7, blok D bus 7001 3000 Leuven Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care KU Leuven Kapucijnenvoer 7, blok D bus 7001 3000 Leuven Belgium
| | - Joris Penders
- Department of Clinical Biology Ziekenhuis Oost‐Limburg (ZOL) Genk Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences Hasselt University Diepenbeek Belgium
| | - Jan Vercammen
- Department of Cardiology Ziekenhuis Oost‐Limburg (ZOL) Genk Belgium
| | - Walter Droogne
- Department of Cardiovascular Diseases University Hospitals Leuven, KU Leuven Leuven Belgium
| | - Wilfried Mullens
- Biomedical Research Institute, Faculty of Medicine and Life Sciences Hasselt University Diepenbeek Belgium
- Department of Cardiology Ziekenhuis Oost‐Limburg (ZOL) Genk Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases University Hospitals Leuven, KU Leuven Leuven Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care KU Leuven Kapucijnenvoer 7, blok D bus 7001 3000 Leuven Belgium
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Performance of the SCORE and Globorisk cardiovascular risk prediction models: a prospective cohort study in Dutch general practice. Br J Gen Pract 2022; 73:e24-e33. [PMID: 36443066 PMCID: PMC9710862 DOI: 10.3399/bjgp.2021.0726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 08/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND GPs frequently use 10-year-risk estimations of cardiovascular disease (CVD) to identify high- risk patients. AIM To assess the performance of four models for predicting the 10-year risk of CVD in Dutch general practice. DESIGN AND SETTING Prospective cohort study. Routine data (2009- 2019) was used from 46 Dutch general practices linked to cause of death statistics. METHOD The outcome measures were fatal CVD for SCORE and first diagnosis of fatal or non- fatal CVD for SCORE fatal and non-fatal (SCORE- FNF), Globorisk-laboratory, and Globorisk-office. Model performance was assessed by examining discrimination and calibration. RESULTS The final number of patients for risk prediction was 1981 for SCORE and SCORE-FNF, 3588 for Globorisk-laboratory, and 4399 for Globorisk- office. The observed percentage of events was 18.6% (n = 353) for SCORE- FNF, 6.9% (n = 230) for Globorisk-laboratory, 7.9% (n = 323) for Globorisk-office, and 0.3% (n = 5) for SCORE. The models showed poor discrimination and calibration. The performance of SCORE could not be examined because of the limited number of fatal CVD events. SCORE-FNF, the model that is currently used for risk prediction of fatal plus non-fatal CVD in Dutch general practice, was found to underestimate the risk in all deciles of predicted risks. CONCLUSION Wide eligibility criteria and a broad outcome measure contribute to the model applicability in daily practice. The restriction to fatal CVD outcomes of SCORE renders it less usable in routine Dutch general practice. The models seriously underestimate the 10-year risk of fatal plus non-fatal CVD in Dutch general practice. The poor model performance is possibly because of differences between patients that are eligible for risk prediction and the population that was used for model development. In addition, selection of higher-risk patients for CVD risk assessment by GPs may also contribute to the poor model performance.
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Branch KRH, Gerstein HC, Probstfield JL. Reply to the letter regarding the article 'Dulaglutide and cardiovascular and heart failure outcomes in patients with and without heart failure: a post-hoc analysis from the REWIND randomized trial'. Eur J Heart Fail 2022; 24:2207-2208. [PMID: 36224326 DOI: 10.1002/ejhf.2719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/07/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ONT, Canada
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7
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Li Y, Wang H, Luo Y. Improving Fairness in the Prediction of Heart Failure Length of Stay and Mortality by Integrating Social Determinants of Health. Circ Heart Fail 2022; 15:e009473. [PMID: 36378761 PMCID: PMC9673161 DOI: 10.1161/circheartfailure.122.009473] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Machine learning (ML) approaches have been broadly applied to the prediction of length of stay and mortality in hospitalized patients. ML may also reduce societal health burdens, assist in health resources planning and improve health outcomes. However, the fairness of these ML models across ethnoracial or socioeconomic subgroups is rarely assessed or discussed. In this study, we aim (1) to quantify the algorithmic bias of ML models when predicting the probability of long-term hospitalization or in-hospital mortality for different heart failure (HF) subpopulations, and (2) to propose a novel method that can improve the fairness of our models without compromising predictive power. METHODS We built 5 ML classifiers to predict the composite outcome of hospitalization length-of-stay and in-hospital mortality for 210 368 HF patients extracted from the Get With The Guidelines-Heart Failure registry data set. We integrated 15 social determinants of health variables, including the Social Deprivation Index and the Area Deprivation Index, into the feature space of ML models based on patients' geographies to mitigate the algorithmic bias. RESULTS The best-performing random forest model demonstrated modest predictive power but selectively underdiagnosed underserved subpopulations, for example, female, Black, and socioeconomically disadvantaged patients. The integration of social determinants of health variables can significantly improve fairness without compromising model performance. CONCLUSIONS We quantified algorithmic bias against underserved subpopulations in the prediction of the composite outcome for HF patients. We provide a potential direction to reduce disparities of ML-based predictive models by integrating social determinants of health variables. We urge fellow researchers to strongly consider ML fairness when developing predictive models for HF patients.
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Affiliation(s)
- Yikuan Li
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Hanyin Wang
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Yuan Luo
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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8
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Olofsson M, Lindmark K, Stålhammar J, Törnblom M, Lundberg A, Wikström G, Boman K. Characteristics and management of very elderly patients with heart failure: a retrospective, population cohort study. ESC Heart Fail 2022; 10:295-302. [PMID: 36208123 PMCID: PMC9871701 DOI: 10.1002/ehf2.14191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/06/2022] [Accepted: 09/21/2022] [Indexed: 01/29/2023] Open
Abstract
AIMS Unmet needs exist in the diagnosis and treatment of heart failure (HF) in the elderly population. Our aim was to analyse and compare data of diagnostics and management of very elderly patients (aged ≥85 years) compared with younger patients (aged 18-84 years) with HF in Sweden. METHODS Incidence of ≥2 HF diagnosis (ICD-10) was identified from primary/secondary care in Uppsala and Västerbotten during 2010-2015 via electronic medical records linked to data from national health registers. Analyses investigated the diagnosis, treatment patterns, hospitalizations and outpatient visits, and mortality. RESULTS Of 8702 patients, 27.7% were ≥85 years old, women (60.2%); most patients (80.7%) had unknown left ventricular ejection fraction; key co-morbidities comprised anaemia, dementia, and cerebrovascular disease. More very elderly patients received cardiovascular disease (CVD)-related management after diagnosis in primary care (13.6% vs. 6.5%; P < 0.0001), but fewer patients underwent echocardiography (19.3% vs. 42.9%; P < 0.0001). Within 1 year of diagnosis, very elderly patients were less likely to be hospitalized (all-cause admissions per patient: 1.9 vs. 2.3; P < 0.0001; CVD-related admissions per patient: 1.8 vs. 2.1; P = 0.0004) or prescribed an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) plus a β-blocker (45.2% vs. 56.9%; P < 0.0001) or an ACEI/ARB plus a β-blocker plus a mineralocorticoid receptor antagonist (15.4% vs. 31.7%; P < 0.0001). One-year mortality was high in patients ≥85 years old, 30.5% (CI: 28.3-32.7%) out of 1797 patients. CONCLUSIONS Despite the large number of very elderly patients with newly diagnosed HF in Sweden, poor diagnostic work-up and subsequent treatment highlight the inequality of care in this vulnerable population.
