Heart Failure Diagnoses Often Missed in Primary Care Setting

By Lisa Rapaport

July 29, 2021

(Reuters Health) - Many patients with heart failure are not diagnosed until they seek care in an acute setting, particularly female and Black patients, a U.S. study suggests.

Researchers examined commercial insurance claims data and Medicare Advantage data for 959,438 patients with a new heart failure diagnosis between 2003 and 2019. Overall, 38% of patients were diagnosed in acute care settings, and 46% of those diagnosed in acute care had potential heart failure symptoms in the previous six months.

Women were significantly more likely than men to be diagnosed in acute settings rather than primary care (adjusted odds ratio 1.11). And Black patients were significantly more likely than white patients to be diagnosed in acute care settings (aOR 1.18).

"Unfortunately, this is not a surprising finding given the disparities that are present throughout the healthcare system for women and racial minorities," said lead study author Dr. Alex Sandhu, an instructor of medicine at Stanford University in California.

The study findings suggest that clinicians may need a lower threshold for evaluating patients for heart failure, Dr. Sandhu said by email.

"This may be increasing the use of natriuretic peptide testing among patients with unexplained symptoms given its high sensitivity for identifying heart failure, or arranging for faster follow-up for symptomatic patients diagnosed with alternate conditions to ensure they improve with initial treatment," Dr. Sandhu said.

Beyond this, primary care clinicians likely need more time with complex symptomatic medical patients to improve diagnosis, and, in many locations, need better access to specialists like cardiologists and testing such as echocardiography, Dr. Sandhu added.

During the study period, the odds of heart failure diagnosis happening in an acute care setting increased by 3.2% annually, the analysis found.

Among patients not diagnosed with heart failure until a hospital admission or emergency department visit, 15% had edema in the previous six months. Many also had other potential heart failure symptoms in the previous six months including cough (12%), shortness of breath (11%), and chest pain (11%), the study team reports in Circulation: Heart Failure.

Patients with the lowest net worth, less than $25,000, were significantly more likely to be diagnosed in acute care settings than patients with the highest net worth, above $500,000 (aOR 1.39).

In addition, patients who identified their occupation as "retired" or "homemaker" were significantly more likely to be diagnosed in acute care settings (aOR 1.04) than those categorized in professional jobs.

Like all claims-based studies, one limitation of the analysis is that researchers only had limited insight into the clinical characteristics and comorbidities of each heart failure case, the authors note.

Even so, the results suggest that heart failure diagnoses are commonly missing in the outpatient setting, said Dr. Gregg Fonarow, co-director of the preventive cardiology program at the David Geffen School of Medicine at the University of California, Los Angeles.

"As other studies have shown less diagnostic testing and lower quality of care for women and minority populations presenting with cardiovascular disease, including heart failure, these results for heart failure diagnosis timing suggest there may be explanations in common," Dr. Fonarow, who wasn't involved in the study, said by email.

"Initiatives are needed to improve the timeliness and accuracy of heart failure diagnoses and reduce the gaps and disparities observed in this important study," Dr. Fonarow said.

SOURCE: https://bit.ly/3zJX53N Circulation: Heart Failure, online July 27, 2021.