Heart Failure In Primary Care Research Articles

An evidence-based structured one-year programme to sustain physical activity in patients with heart failure in primary care: A non-randomized longitudinal feasibility study.

AimThe primary objective of this non‐randomized feasibility study was to test a 1‐year model programme for sustaining/increasing patients’ motivation to perform daily physical activity.DesignNon‐randomized longitudinal feasibility study with a one‐group repeated measures design.MethodsThe study took place at a primary care centre in mid‐Sweden in 2017–2018. The model programme included individual and group‐based support, individualized physical activity prescriptions, a wrist‐worn activity tracker and an activity diary. The main outcomes were the participants’ perceptions of programme feasibility and scores on the Exercise Self‐Efficacy Scale.ResultsSeven patients were recruited. Six patients completed the programme that was perceived to imply learning, motivation and support. Compared with baseline, the median score of the Exercise Self‐Efficacy Scale improved 3 months after participants completed the programme.

Association of depression and anxiety with adherence in primary care patients with heart failure-cross-sectional results of the observational RECODE-HF cohort study.

Psychological distress has a negative impact on the prognosis and quality of life for patients with heart failure. We investigated the association between psychological distress and the patients' adherence to medical treatment (medication adherence) and self-care advice (lifestyle adherence) in heart failure. We further examined whether there are different factors associated with low medication compared to low lifestyle adherence. This secondary analysis of the RECODE-HF cohort study analyzed baseline data of 3099 primary care heart failure patients aged 74 ± 10 years, 44.5 % female. Using multivariable regression, factors relating to medication and lifestyle adherence were investigated in order to estimate the extent to which these factors confound the association between psychological distress and adherence. Psychological distress was significantly associated with poorer medication adherence but not with lifestyle adherence after controlling for confounders. We identified different factors associated with medication compared to lifestyle adherence. A higher body mass index, a less developed social network, living alone, fewer chronic co-morbidities and unawareness of the heart failure diagnosis were only related to lower lifestyle adherence. Higher education was associated with poorer medication adherence. Male sex, younger age, lower self-efficacy and less familiar relation with the general practitioner were common factors associated with both lower medication and lifestyle adherence. Promising factors for increasing medication adherence (reduction of psychological distress) and lifestyle adherence (explaining the patient his/her heart failure diagnosis more than once and increase in the patients' self-efficacy), which were found in this cross-sectional study, must be further investigated in longitudinal studies.

Tissue Doppler indices of diastolic function as prognosticator in patients without heart failure in primary care

BackgroundTissue Doppler imaging (TDI) indices of left ventricular (LV) diastolic function provide incremental prognostic information on mortality and morbidity in the general population and in several clinical scenarios. Their independent, additional role in outpatients with normal LV ejection fraction (LVEF) and without heart failure (HF) is undefined. MethodsWe reviewed clinical and echocardiographic records of 2628 consecutive outpatients 52.8% male, median age 71 years) with LVEF > 50% without concurrent or prior HF, from the Cardiovascular Center of Trieste. We analyzed septal early mitral annular velocity (e’) and its combination with mitral peak early filling velocity (E/e’) in relation to the composite end-point of death and cardiovascular hospitalizations. ResultsDuring follow-up of 26 months (interquartile range: 12–41), 392 (15%) patients experienced the endpoint (88 deaths). Increasing E/e’ showed an overall association with the clinical end-point (log rank p < 0.02), but with no prognostic difference between the middle and upper tertile. Decreasing e’ also showed an association with the end-point, with a more balanced stepwise risk increase for increasing tertiles (log rank p < 0.01 for all contrasts). At multivariable analysis, E/e’ (either in tertiles or dichotomized according to the threshold of 15) was no longer associated with clinical outcome, whereas e’ independently predicted the combined endpoint [hazard ratio 0.73 (0.53-0.94), p = 0.04]. The prognostic value of e’ was incremental to that of other clinical and echocardiographic variables (p = 0.04). ConclusionsIn outpatients with normal LVEF and without HF, e’ and E/e’ are both associated with clinical end-points, though only e’ is an independent and incremental predictor of outcome. These findings suggest a potential role for e’ as a prognosticator, and spread a cautionary word about the utilization of septal E/e’ alone as a surrogate for a comprehensive assessment of diastolic function in this context.