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Affiliation(s)
- Mona Olofsson
- Research Unit, Medicine‐GeriatricSkellefteå County HospitalSkellefteåSweden,Department of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
| | - Krister Lindmark
- Department of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
| | - Jan Stålhammar
- Department of Public Health and Caring Sciences, Family Medicine and Preventive MedicineUppsala UniversityUppsalaSweden
| | | | | | | | - Kurt Boman
- Research Unit, Medicine‐GeriatricSkellefteå County HospitalSkellefteåSweden,Department of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
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Gouda P, Alemayehu W, Rathwell S, Ian Paterson D, Anderson T, Dyck JRB, Howlett JG, Oudit GY, McAlister FA, Thompson RB, Ezekowitz J. Clinical Phenotypes of Heart Failure across the spectrum of Ejection Fraction: A Cluster Analysis. Curr Probl Cardiol 2022; 47:101337. [PMID: 35878816 DOI: 10.1016/j.cpcardiol.2022.101337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Heart failure (HF), and especially HF with preserved ejection fraction (HFpEF), remains a challenging condition to define. The heterogenous nature of this population may be related to a variety of underlying etiologies interacting myocardial dysfunction. METHOD Alberta HEART study was a prospective, observational cohort that enrolled participants along the spectrum of heart failure including: healthy controls, people at risk of HF, and patients with HF and preserved (HFpEF) or reduced ejection fraction (HFrEF). We aimed to explore phenotypes of patients with HF and at-risk of developing HF. Utilising 27 detailed clinical, echocardiographic and biomarker variables, latent class analysis with and without multiple imputation was undertaken to identify distinct clinical phenotypes. RESULTS Of 621 participants, 191 (30.8%) and 169 (27.2%) were adjudicated by cardiologists to have HFpEF and HFrEF respectively. In the overall cohort, latent class analysis identified four distinct phenotypes. Phenotype A (n=152, 24.5%) was a healthy and low risk group. Phenotype B (n=129, 20.8%) demonstrated increased left ventricular mass and end-diastolic volumes, with elevated natriuretic peptides and clinical features of congestion. Phenotype C (n=128, 20.6%) was primarily characterised by obesity (80%) and normal indexed cardiac chamber sizes, low natriuretic peptide levels and minimal features of congestion. Phenotype D (n=212, 34.1%) consisted of elderly patients with clinical features of congestions. Phenotypes B and D demonstrated the highest risk of mortality and hospitalization over a median follow-up of 3.7 years. CONCLUSION Phenotypes with congestive features demonstrated increased risk profiles. Heart failure is a heterogenous classification which requires further work to appropriately categorise patients based on the underlying etiology or mechanism of impairment.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Canadian VIGOUR Centre, Edmonton, Alberta, Canada; University of Alberta, Division of Cardiology, Edmonton, Alberta, Canada
| | | | - Sarah Rathwell
- University of Alberta, Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - D Ian Paterson
- University of Alberta, Division of Cardiology, Edmonton, Alberta, Canada
| | - Todd Anderson
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jason R B Dyck
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan G Howlett
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gavin Y Oudit
- University of Alberta, Division of Cardiology, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- University of Alberta, Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - Richard B Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Justin Ezekowitz
- University of Alberta, Canadian VIGOUR Centre, Edmonton, Alberta, Canada; University of Alberta, Division of Cardiology, Edmonton, Alberta, Canada.
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Kuiper JG, van Herk-Sukel MPP, Lemmens VEPP, Kuiper MJ, Kuipers EJ, Herings RMC. Risk of heart failure among colon and rectal cancer survivors: a population-based case-control study. ESC Heart Fail 2022; 9:2139-2146. [PMID: 35451236 PMCID: PMC9288790 DOI: 10.1002/ehf2.13923] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/02/2022] [Accepted: 03/27/2022] [Indexed: 11/06/2022] Open
Abstract
AIMS This population-based case-control study aims to investigate the occurrence of heart failure (HF) among colon and rectal cancer survivors compared with a cancer-free control population taking into account pre-existing cardiovascular risk factors and the influence of treatment. METHODS AND RESULTS Colon and rectal cancer survivors diagnosed between 2007 and 2014 were selected from a linked cohort of cancer and primary care data in the Netherlands and matched based on gender, birth year, general practitioner (GP) practice, and follow-up period to cancer-free controls. The occurrence of HF was identified based on GP recorded diagnoses after index date (diagnosis date for cases). A Cox proportional hazards model was used to estimate hazard ratios (HRs), adjusted for age, sex, hypertension, diabetes, and hypercholesterolaemia. A total of 5333 colon cancer cases and 2468 rectal cancer cases could be matched to a total of 31 204 cancer-free controls. A statistically significant increased risk of HF was seen among all cases compared with cancer-free controls (HR 1.33; 95% confidence interval: 1.12-1.59). This was also seen when analysing colon cancer and rectal cancer separately. Being diagnosed with stage IV cancer, having hypertension, or having hypercholesterolaemia statistically significantly increased the risk of HF among colon cancer. Hypertension was a statistically significant risk factor for developing HF among rectal cancer cases. CONCLUSIONS Colon and rectal cancer survivors are at increased risk for developing HF. More awareness should be created by treating physicians and GPs for this potential increased risk in order to further improve survival.
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Affiliation(s)
- Josephina G Kuiper
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, Utrecht, 3528 AE, The Netherlands.,Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Myrthe P P van Herk-Sukel
- Department of Internal Medicine and Dermatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Valery E P P Lemmens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.,Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Mathijs J Kuiper
- Department of Cardiology, Haga Hospital, The Hague, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron M C Herings
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, Utrecht, 3528 AE, The Netherlands.,Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
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11
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de Boer AR, Vaartjes I, Gohar A, Valk MJM, Brugts JJ, Boonman-de Winter LJM, van Riet EE, van Mourik Y, Brunner-La Rocca HP, Linssen GCM, Hoes AW, Bots ML, den Ruijter HM, Rutten FH. Heart failure with preserved, mid-range, and reduced ejection fraction across health care settings: an observational study. ESC Heart Fail 2021; 9:363-372. [PMID: 34889076 PMCID: PMC8787985 DOI: 10.1002/ehf2.13742] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/12/2021] [Indexed: 11/10/2022] Open
Abstract
AIMS This study aimed to assess the sex-specific distribution of heart failure (HF) with preserved, mid-range, and reduced ejection fraction across three health care settings. METHODS AND RESULTS In this descriptive observational study, we retrieved the distribution of HF types [with reduced ejection fraction (HFrEF), mid-range ejection fraction (HFmrEF), and preserved ejection fraction (HFpEF)] for men and women between 65 and 79 years of age in three health care settings from a single country: (i) patients with screening-detected HF in the high-risk community (i.e. those with shortness of breath, frailty, diabetes mellitus, and chronic obstructive pulmonary disease) from four screening studies, (ii) patients with confirmed HF from primary care derived from a single observational study, and (iii) patients with confirmed HF from outpatient cardiology clinics participating in a registry. Among 1407 patients from the high-risk community, 288 had screen-detected HF (15% HFrEF, 12% HFmrEF, 74% HFpEF), and 51% of the screen-detected HF patients were women. In both women (82%) and men (65%), HFpEF was the most prevalent HF type. In the routine general practice population (30 practices, 70 000 individuals), among the 160 confirmed HF cases, 35% had HFrEF, 23% HFmrEF, and 43% HFpEF, and in total, 43% were women. In women, HFpEF was the most prevalent HF type (52%), while in men, this was HFrEF (41%). In outpatient cardiology clinics (n = 34), of the 4742 HF patients (66% HFrEF, 15% HFmrEF, 20% HFpEF), 36% were women. In both women (56%) and men (71%), HFrEF was the most prevalent HF type. CONCLUSIONS Both HF types and sex distribution vary considerably in HF patients of 65-79 years of age among health care settings. From the high-risk community through to general practice to the cardiology outpatient setting, there is a shift in HF type from HFpEF to HFrEF and a decrease in the proportion of HF patients that are women.
