Department of Primary Care Health Sciences, University of Oxford, UK.
Eur J Heart Fail. 2013 Dec;15(12):1335-42. doi: 10.1093/eurjhf/hft107. Epub 2013 Jul 11.
Heart failure (HF) is an important clinical problem. Expert consensus has defined HF as a primary care-sensitive condition for which the risk of unplanned admissions may be reduced by high quality primary care, but there is little supporting evidence. We analysed time trends in HF admission rates in England and risk and protective factors for admission.
We used Hospital Episodes Statistics to produce indirectly standardized HF admission counts by general practice for 2004-2011. Clustered negative binomial regression analysis produced admission risk ratios and assessed the significance of potential explanatory covariates. These included population factors (deprivation; HF, coronary heart disease, and smoking prevalence), primary care resourcing [access; general practitioner (GP) supply], and primary care quality ('Quality and Outcomes Framework' indicator.) There were 327,756 HF admissions of patients registered with 8405 practices over the study period. There was a significant reduction in admissions over time, from 6.96/100,000 in 2004 to 5.60/100,000 in 2010 (P < 0.001). Deprivation and HF prevalence were risk factors for admission. GP supply and access protected against admission. However, these effects were small and did not explain the large and highly significant annual trend in falling admission rates.
The observed fall in admissions over time cannot be explained by the primary care covariates we included. This analysis suggests that the potential for further significant reduction in emergency HF admissions by improving clinical quality of primary care (as currently measured) may be limited. Further work is required to identify the reasons for the reduction in admissions.
心力衰竭（HF）是一个重要的临床问题。专家共识将 HF 定义为一种初级保健敏感状况，通过高质量的初级保健可以降低其非计划性住院的风险，但支持这一观点的证据很少。我们分析了英国 HF 入院率的时间趋势以及入院的风险和保护因素。
我们使用医院住院统计数据，通过一般实践为 2004-2011 年制作了 HF 间接标准化入院计数。聚类负二项回归分析产生了入院风险比，并评估了潜在解释性协变量的意义。这些协变量包括人口因素（贫困；HF、冠心病和吸烟流行率）、初级保健资源（可及性；全科医生供应）和初级保健质量（“质量和结果框架”指标）。在研究期间，有 327756 名登记在 8405 个实践中的患者患有 HF 入院。入院人数随时间显著减少，从 2004 年的 6.96/100000 减少到 2010 年的 5.60/100000（P<0.001）。贫困和 HF 流行率是入院的危险因素。GP 供应和可及性可预防入院。然而，这些效果很小，无法解释入院率大幅且显著的年度下降趋势。
随着时间的推移，观察到的入院人数下降不能用我们纳入的初级保健协变量来解释。这项分析表明，通过提高初级保健的临床质量（如目前所衡量的）进一步显著降低急诊 HF 入院的潜力可能有限。需要进一步工作来确定入院人数减少的原因。
