Predictors and outcomes of heart failure diagnosis in the community when compared to acute care settings: insights from linked administrative health databases

Background — Heart failure (HF) is often diagnosed during acute decompensation, but earlier diagnosis in community settings may improve outcomes. We examined differences in patient characteristics, care models, and clinical outcomes by diagnosis setting.

Methods — We conducted a population-based cohort study of 597,025 Ontarians aged ≥40 with incident HF between 2010-2022. Patients were classified by diagnosis setting (community vs. acute care). We compared baseline characteristics, primary care models, and outcomes, including all-cause mortality and HF-related healthcare use.

Results — Of the cohort, 36.9% were diagnosed in acute care settings. This was more common among older adults (46.4% among patients >85 years vs. 28% in 40-61 years, p<0.0001), women (38.2% vs. 35.8% in men; p< 0.0001), individuals in the lowest income quintile (40.4% vs. 33.3% in the highest; p< 0.0001), and people without a primary care provider (57.2% vs [36.1%] for those with a PCP; p< 0.0001). After adjusting for age, sex and comorbidities, acute care diagnosis was associated with increased risk of 1-year all-cause mortality (hazard ratio [HR] at 1 year 1.81, 95% CI: 1.80–1.83), HF-related hospitalizations (rate ratio [RR] 2.78, 95% CI 2.74–2.83), and emergency department visits (RR 2.58, 95% CI 2.51–2.65).

Conclusion — More than one-third of patients are diagnosed with HF in acute care with disproportionately higher rates among older adults, women, low-income individuals, and those with no primary care provider. Acute care diagnosis was also associated with higher mortality and greater HF-related acute care use, underscoring missed opportunities for earlier community diagnosis and treatment.