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Affiliation(s)
- Annemarijn R de Boer
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands.,Dutch Heart Foundation, The Hague, The Netherlands
| | - Ilonca Vaartjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands.,Dutch Heart Foundation, The Hague, The Netherlands
| | - Aisha Gohar
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Mark J M Valk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Evelien E van Riet
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Yvonne van Mourik
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | | | - Gerard C M Linssen
- Department of Cardiology, Hospital Group Twente, Almelo and Hengelo, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Hester M den Ruijter
- Experimental Cardiology, Division Heart & Lung Disease, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
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12
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Raat W, Smeets M, Henrard S, Aertgeerts B, Penders J, Droogne W, Mullens W, Janssens S, Vaes B. Machine learning optimization of an electronic health record audit for heart failure in primary care. ESC Heart Fail 2021; 9:39-47. [PMID: 34816632 PMCID: PMC8787980 DOI: 10.1002/ehf2.13724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/27/2021] [Accepted: 11/06/2021] [Indexed: 11/04/2022] Open
Abstract
Aims The diagnosis of heart failure (HF) is an important problem in primary care. We previously demonstrated a 74% increase in registered HF diagnoses in primary care electronic health records (EHRs) following an extended audit procedure. What remains unclear is the accuracy of registered HF pre‐audit and which EHR variables are most important in the extended audit strategy. This study aims to describe the diagnostic HF classification sequence at different stages, assess general practitioner (GP) HF misclassification, and test the predictive performance of an optimized audit. Methods and results This is a secondary analysis of the OSCAR‐HF study, a prospective observational trial including 51 participating GPs. OSCAR used an extended audit based on typical HF risk factors, signs, symptoms, and medications in GPs' EHR. This resulted in a list of possible HF patients, which participating GPs had to classify as HF or non‐HF. We compared registered HF diagnoses before and after GPs' assessment. For our analysis of audit performance, we used GPs' assessment of HF as primary outcome and audit queries as dichotomous predictor variables for a gradient boosted machine (GBM) decision tree algorithm and logistic regression model. Of the 18 011 patients eligible for the audit intervention, 4678 (26.0%) were identified as possible HF patients and submitted for GPs' assessment in the audit stage. There were 310 patients with registered HF before GP assessment, of whom 146 (47.1%) were judged not to have HF by their GP (over‐registration). There were 538 patients with registered HF after GP assessment, of whom 374 (69.5%) did not have registered HF before GP assessment (under‐registration). The GBM and logistic regression model had a comparable predictive performance (area under the curve of 0.70 [95% confidence interval 0.65–0.77] and 0.69 [95% confidence interval 0.64–0.75], respectively). This was not significantly impacted by reducing the set of predictor variables to the 10 most important variables identified in the GBM model (free‐text and coded cardiomyopathy, ischaemic heart disease and atrial fibrillation, digoxin, mineralocorticoid receptor antagonists, and combinations of renin‐angiotensin system inhibitors and beta‐blockers with diuretics). This optimized query set was enough to identify 86% (n = 461/538) of GPs' self‐assessed HF population with a 33% reduction (n = 1537/4678) in screening caseload. Conclusions Diagnostic coding of HF in primary care health records is inaccurate with a high degree of under‐registration and over‐registration. An optimized query set enabled identification of more than 80% of GPs' self‐assessed HF population.
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Affiliation(s)
- Willem Raat
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Miek Smeets
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Severine Henrard
- Louvain Drug Research Institute, Clinical Pharmacy Research Group (CLIP) and Institute of Health and Society (IRSS), Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Joris Penders
- Ziekenhuis Oost-Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | - Walter Droogne
- Department of Cardiovascular Diseases, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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13
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Maffeis C, Inciardi RM, Khan MS, Tafciu E, Bergamini C, Benfari G, Setti M, Ribichini FL, Cicoira M, Butler J, Rossi A. Determinants of exercise intolerance symptoms considered non-specific for heart failure in patients with stage A and B: role of the left atrium in the transition phase to overt heart failure. Int J Cardiovasc Imaging 2021; 38:103-112. [PMID: 34460024 PMCID: PMC8818638 DOI: 10.1007/s10554-021-02375-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/04/2021] [Indexed: 11/08/2022]
Abstract
To assess to what extent left atrial (LA) structure and function are associated with non-specific heart failure symptoms, so that patients were classified as HF stage A and B. Mechanisms underlying the transition to overt HF in patients with stage A and B HF are unclear. Consecutive outpatients undergoing echocardiography and clinical evaluation and classified as HF stage A and B with preserved left ventricular ejection fraction (LVEF) were included. The association between LA measures [volume (LAVi), peak longitudinal-(PALS), contraction-(PACS) and conduit-strain] and non-specific HF symptoms was assessed using adjusted logistic regression analyses. The incremental value of atrial myopathy in symptoms prediction on top of clinical or echocardiographic confounders was assessed through ROC curves analyses. The cohort comprehended 185 patients (63 ± 16 years, 47% women) of whom 133 (72%) were asymptomatic, and 52 (28%) reported non-specific HF symptoms. After adjustment for clinical and echocardiographic confounders for HF symptoms, LAVi, PALS and PACS were associated with symptoms (p < 0.05). Among echocardiographic variables, only LA parameters were significantly associated with symptoms on top of clinical confounders (for LAVi OR [95% CI] 1.56 [1.21–2.00], p < 0.0001; for PALS 1.45 (1.10–1.91), p = 0.0009; for PACS 2.10 [1.33–3.30], p = 0.002). After adjustment for age, hypertension and COPD or E/E′, LV mass-i and mitral ERO, atrial myopathy added predictive value for symptoms presence compared to the clinical variables or echocardiographic parameters described (AUC increase 0.80 to 0.88, p = 0.004, and 0.79 to 0.84, p = 0.06, respectively). In patients with HF stages A–B and preserved LVEF, measures of LA structure and function were associated with non-specific HF symptoms. A comprehensive LA remodeling evaluation may help clinicians in the appropriate identification of overt HF.
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Affiliation(s)
- Caterina Maffeis
- Division of Cardiology, Department of Medicine, University Hospital of Verona, University of Verona, P.le Stefani 1, 37126, Verona, Italy
| | - Riccardo M Inciardi
- Division of Cardiology, Department of Medicine, University Hospital of Verona, University of Verona, P.le Stefani 1, 37126, Verona, Italy
| | | | - Elvin Tafciu
- Division of Cardiology, Department of Medicine, University Hospital of Verona, University of Verona, P.le Stefani 1, 37126, Verona, Italy
| | - Corinna Bergamini
- Division of Cardiology, Department of Medicine, University Hospital of Verona, University of Verona, P.le Stefani 1, 37126, Verona, Italy
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University Hospital of Verona, University of Verona, P.le Stefani 1, 37126, Verona, Italy
| | - Martina Setti
- Division of Cardiology, Department of Medicine, University Hospital of Verona, University of Verona, P.le Stefani 1, 37126, Verona, Italy
| | - Flavio L Ribichini
- Division of Cardiology, Department of Medicine, University Hospital of Verona, University of Verona, P.le Stefani 1, 37126, Verona, Italy
| | - Mariantonietta Cicoira
- Division of Cardiology, Department of Medicine, University Hospital of Verona, University of Verona, P.le Stefani 1, 37126, Verona, Italy
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Andrea Rossi
- Division of Cardiology, Department of Medicine, University Hospital of Verona, University of Verona, P.le Stefani 1, 37126, Verona, Italy.
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14
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Groepenhoff F, Eikendal ALM, Rittersma ZHS, Gijsberts CM, Asselbergs FW, Hoefer IE, Pasterkamp G, Rutten FH, Onland-Moret NC, Den Ruijter HM. Persistent Symptoms and Health Needs of Women and Men With Non-Obstructed Coronary Arteries in the Years Following Coronary Angiography. Front Cardiovasc Med 2021; 8:670843. [PMID: 34012986 PMCID: PMC8126611 DOI: 10.3389/fcvm.2021.670843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/08/2021] [Indexed: 01/09/2023] Open
Abstract
Background: The prognosis of women and men with persistent anginal complaints and non-obstructed coronary arteries is impaired as compared with asymptomatic women and men. The increased healthcare burden in the hospital due to repeated coronary angiography in these women and men has been documented, yet little is known about the percentage of women and men who remain symptomatic and under care of the general practitioner in the years following a coronary angiographic outcome of non-obstructed coronary arteries. Methods: From the Utrecht Coronary Biobank study, including individuals who underwent a coronary angiography from 2011 to 2015 (N = 2,546, 27% women), we selected women and men with non-obstructed coronary arteries (N = 687, 39% women). This population was linked to the Julius General Practitioners Network (JGPN); a database with routine care data of general practitioners. For every individual with non-obstructed coronary arteries, we selected an asymptomatic non-referred age-, sex-, and general practitioner-matched individual from the JGPN. We compared the healthcare consumption of men and women with non-obstructed coronary arteries to these matched individuals. The McNemar's test was used for pairwise comparison, and sex differences were assessed using stratified analyses. Results: The prevalence of non-obstructed coronary arteries was higher in women as compared with men (39 vs. 23%). During a median follow-up of 7 years [IQR 6.4-8.0], 89% of the individuals with non-obstructed coronary arteries (91% women and 87% men) visited their general practitioner for one or more cardiovascular consultations. This was compared to 34% of the matched individuals (89 vs. 34%, p < 0.001). The consultations were most often for angina (equivalents) (57 vs. 11%, p < 0.001) and heart failure (10 vs. 2%, p = 0.015). In addition, they more often consulted the general practitioner for psychosocial complaints (31 vs. 15%, p = 0.005). Findings were similar for women and men. Conclusions: A coronary angiographic outcome of non-obstructed coronary arteries is more common in women than in men. In the years following the coronary angiography, the majority of the population remains symptomatic. Both women and men with non-obstructed coronary arteries had higher health needs for angina, heart failure, and psychosocial complaints than matched asymptomatic individuals.
