Management of heart failure in primary care after implementation of the National Service Framework for Coronary Heart Disease: a cross-sectional study
Introduction
Heart failure is one of the more common chronic diseases seen by general practitioners, affecting about 0.5–1% of the population.1 It is most common in older people and, until relatively recently, its public health importance has been underestimated. However, the impact of heart failure on both patients and the National Health Service (NHS) is being increasingly recognized. For example, people with heart failure have 5-year survival rates comparable to that of colorectal cancer,2 and a worse quality of life than people with illnesses such as diabetes.3 Heart failure is also one of the most common reasons for hospital admission among the elderly, and accounts for a significant proportion of NHS spending on inpatient care.4
The publication in March 2000 of the National Service Framework (NSF) for Coronary Heart Disease (CHD) set national standards for improving the diagnosis and treatment of heart failure.5 Primary healthcare teams will have a key role in ensuring that the NSF standards are met because they treat most of the patients with heart failure. They also act as gatekeepers to hospital care for patients who need specialist services, such as an echocardiogram, or a consultation with a cardiologist or elderly care physician.
The NSF requires general practitioners to establish practice-based disease registers for heart failure as a first step towards improving the systematic care of patients. Although the usefulness of a register depends on an accurate diagnosis, research suggests that heart failure is both underdiagnosed and misdiagnosed in primary care.6 Furthermore, although appropriate drug therapy is the mainstay of heart failure management, many patients do not receive optimal drug treatment.7, 8
The main objective of this study was to compare the investigation and treatment of patients with heart failure in primary care against the NSF standards (Box 1). A second objective was to examine whether differences in management were associated with factors such as the age and sex of the patient. The study was carried out among practices participating in the Kent, Surrey and Sussex Primary Care Research Network. All the practices were fully computerized, had extensive experience of collecting morbidity information, and were interested in using information technology to improve the services they provide.
Section snippets
Methods
This study was carried out in 26 general practices, with a total registered population of 256,188, that participate in the Kent, Surrey and Sussex Primary Care Research Network. Before the study started, three local meetings were held for the participating practices to send representatives to discuss the protocol and the plan to collect data from practice computers. Comments from the participants were incorporated into the protocol and the data-collection plan.
Between June 2002 and January
Results
In total, there were 2129 patients with heart failure; an overall prevalence of 8.3 per 1000, consistent with the 0.5–1.0% range seen in previous studies. Rates increased with age, from 0.2 per 1000 in people aged under 35 years of age to 125 per 1000 in those aged 85 years and over (Table 1). Age-specific rates were a little higher in males than females but the overall crude prevalence was higher in females because there are more elderly women than men. As heart failure was rare in younger
Discussion
The prevalence of heart failure in our study (8 per 1000) was similar to the 5–10 per 1000 reported in most previous studies.1 We found that prevalence rates increased with age and were substantially higher in people aged 85 years and over than in any other age group. People with heart failure had high levels of cardiovascular comorbidity (CHD, hypertension and atrial fibrillation) and diabetes, illustrating the complexity of managing these patients. This high level of comorbidity may be one of
Conclusions
Our study of heart failure management showed higher levels of use of drugs such as ACE inhibitors than previous studies, which suggests that the NSF may be starting to have an impact. However, confirmation of diagnosis by echocardiography, and its documentation on patients's computerized records, needs to be improved. We have fed back data on their own performance to each of the 26 practices in the study using a previously established method.19 We now plan to work with the practices and the
Acknowledgements
We thank the 26 general practices that took part in this study, and Nigel Hague and Ross Lawrenson for their advice. AM holds a National Primary Care Scientist Award, funded by the Department of Health. The Kent, Surrey and Sussex Research Network is funded by the Department of Health.
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