| アブストラクト | BACKGROUND: Effective management of heart failure is complex, and ensuring evidence-based practice presents a major challenge to health services worldwide. Over the past decade, the United Kingdom introduced a series of national initiatives to improve evidence-based heart failure management, including a landmark pay-for-performance scheme in primary care and a national audit in secondary care started in 2004 and 2007, respectively. Quality improvement efforts have been evaluated within individual clinical settings, but patterns of care across its continuum, although a critical component of chronic disease management, have not been studied. We have designed this study to investigate patients' trajectories of care around the time of diagnosis and their variation over time by age, sex, and socioeconomic status. METHODS AND FINDINGS: For this retrospective population-based study, we used linked primary and secondary health records from a representative sample of the UK population provided by the Clinical Practice Research Datalink (CPRD). We identified 93,074 individuals newly diagnosed with heart failure between 2002 and 2014, with a mean age of 76.7 years and of which 49% were women. We examined five indicators of care: (i) diagnosis care setting (inpatient or outpatient), (ii) posthospitalisation follow-up in primary care, (iii) diagnostic investigations, (iv) prescription of essential drugs, and (v) drug treatment dose. We used Poisson and linear regression models to calculate category-specific risk ratios (RRs) or adjusted differences and 95% confidence intervals (CIs), adjusting for year of diagnosis, age, sex, region, and socioeconomic status. From 2002 to 2014, indicators of care presented diverging trends. Outpatient diagnoses and follow-up after hospital discharge in primary care declined substantially (ranging from 56% in 2002 to 36% in 2014, RR 0.64 [0.62, 0.67] and 20% to 14%, RR 0.73 [0.65, 0.82], respectively). Primary care referral for diagnostic investigations and appropriate initiation of beta blockers and angiotensin-converting-enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) both increased significantly (37% versus 82%, RR 2.24 [2.15, 2.34] and 18% versus 63%, RR 3.48 [2.72, 4.43], respectively). Yet, the average daily dose prescribed remained below guideline recommendations (42% for ACE-Is or ARBs, 29% for beta blockers in 2014) and was largely unchanged beyond the first 30 days after diagnosis. Despite increasing rates of treatment initiation, the overall dose prescribed to patients in the 12 months following diagnosis improved little over the period of study (adjusted difference for the combined dose of beta blocker and ACE-I or ARB: +6% [+2%, +10%]). Women and patients aged over 75 years presented significant gaps across all five indicators of care. Our study was limited by the available clinical information, which did not include exact left ventricular ejection fraction values, investigations performed during hospital admissions, or information about follow-up in community heart failure clinics. CONCLUSIONS: Management of heart failure patients in the UK presents important shortcomings that affect screening, continuity of care, and medication titration and disproportionally impact women and older people. National reporting and incentive schemes confined to individual clinical settings have been insufficient to identify these gaps and address patients' long-term care needs. |
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| ジャーナル名 | PLoS medicine |
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| Pubmed追加日 | 2019/5/22 |
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| 投稿者 | Conrad, Nathalie; Judge, Andrew; Canoy, Dexter; Tran, Jenny; O'Donnell, Johanna; Nazarzadeh, Milad; Salimi-Khorshidi, Gholamreza; Hobbs, F D Richard; Cleland, John G; McMurray, John J V; Rahimi, Kazem |
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| 組織名 | The George Institute for Global Health, University of Oxford, Oxford, United;Kingdom.;Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences,;Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom.;Bristol National Institute for Health Research Biomedical Research Centre,;Musculoskeletal Research Unit, University of Bristol, Southmead Hospital,;Bristol, United Kingdom.;Medical Research Council Lifecourse Epidemiology Unit, University of Southampton,;Southampton General Hospital, Southampton, United Kingdom.;National Institute for Health Research Oxford Biomedical Research Centre,;University of Oxford, Oxford, United Kingdom.;Deep Medicine, Oxford Martin School, University of Oxford, Oxford, United;Collaboration Center of Meta-Analysis Research, Torbat Heydariyeh University of;Medical Sciences, Torbat Heydariyeh, Iran.;Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory;Quarter, University of Oxford, Oxford, United Kingdom.;Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow and;National Heart & Lung Institute, Imperial College London, London, United Kingdom.;Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow,;United Kingdom.;Oxford University Hospitals National Health Service Foundation Trust, Oxford, |
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| Pubmed リンク | https://www.ncbi.nlm.nih.gov/pubmed/31112552/ |
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