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Affiliation(s)
- Floor Groepenhoff
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Anouk L M Eikendal
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Z H Saskia Rittersma
- Department of Cardiology, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Crystel M Gijsberts
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands.,Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, United Kingdom.,Institute of Health Informatics, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Imo E Hoefer
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Gerard Pasterkamp
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - N Charlotte Onland-Moret
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Hester M Den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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15
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Verdu-Rotellar JM, Vaillant-Roussel H, Abellana R, Jevsek LG, Assenova R, Lazic DK, Torsza P, Glynn LG, Lingner H, Demurtas J, Borgström B, Gibot-Boeuf S, Muñoz MA. Precipitating factors of heart failure decompensation, short-term morbidity and mortality in patients attended in primary care. Scand J Prim Health Care 2020; 38:473-480. [PMID: 33201746 PMCID: PMC7782727 DOI: 10.1080/02813432.2020.1844387] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To evaluate the precipitating factors for heart failure decompensation in primary care and associations with short-term prognosis. Design Prospective cohort study with a 30-d follow-up from an index consultation. Regression models to determine independent factors associated with hospitalisation or death. SETTING Primary care in ten European countries. Patients Patients with diagnosis of heart failure attended in primary care for a heart failure decompensation (increase of dyspnoea, unexplained weight gain or peripheral oedema). MAIN OUTCOME MEASURES Potential precipitating factors for decompensation of heart failure and their association with the event of hospitalisation or mortality 30 d after a decompensation. RESULTS Of 692 patients 54% were women, mean age 81 (standard deviation [SD] 8.9) years; mean left ventricular ejection fraction (LVEF) 55% (SD 12%). Most frequently identified heart failure precipitation factors were respiratory infections in 194 patients (28%), non-compliance of dietary recommendations in 184 (27%) and non-compliance with pharmacological treatment in 157 (23%). The two strongest precipitating factors to predict 30 d hospitalisation or death were respiratory infections (odds ratio [OR] 2.8, 95% confidence interval [CI] (2.4-3.4)) and atrial fibrillation (AF) > 110 beats/min (OR 2.2, CI 1.5-3.2). Multivariate analysis confirmed the association between the following variables and hospitalisation/death: In relation to precipitating factors: respiratory infection (OR 1.19, 95% CI 1.14-1.25) and AF with heart rate > 110 beats/min (OR 1.22, 95% CI 1.10-1.35); and regarding patient characteristics: New York Heart Association (NYHA) III or IV (OR 1.22, 95% CI 1.15-1.29); previous hospitalisation (OR 1.15, 95% CI 1.11-1.19); and LVEF < 40% (OR 1.14, 95% CI 1.09-1.19). CONCLUSIONS In primary care, respiratory infections and rapid AF are the most important precipitating factors for hospitalisation and death within 30 d following an episode of heart failure decompensation. Key points Hospitalisation due to heart failure decompensation represents the highest share of healthcare costs for this disease. So far, no primary care studies have analysed the relationship between precipitating factors and short term prognosis of heart failure decompensation episodes. We found that in 692 patients with heart failure decompensation in primary care, the respiratory infection and rapid atrial fibrillation (AF) increased the risk of short-term hospital admission or death. Patients with a hospital admission the previous year and a decompensation episode caused by respiratory infection were even more likely to be hospitalized or die within 30 d.
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Affiliation(s)
- José María Verdu-Rotellar
- Institut Català de la Salut, Barcelona, Spain
- Unitat de Suport a la Recerca de Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
- CONTACT José María Verdu-Rotellar Departament de Salut, Unitat de Suport a la Recerca, Gerència Territorial de Barcelona, Institut Català de la Salut-IDIAP Jordi Gol, | Generalitat de Catalunya Carrer Sardenya, 375 Entlo, Barcelona08025, Spain
| | - Helene Vaillant-Roussel
- Department of General Practice, Clermont Auvergne University, Faculty of Medicine, UPU ACCePPT, Clermont-Ferrand, France
| | - Rosa Abellana
- Departament de Fonaments Clinics, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | | | - Radost Assenova
- School of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Djurdjica Kasuba Lazic
- Department of Family Medicine ‘Andrija Stampar’ School of Public Health, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Peter Torsza
- School of Medicine, Semmelweis University, Budapest, Hungary
| | - Liam George Glynn
- Health Research Institute and Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Heidrun Lingner
- Hannover Medical School, Center for Public Health and Healthcare, Hannover, Germany
| | - Jacopo Demurtas
- Primary Care Department, Azienda Usl Toscana Sud Est, Grosseto, Italy
| | - Beata Borgström
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Sylvaine Gibot-Boeuf
- Department of General Practice, Clermont Auvergne University, Faculty of Medicine, UPU ACCePPT, Clermont-Ferrand, France
| | - Miguel Angel Muñoz
- Institut Català de la Salut, Barcelona, Spain
- Unitat de Suport a la Recerca de Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
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16
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Davidson J, Banerjee A, Muzambi R, Smeeth L, Warren-Gash C. Validity of Acute Cardiovascular Outcome Diagnoses Recorded in European Electronic Health Records: A Systematic Review. Clin Epidemiol 2020; 12:1095-1111. [PMID: 33116903 PMCID: PMC7569174 DOI: 10.2147/clep.s265619] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/06/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Electronic health records are widely used in cardiovascular disease research. We appraised the validity of stroke, acute coronary syndrome and heart failure diagnoses in studies conducted using European electronic health records. METHODS Using a prespecified strategy, we systematically searched seven databases from dates of inception to April 2019. Two reviewers independently completed study selection, followed by partial parallel data extraction and risk of bias assessment. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value estimates were narratively synthesized and heterogeneity between sensitivity and PPV estimates were assessed using I2. RESULTS We identified 81 studies, of which 20 validated heart failure diagnoses, 31 validated acute coronary syndrome diagnoses with 29 specifically recording estimates for myocardial infarction, and 41 validated stroke diagnoses. Few studies reported specificity or negative predictive value estimates. Sensitivity was ≤66% in all but one heart failure study, ≥80% for 91% of myocardial infarction studies, and ≥70% for 73% of stroke studies. PPV was ≥80% in 74% of heart failure, 88% of myocardial infarction, and 70% of stroke studies. PPV by stroke subtype was variable, at ≥80% for 80% of ischaemic stroke but only 44% of haemorrhagic stroke. There was considerable heterogeneity (I2 >75%) between sensitivity and PPV estimates for all diagnoses. CONCLUSION Overall, European electronic health record stroke, acute coronary syndrome and heart failure diagnoses are accurate for use in research, although validity estimates for heart failure and individual stroke subtypes were lower. Where possible, researchers should validate data before use or carefully interpret the results of previous validation studies for their own study purposes.
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Affiliation(s)
- Jennifer Davidson
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
| | - Rutendo Muzambi
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Warren-Gash
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
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17
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Valk M, Hoes AW, Mosterd A, Broekhuizen B, Zuithoff N, Rutten FH. Time trends in the use and appropriateness of natriuretic peptide testing in primary care: an observational study. BJGP Open 2020; 4:bjgpopen20X101074. [PMID: 32788172 PMCID: PMC7606146 DOI: 10.3399/bjgpopen20x101074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/06/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Diagnosing heart failure (HF) is difficult, relying on medical history, symptoms, and signs only. Clinical guidelines recommend natriuretic peptides (NPs) as an additional diagnostic test, notably to exclude HF in suspected patients. NP testing has been available since 2003 for primary care in the Netherlands, but little is known about its uptake. AIM To evaluate the trend in ordering and appropriateness of NP testing in primary care. DESIGN & SETTING An observational study was performed between January 2005 and December 2013. Nine Dutch general practices participated, with 21 000 registered people (approximately 4300 aged ≥65 years). METHOD The total number of patients undergoing NP testing each year was calculated per 1000 patient years (PY) based on the total practice population. NP levels were used to assess whether NP testing was applied to exclude or confirm HF. RESULTS The number of NP testing increased from 2.5 per 1000 PY in 2005 to 14.0 per 1000 PY in 2013, with a peak in 2009 of 15.6 per 1000 PY. The proportion of participants with N-terminal B-type natriuretic peptide (NTproBNP) below 125 pg/ml (the exclusionary threshold recommended by the European Society of Cardiology [ESC] guidelines on HF) was on average 30%, and highest in the first year (47%). CONCLUSION After a rapid uptake of NP testing in primary care from 2005 onwards, the use of it seemed to stabilise after 2009, thus leaving patients who are prone to HF without an optimal diagnostic work-up.
