Department of Primary Care and Public Health, Imperial College London, London, UK.
Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK.
Heart. 2019 May;105(9):678-685. doi: 10.1136/heartjnl-2018-313971. Epub 2018 Dec 4.
Clinical guidelines on heart failure (HF) suggest timings for investigation and referral in primary care. We calculated the time for patients to achieve key elements in the recommended pathway to diagnosis of HF.
In this observational study, we used linked primary and secondary care data (Clinical Practice Research Datalink, a database of anonymised electronic records from UK general practices) between 2010 and 2013. Records were examined for presenting symptoms (breathlessness, fatigue, ankle swelling) and key elements of the National Institute for Health and Care Excellence-recommended pathway to diagnosis (serum natriuretic peptide (NP) test, echocardiography, specialist referral).
42 403 patients were diagnosed with HF, of whom 16 597 presented in primary care with suggestive symptoms. 6464 (39%) had recorded NP or echocardiography, and 6043 (36%) specialist referral. Median time from recorded symptom(s) to investigation (NP or echocardiography) was 292 days (IQR 34-844) and to referral 236 days (IQR 42-721). Median time from symptom(s) to diagnosis was 972 days (IQR 337-1468) and to treatment with HF-relevant medication 803 days (IQR 230-1364). Factors significantly affecting timing of referral, treatment and diagnosis included patients' sex (p=0.001), age (p<0.001), deprivation score (p=0.001), comorbidities (p<0.001) and presenting symptom type (p<0.001).
Median times to investigation or referral of patients presenting in primary care with symptoms suggestive of HF considerably exceeded recommendations. There is a need to support clinicians in the diagnosis of HF in primary care, with improved access to investigation and specialist assessment to support timely management.
心力衰竭（HF）的临床指南建议在初级保健中进行调查和转诊的时间。我们计算了患者实现 HF 推荐诊断途径关键要素的时间。
在这项观察性研究中，我们使用了 2010 年至 2013 年期间链接的初级保健和二级保健数据（临床实践研究数据链接，一个来自英国普通实践的匿名电子记录数据库）。记录了患者的主要症状（呼吸困难、疲劳、脚踝肿胀）和国家卫生与保健卓越研究所推荐的诊断途径的关键要素（血清钠尿肽（NP）检测、超声心动图、专科转诊）。
42403 例患者被诊断为 HF，其中 16597 例在初级保健中出现提示性症状。6464 例（39%）记录了 NP 或超声心动图，6043 例（36%）专科转诊。从记录的症状到检查（NP 或超声心动图）的中位数时间为 292 天（IQR 34-844），到转诊的中位数时间为 236 天（IQR 42-721）。从症状到诊断的中位数时间为 972 天（IQR 337-1468），到 HF 相关药物治疗的中位数时间为 803 天（IQR 230-1364）。影响转诊、治疗和诊断时间的因素包括患者的性别（p=0.001）、年龄（p<0.001）、贫困评分（p=0.001）、合并症（p<0.001）和主要症状类型（p<0.001）。
在初级保健中出现提示 HF 症状的患者进行调查或转诊的中位数时间大大超过了建议。需要支持临床医生在初级保健中诊断 HF，改善调查和专科评估的机会，以支持及时管理。
