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Vol. 54. Núm. 8.
(agosto 2022)
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Visitas
1112
Vol. 54. Núm. 8.
(agosto 2022)
Original article
Open Access
Burden of heart failure in primary healthcare
Impacto de la insuficiencia cardíaca en la atención primaria
Visitas
1112
Felipe-Estuardo Gonzalez-Loyolaa,b, Miguel-Angel Muñoza,c,d,
Autor para correspondencia
mamunoz.bcn.ics@gencat.cat

Corresponding author.
, Elena Navasa, Jordi Reala, Ernest Vinyolesa,c, José-Maria Verdú-Rotellara,c,d
a Unitat de Suport a la Recerca de Barcelona, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
b Departament de Pediatría, Obstetricia i Ginecología i Medicina Preventiva, Programa de Doctorat en Metodología de la Recerca BIomèdica, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
c Gerència d’Àmbit d’Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, Spain
d Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
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Abstract
Objectives

To determine the epidemiology of heart failure registered in primary healthcare clinical records in Catalunya, Spain, between 2010 and 2014, focusing on incidence, mortality, and resource utilization.

Design

Retrospective observational cohort study.

Setting

Study was carried out in primary care setting.

Participants and interventions

Patients registered as presenting a new heart failure diagnosis. The inclusion period ran from 1st January 2010 to 31st December 2013, but patients were followed until 31st December 2013 in order to analyze mortality.

Main measures

Information came from electronic medical records.

Results

A total of 64441 patients were registered with a new diagnosis of heart failure (2.76 new cases per 1000 persons-year). Among them, 85.8% were ≥65 years. The number of cases/1000 persons-year was higher in men in all age groups. Incidence ranged from 0.04 in women <45 years to 27.61 in the oldest group, and from 0.08 in men <45 years to 28.52 in the oldest group. Mortality occurred in 16305 (25.3%) patients. Primary healthcare resource utilization increased after the occurrence of heart failure, especially the number of visits made by nurses to the patients’ homes.

Conclusion

Heart failure incidence increases with age, is greater in men, and remains stable. Mortality continues to be high in newly diagnosed patients in spite of the current improvements in treatment. Home visits represent the greatest cost for the management of this disease in primary care setting.

Keywords:
Primary healthcare
Heart failure
Epidemiology
Healthcare resource utilization
Resumen
Objetivo

Determinar la epidemiología de la insuficiencia cardíaca registrada en las historias clínicas de atención primaria en Cataluña, España, entre 2010 y 2014, centrándose en la incidencia, la mortalidad y la utilización de recursos sanitarios.

Diseño

Estudio de cohorte observacional retrospectivo.

Emplazamiento

El estudio se llevó a cabo en atención primaria.

Participantes e intervenciones

Pacientes registrados con nuevo diagnóstico de insuficiencia cardíaca en el período de estudio. El período de inclusión fue del 1 de enero de 2010 al 31 de diciembre de 2013, pero los pacientes se siguieron hasta el 31 de diciembre de 2014 para poder determinar la mortalidad.

Mediciones principales

La información se obtuvo de la historia clínica electrónica de los participantes.

Resultados

Se registraron un total de 64.441 pacientes con nuevo diagnóstico de insuficiencia cardíaca (2,76 nuevos casos/1000 personas-año). De ellos, el 85,8% tenían ≥65 años. El número de casos/1000 personas-año fue mayor en hombres en todos los grupos de edad. La incidencia varió de 0,04 en mujeres <45 años a 27,61 en el grupo de mayor edad, y de 0,08 en hombres <45 años a 28,52 en el grupo de mayor edad. La mortalidad se produjo en 16.305 (25,3%) pacientes. La utilización de los recursos de atención primaria aumentó tras el diagnóstico de insuficiencia cardíaca, especialmente el número de visitas realizadas por las enfermeras a los pacientes en su domicilio.