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Affiliation(s)
- Mark Valk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arend Mosterd
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Meander Medical Center, The Netherlands, Amersfoort
| | - Brenda Broekhuizen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolaas Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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18
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Valk MJM, Hoes AW, Mosterd A, Landman MA, Zuithoff NPA, Broekhuizen BDL, Rutten FH. Training general practitioners to improve evidence-based drug treatment of patients with heart failure: a cluster randomised controlled trial. Neth Heart J 2020; 28:604-612. [PMID: 32997300 PMCID: PMC7596131 DOI: 10.1007/s12471-020-01487-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Aims To assess whether a single training session for general practitioners (GPs) improves the evidence-based drug treatment of heart failure (HF) patients, especially of those with HF with reduced ejection fraction (HFrEF). Methods and results A cluster randomised controlled trial was performed for which patients with established HF were eligible. Primary care practices (PCPs) were randomised to care-as-usual or to the intervention group in which GPs received a half-day training session on HF management. Changes in HF medication, health status, hospitalisation and survival were compared between the two groups. Fifteen PCPs with 200 HF patients were randomised to the intervention group and 15 PCPs with 198 HF patients to the control group. Mean age was 76.9 (SD 10.8) years; 52.5% were female. On average, the patients had been diagnosed with HF 3.0 (SD 3.0) years previously. In total, 204 had HFrEF and 194 HF with preserved ejection fraction (HFpEF). In participants with HFrEF, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers decreased in 6 months in both groups [5.2%; (95% confidence interval (CI) 2.0–10.0)] and 5.6% (95% CI 2.8–13.4)], respectively [baseline-corrected odds ratio (OR) 1.07 (95% CI 0.55–2.08)], while beta-blocker use increased in both groups by 5.2% (95% CI 2.0–10.0) and 1.1% (95% CI 0.2–6.3), respectively [baseline-corrected OR 0.82 (95% CI 0.42–1.61)]. For health status, hospitalisations or survival after 12–28 months there were no significant differences between the two groups, also not when separately analysed for HFrEF and HFpEF. Conclusion A half-day training session for GPs does not improve drug treatment of HF in patients with established HF. Electronic supplementary material The online version of this article (10.1007/s12471-020-01487-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M J M Valk
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - A W Hoes
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A Mosterd
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department of Cardiology, Meander Medical Centre, Amersfoort, The Netherlands
| | | | - N P A Zuithoff
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - B D L Broekhuizen
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - F H Rutten
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
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19
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Smeets M, Vaes B, Aertgeerts B, Raat W, Penders J, Vercammen J, Droogne W, Mullens W, Janssens S. Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR-HF pilot study. ESC Heart Fail 2020; 7:3950-3961. [PMID: 32969599 PMCID: PMC7754725 DOI: 10.1002/ehf2.12990] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium.,Institute of Health and Society, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Willem Raat
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Joris Penders
- Department of Clinical Biology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Jan Vercammen
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Walter Droogne
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, KU Leuven (KUL), Leuven, Belgium
| | - Wilfried Mullens
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, KU Leuven (KUL), Leuven, Belgium
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20
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Maffeis C, Inciardi RM, Benfari G, Bergamini C, Ribichini FL, Cicoira M, Rossi A. Mitral regurgitation and dyspnoea: the expanding role of mitral effective regurgitant orifice among un-selected patients. J Cardiovasc Med (Hagerstown) 2020; 21:503-509. [PMID: 32443135 DOI: 10.2459/jcm.0000000000000975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Mitral regurgitation is frequent in the general population and among suspected heart failure patients; however, to what extent it contributes to dyspnoea is unclear. We hypothesized mitral regurgitation to have a role in determining dyspnoea in unselected ambulatory patients. METHODS Consecutive outpatients referred for echocardiography were retrospectively screened and included. We excluded patients with mitral stenosis or prosthesis, congenital heart disease, cardiac surgery (previous 6 months) and atrial fibrillation. Patients were classified into four dyspnoea grades based on how they perceived their disability. We assessed mitral regurgitation severity through the effective regurgitant orifice area (ERO). RESULTS One hundred and fifty-four patients (58% men; age 67 ± 14 years; mean ejection fraction 54 ± 12%) formed the study population; 76 (49%) classified asymptomatic (grade I), 63 (41%) dyspnoea grade II and 15 (10%) grade III; none was in grade IV. Mitral regurgitation was present in 102 patients (66%): primary in 14 (14%) and secondary in 88 (86%); among grades I, II and III patients, mitral regurgitation was present in 35 (46%; ERO 0.05 ± 0.10 cm), 52 (82%; ERO 0.10 ± 0.13 cm) and 15 (100%; ERO 0.20 ± 0.11 cm) patients, respectively (P < 0.0001). After adjusting for clinical (age, hypertension, ischemic heart disease, chronic kidney injury, chronic pulmonary disease) and echocardiographic confounders (ejection fraction, E/e'), ERO remained associated with symptoms presence (grade I versus II - III; P = 0.01 and P = 0.03, respectively). CONCLUSION Among unselected heterogeneous ambulatory patients, mitral ERO was associated with the presence of dyspnoea and could therefore help in identifying symptomatic patients and in clinical characterization of patients with perceived dyspnoea.
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Affiliation(s)
- Caterina Maffeis
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
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21
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de-Miguel-Díez J, Jiménez-García R, Hernández-Barrera V, Zamorano-Leon JJ, Villanueva-Orbaiz R, Albaladejo-Vicente R, López-de-Andrés A. Trends in mechanical ventilation use and mortality over time in patients receiving mechanical ventilation in Spain from 2001 to 2015. Eur J Intern Med 2020; 74:67-72. [PMID: 31822367 DOI: 10.1016/j.ejim.2019.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/11/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND We examined trends in the incidence of ventilator support with noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV) among patients hospitalized in Spain from 2001 to 2015. We also assessed in-hospital mortality (IHM) after receiving these types of ventilator support. METHODS This study was an observational retrospective epidemiological study. Our data source was the Spanish National Hospital Discharge Database. RESULTS In total, 1,031,497 patients received ventilator support in Spain over the study period. NIV use increased from 18.8 patients per 100.000 inhabitants in 2001 to 108.7 in 2015. IMV utilization increased significantly from 2001 to 2003 and then decreased from 2003 until 2015. Patients who required NIV had the highest mean Charlson Comorbidity Index (CCI) score. Patients who received IMV had the highest in-hospital mortality. Factors associated with an increased risk for IHM were sex, age, conditions included in the CCI (except for COPD and diabetes), haemodialysis, presence of a peripheral arterial catheter, presence of a central venous catheter, readmission and emergency room admission. Undergoing a surgical procedure was a risk factor only for IMV. IHM decreased significantly from 2001 to 2015 in patients who underwent NIV or IMV. CONCLUSIONS We identified an increase in the utilization of NIV over time, whereas use of IMV decreased from 2003 until 2015 after an initial increase from 2001 to 2003. We also found a significant decrease in IHM over time.
