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Mrs. Nathalie Conrad
A late-breaking trial presentation by Mrs. Nathalie Conrad (University of Oxford, Oxford, UK) yesterday reported a strong reduction in rates of primary care follow-up of heart failure patients in the UK (LBT17).
The study used primary and secondary care electronic heath records of 93,000 individuals with newly diagnosed heart failure over a 12-year period up to 2014.
Out of all heart failure diagnoses, only about half were recorded in primary care, with rates declining from 63% in 2002 to 44% in 2014 (p<0.01).
“Why this should be the case is a tough question,” says Mrs. Conrad, “and without additional investigation, we can really only speculate as to the reasons.” A possible explanation could relate to the introduction of a national care audit and pay-for-performance scheme (the ‘quality and outcomes framework’ introduced in 2004). “Although this system was brought in to improve practice, it is possible that the scheme has paradoxically led to lower registration rates, with GPs for instance using free-text descriptions to record patients’ problems rather than formally recording heart failure as a diagnosis, as a way to exempt some patients from the audit,” suggests Mrs. Conrad. “Other possible reasons could be the increased awareness of heart failure in the secondary care setting—among patients admitted to hospital for other conditions—and follow-up offered by heart failure nurses and in specialist clinics.”
The study also highlighted that while initial prescriptions of medications increased between 2002 and 2014, average daily drug doses in the year following diagnosis remained below the 2012 ESC guideline-recommended targets.
“On average in the first 12 months after diagnosis, patients received about 30–40% of the recommended dose and there was no evidence of consistent uptitration, despite guideline recommendations to do so.”
“This could be related to treatment side effects being higher in real-world populations than in trial participants,” says Mrs. Conrad, “and/or doctors not being sufficiently aware of the benefits of uptitration, or that uptitration efforts are not sufficiently incentivised.”
The other main findings of the study were that women and patients over the age of 75 years are still falling through the cracks, being less likely to receive treatment initiation, primary care monitoring and diagnostic tests. “Sadly,” admits Mrs. Conrad, “this is not something new. For women, the difference—which persisted after correcting for age, comorbidities and socio-economic factors—may be due to a variety of issues, including a perception of a lower risk of heart failure consequences, a reluctance to seek care or an increased incidence of treatment-related side effects, compared with men. With regard to the elderly, GPs may try to minimise additional medications for patients with multiple comorbidities and to avoid hypotension-associated complications, such as falls, which can result from excessive blood-pressure reduction.” Mrs. Conrad recognises there is no simple solution to this complex problem. “However,” she says, “we can start by improving communication between different sectors of the UK healthcare system to ensure that all patients have continuous follow-up. We also have to move away from the one-size-fits-all approach to heart failure care and tailor management to the patient, so that all patients, whatever their age and gender, receive the best treatment for them.”
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