Trends in heart failure care: has the incident diagnosis of heart failure shifted from the hospital to the emergency department and outpatient clinics?
OBJECTIVE
Studies of heart failure (HF) incidence and prevalence frequently rely on hospitalization to identify patients. Our objective was to describe the incidence, prevalence, or outcomes for HF patients diagnosed in the outpatient or emergency department (ED) setting.


RESULTS
In a population-based study of 82,323 HF patients in a single-payer health-care system in Alberta, Canada from 1999 to 2007, we examined trends over time and clinical outcomes. Heart failure patients were first diagnosed in a general outpatient clinic (45.7%), a specialty outpatient clinic (4.0%), the ED (13.7%), or in hospital (36.6%). From years 2000 to 2006, the age-standardized incidence (per 100 000 population) decreased from 538 to 403, whereas the overall prevalence increased from 1585 to 2510. One-year mortality was significantly different among patients first diagnosed in a general outpatient clinic (6.6%), a specialty outpatient clinic (7.5%), ED (19.1%), and hospital (29.8%). Patients initially diagnosed at the time of hospitalization had the fewest median days alive and out of hospital [347, inter-quartile range (IQR): 136-363] over the next year compared with patients in the ED (354, IQR 313-365), specialty outpatient clinic (365, IQR 355-365), and general outpatient clinics (365, IQR: 359-365, P < 0.0001). Patients in the ED had the highest rate of subsequent ED visits, and all-cause, cardiovascular, or HF hospitalization.


CONCLUSIONS
Over time, more patients were diagnosed as outpatients compared with a hospital setting. The trends observed in incidence, prevalence, and outcomes for patients with HF differ substantially depending on the location of initial diagnosis. Additionally, efforts to study patients with HF in the ED should be a priority.
Division of Cardiology 2C2 WMC, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada. justin.ezekowitz@ualberta.ca
Justin A
JA
Ezekowitz
Padma
P
Kaul
Jeffrey A
JA
Bakal
Hude
H
Quan
Finlay A
FA
McAlister
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta / Q000453:epidemiology; D000553:Ambulatory Care / Q000639:trends; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data* / Q000639:trends; D000704:Analysis of Variance; D015331:Cohort Studies; D016001:Confidence Intervals; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data* / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006333:Heart Failure / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D006760:Hospitalization / Q000706:statistics & numerical data* / Q000639:trends; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D015995:Prevalence; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult