Background:Early heart failure (HF) recognition can reduce morbidity, yet HF is often initially diagnosed only after a patient clinically worsens. We sought to identify characteristics that predict diagnosis in the acute care setting versus the outpatient setting.Methods:We estimated the proportion of incident HF diagnosed in the acute care setting (inpatient hospital or emergency department) versus outpatient setting based on diagnostic codes from a claims database covering commercial insurance and Medicare Advantage between 2003 and 2019. After excluding new-onset HF potentially caused by a concurrent acute cause (eg, acute myocardial infarction), we identified demographic, clinical, and socioeconomic predictors of diagnosis setting. Patients were linked to their primary care clinicians to evaluate diagnosis setting variation across clinicians.Results:Of 959 438 patients with new HF, 38% were diagnosed in acute care. Of these, 46% had potential HF symptoms in the prior 6 months. Over time, the relative odds of acute care diagnosis increased by 3.2% annually after adjustment for patient characteristics (95% CI, 3.1%–3.3%). Acute care diagnosis setting was more likely for women compared with men (adjusted odds ratio, 1.11 [95% CI, 1.10–1.12]) and for Black patients compared with White patients (adjusted odds ratio, 1.18 [95% CI, 1.16–1.19]). The proportion of acute care diagnosis varied substantially (interquartile range: 24%–39%) among clinicians after adjusting for patient-level risk factors.Conclusions:A large proportion of first HF diagnoses occur in the acute care setting, particularly among women and Black patients, yet many had potential HF symptoms in the months before acute care visits. These results raise concerns that many HF diagnoses are missed in the outpatient setting. Earlier diagnosis could allow for timelier high-value interventions, addressing disparities and reducing the progression of HF.

中文翻译：

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突发性心力衰竭诊断设置的差异

背景：早期识别心力衰竭 (HF) 可以降低发病率，但 HF 通常仅在患者临床恶化后才被初步诊断。我们试图确定在急症护理环境和门诊环境中预测诊断的特征。涵盖 2003 年至 2019 年商业保险和 Medicare Advantage 的数据库。在排除可能由并发急性原因（例如，急性心肌梗死）引起的新发 HF 后，我们确定了诊断环境的人口统计、临床和社会经济预测因素。患者与他们的初级保健临床医生联系起来，以评估临床医生之间的诊断设置差异。结果：在 959 438 名新发心衰患者中，38% 的患者在急症室被诊断。其中，46% 在过去 6 个月内有潜在的 HF 症状。随着时间的推移，在调整患者特征后，急性护理诊断的相对几率每年增加 3.2%（95% CI，3.1%–3.3%）。与男性相比，女性（调整后的优势比为 1.11 [95% CI，1.10-1.12]）和黑人患者与白人患者相比（调整后的优势比，1.18 [95% CI，1.16-1.19]）更可能出现急症护理诊断]). 调整患者水平的风险因素后，临床医生的急症护理诊断比例差异很大（四分位间距：24%–39%）。结论：很大一部分首次 HF 诊断发生在急症护理环境中，尤其是女性和黑人患者，然而，许多人在急诊就诊前几个月就有潜在的心力衰竭症状。这些结果引起了人们的担忧，即许多 HF 诊断在门诊环境中被遗漏了。早期诊断可以允许更及时的高价值干预，解决差异并减少 HF 的进展。