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Affiliation(s)
- Javier de-Miguel-Díez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Rodrigo Jiménez-García
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
| | - Valentín Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty. Rey Juan Carlos University, Alcorcón, Madrid, Spain
| | - Jose J Zamorano-Leon
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Rosa Villanueva-Orbaiz
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Romana Albaladejo-Vicente
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty. Rey Juan Carlos University, Alcorcón, Madrid, Spain
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22
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Forsyth F, Mant J, Taylor CJ, Hobbs FR, Chew-Graham CA, Blakeman T, Sowden E, Long A, Hossain MZ, Edwards D, Deaton C. Optimising Management of Patients with Heart Failure with Preserved Ejection Fraction in Primary Care (OPTIMISE-HFpEF): rationale and protocol for a multi-method study. BJGP Open 2019; 3:bjgpopen19X101675. [PMID: 31772040 PMCID: PMC6995858 DOI: 10.3399/bjgpopen19x101675] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/27/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is less well understood than heart failure with reduced ejection fraction (HFrEF), with greater diagnostic difficulty and management uncertainty. AIM The primary aim is to develop an optimised programme that is informed by the needs and experiences of people with HFpEF and healthcare providers. This article presents the rationale and protocol for the Optimising Management of Patients with Heart Failure with Preserved Ejection Fraction in Primary Care (OPTIMISE-HFpEF) research programme. DESIGN & SETTING This is a multi-method programme of research conducted in the UK. METHOD OPTIMISE-HFpEF is a multi-site programme of research with three distinct work packages (WPs). WP1 is a systematic review of heart failure disease management programmes (HF-DMPs) tested in patients with HFpEF. WP2 has three components (a, b, c) that enable the characteristics, needs, and experiences of people with HFpEF, their carers, and healthcare providers to be understood. Qualitative enquiry (WP2a) with patients and providers will be conducted in three UK sites exploring patient and provider perspectives, with an additional qualitative component (WP2c) in one site to focus on transitions in care and carer perspectives. A longitudinal cohort study (WP2b), recruiting from four UK sites, will allow patients to be characterised and their illness trajectory observed across 1 year of follow-up. Finally, WP3 will synthesise the findings and conduct work to gain consensus on how best to identify and manage this patient group. RESULTS Results from the four work packages will be synthesised to produce a summary of key learning points and possible solutions (optimised programme) which will be presented to a broad spectrum of stakeholders to gain consensus on a way forward. CONCLUSION HFpEF is often described as the greatest unmet need in cardiology. The OPTIMISE-HFpEF programme aims to address this need in primary care, which is arguably the most appropriate setting for managing HFpEF.
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Affiliation(s)
- Faye Forsyth
- Senior Research Nurse, Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Jonathan Mant
- Professor of Primary Care Research, Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Clare J Taylor
- General Practitioner and NIHR Academic Clinical Lecturer, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fd Richard Hobbs
- Nuffield Professor of Primary Care Health Sciences, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carolyn A Chew-Graham
- Professor of General Practice Research, School of Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Thomas Blakeman
- Clinical Senior Lecturer in Primary Care, Centre for Primary Care, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Emma Sowden
- Research Associate, Centre for Primary Care, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Aaron Long
- Assistant Trial Manager, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Muhammad Zakir Hossain
- Research Assistant, Health Services Research, School of Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Duncan Edwards
- Senior Clinical Research Associate, Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Christi Deaton
- Florence Nightingale Foundation Clinical Professor of Nursing, Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
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23
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Smeets M, Aertgeerts B, Mullens W, Penders J, Vercammen J, Janssens S, Vaes B. Optimising standards of care of heart failure in general practice the OSCAR-HF pilot study protocol. Acta Cardiol 2019; 74:371-379. [PMID: 30507291 DOI: 10.1080/00015385.2018.1507426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Joris Penders
- Department of Clinical Biology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Jan Vercammen
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, KU Leuven (KUL), Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
- Institute of Health and Society, Université Catholique de Louvain (UCL), Brussels, Belgium
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24
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Abstract
Background Diagnosing heart failure (HF) in primary care can be challenging, especially
in elderly patients with comorbidities. Insight in the prevalence, age,
comorbidity and routine practice of diagnosing HF in general practice may
improve the process of diagnosing HF. Aim To examine the prevalence of HF in relation to ageing and comorbidities, and
routine practice of diagnosing HF in general practice. Methods A retrospective cohort study was performed using data from electronic health
records of 56 320 adult patients of 11 general practices. HF patients were
compared with patients without HF using descriptive analyses and
χ2 tests. The following comorbidities were considered: chronic
obstructive pulmonary disorder (COPD), diabetes mellitus (DM), hypertension,
anaemia and renal function disorder (RFD). Separate analyses were performed
for men and women. Findings The point prevalence of HF was 1.2% (95% confidence interval
1.13–1.33) and increased with each age category from 0.04%
(18–44 years) to 20.9% (⩾85 years). All studied
comorbidities were significantly (P<0.001) more
common in HF patients than in patients without HF: COPD (24.1% versus
3.1%), DM (34.7% versus 6.5%), hypertension
(52.7% versus 16.0%), anaemia (10.9% versus
2.3%) and RFD (61.8% versus 7.5%). N-terminal pro-BNP
(NT-proBNP) was recorded in 38.1% of HF patients. Conclusions HF is highly associated with ageing and comorbidities. Diagnostic use of
NT-proBNP in routine primary care seems underutilized. Instruction of GPs to
determine NT-proBNP in patients suspected of HF is recommended, especially
In elderly patients with comorbidities.
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25
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Tran P, McDonald M, Kunaselan L, Umar F, Banerjee P. A hundred heart failure deaths: lessons learnt from the Dr Foster heart failure hospital mortality alert. Open Heart 2019; 6:e000970. [PMID: 31168377 PMCID: PMC6519425 DOI: 10.1136/openhrt-2018-000970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/26/2019] [Accepted: 02/16/2019] [Indexed: 11/11/2022] Open
Abstract
Background Despite advances in evidence-based pharmacotherapy, the latest National Heart Failure Audit (NHFA) has shown that in-hospital mortality of heart failure (HF) remains high with large interhospital variations. University Hospitals Coventry & Warwickshire, a tertiary cardiac centre, received a mortality alert of excess HF deaths based on a high Dr Foster hospital standardised mortality ratio (HSMR). This conflicted with our local NHFA data which showed lower than national average mortality rates. Objective To review various systemic and individual processes of care in patients admitted with HF and examine the validity of HSMR in HF. Design, setting, patients A retrospective case note analysis was performed on a random sample of 100 HF deaths identified by Dr Foster from 2010 to 2016. Measures Case record reviews were performed on the following aspects of care: admission to appropriate wards, resuscitation status, palliative care input and National Confidential Enquiry into Patient Outcome and Death classification. Primary diagnosis coding, diagnostic accuracy and actual causes of death were examined to assess limitations of HSMR. Results Despite evidence of lower mortality on cardiology wards, only 28% of patients with acute HF were admitted to a cardiology-ward. Sixty four per cent were considered palliative but only 4.6% were referred to palliative care. The Do Not Attempt Resuscitation order was appropriate in 91% patients but only 74% had this in place. The primary diagnosis of HF was incorrectly coded in 34% while three cases were misdiagnosed. Conclusion HF may be coded as a cause of death in some cases where the cause is uncertain and misdiagnosed. Although HSMR has many limitations, it is a smoke alarm that should not be ignored.
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Affiliation(s)
- Patrick Tran
- Department of Cardiology, University Hospitals Coventry & Warwickshire, Coventry, United Kingdom
| | | | | | - Fraz Umar
- Department of Cardiology, University Hospitals Coventry & Warwickshire, Coventry, United Kingdom
| | - Prithwish Banerjee
- Department of Cardiology, University Hospitals Coventry & Warwickshire, Coventry, United Kingdom.,Warwick Medical School, Coventry, United Kingdom.,CIRAL, Coventry University, Coventry, United Kingdom
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26
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Smeets M, De Witte P, Peters S, Aertgeerts B, Janssens S, Vaes B. Think-aloud study about the diagnosis of chronic heart failure in Belgian general practice. BMJ Open 2019; 9:e025922. [PMID: 30898828 PMCID: PMC6475198 DOI: 10.1136/bmjopen-2018-025922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/17/2018] [Accepted: 02/06/2019] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Pieter De Witte
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Sanne Peters
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Leuven Context, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
- Institute of Health and Society, Université Catholique de Louvain (UCL), Brussels, Belgium
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27
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Affiliation(s)
- Łukasz Pyka
- Silesian Centre for Heart Diseases, Zabrze, Poland
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28
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Rutten FH, Broekhuizen BDL. Misclassification of Both Chronic Obstructive Pulmonary Disease and Heart Failure. JAMA Netw Open 2018; 1:e185486. [PMID: 30646286 DOI: 10.1001/jamanetworkopen.2018.5486] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Frans H Rutten
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Berna D L Broekhuizen
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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29
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Cuthbert JJ, Gopal J, Crundall-Goode A, Clark AL. Are there patients missing from community heart failure registers? An audit of clinical practice. Eur J Prev Cardiol 2018; 26:291-298. [PMID: 30396291 DOI: 10.1177/2047487318810839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND General practitioners in the UK are financially incentivised, via the Quality Outcomes Framework, to maintain a record of all patients at their practice with heart failure and manage them appropriately. The prevalence of heart failure recorded in primary care registers (0.7-1.0%) is less than reported in epidemiological studies (3-5%). Using an audit of clinical practice, we set out to investigate if there are patients 'missing' from primary care heart failure registers and what the underlying mechanisms might be. DESIGN The design of this study was as an audit of clinical practice at a UK general practice ( n = 9390). METHODS Audit software (ENHANCE-HF) was used to identify patients who may have heart failure via a series of hierarchical searches of electronic records. Heart failure was then confirmed or excluded based on the electronic records by a heart failure specialist nurse and patients added to the register. Outcome data for patients without heart failure was collected after two years. RESULTS Heart failure prevalence was 0.63% at baseline and 1.12% after the audit. Inaccurate coding accounted for the majority of missing patients. Amongst patients without heart failure who were taking a loop diuretic, the rate of incident heart failure was 13% and the rate of death or hospitalization with heart failure was 25% respectively during two-year follow-up. CONCLUSION There are many patients missing from community heart failure registers which may detriment patient outcome and practice income. Patients without heart failure who take loop diuretics are at high risk of heart failure-related events.
