Introduction
Heart failure (HF) is a complex condition that affects more than 26 million people worldwide.1 The prevalence of HF is growing and costs US$108 billion a year globally.2 HF is a highly heterogeneous condition in its presentation and prognosis, so a better understanding of risk may not only improve shared decision making between patients and clinicians but also assist in identifying high-risk patients and facilitate better targeting of monitoring and potentially costly treatments.3–5 Most HF patients in the UK are managed in primary care by general practitioners (GPs). However, GPs face diagnostic uncertainty for patients in whom they suspect HF, which may contribute to a lack in confidence surrounding treatment selection.6–8 Survival has improved modestly in newly diagnosed patients since 2000 in the UK. In an analysis of a linked GP-based research database, the Clinical Practice Research Datalink (CPRD), Taylor et al found that the 5-year survival rate rose from 41.0% in 2000 to 48.2% in 2012, and the 10-year rate rose from 19.8% in 2000 to 26.2% in 2007.9 Survival was worse for those admitted to hospital around the time of diagnosis, for example, 5-year survival was 36.7% vs 51.8% for those without such an admission, and their survival rates improved less over time than those diagnosed in primary care.
Prescribing and subsequent adherence to HF medications is central to reducing HF mortality and morbidity in clinical practice.10 A 2005 study of six European countries including the UK found that treatment guideline adherence for ACE-inhibitors was 88% but only 55% for beta-blockers (BB), indicating variations between medication groups in addition to highlighting a need for improvement.11 The international QUALIFY registry, covering adult patients with reduced ejection fraction in 36 countries, found low rates of baseline prescribing and uptitration, particularly for angiotensin receptor blockers and BBs.12 To our knowledge, only two studies have analysed HF prescribing using CPRD data, which covers all patients with HF. Koudstaal et al13 extracted HF patients from 1997 to 2010 and found renin–angiotensin system blockers (RAS), BB and mineralocorticoid receptor antagonists (MRA) were prescribed 56%, 31% and 10% of the time, respectively, among those managed in solely through primary care. Conrad et al14 analysed medication prescribing in 2014 within 3 months of incident HF, and RAS, BB and MRA prescribing was 80%, 72% and 28%, respectively. Little work has directly compared prescribing trends of HF medications over time using representative data within a community setting.
Our study straddles the introduction of two key England-wide programmes aimed at reducing long-term conditions. In 2004, the Quality and Outcomes Framework (QOF), a pay-for-performance scheme in primary care, was introduced to reward GPs for better managing patients with long-term conditions, including HF. The 2009 saw the initiation of National Health Service (NHS) Health Checks, a primary care screening programme for adults aged 40–74 to detect early signs of stroke, kidney disease, heart disease, type 2 diabetes or dementia. Given this context and to better interpret the differences in mortality between the two cohorts, we also describe changes over that period in compliance with national guidelines (from NICE, the National Institute for Health and Care Excellence) on diagnosis and management in primary care and differences in drug prescription between the two time points.