Conclusión

La incidencia de insuficiencia cardíaca aumenta con la edad, es mayor en hombres y se mantiene estable en el tiempo. La mortalidad continúa siendo alta en pacientes recién diagnosticados a pesar de las mejoras actuales en el tratamiento. Las visitas domiciliarias representan el mayor coste para el manejo de esta enfermedad en el ámbito de atención primaria.

Palabras clave:
Atención primaria
Insuficiencia cardiaca
Epidemiología
Utilización de recursos sanitarios
Texto completo
Introduction

Heart failure (HF) is a growing public health concern and accounts for 1% of the general adult population.1 In Spain more than 10% of those aged >70 years are affected by HF, and it has become the third leading cause of death.2 Moreover, since current therapies prolong the lives of HF patients in the following decades its incidence is expected to increase.3 This does, however, depend on the diagnostic criteria employed and population studied,4 HF epidemiology has changed, and a decline in incidence has even been reported.5

A recent Spanish publication, using an administrative database to identify HF codified according to the International Codification Disease 9th revision (CIE-9), reported an incidence of 2.78 per 1000 persons-year.6

An ever-increasing number of healthcare resources are employed in attending HF patients.7–9 In Europe the economic burden of managing HF accounts for almost 7% of the global healthcare expenditure,10 the main cost coming from hospitalizations.11,12 Although there has been an improvement in prognosis, mortality in the first three years following diagnosis remains close to 25%.13,14

This study aims to determine the epidemiology of HF registered in the primary healthcare records in Catalunya, Spain, between 2010 and 2013. It focuses on HF incidence, mortality, and PHC resource utilization.

MethodsStudy design

A retrospective observational cohort study based on PHC electronic medical records (EMR). Its objective was to determine the incidence, healthcare resource utilization, and mortality of HF patients attended in PHC.

Study period

The study period ran from 1st January 2010 until 31st December 2013, but patients were followed until 31st December 2013 in order to analyze mortality.

Study population

Information came from the EMR of PHC patients ≥18 years attended at any of the 279 centres managed by the Catalan Institute of Health, Spain.

Variables

To estimate incidence we analyzed the new HF cases that occurred among the 5165778 individuals residing in Catalunya during the study period who were free from this disease at baseline.

Comorbidities and demographic information were taken at the moment of HF onset. Mortality was calculated as all-cause death for the incident cases.

Age, gender, body mass index (BMI), smoking status, alcohol consumption, and associated comorbidities were also recorded.

Diagnoses were registered following the International Classification of Diseases, Tenth Revision (ICD-10) codes: heart failure [HF(I50)], dementia (F00–F03), anaemia (D50–D64), atrial fibrillation [AF(I48)], cancer (C00–C97), chronic kidney disease [CKD(N18)], chronic obstructive pulmonary disease [COPD(J40–J44)], diabetes mellitus(E10–E14)], depression (F32–F33), lipoprotein metabolism disorders and other lipidaemias (E78), hypertension (I10–I15), peripheral artery disease (I73.9), coronary heart disease [CHD(I20–I25)], stroke (I63–I65), and obesity (E66.0–66.2, E66.8–E66.9).

Data sources

Data were obtained from the SIDIAP database (Information System for the Enhancement of Research in Primary Care)15 which stores records from routine PHC clinical practice. An anonymization algorithm was used to encrypt the information.

Costs and healthcare resource utilization were calculated according to the following: PHC nurse consultations/home visits, laboratory tests, PHC General Practitioner (GP) consultations/home visits, and primary care emergency consultations.

Statistical analyses

Continuous variables were summarized and mean and standard deviations calculated to describe the cohorts. Categorical variables were summarized by frequency and percentage.

The incidence of HF was computed between 2010 and 2013 in the population at risk without prior HF diagnosis on 1st January 2010. Incidence rates were calculated as the number of patients with HF divided by the sum of all individual-time at risk out of 5165778 subjects. In order to determine mortality, patients were followed until 31st December 2014.