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Affiliation(s)
| | | | | | - Andrew L Clark
- 1 Department of Academic Cardiology, Hull York Medical School, UK
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30
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The tip of the iceberg: finding patients with heart failure with preserved ejection fraction in primary care. An observational study. BJGP Open 2018; 2:bjgpopen18X101606. [PMID: 30564739 PMCID: PMC6189778 DOI: 10.3399/bjgpopen18x101606] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 05/25/2018] [Indexed: 12/24/2022] Open
Abstract
Background Heart failure with preserved ejection fraction (HFpEF) is under-identified in primary care. Aim The aim of this study was to determine what information is available in patients' primary care practice records that would identify patients with HFpEF. Design & setting Record review in two practices in east of England. Method Practices completed a case report form on each patient on the heart failure register and sent anonymised echocardiography reports on patients with an ejection fraction (EF) >50%. Reports were reviewed and data analysed using SPSS (version 25). Results One hundred and forty-eight patients on the heart failure registers with mean age 77 +12 years were reviewed. Fifty-three patients (36%) had possible HFpEF based on available information. These patients were older and multimorbid, with a high prevalence of overweight and obesity. Confirmation of diagnosis was not possible as recommended HFpEF diagnostic information (natriuretic peptides, echocardiogram parameters of structural heart disease and diastolic function) was widely inconsistent or absent in these patients. Conclusion Without correct identification of HFpEF, patient management may be suboptimal or inappropriate, and lack the needed focus on comorbidities and lifestyle that can improve patient outcomes. This study describes in detail the characteristics of many of the patients who probably have HFpEF in a real-world sample, and the improvements and diagnostic information required to better identify them. Identifying more than the tip of the iceberg that is the HFpEF population will allow the improvement of the quality of their management, the prevention of ineffective health care, and the recruitment of patients into research.
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Abstract
Overdiagnosis, is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm a patient during his or her lifetime, and it is increasingly acknowledged as a consequence of screening for cancer and other conditions. Because preventive care is a crucial component of primary care, which is delivered to the broad population, overdiagnosis in primary care is an important problem from a public health perspective and has far reaching implications. The scope of overdiagnosis as a result of services delivered in primary care is unclear, though overdiagnosis of indolent breast, prostate, thyroid, and lung cancers is well described and overdiagnosis of chronic kidney disease, depression, and attention-deficit/hyperactivity disorder is also recognized. However, overdiagnosis is a known consequence of all screening and can be assumed to occur in many more clinical contexts. Overdiagnosis can harm patients by leading to overtreatment (with associated potential toxicities), diagnosis related anxiety or depression, and labeling, or through financial burden. Many entrenched factors facilitate overdiagnosis, including the growing use of advanced diagnostic technology, financial incentives, a medical culture that encourages greater use of tests and treatments, limitations in the evidence that obscure the understanding of diagnostic utility, use of non-beneficial screening tests, and the broadening of disease definitions. Efforts to reduce overdiagnosis are hindered by physicians' and patients' lack of awareness of the problem and by confusion about terminology, with overdiagnosis often conflated with related concepts. Clarity of terminology would facilitate physicians' understanding of the problem and the growth in evidence regarding its prevalence and downstream consequences in primary care. It is hoped that international coordination regarding diagnostic standards for disease definitions will also help minimize overdiagnosis in the future.
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Affiliation(s)
- Minal S Kale
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Deborah Korenstein
- Department of Medicine and Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
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Kalhan R, Mutharasan RK. Reducing Readmissions in Patients With Both Heart Failure and COPD. Chest 2018; 154:1230-1238. [PMID: 29908152 DOI: 10.1016/j.chest.2018.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/25/2018] [Accepted: 06/01/2018] [Indexed: 01/27/2023] Open
Abstract
Patients with both COPD and heart failure (HF) pose particularly high costs to the health-care system. These diseases arise from similar root causes, have overlapping symptoms, and share similar clinical courses. Because of these strong parallels, strategies to reduce readmissions in patients with both conditions share synergies. Here we present 10 practical tips to reduce readmissions in this challenging population: (1) diagnose the population accurately, (2) detect admissions for exacerbations early and consider risk stratification, (3) use specialist management in hospital, (4) modify the underlying disease substrate, (5) apply and intensify evidence-based therapies, (6) activate the patient and develop critical health behaviors, (7) setup feedback loops, (8) arrange an early follow-up appointment prior to discharge, (9) consider and address other comorbidities, and (10) consider ancillary support services at home. The multidisciplinary care teams needed to support these care models pose expense to the health-care system. Although these costs may more easily be recouped under financial models such as accountable care organizations and bundled payments, the opportunity cost of an admission for COPD or HF may represent an underrecognized financial lever.
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Affiliation(s)
- Ravi Kalhan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Raja Kannan Mutharasan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Smeets M, Henrard S, Aertgeerts B, Cools F, Janssens S, Vaes B. Methods to identify heart failure patients in general practice and their impact on patient characteristics: A systematic review. Int J Cardiol 2018; 257:199-206. [PMID: 29395362 DOI: 10.1016/j.ijcard.2017.06.108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 06/07/2017] [Accepted: 06/27/2017] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
| | - Séverine Henrard
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Institute of Health and Society, Université Catholique de Louvain, Brussel, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; CEBAM, Centre for Evidence Based Medicine, Belgium Cochrane Centre, Belgium
| | - Filip Cools
- CEBAM, Centre for Evidence Based Medicine, Belgium Cochrane Centre, Belgium; Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Institute of Health and Society, Université Catholique de Louvain, Brussel, Belgium
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Wizner B, Fedyk-Łukasik M, Opolski G, Zdrojewski T, Windak A, Czech M, Dubiel JS, Marchel M, Rewiuk K, Rywik T, Korewicki J, Grodzicki T. Chronic heart failure management in primary healthcare in Poland: Results of a nationwide cross-sectional study. Eur J Gen Pract 2017; 24:1-8. [PMID: 29164946 PMCID: PMC5774260 DOI: 10.1080/13814788.2017.1368490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Barbara Wizner
- a Department of Internal Medicine and Gerontology , Jagiellonian University Medical College , Krakow , Poland
| | - Małgorzata Fedyk-Łukasik
- a Department of Internal Medicine and Gerontology , Jagiellonian University Medical College , Krakow , Poland
| | - Grzegorz Opolski
- b Department of Cardiology , Medical University of Warsaw , Warsaw , Poland
| | - Tomasz Zdrojewski
- c Department of Preventive Medicine and Education , Medical University of Gdansk , Gdansk , Poland
| | - Adam Windak
- d Department of Family Medicine , Jagiellonian University Medical College , Krakow , Poland
| | - Marcin Czech
- e Department of Pharmacoeconomics , Medical University of Warsaw , Warsaw , Poland.,f Business School , Warsaw University of Technology , Warsaw , Poland
| | - Jacek S Dubiel
- g Department of Cardiology , Jagiellonian University Medical College and University Hospital , Krakow , Poland
| | - Michał Marchel
- b Department of Cardiology , Medical University of Warsaw , Warsaw , Poland
| | - Krzysztof Rewiuk
- a Department of Internal Medicine and Gerontology , Jagiellonian University Medical College , Krakow , Poland
| | - Tomasz Rywik
- h Department of Heart Failure and Transplantology , Institute of Cardiology , Warsaw , Poland
| | - Jerzy Korewicki
- h Department of Heart Failure and Transplantology , Institute of Cardiology , Warsaw , Poland
| | - Tomasz Grodzicki
- a Department of Internal Medicine and Gerontology , Jagiellonian University Medical College , Krakow , Poland
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35
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Bottle A, Kim D, Aylin P, Cowie MR, Majeed A, Hayhoe B. Routes to diagnosis of heart failure: observational study using linked data in England. Heart 2017; 104:600-605. [PMID: 28982720 DOI: 10.1136/heartjnl-2017-312183] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/08/2017] [Accepted: 09/12/2017] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Timely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care. We describe the journey of people with HF in primary care from presentation through to diagnosis and initial management. METHODS We used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis. RESULTS 36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years prior to diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral. CONCLUSIONS Patients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. There are likely to be missed opportunities for earlier HF diagnosis in primary care.
