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Background  Despite the existence of evidence-based guidelines supporting the identification of heart failure (HF) in primary care, the proportion of patients diagnosed in this setting remains low. Understanding variation in patients’ routes to diagnosis will better inform HF management.    Aim  To identify the factors associated with variation in patients’ routes to HF diagnosis in primary care.    Design and setting  A retrospective cohort study of 13 897 patients diagnosed with HF between 1 January 2010 and 31 March 2013 in English primary care.    Method  This study used primary care electronic health records to identify routes to HF diagnosis, defined using the National Institute for Health and Care Excellence (NICE) guidelines, and adherence to the NICE-recommended guidelines. Multilevel logistic regression was used to investigate factors associated with the recommended route to HF diagnosis, and funnel plots were used to visualise variation between practices.    Results  Few patients (7%,  n  = 976) followed the recommended route to HF diagnosis. Adherence to guidelines was significantly associated with younger age ( P  = 0.001), lower deprivation level ( P  = 0.007), HF diagnosis source ( P &lt;0.001), not having chronic pulmonary disease ( P &lt;0.001), receiving further consultation for symptom(s) suggestive of HF ( P &lt;0.001), and presenting with breathlessness ( P &lt;0.001). Route to diagnosis also varied significantly between GP practices ( P &lt;0.001).    Conclusion  The significant association of certain patient characteristics with route to HF diagnosis and the variation between GP practices raises concerns about equitable HF management. Further studies should investigate reasons for this variation to improve the diagnosis of HF in primary care. However, these must consider the complexities of a patient group often affected by frailty and multiple comorbidities.

Route to heart failure diagnosis in English primary care: a retrospective cohort study of variation