All-cause mortality rates for patients in the incident cohort were computed as the number of patients who died divided by the sum of all individual-time at risk since the diagnosis was recorded. Individual-time at risk for the outcome was defined as the number of days from incidence date to the date of death or to end of follow-up, whichever occurred first.

Cox regression models were performed to estimate mortality rate related with comorbidities. Crude and adjusted hazard ratios (HR) with their 95% confidence interval (95%CI) were calculated. The models were constructed using the covariates clinically associated with HF incidence. Furthermore, the HR were computed specifically by age group. Resource utilization was assessed before and after HF diagnosis.

Data management and statistical analysis were performed with R3.5.1 statistical package.

Ethics

The study protocol was approved by the Clinical Research Ethics Committee, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) (Ref: P15/147). All data were anonymized, and EMR confidentiality was respected in accordance with national and international regulations regarding personal data protection.

ResultsIncidence

Median follow-up was 21 (interquartile interval 10–36) months.

A total of 64441 patients had a new HF diagnosis recorded between 2010 and 2014, a figure that represents 2.76 new cases per 1000 persons-year. Among the patients 85.8% were >65 years.

Men presented higher rates of smoking, alcohol consumption, type 2 diabetes mellitus, chronic pulmonary disease, myocardial infarction, and cancer. Women presented higher rates for obesity, anaemia, atrial fibrillation, depression, dyslipidemia, and hypertension (Table 1). The incidence of HF remained stable along the study period.

Table 1.

Characteristics of incident heart failure cases.

  Total  Women  Men  p-value 
  N=64441  N=35832  N=28609   
  N (%)  N (%)  N (%)   
Age (years)        0.000 
<45  804 (1.2)  257 (0.7)  547 (1.9)   
45–54  2190 (3.4)  609 (1.7)  1581 (5.5)   
55–64  6105 (9.4)  2209 (6.1)  3896 (13.6)   
65–74  14518 (22.5)  7164 (20.0)  7354 (25.7)   
75–84  27959 (43.4)  16664 (46.5)  11295 (39.5)   
≥85  12865 (20.0)  8929 (24.9)  3936 (13.8)   
Risk factors
Smoking  6049 (9.3)  1232 (3.4)  4817 (16.8)  0.000 
Alcohol  10633 (16.5)  2565 (7.1)  8068 (28.2)  0.000 
Hypertension  49384 (76.6)  28931 (80.7)  20453 (71.5)  <0.001 
Dyslipidaemia  29481 (45.7)  16892 (47.1)  12589 (44.0)  <0.001 
Obesity  18363 (28.5)  11415 (31.9)  6948 (24.3)  <0.001 
Diabetes  22093 (34.3)  11267 (31.4)  10826 (37.8)  <0.001 
Cardiovascular comorbidity
Peripheral artery disease  4321 (6.7)  1322 (3.6)  2999 (10.5)  <0.001 
Acute myocardial infarction  5709 (8.8)  1804 (5.0)  3905 (13.6)  <0.001 
Atrial fibrillation  21985 (34.1)  12382 (34.6)  9603 (33.6)  0.009 
Non-cardiovascular comorbidities
Anaemia  12674 (19.7)  7604 (21.2)  5070 (17.7)  <0.001 
Cancer  9429 (14.6)  4282 (12.0)  5147 (18.0)  <0.001 
Chronic kidney disease  12506 (19.4)  6962 (19.4)  5544 (19.4)  0.879 
Chronic obstructive pulmonary disease  11867 (18.4)  3526 (9.8)  8341 (29.2)  0.000 
Depression  7540 (11.7)  5601 (15.6)  1939 (6.7)  <0.001 
Mortality during follow-up  16305 (25.3)  8709 (24.3)  7596 (26.6)  <0.001 

Incidence rates (cases/1000 person/year) in women ranged from 0.04 cases/1000 person/year in those <45 years to 27.61 in the oldest subjects, and from 0.08 in men <45 years to 28.52 in the oldest subjects (Table 2).