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Affiliation(s)
- Alex Bottle
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Dani Kim
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Martin R Cowie
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, Imperial College London, London, UK
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36
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Rutten FH, Gallagher J. What the General Practitioner Needs to Know About Their Chronic Heart Failure Patient. Card Fail Rev 2017; 2:79-84. [PMID: 28785457 DOI: 10.15420/cfr.2016:18:1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
In this article we highlight what general practitioners (GPs) need to know about heart failure (HF). We pay attention to its definition, diagnosis - with risks of under- and over-diagnosis - and the role natriuretic peptides, electrocardiography, echocardiography, but also spirometry. We stress the role of the GP in case finding and risk stratification with optimisation of cardiovascular drug use in high-risk groups. Epidemiological data are provided, followed by discussion of the management aspects and possibilities of cooperative care of patients with chronic HF, focussing on pharmacological treatment, comorbidities and end-of-life care. This article highlights the experience and clinical practice of the authors: specifics of local heart failure management, and the role of the GP, will naturally vary.
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Affiliation(s)
- Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Joe Gallagher
- Department of General Practice, Health Research Group, University College Dublin, Dublin, Ireland
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37
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Gallagher J, James S, Keane C, Fitzgerald A, Travers B, Quigley E, Hecht C, Zhou S, Watson C, Ledwidge M, McDonald K. Heart Failure Virtual Consultation: bridging the gap of heart failure care in the community - A mixed-methods evaluation. ESC Heart Fail 2017; 4:252-258. [PMID: 28772044 PMCID: PMC5542774 DOI: 10.1002/ehf2.12163] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/04/2017] [Accepted: 03/09/2017] [Indexed: 12/11/2022] Open
Abstract
Aims We undertook a mixed‐methods evaluation of a Web‐based conferencing service (virtual consult) between general practitioners (GPs) and cardiologists in managing patients with heart failure in the community to determine its effect on use of specialist heart failure services and acceptability to GPs. Methods and results All cases from June 2015 to October 2016 were recorded using a standardized recording template, which recorded patient demographics, medical history, medications, and outcome of the virtual consult for each case. Quantitative surveys and qualitative interviewing of 17 participating GPs were also undertaken. During this time, 142 cases were discussed—68 relating to a new diagnosis of heart failure, 53 relating to emerging deterioration in a known heart failure patient, and 21 relating to therapeutic issues. Only 17% required review in outpatient department following the virtual consultation. GPs reported increased confidence in heart failure management, a broadening of their knowledge base, and a perception of overall better patient outcomes. Conclusions These data from an initial experience with Heart Failure Virtual Consultation present a very positive impact of this strategy on the provision of heart failure care in the community and acceptability to users. Further research on the implementation and expansion of this strategy is warranted.
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Affiliation(s)
- Joseph Gallagher
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Stephanie James
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,St Vincent's University Hospital Group, Dublin, Ireland
| | - Ciara Keane
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Annie Fitzgerald
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,St Vincent's University Hospital Group, Dublin, Ireland
| | - Bronagh Travers
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,St Vincent's University Hospital Group, Dublin, Ireland
| | - Etain Quigley
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,Applied Research for Connected Health, NexusUCD, Dublin, Ireland
| | - Christina Hecht
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,Applied Research for Connected Health, NexusUCD, Dublin, Ireland
| | - Shuaiwei Zhou
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,Heartbeat Trust, Dun Laoghaire, Dublin, Ireland
| | - Chris Watson
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,Queen's University, Belfast, UK
| | - Mark Ledwidge
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,Heartbeat Trust, Dun Laoghaire, Dublin, Ireland
| | - Kenneth McDonald
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,St Vincent's University Hospital Group, Dublin, Ireland.,Heartbeat Trust, Dun Laoghaire, Dublin, Ireland
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38
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McDonald K, Gallagher J. The practice gap in heart failure-the elephant in the room. Eur J Heart Fail 2017; 19:301-303. [DOI: 10.1002/ejhf.734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/22/2016] [Accepted: 11/16/2016] [Indexed: 12/28/2022] Open
Affiliation(s)
- Kenneth McDonald
- Heart Failure Unit; St Vincent's University Hospital; Elm Park Dublin 4 Ireland
| | - Joe Gallagher
- School of Medicine; University College Dublin; Ireland
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39
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van Doorn S, Brakenhoff TB, Moons KGM, Rutten FH, Hoes AW, Groenwold RHH, Geersing GJ. The effects of misclassification in routine healthcare databases on the accuracy of prognostic prediction models: a case study of the CHA2DS2-VASc score in atrial fibrillation. Diagn Progn Res 2017; 1:18. [PMID: 31093547 PMCID: PMC6460749 DOI: 10.1186/s41512-017-0018-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/08/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Research on prognostic prediction models frequently uses data from routine healthcare. However, potential misclassification of predictors when using such data may strongly affect the studied associations. There is no doubt that such misclassification could lead to the derivation of suboptimal prediction models. The extent to which misclassification affects the validation of existing prediction models is currently unclear.We aimed to quantify the amount of misclassification in routine care data and its effect on the validation of the existing risk prediction model. As an illustrative example, we validated the CHA2DS2-VASc prediction rule for predicting mortality in patients with atrial fibrillation (AF). METHODS In a prospective cohort in general practice in the Netherlands, we used computerized retrieved data from the electronic medical records of patients known with AF as index predictors. Additionally, manually collected data after scrutinizing all complete medical files were used as reference predictors. Comparing the index with the reference predictors, we assessed misclassification in individual predictors by calculating Cohen's kappas and other diagnostic test accuracy measures. Predictive performance was quantified by the c-statistic and by determining calibration of multivariable models. RESULTS In total, 2363 AF patients were included. After a median follow-up of 2.7 (IQR 2.3-3.0) years, 368 patients died (incidence rate 6.2 deaths per 100 person-years). Misclassification in individual predictors ranged from substantial (Cohen's kappa 0.56 for prior history of heart failure) to minor (kappa 0.90 for a history of type 2 diabetes). The overall model performance was not affected when using either index or reference predictors, with a c-statistic of 0.684 and 0.681, respectively, and similar calibration. CONCLUSION In a case study validating the CHA2DS2-VASc prediction model, we found substantial predictor misclassification in routine healthcare data with only limited effect on overall model performance. Our study should be repeated for other often applied prediction models to further evaluate the usefulness of routinely available healthcare data for validating prognostic models in the presence of predictor misclassification.
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Affiliation(s)
- S. van Doorn
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - T. B. Brakenhoff
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - K. G. M. Moons
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - F. H. Rutten
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - A. W. Hoes
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - R. H. H. Groenwold
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
| | - G. J. Geersing
- 0000000090126352grid.7692.aJulius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, 3508 AB Utrecht, The Netherlands
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40
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Deaton C, Benson J. Time for correct diagnosis and categorisation of heart failure in primary care. Br J Gen Pract 2016; 66:554-555. [PMID: 27789488 PMCID: PMC5072893 DOI: 10.3399/bjgp16x687649] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Christi Deaton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge
| | - John Benson
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge
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