Cardiologist follow-up and improved outcomes of heart failure: a French nationwide cohort

Abstract

Background and aims: Outpatient cardiology follow-up is the cornerstone of heart failure (HF) management, requiring adaptation based on patient severity. However, risk stratification using administrative data is scarce, and the association between follow-up and prognosis according to patient risk has yet to be described at a population level. This study aimed to describe prognosis and management across different strata using simple criteria, including diuretic use and prior HF hospitalization (HFH).

Methods: This nationwide cohort included all French patients reported as having HF in the previous 5 years and alive on 1 January 2020. Patients were categorized into four groups: (i) HFH within the past year (HFH ≤ 1y), (ii) HFH 1-5 years ago (HFH > 1y), (iii) not hospitalized using loop diuretics (NoHFH/LD+), and (iv) not hospitalized without loop diuretics (NoHFH/LD-). Between-group associations, all-cause mortality (ACM), and cardiology follow-up were analysed using survival models.

Results: The study included 655 919 patients [80 years (70-87), 48% female]. One-year ACM risk was 15.9%, ranging from 8.0% (NoHFH/LD-) to 25.0% (HFH ≤ 1y). Mortality risk was 1.61-fold higher for NoHFH/LD+, 1.83-fold for HFH > 1y, and 2.32-fold for HFH ≤ 1y compared to NoHFH/LD- (P < .0001). During the first year of follow-up (2020), cardiology consultation rates were similar across groups, with 40% of patients lacking an annual visit. Compared to no consultation, a single cardiology visit in the previous year (2019) was associated with a 6%-9% absolute reduction in 1-year ACM during the following year (2020) across all groups. The number needed to consult (NNC) to prevent one modelled death was 11-16. Additional visits showed greater benefit with increasing HF severity, with NNC ranging from 55 (NoHFH/LD-) to 20 (HFH ≤ 1y). The optimal follow-up to minimize the number of deaths without increasing the total number of consultations was 1 annual visit for NoHFH/LD-, 2-3 visits for NoHFH/LD+ and HFH > 1y, and 4 visits for HFH ≤ 1y patients.

Conclusions: Despite having a HF diagnosis, 40% of patients do not see a cardiologist annually, regardless of disease severity. Simple stratification based on hospitalization history and diuretic use effectively predicts outcomes. Tailoring the annual number of HF consultations according to this stratification could optimize resource use and reduce avoidable modelled deaths.

Keywords: Epidemiology; Healthcare pathways; Heart failure; Mortality; Nationwide; Risk stratification.

Structured Graphical Abstract

Figure 1

Cumulative incidence curves of (A) all-cause mortality, (B) first heart failure hospitalization, and (C) first heart failure hospitalization or all-cause mortality

Figure 2

Association between cardiology consultations in 2019 and 1-year absolute risk of all-cause mortality after 1 January 2020. This figure illustrates the 1-year all-cause mortality risk (%) in heart failure (HF) patients across different clinical groups based on their history of HF hospitalization and loop diuretics use (NoHFH/LD−, NoHFH/LD+, HFH > 1y, and HFHs ≤ 1y). The mortality risk is shown for patients receiving 0, 1, 2–3, or ≥4 cardiologist visits. The coloured bars represent the percentage risk of 1-year mortality for each group, while the arrows indicate the number of patients requiring an incremental number of cardiology consultations to reduce one modelled death within 1 year. Example: In the ‘NoHFH/LD−’ group, the risk of 1-year all-cause mortality is 13.0% for those with no annual cardiologist visit. However, for patients who had one cardiologist visit, the mortality risk drops to 6.7%, meaning that 15.9 patients would need to be seen once to reduce one modelled death within 1 year. To reduce an additional modelled death within 1 year, 55.4 patients would need 2 or 3 cardiologist visits (one or two additional visits compared to the previous step). NoHFH/LD−, not hospitalized in the past 5 years, without loop diuretics, NoHFH/LD+, not hospitalized in the past 5 years, but using loop diuretics, HFH > 1y, HF hospitalization 1–5 years ago, HFH ≤ 1y, HF hospitalization within the past year