Diagnostic accuracy and clinical impact of natriuretic peptide screening for the detection of heart failure in the community: a protocol for systematic review and meta-analysis

Introduction: Patients diagnosed with heart failure in primary care have a better prognosis than those diagnosed in hospital. However, most cases are missed in the community. Recent attention has focussed on the potential of early detection through screening. Natriuretic peptides (NPs) are tested by GPs and used to rule out heart failure in patients presenting with symptoms. Evidence is now emerging that they may also have a role in screening but their accuracy in this context and the associated optimal thresholds, have not been established. The impact that NP screening would have on patients and health care systems also remains unclear. Methods: We aim to undertake a systematic search of the following sources: Ovid Medline, Embase, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials. Screening, data extraction and critical appraisal will be carried out independently and in duplicate by two reviewers. We will include studies based in the community with &gt;100 participants that recruited a screened population. We will not add a study design filter and there will be no language restriction. The primary outcome will be the sensitivity and the specificity of NP screening and optimal thresholds for screening will be explored. Outcomes of interest for the impact analysis will include mortality, hospital admissions and cost effectiveness. This protocol has been developed in accordance with guidelines from the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). Discussion: This systematic review will identify how accurately NP screen for heart failure in the community and explore where NP screening thresholds should be set. It also aims to summarise the clinical impact of this strategy. Together, these results should inform future interventions that may provide an alternative pathway to facilitate improved detection of heart failure in the community. Registration: PROSPERO CRD42018087498; registered on 11 May 2018.

Diagnostic accuracy and clinical impact of natriuretic peptide screening for the detection of heart failure in the community: a protocol for systematic review and meta-analysis

Introduction: Patients diagnosed with heart failure in primary care have a better prognosis than those diagnosed in hospital. However, most cases are missed in the community. Recent attention has focussed on the potential of early detection through screening. Natriuretic peptides (NPs) are tested by GPs and used to rule out heart failure in patients presenting with symptoms. Evidence is now emerging that they may also have a role in screening but their accuracy in this context and the associated optimal thresholds, have not been established. The impact that NP screening would have on patients and health care systems also remains unclear. Methods: We aim to undertake a systematic search of the following sources: Ovid Medline, Embase, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials. Screening, data extraction and critical appraisal will be carried out independently and in duplicate by two reviewers. We will include studies based in the community with &gt;100 participants that recruited a screened population. We will not add a study design filter and there will be no language restriction. The primary outcome will be the sensitivity and the specificity of NP screening and optimal thresholds for screening will be explored. Outcomes of interest for the impact analysis will include mortality, hospital admissions and cost effectiveness. This protocol has been developed in accordance with guidelines from the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). Discussion: This systematic review will identify how accurately NP screen for heart failure in the community and explore where NP screening thresholds should be set. It also aims to summarise the clinical impact of this strategy. Together, these results should inform future interventions that may provide an alternative pathway to facilitate improved detection of heart failure in the community. Registration: PROSPERO CRD42018087498; registered on 11 May 2018.

