Patient profile and outcomes associated with follow‐up in specialty vs. primary care in heart failure

Abstract

Aims Factors influencing follow-up referral decisions and their prognostic implications are poorly investigated in patients with heart failure (HF) with reduced (HFrEF), mildly reduced (HFmrEF), and preserved (HFpEF) ejection fraction (EF). We assessed (i) the proportion of, (ii) independent predictors of, and (iii) outcomes associated with follow-up in specialty vs. primary care across the EF spectrum. Methods and resultsWe analysed 75 518 patients from the large and nationwide Swedish HF registry between 2000-2018. Multivariable logistic regression models were fitted to identify the independent predictors of planned follow-up in specialty vs. primary care, and multivariable Cox models to assess the association between follow-up type and outcomes. In this nationwide registry, 48 115 (64%) patients were planned for follow-up in specialty and 27 403 (36%) in primary care. The median age was 76 [interquartile range (IQR) 67-83] years and 27 546 (36.5%) patients were female. Key independent predictors of planned follow-up in specialty care included optimized HF care, that is follow-up in a nurse-led HF clinic [odds ratio (OR) 4.60, 95% confidence interval (95% CI) 4.41-4.79], use of HF devices (OR 3.99, 95% CI 3.62-4.40), beta-blockers (OR 1.39, 95% CI 1.32-1.47), renin-angiotensin system/angiotensin-receptor-neprilysin inhibitors (OR 1.21, 95% CI 1.15-1.27), and mineralocorticoid receptor antagonists (OR 1.31, 95% CI 1.26-1.37); and more severe HF, that is higher NT-proBNP (OR 1.13, 95% CI 1.06-1.20) and NYHA class (OR 1.13, 95% CI 1.08-1.19). Factors associated with lower likelihood of follow-up in specialty care included older age (OR 0.29, 95% CI 0.28-0.30), female sex (OR 0.89, 95% CI 0.86-0.93), lower income (OR 0.79, 95% CI 0.76-0.82) and educational level (OR 0.77, 95% CI 0.73-0.81), higher EF [HFmrEF (OR 0.65, 95% CI 0.62-0.68) and HFpEF (OR 0.56, 95% CI 0.53-0.58) vs. HFrEF], and higher comorbidity burden, such as presence of kidney disease (OR 0.91, 95% CI 0.87-0.95), atrial fibrillation (OR 0.85, 95% CI 0.81-0.89), and diabetes mellitus (OR 0.92, 95% CI 0.88-0.96). A planned follow-up in specialty care was independently associated with lower risk of all-cause [hazard ratio (HR) 0.78, 95% CI 0.76-0.80] and cardiovascular death (HR 0.76, 95% CI 0.73-0.78) across the EF spectrum, but not of HF hospitalization (HR 1.06, 95% CI 1.03-1.10). Conclusions In a large nationwide HF population, referral to specialty care was linked with male sex, younger age, lower EF, lower comorbidity burden, better socioeconomic environment and optimized HF care, and associated with better survival across the EF spectrum. Our findings highlight the need for greater and more equal access to HF specialty care and improved quality of primary care.

Trajectories in New York Heart Association functional class in heart failure across the ejection fraction spectrum: data from the Swedish Heart Failure Registry

“…Patients who were referred to follow-up in specialty care, a nurse-led HF unit, and enrolled in the registry at a later date were more likely to experience overall more favourable NYHA class trajectories. These findings are consistent with previous reports of better outcomes and care associated with specialty care, 15,16 nurse-led HF units, 17 and temporal improvements in outcomes over the past decades also linked with the availability of further HF treatments. 18 Patients who were older and burdened by multi-comorbidity experienced less favourable NYHA class trajectories.…”

Association between a hospitalization for heart failure and the initiation/discontinuation of guideline‐recommended treatments: An analysis from the Swedish Heart Failure Registry

“…hypotension, worsening renal function. 9 These factors might trigger treatment discontinuation/down-titration or missed re-initiation, although the 2021 ESC HF guidelines recommend re-initiation/optimization of HF treatments before discharge and early follow-up visit to start/up-titrate therapies (class I recommendation, level of evidence C). 3 Unfortunately, the use of HF treatments in the real world before but also after a worsening HF event seems to be low, which might impact outcomes.…”

Use of guideline‐recommended medical therapy in patients with heart failure and chronic kidney disease: from physician's prescriptions to patient's dispensations, medication adherence and persistence

“…The recent introduction of SGLT2i in the HFrEF guidelines, together with the positive results of SGLT2i trials in HFmrEF/HFpEF trials, highlights the need to developing implementation strategies to ensure the uptake of these recommendations. Implementing referral to HF specialist care has shown to positively affect prescription rates of guideline‐recommended medications 37 . Educational opportunities for primary care physicians on clinical updates in HF and its management, and on how to face side effects and tolerance issues might also contribute to foster implementation of novel therapies and lower the risk of patients having life‐saving treatments interrupted.…”

“…Implementing referral to HF specialist care has shown to positively affect prescription rates of guideline‐recommended medications. 37 Educational opportunities for primary care physicians on clinical updates in HF and its management, and on how to face side effects and tolerance issues might also contribute to foster implementation of novel therapies and lower the risk of patients having life‐saving treatments interrupted. Use of potassium binders, as suggested by current guidelines, 6 may help alleviate prescribers' fear of hyperkalaemia during treatment with MRA, ARNi and RAASi, which may be of particular concern among persons with compromised kidney function.…”