Table 2.

Heart failure incidence according to gender and age.

Age groups  WomenMen
  Incidente cases  Cumulate incidence  Cases/1000 persons/year  Incidente cases  Cumulate incidence  Cases/1000 person/year 
<45  257  0.02%  0.04  547  0.03%  0.08 
45–54  609  0.14%  0.31  1.581  0.37%  0.80 
55–64  2.209  0.65%  1.37  3.896  1.22%  2.62 
65–74  7.164  2.77%  5.97  7.354  3.26%  7.24 
75–84  16.664  7.61%  17.75  11.295  7.50%  18.29 
≥85  8.929  9.22%  27.61  3.936  9.06%  28.52 
Mortality

Among the patients who presented incident HF between 1st January 2010 and 31st December 2014, a total of 16305 (25.3%) died during follow-up. Mortality was higher in men than in women (26.6% versus 24.3%, p<0.001, respectively) (Fig. 1).

Figure 1.

Mortality in incident heart failure patients between 2012 and 2014.

Panel A: mortality according to age groups

Panel B: mortality according to sex and age.

(0,42MB).

A total of 10068 patients died during the first year of follow-up (15.6%). This percentage represented 61.7% of mortality in the whole period.

Healthcare resource utilization and costs

Before the first registered HF episode, the median number of consultations with the GP and nurse at the PHC was 19 (interquartile interval 9–34) and 12 (interquartile interval 5–27), respectively. After the first episode, the median number of consultations at the PHC with the GP were 16 (interquartile interval 7–30) and 12 (interquartile interval 5–28) with the nurse. Home visits by the GP increased from 2 (interquartile interval 1–4) to 3 (interquartile interval 1–6) whilst those made by the nurse rose from 3 (interquartile interval 1–10) to 5 (interquartile interval 2–14).

Primary care emergencies were used at least once by 7.27% of the patients following HF diagnosis.

The total number of encounters with PHC professionals increased dramatically after HF occurrence, especially regarding the number of home visits made by the nurses (from 181826 to 318662). The total cost for the PHC as a consequence of HF diagnosis was approximately 223.31 euros/individual/year. When compared to the figure prior to diagnosis this represents a difference of 4553411 euros for the 64441 patients. The global cost was higher in women, who represented the 55.6% of the sample (Table 3).

Table 3.

Differences in primary healthcare resource utilization and costs before and after diagnosis of heart failure by sex (women: 35832 (55.6%) and men 28609 (44.4%).

  Total of encounters (N)Total cost (€)
  After HFa diagnosisBefore HF diagnosisAfter HF diagnosisBefore HF diagnosis
  Total  Women  Men  Total  Women  Men  Total  Women  Men  Total  Women  Men 
Type of consultation
Nurse at PHCb  1222671  652104  570567  1198277  657062  541215  34234788  18258912  15975876  33551756  18397736  15154020 
Nurse at patient's home  318662  208595  110067  181826  126576  55250  14339790  9386775  4953015  8182170  5695920  2486250 
Laboratory testc  164861  90567  74294  180531  99885  80646  1500235  824160  676075  1642832  908954  733879 
General practitioner at PHCb  1320889  741253  579636  1526364  870065  656299  52835560  29650120  23185440  61054560  34802600  26251960 
General practitioner visit at patient's home  128248  83651  44597  86240  59298  26942  8336120  5437314  2898806  5605600  3854370  1751230 
Primary care emergency visits  30640  16039  14601  8406  4945  3461  1838400  962340  876060  504360  296700  207660 
Total  3185971  1792209  1393762  3181644  1817831  1363813  113084893  64519621  48565272  110541278  63956280  46584999 
  Yearly person cost (€)
  After HFa diagnosisBefore HF diagnosis
  Total  Women  Men  Total  Women  Men 
Type of consultation
Nurse at PHCb  268.68  254.55  286.90  201.60  199.33  204.43 
Nurse at patient's home  112.54  130.86  88.95  49.16  61.71  33.54 
Laboratory testc  11.77  11.49  12.14  9.87  9.85  9.90 
General practitioner at PHCb  414.67  413.35  416.37  366.85  377.08  354.14 
General practitioner visit at patient's home  65.42  75.80  52.06  33.68  41.76  23.62 
Primary care emergency visits  14.42  13.42  15.73  3.03  3.21  2.80 
Total  887.50  899.47  872.15  664.19  692.95  628.43 
a