Quality of life assessment in patients with heart failure: validity of the German version of the generic EQ-5D-5L\u2122

BackgroundChronic heart failure patients typically suffer from tremendous strain and are managed mainly in primary care. New care concepts adapted to the severity of heart failure are a challenge and need to consider health-related quality of life aspects. This is the first psychometric validation of the German EQ-5D-5L™ as a generic instrument for assessing health-related quality of life (HRQOL) in a primary care heart failure patient sample.MethodsConfirmatory factor analysis (CFA) was performed on the baseline EQ-5D-5L™ data from the RECODE-HF study (responses to all items from n = 3225 of 3778 patients). Basic CFA models for HRQOL were calculated based on the EQ-5D-5L™ items using the maximum likelihood (ML) and the asymptotic distribution-free method. In an extended CFA, physical activity and depression were added. The basic CFA ML model was verified for the reduced number of cases of the extended CFA model (n = 3064). In analyses of variance the association of the EQ-5D-5L™ visual analogue scale (VAS) and both the German and the British EQ-5D-5L™ crosswalk index with the SF-36 measure of general health were examined. The discriminant validity was analysed using Pearson’s chi-squared tests applying the New York Heart Association classification, for the VAS and indices analyses of variance were calculated.ResultsIn the basic CFA models the root mean square error of approximation was 0.095 with the ML method, and 0.081 with the asymptotic distribution-free method (Comparative Fit Index > 0.90 for both). Physical activity and depression were confirmed as influential factors in the extended model. The VAS and indices were strongly associated with the SF-36 measure of general health (partial eta-squared 0.525/0.454/0.481; all p < 0.001; n = 3155/3210/3210, respectively), also for physical activity and depression when included together (partial eta-squared 0.050, 0.200/0.047, 0.213/0.051 and 0.270; all p < 0.001; n = 3015/n = 3064/n = 3064, respectively). The discriminant validity analyses showed p-values < 0.001 and small to moderate effect sizes for all EQ-5D-5L™ items. Analyses of variance demonstrated moderate effect sizes for the VAS and indices (0.067/0.087/0.084; all p < 0.001; n = 3110/3171/3171).ConclusionThe German EQ-5D-5L™ is a suitable method for assessing HRQOL in heart failure patients.

Nursing knowledge of the principles of self-care of heart failure in primary care: a multicentre study.

Nurses play an important part in the education of patients with HF. To prepare patients with HF for self-care maintenance behaviours, nurses must have knowledge of basic self-care maintenance principles. The aim of this study was to determine the degree of knowledge of primary care (PC) nurses on the principles of self-management of HF and variables associated with this. This is an observational, cross-sectional descriptive study, carried out in 2014, in the city of Barcelona (Catalonia). Nurses' Knowledge of Heart Failure Education Principles questionnaire (NKHFEP) was used to assess the principles of HF self-care education. Instrument items assess knowledge of nurses on 5 themes: diet, liquids/weight, worsening signs or symptoms, medication and exercise. Factors related to adequate knowledge were evaluated. Of 216 PC nurses, who completed the questionnaire, the average score was 15.6 (SD: 2.2). Only 36 (16.7%) obtained an adequate level of knowledge and defined as a score≥18 points. In multivariate logistic regression, nurse factors associated with an adequate knowledge of principles of self-care of HF were having achieved a PhD degree (OR: 36.4, 95% CI: 2.8-468.2, p=0.006) and previous specific training in HF (OR: 19.8, 95% CI: 1.4-279.3, p=0.026). The degree of knowledge of PC nurses in the principles of self-care in HF was higher among nurses who had completed the doctorate and in nurses who had received specific training in HF.

Route to heart failure diagnosis in English primary care: a retrospective cohort study of variation.

Despite the existence of evidence-based guidelines supporting the identification of heart failure (HF) in primary care, the proportion of patients diagnosed in this setting remains low. Understanding variation in patients' routes to diagnosis will better inform HF management. To identify the factors associated with variation in patients' routes to HF diagnosis in primary care. A retrospective cohort study of 13 897 patients diagnosed with HF between 1 January 2010 and 31 March 2013 in English primary care. This study used primary care electronic health records to identify routes to HF diagnosis, defined using the National Institute for Health and Care Excellence (NICE) guidelines, and adherence to the NICE-recommended guidelines. Multilevel logistic regression was used to investigate factors associated with the recommended route to HF diagnosis, and funnel plots were used to visualise variation between practices. Few patients (7%, n = 976) followed the recommended route to HF diagnosis. Adherence to guidelines was significantly associated with younger age (P = 0.001), lower deprivation level (P = 0.007), HF diagnosis source (P<0.001), not having chronic pulmonary disease (P<0.001), receiving further consultation for symptom(s) suggestive of HF (P<0.001), and presenting with breathlessness (P<0.001). Route to diagnosis also varied significantly between GP practices (P<0.001). The significant association of certain patient characteristics with route to HF diagnosis and the variation between GP practices raises concerns about equitable HF management. Further studies should investigate reasons for this variation to improve the diagnosis of HF in primary care. However, these must consider the complexities of a patient group often affected by frailty and multiple comorbidities.

