Specialty vs Primary Care Follow-up for Patients With Heart Failure

African American female nurse helping senior 70s woman stand up out of bed in hospital
Investigators compared specialty vs primary care follow-up and outcomes in patients with heart failure.

In patients with heart failure (HF), the need exists to improve identification of individuals who require specialty care and to enhance the use of guideline-recommended treatments for HF in primary care while working to avoid unjustified inequalities in referrals in public health. These findings were published in the journal ESC Heart Failure.

Researchers sought to evaluate the proportion of, the independent predictors of, and the outcomes associated with the use of follow-up in specialty care compared with primary care in a large, unselected patient population with HF. The study focused on the different ejection fraction (EF) phenotypes and cause-specific outcomes. In this study, the Swedish HF registry (SwedeHF) was linked with Statistics Sweden, which provided socioeconomic data; the Swedish National Patient Registry, which provided additional comorbidities and the outcome associated with HF hospitalization (according  to ICD-10 codes); and the Cause of Death Registry, which provided data on all-cause and cardiovascular (CV) mortality.

Patients registered in SwedeHF from 2000 to 2018, with available data on ejection fraction and planned follow-up in specialty or primary care, were included in the study. Heart failure with reduced ejection fraction (HFrEF), heart failure with mildly reduced ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF) were defined according to 2016 European guidelines on HF, with ejection fraction of less than 40%, 40% to 49%, and 50% or more, respectively.

Among a total of 75,518 patients included in the study, 52.5% had HFrEF, 23.5% had HFmrEF, and 24.1% had HFpEF. The median participant age in the overall population was 76 years (IQR, 67-83 years), which increased according to ejection fraction status (median age 74 years [IQR, 66-82 years], 76 years [IQR, 67-83 years], and 79 years [IQR, 72-89 years] in those with HFrEF, HFmrEF, and HFpEF, respectively).

Overall, 36.5% of the patients were women, with fewer female patients in the HFrEF (28.7%) and the HFmrEF (37.6%) cohorts than in the HFpEF cohort (52.2%). In the study population, 63.7% and 36.3% of patients were scheduled for follow-up in specialty care and primary care, respectively. Further, referral to specialty care occurred more often among patients with HFrEF (72.6%) compared with those with HFmrEF (60.0%) and HFpEF (47.8%).

Key independent predictors of planned referral to specialized care included optimized HF care with follow-up in a nurse-led HF clinic (odds ratio [OR], 4.60; 95% CI, 4.41-4.79); use of HF devices (OR, 3.99; 95% CI, 3.62-4.40), beta-blockers (OR, 1.39; 95% CI, 1.32-1.47), renin-angiotensin system or angiotensin-receptor-neprilysin inhibitors (OR, 1.21; 95% CI, 1.15-1.27), and mineralocorticoid receptor antagonists (OR, 1.31;

95% CI, 1.26-1.27); and more severe HF, defined as having higher N-terminal pro-B-type natriuretic peptide (NTproBNP; OR,  1.13; 95% CI,. 1.06-1.20) and New York Heart Association (NYHA) class (OR, 1.13; 95% CI, 1.08-1.19).

Factors that were linked to a lower likelihood of follow-up in specialty care included female sex (OR, 0.89; 95% CI, 0.86-0.93), older age (OR, 0.29; 95% CI, 0.28-0.30), lower educational level (OR, 0.77; 95% CI, 0.73-0.81), lower income (OR, 0.79; 95% CI, 0.76-0.82), higher ejection fraction (HFmrEF [OR, 0.65; 95% CI, 0.62-0.68] and HFpEF [OR, 0.56; 95% CI, 0.53-0.58] compared with HFrEF), as well as a higher comorbidity index (presence of kidney disease [OR, 0.91; 95% CI, 0.87-0.95], atrial fibrillation [OR, 0.85; 95% CI, 0.81-0.89], and diabetes [OR, 0.92; 95% CI, 0.88-0.96).

Planned follow-up in specialty care was independently associated with a lower risk for all-cause death (hazard ratio [HR], 0.78; 95% CI, 0.76-0.80) and CV death (HR, 0.76; 95% CI, 0.73-0.78) across the spectrum of ejection fraction, but not for HF hospitalization (HR, 1.06; 95% CI, 1.03-1.10).

Limitations of the study include the fact that residual confounding cannot be ruled out, with differences in patient characteristics other than those obtained in SwedeHF possibly clarifying the difference in outcomes associated with type of follow-up, rather than a different performance with specialty vs primary care.

 “Our findings highlight the need to enable better identification of patients in need of follow-up in specialty care, for public health strategies to avoid unjustified inequalities in referrals, and to improve the use of guideline-recommended HF treatments in primary care,” the study authors wrote.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Lindberg F, Lund LH, Benson L, et al. Patient profile and outcomes associated with follow-up in specialty vs. primary care in heart failure. ESC Heart Fail. Published online February 15, 2022. doi:10.1002/ehf2.13848