Trends in Diagnostic Delays and Investigation Rates for Heart Failure in England

Article Impact Level: HIGH
Data Quality: STRONG
Summary of  The Lancet Primary Care https://doi.org/10.1016/j.lanprc.2025.100060  
Dr. Claire A Lawson  et al.

Points

This retrospective study analyzed over four hundred thousand heart failure diagnoses to evaluate trends in diagnostic timing and the utilization of primary care investigations over a twenty-year period.
Diagnostic delays worsened significantly over the study duration as the median lag time between initial clinical indicators and confirmed diagnosis increased from roughly sixteen months to over thirty-five months.
Women and patients living in deprived areas experienced up to five times longer delays and were systematically less likely to receive recommended diagnostic tests compared to other demographic groups.
More than half of the patients presenting with previous heart failure indicators underwent no diagnostic investigations in primary care which contributed to a reliance on emergency inpatient diagnoses.
Patients diagnosed in hospital settings without prior investigation faced the highest mortality risk with an adjusted hazard ratio of over five compared to those investigated in outpatient settings.

Summary

This retrospective cohort study examined trends and inequalities in heart failure diagnosis among 412,173 adults in England between 2000 and 2021 using the Clinical Practice Research Datalink. Despite 66.5% of patients presenting with prior clinical indicators, diagnostic timing worsened significantly over the study period, with the median lag time increasing from 16.4 months (IQR 1.6–45.7) to 35.4 months (IQR 6.4–54.7). Consequently, the proportion of diagnoses made in inpatient settings rose from 33.9% to 46.8%. Among those with prior indicators diagnosed between 2015 and 2019, 52.3% had no diagnostic investigations recorded in primary care, while only 12.5% underwent natriuretic peptide testing and 19.8% received echocardiography.

The analysis revealed profound sociodemographic disparities, as women, individuals in deprived areas, and those with multimorbidity experienced up to five times longer delays and lower investigation rates. These groups were also more likely to be diagnosed during hospital admission. Diagnostic delays (adjusted HR 1.15 [95% CI 1.10–1.20]) and the absence of primary care investigations (adjusted HR 1.89 [95% CI 1.83–1.95]) were independently associated with higher one-year mortality. Inpatient diagnosis carried a substantial risk burden (adjusted HR 2.58 [95% CI 2.50–2.66]) compared to outpatient identification.

Survival outcomes were strongly correlated with the diagnostic pathway utilized. Mortality was lowest (5.5%) among outpatients who received appropriate primary care investigations. Conversely, mortality was highest (33.0%) among inpatients with a history of long-term loop diuretic use who had received no prior investigation, resulting in an adjusted hazard ratio of 5.29 (95% CI 4.83–5.79). These findings underscore a critical need to improve early detection strategies in primary care to mitigate survival penalties associated with late, acute-setting diagnoses.

Link to the article: https://www.thelancet.com/journals/lanprc/article/PIIS3050-5143(25)00060-3/fulltext

References

Lawson, C. A., Ali, M. R., McCann, G. P., Squire, I., Zaccardi, F., Rashid, M., Barber, K., Alaei Kalajahi, R., Miller, C. A., Williams, R., Clark, A. L., Petrie, M. C., Taylor, C. J., Friday, J. M., Conrad, N., Cleland, J. G. F., & Khunti, K. (2025). Health inequalities and trends in heart failure diagnosis in primary care in England, 2000–21: A national retrospective cohort data-linkage study. The Lancet Primary Care, 100060. https://doi.org/10.1016/j.lanprc.2025.100060