Integrated Disease Management of Heart Failure in Primary Care

Integrated Disease Management of Heart Failure in Primary Care

Effectiveness of an exercise programme to improve the quality of life of patients with heart failure in primary care: The EFICAR study

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Mid‐regional pro‐atrial natriuretic peptide for the early detection of non‐acute heart failure

Diagnosing non-acute heart failure (HF) remains challenging, notably in the early stages of the syndrome. The diagnostic value of mid-regional pro-atrial natriuretic peptide (MR-proANP) has been proven in acute onset HF, but its role in early non-acute HF is unknown. We aimed to determine the diagnostic value of MR-proANP in suspected non-acute HF. In total, 721 people suspected of non-acute HF in primary care underwent standardised diagnostic work-up including chest X-ray, electrocardiogram, N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement and echocardiography. Of these, 245 people underwent additional MR-proANP measurements. The outcome of HF was assessed by an expert panel comprised of two cardiologists and one expert physician, who used all available diagnostic information including echocardiography, but were blinded to biomarker results. Of the 245 people (mean age 71.0years, 62.9% female), 72 (29.4%) were diagnosed with HF. The c-statistics of MR-proANP and NT-proBNP as single diagnostic test were 0.77 [95% confidence interval (CI) 0.70-0.84] and 0.79 (95% CI 0.73-0.86), respectively. The cut-point with the highest accuracy for MR-proANP was 120 pmol/L [sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) 0.72, 0.69, 0.46, and 0.86, respectively], and the best exclusionary cut-point was 40 pmol/L (sensitivity/specificity/PPV/NPV 0.99, 0.06, 0.30, and 0.92, respectively). After addition of MR-proANP on top of a previously validated clinical model, the c-statistic rose from 0.82 (95% CI 0.76-0.88) to 0.86 (95% CI 0.80-0.92), and with the addition of NT-proBNP to 0.87 (95% CI 0.81-0.92). No sex interactions between the biomarkers and HF were found in the multivariable models. MR-proANP provides added diagnostic value in suspected non-acute HF, similar to NT-proBNP.

Opportunities and challenges of a novel cardiac output response to stress (CORS) test to enhance diagnosis of heart failure in primary care: a qualitative study

BackgroundPrimary care physicians lack access to an objective cardiac function test during diagnostic testing for suspected heart failure.AimTo determine the role of the novel Cardiac Output Response to Stress (CORS) test in the current diagnostic pathway for heart failure and the opportunities and challenges to potential implementation in primary care.MethodQualitative study using semi-structured in-depth interviews which were audiorecorded and transcribed verbatim. Data from the interviews were analysed thematically using an inductive approach. Fourteen healthcare professionals (six males, eight females) from primary (GPs, nurses, healthcare assistants, and practice managers) and secondary care (consultant cardiologists) participated.ResultsFour themes relating to opportunities and challenges surrounding the implementation of the new diagnostic technology were identified. These reflected that adoption of CORS test would be an advantage to primary care but the test had barriers to implementation which include establishment of clinical utility, suitability for immobile patients, and cost implication to GP practices.ConclusionThe development of a simple non-invasive clinical test to accelerate the diagnosis of heart failure in primary care maybe helpful to reduce unnecessary referrals to secondary care. The CORS test has the potential to serve this purpose however, factors such as cost-effectiveness, diagnostic accuracy, and seamless implementation in primary care have to be fully explored.

