Heart failure patients in the UK are being let down by limited follow-up care after leaving hospital, insufficient doses of life-saving medicines, and dangerously unequal care for women and the elderly, according to new research funded by the British Heart Foundation and presented today at the European Society of Cardiology (ESC) Congress in Munich.
The findings question the validity of the UK’s Quality of Outcomes framework scheme, which aims to reward good practice in primary care in order to improve outcomes. The scheme was introduced in 2004 and rewards primary care physicians, including GP’s, when they meet certain targets.
QOF reports depict a very positive picture of heart failure care in the UK with a 90% achievement rate of these targets. However, these targets only reflect two narrow measures – use of diagnostic investigations and yearly drug prescriptions. The report from BHF-funded researchers at the University of Oxford points to major shortfalls in heart failure care which are not adequately addressed by QOF.
Patients more likely to be diagnosed in hospital
Researchers found that heart failure patients are more and more likely to be diagnosed in hospital rather than outpatient settings (i.e. a GP or an outpatient specialist consultation), that too few patients are being followed-up by their GP after being diagnosed in hospital, and that doses of essential heart failure medicines are too low across the board. Women are also far more likely to experience these shortcomings.
Amongst heart failure patients who survived hospitalisation, only 17 per cent had their heart failure diagnosis recorded by their GP pointing to a lack of communication between hospitals and GPs. This is concerning because patients with heart failure will be managed across Primary, Secondary and Community care systems therefore, it’s imperative that an accurate record is maintained across the system. Estimates suggest that, of the 920,000 people living with heart failure in the UK, only 550,000 are registered with their GP.
Inadequate doses of key medicines
Heart failure patients are also receiving inadequate doses of key medicines, far below those recommended in guidelines. The average daily dose prescribed was less than half the recommended dose for ACE-inhibitors, a quarter of the recommended dose for beta-blockers, and a fifth of the recommended dose for diuretics. The study also shows that doses of medicines have changed little over the past decade, and even declined for ACE-inhibitors.
Women fare worst
Women were less likely have their condition diagnosed outside of hospital, received fewer investigations in diagnosis (for example echocardiograms or ECG’s), received fewer treatments, were given lower treatment doses and were less likely to receive follow-up care after being discharged from hospital compared to males of a similar age and background. The findings add to a large and alarming body of evidence that shows women are at a disadvantage in cardiac care.
The team of researchers from the University of Oxford used electronic health records from one of the largest anonymised patient databases, the Clinical Practice Research Datalink (CPRD) and linked this to data on hospital admissions to make the analysis. They identified 93,074 patients diagnosed with heart failure between 2002 and 2014, and followed their pathway of care for one year.
Addressing the shortfall
Jeremy Pearson, Associate Medical Director from the British Heart Foundation said:
“Heart failure is a cruel and debilitating illness affecting more than half a million people across the UK, and the leading cause of hospital admissions in over 65’s.
“This study paints a worrying picture of heart failure care in the UK, but identifying the shortfalls is the first step towards addressing them. We need the communication between hospitals and primary care providers to make sure patients with heart failure receive that all-important follow-up care after they leave hospital.
“We may need to develop targeted, specific health policies for managing heart failure for women, with more research to identify the best way to treat women who have heart failure.”