Introduction Heart failure (HF) is associated with significant morbidity and the prognosis is frequently poor. Symptoms, quality of life and outcome can be hugely improved by the implementation of appropriate evidence based therapies by a specialist multidisciplinary team. Current NICE guidelines therefore recommend that patients with suspected HF and raised natriuretic peptides are seen for echocardiography and specialist assessment within 2 or 6 weeks of referral. We established a dedicated HF clinic locally; natriuretic peptides are checked in primary care and patients with a positive result are referred via fax. Given the time-critical nature of these guidelines we investigated local adherence to the 2 and 6-week targets and the interval from a positive natriuretic result in primary care to referral.
Methods Information on the referral pathway was disseminated to all primary care referrers. Patient data were prospectively collected after establishment of the HF clinic in February 2014 to the end of November 2015. The interval from a positive NTproBNP result to referral and the interval from referral to appointment were calculated. Basic demographic data, NTproBNP level and the final specialist opinion as to whether the patient had heart failure were also collated. Patients with incomplete data sets were excluded.
Results A total of 432 patients were included. 226 (52%) were female and 206 (48%) male. Mean age was 78 ± 9 and mean NTproBNP 3101 ± 4445 pg/ml. 239 (55%) patients had a diagnosis of HF following review, of these 123 (51.5%) had a reduced ejection fraction and 116 (48.5%) a preserved ejection fraction.
All 212 (100%) patients were offered an appointment within the 6 week target and 211 (97%) within the 2 week target. 9 patients (4%) in the 2 week pathway and 3 (1%) in the 6 week pathway declined the appointment that was offered and where therefore seen beyond the target timeframe.
There were significant delays between the positive NTproBNP result and referral to the HF clinic (Table 1). Most notably for the 2 week pathway the mean interval from a positive NTproBNP to referral was longer than the interval from referral to appointment (16 days versus 11 days respectively). One patient was referred 124 days after the positive NTproBNP result.
Conclusion The purpose of including referral-time targets in the NICE guidelines is so that patients with suspected HF are seen rapidly as they are at high risk of adverse outcome. Despite offering a service compliant with these targets we’ve identified significant delays between a positive NTproBNP result in primary care and referral to clinic. This unnecessary delay may have an adverse effect on outcome. Further refinement of the primary care aspect of the referral pathway is required.
- Improving Outcomes
- Referral Pathway
- NICE Adherance
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