NT-proBNP to exclude heart failure in primary care – a pragmatic, cluster-randomized study

Heart failure (HF) is difficult to recognize in primary care. N-terminal pro B-type natriuretic peptide (NT-proBNP) can be used as a rule-out test in HF due to its high negative predictive value. We aim to determine whether the number per 1000 patients of HF diagnoses increase among patients referred from primary care to an outpatient HF clinic, if general practitioners (GPs) were offered NT-proBNP in a real-life setting. All GP practices covered by Randers Regional Hospital were randomized to an intervention group (34 GP practices) and a control group (35 GP practices) in this pragmatic, cluster-randomized controlled trial. The main outcome was the number of patients referred to echocardiography and diagnosed with HF in each group. The number of patients per 1000 diagnosed with HF in the two groups was the same (0.09 (0.02–0.16) vs. 0.14 (0.07–0.21), p = .3541). A total of 700 NT-proBNP analyses, of which 611 were unique, were requested from 31 GP practices in 17.5 months. A total of 184 patients were referred to echocardiography on suspicion of HF. The number of patients per 1000 referred in the intervention group was significantly higher (p < .010). NT-proBNP was measured in 36.6% of referred patients in the intervention group. Significantly more women were diagnosed with HF in the intervention group (56.3% vs. 0%, p = .019). Hence, increased diagnostic effectiveness could not be shown in this real-life setting.

Opportunities and challenges of a novel cardiac output response to stress (CORS) test to enhance diagnosis of heart failure in primary care: qualitative study

ObjectiveTo explore the role of the novel cardiac output response to stress (CORS), test in the current diagnostic pathway for heart failure and the opportunities and challenges to potential implementation...

Frailty and co-morbidity predict first hospitalisation after heart failure diagnosis in primary care: population-based observational study in England.

frailty has only recently been recognised as important in patients with heart failure (HF), but little has been done to predict the first hospitalisation after diagnosis in unselected primary care populations. to predict the first unplanned HF or all-cause admission after diagnosis, comparing the effects of co-morbidity and frailty, the latter measured by the recently validated electronic frailty index (eFI). observational study. primary care in England. all adult patients diagnosed with HF in primary care between 2010 and 2013. we used electronic health records of patients registered with primary care practices sending records to the Clinical Practice Research Datalink (CPRD) in England with linkage to national hospital admissions and death data. Competing-risk time-to-event analyses identified predictors of first unplanned hospitalisation for HF or for any condition after diagnosis. of 6,360 patients, 9% had an emergency hospitalisation for their HF, and 39% had one for any cause within a year of diagnosis; 578 (9.1%) died within a year without having any emergency admission. The main predictors of HF admission were older age, elevated serum creatinine and not being on a beta-blocker. The main predictors of all-cause admission were age, co-morbidity, frailty, prior admission, not being on a beta-blocker, low haematocrit and living alone. Frailty effects were largest in patients aged under 85. this study suggests that frailty has predictive power beyond its co-morbidity components. HF patients in the community should be assessed for frailty, which should be reflected in future HF guidelines.

Heart failure in primary care: prevalence related to age and comorbidity

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. To examine the prevalence of HF in relation to ageing and comorbidities, and routine practice of diagnosing HF in general practice. 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. 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. 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.

Chronic Care Model for the Management of Patients with Heart Failure in Primary Care.

