Identifying Heart Failure from Electronic Health Records: A Systematic Evidence Review

Background: Heart failure (HF) is a complex syndrome associated with significant morbidity and healthcare costs. Electronic health records (EHRs) are widely used to identify patients with HF and other phenotypes. Despite widespread use of EHRs for phenotype algorithm development, it is unclear if the characteristics of identified populations mirror those of clinically observed patients and reflect the known spectrum of HF phenotypes. Methods: We performed a subanalysis within a larger systematic evidence review to assess the different methods used for HF algorithm development and their application to research and clinical care. We queried PubMed for articles published up to November 2020. Out of 318 studies screened, 25 articles were included for primary analysis and 15 studies using only International Classification of Diseases (ICD) codes were evaluated for secondary analysis. Results are reported descriptively. Results: HF algorithms were most often developed at academic medical centers and the V.A. One health system was responsible for 8 of 10 HF algorithm studies. HF and congestive HF were the most frequent phenotypes observed and less frequently, specific HF subtypes and acute HF. Diagnoses were the most common data type used to identify HF patients and echocardiography was the second most frequent. The majority of studies used rule-based methods to develop their algorithm. Few studies used regression or machine learning methods to identify HF patients. Validation of algorithms varied considerably: only 52.9% of HF and 44.4% of HF subtype algorithms were validated, but 75% of acute HF algorithms were. Demographics of any study population were reported in 68% of algorithm studies and 53% of ICD-only studies. Fewer than half reported demographics of their HF algorithm-identified population. Of those reporting, most identified majority male (>50%) populations, including both algorithms for HF with preserved ejection fraction. Conclusion: There is significant heterogeneity in phenotyping methodologies used to develop HF algorithms using EHRs. Validation of algorithms is inconsistent but largely relies on manual review of patient records. The concentration of algorithm development at one or two sites may reduce potential generalizability of these algorithms to identify HF patients at non-academic medical centers and in populations from underrepresented regions. Differences between the reported demographics of algorithm-identified HF populations those expected based on HF epidemiology suggest that current algorithms do not reflect the full spectrum of HF patient populations.