As GPs with clinical lead roles for cardiology in our local system we read this study by Chen et al with interest and thank them for shedding light on the management of heart failure in primary and secondary care.1 We recognise that there is a growing burden of heart failure at the population level with an ageing society, and therefore understanding the nuances of management for cohorts of heart failure patients seen in primary versus secondary care is appreciated. Some of the findings around characteristics of patients managed purely in primary care do not come as a surprise, such as older age and being in long-term care. These cohorts of patients would make us question whether the burden of specialist investigations and treatment are warranted with coexistent significant frailty or other competing risks of death, and indeed whether further guidance should exist around supporting these vulnerable cohorts in the community with specialist input where appropriate. We second the authors’ call for patient-centred outcomes and more inclusive trials in future heart failure research to fill this evidence gap, as this invariably creates tension between what we feel as clinicians may be in the best medical interest versus what guidelines or other incentives of clinical activity (such as the Quality and Outcomes Framework [QOF] in England) would recommend. Of note, QOF indicators for heart failure currently prioritise the prescription of two classes of drugs for heart failure with reduced ejection2 fraction, when we know there are four prognostically important classes of drugs for this cohort. These systemic factors drive inequities in care and we wonder whether similar incentive structures exist in Swedish primary care to partially explain the disparity in prescriptions of heart failure medications observed in this study.
Another key area for improvement highlighted by this study is the lack of adequate coding of the subtype of heart failure; this is something that is mirrored in our system. Population health management tools that can be integrated into the GP electronic heath record to cleanse heart failure registers such that care for patients can be optimised should be prioritised and supported for primary care administrative teams.
An update to the National Institute for Health and Care Excellence guidelines on the diagnosis and management of chronic heart failure in England are due to be published later in 2025. This could present an opportune moment to improve the care for people living with heart failure in conjunction with primary care and community providers to help support care in the community, provided they are adequately resourced, trained, and supported to do so.
- © British Journal of General Practice 2025