We recently investigated the prognostic impact of a Chronic Care Model (CCM)-based healthcare program applied in primary care in Tuscany Region mainly run by multidisciplinary teams composed of general practitioners (GPs) and nurses. The project included proactively planned follow-up visits for each patient, individualized counselling to optimize lifestyle modifications and adherence to appropriate diagnostic and therapeutic pathways. 1761 patients with Chronic heart failure (CHF) directly enrolled by the GPs were matched with 3522 CHF controls not involved in the project. Over a 4-year follow-up in the CCM group a higher CHF hospitalization rate was found (12.1 vs 10.3 events/100 patient-years; incidence rate ratio [IRR] 1.15, p=0.0030), whereas mortality was lower (10.8 vs 12.6 events/100 patient-years; IRR 0.82, p<0.0001). The CCM status was independently associated with a 34% increase in the risk of CHF hospitalization and a 18% reduction in the risk of death (p<0.0001 for both). The CCM status was associated with a 50% increase in the rate of planned Heart failure (HF) hospitalizations whereas the rate of 1-month CHF readmissions showed no differences. Such a divergent trend could be explained by the direct involvement of GPs in the CCM program, leading them to a better awareness of patients’ clinical status, and then to a more frequent use of clinical pathways and facilities, including hospitalization. It is reasonable to argue that not all hospitalizations must necessarily be considered as a poor outcome, as they often provide additional opportunities to improve therapies, optimize patient education, or define follow-up strategies. The evidence of a divergent trend between mortality and hospitalization in our population might support the clinical importance of a multidisciplinary approach for the management of patients with HF.

Are there patients missing from community heart failure registers? An audit of clinical practice.

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. The design of this study was as an audit of clinical practice at a UK general practice ( n = 9390). 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. 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. 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.

Variation in route to diagnosis of heart failure in primary care in England: analysis of a retrospective cohort between 2010 and 2013

BackgroundHeart failure is common (affecting at least 550 000 people in the UK) and costly, with frequent admission to hospital and high mortality. Diagnosis remains difficult in primary care. We have demonstrated previously that few patients follow a route to diagnosis aligned with National Institute for Health and Care Excellence (NICE) guidelines, suggesting lack of implementation of evidence-based guidelines and variability in provision of care. Therefore, we explored variation in the route to diagnosis of heart failure in primary care by key patient factors and general practice. MethodsWe analysed a retrospective cohort of 13 897 patients (349 general practices) diagnosed with heart failure in England between 2010 and 2013 from a linked primary care database. The primary outcome was receipt of care aligned with NICE guidelines within 6 months of initial presentation with symptoms of heart failure. Explanatory variables were key patient demographics, comorbidities, symptom type, consultation history, and diagnosis route. We used logistic regression to investigate association, funnel plots to visualise variation between practices, and multilevel logistic regression to estimate the intracluster correlation coefficient (ICC). FindingsPatient characteristics significantly associated with the primary outcome were age group, deprivation level, chronic pulmonary disease, presenting symptom type, consultation received for symptom, and diagnosis route (sex or myocardial infarction were not associated). The strongest predictor for care aligned with NICE guidelines was presentation with breathlessness only (odds ratio 3·07, 95% CI 2·40–3·93). The funnel plot showed wide variation in the proportion of patients following NICE guidelines between practices, identifying 45 (13%) outliers. Eight general practices (2%) fell above the upper limit of 3SD of the funnel distribution, and 31 (9%) above the limit of 2SD. Only six practices (2%) fell below the lower limit of 2SD. There was statistically significant variation between practices, and practices accounted for 9% of this variability (ICC 8·6%, p<0·0001). InterpretationA strong association of certain patient characteristics with likelihood of following the recommended NICE pathway suggests potential targets to improve diagnosis and management of heart failure in primary care. We found significant variation in care between general practices, which merits further investigation of practice-level factors. Our findings have potential to better inform implementation of current guidelines, and they demonstrate a useful approach to investigating the implementation of evidence-based guidelines that highlight novel areas for improvement. FundingSupported by the Imperial National Institute for Health Research (NIHR) Biomedical Research Centre and the NIHR Collaboration in Leadership in Applied Health and Care Northwest London.

Real-world presentation with heart failure in primary care: do patients selected to follow diagnostic and management guidelines have better outcomes?

ObjectiveTo describe associations between initial management of people presenting with heart failure (HF) symptoms in primary care, including compliance with the recommendations of the National Institute for Health and Care...