Heart failure may be missed despite frequent health care contacts before hospitalization

A Canadian cohort study found that patients with acute heart failure had more outpatient physician visits, hospitalizations for unrelated conditions, and ED visits before index hospitalization than those with chronic obstructive pulmonary disease or stable heart failure.

Patients hospitalized for acute heart failure often have increased contact with the health care system without a heart failure diagnosis in the period before their index admission, according to a recent study.

Researchers studied three matched population cohorts in Ontario, Canada, from 2006 to 2013 that were divided into patients with incident hospitalization for acute heart failure, incident hospitalization for chronic obstructive pulmonary disease (COPD), or stable heart failure. The goal of the study was to determine the pattern of health care contacts in patients hospitalized with acute heart failure versus patients in the other two groups. The primary outcome was the aggregate number of health care contacts, defined as total number of outpatient physician visits, hospitalizations for unrelated conditions, or ED visits, in each of the thirteen 28-day periods in the year before the index hospitalization. The results were published Nov. 11 by JACC: Heart Failure.

Overall, 79,389 patients were included in the study, 26,463 in each population cohort. Each cohort included 51.1% women and had a mean age of approximately 75 years. Health care contacts increased significantly in patients with new hospitalization for acute heart failure as the index hospitalization approached, with a 28% increase in the last time period before hospitalization (adjusted rate ratio, 1.28; 95% CI, 1.25 to 1.31; P<0.001) versus matched COPD controls and a 75% increase (adjusted rate ratio, 1.75; 95% CI, 1.71 to 1.79; P<0.001) versus matched controls with stable heart failure. The rate of increase in health care contacts was more significant among heart failure patients ages 20 to 40 years than among those 65 years of age or older (adjusted rate ratio, 1.18; 95% CI, 1.08 to 1.28; P<0.001).

The authors noted that their findings could have been affected by misclassification bias and that they could not account for clustering or for all potential confounders. They concluded that initial hospitalizations for heart failure are preceded by an increased rate of health care contacts that do not always result in a heart failure diagnosis. “Our study confirms that challenges exist in the timely recognition of HF [heart failure] before acute decompensation occurs, which is an important but poorly understood part of the HF patient trajectory,” they wrote. They noted that late recognition of heart failure will lead to more severe disease and higher costs and said that higher suspicion and timely access to tests and imaging could decrease heart failure deterioration and decompensation.

An accompanying editorial said the study is an early step in developing systems based on real-world evidence that can be used by health systems to identify at-risk patients. “The health system is well equipped to react to acute symptoms but less well positioned to be proactive in identifying symptoms across time that may ultimately lead to a health event that requires hospitalization and may even be life-threatening. But, in a digital data world, where clinical, patient-generated, and patient-reported data may flow into analytic engines, there is the prospect of producing platforms that can dynamically assess risk and trigger interventions as necessary to mitigate the threat,” the editorialists wrote. They called for efforts to engage clinicians in primary care, internal medicine, and emergency medicine, who are likely to be the first to evaluate patients, and to improve implementation of monitoring devices, wearables, and other digital tools.