Heart failure.

b

Primary healthcare.

c

Includes the following (haemoglobin, total cholesterol, HDL cholesterol, LDL cholesterol, fasting blood glucose, glycosylated haemoglobin in diabetics, creatinine, glomerular filtration rate.

DiscussionMain findings

Incidence of HF increased dramatically with age and was greater in men, particularly in the younger strata populations. Mortality in incident HF patients grew steadily across the age groups, it was ten-fold higher in the oldest group, and was also higher in men. We observed an increment in PHC resource utilization after the first episode of HF registered in the clinical records.

Several factors have been identified in the literature explaining differences in incidence rates. They include methodologies, diagnosis criteria, and HF approaches employed by local health systems. Moreover, it has been reported that diagnosis could be confirmed in only half of the patients labelled as HF in the PHC records.16

Age-adjusted HF incidence may tend to decrease in western countries, possibly due to optimized cardiovascular risk factor management.17 Our findings show that HF incidence remained almost stable along the study period and was much lower in the youngest subjects compared to the oldest. A study from administrative databases in Spain found similar rates to those described in our population.6 The incidence observed by the Rotterdam study was 1.4%.18 Similar results in a Swedish one analysing information from an administrative database.19

Regarding mortality, a meta-analysis of 1.5 million HF patients observed an 87% survival rate the first year and 35% five years after diagnosis. Five-year survival, however, increased from 29.1% in the period before 1979 to 59.7% in the period 2000–2009.20

After a median follow-up of 5 years, a study based on England, found up to 56.1% mortality among incident HF patients.21 A recent publication from Spain found a mortality rate of 14% and was even higher in hospitalized patients (24%).22

Healthcare resource utilization may be approached from a number of perspectives, depending on setting, healthcare system, and variables analyzed. A publication from Spain described a lower number of PHC consultations, but higher emergency care use, in HF patients. Findings probably were due to the sample taken from secondary care and because all subjects were symptomatic at the inclusion baseline.23

In agreement with our research, it has been observed that the highest costs regarding HF patients are related to hospitalization episodes, and, in second term, PHC home visits.24 Findings that concur with another study from an administrative database in Catalunya (Spain) in which the main expense was attributable to hospitalization.25

The number of GP and the PHC nurse home visits increased after the first HF episode, probably due to the inherent limitations of the patient's new condition.

Strengths and limitations

We analyzed the registered diagnosis from an administrative database oriented towards clinical purposes. It is possible, therefore, that the percentage of HF diagnoses was lower than expected.

Other variables could have been included in the resource utilization category such as medication. Nevertheless, as specific HF medication is usually prescribed by cardiologists after the first HF episode we cannot attribute the cost exclusively to the PHC setting.

Data from this study period do not allow discrimination between reduced and preserved ejection fraction, since this variable was not registered systematically at that time and we found some missing values.

Conclusion

Incidence of HF in the adult population increases with age, is greater in men, and remains stable. Mortality continues to be high in newly diagnosed HF patients in spite of the current, improved treatment. The greatest expense resulting from HF management in the PHC setting is due to home visits.

Conflict of interests

None declared.

Acknowledgements

The authors gratefully acknowledge Novartis Pharma AG for partially funding this project, and SIDIAP database for providing data.

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