The Integrated Team Approach to the Care of the Patient with Cardiovascular Disease

"Patients would probably be more compliant to therapy if encouraged by those around them": a qualitative study exploring primary care physicians' perceptions on barriers to CVD risk management

Background

Public health prevention strategies have been developed to overcome the disease burden. Despite all the available resources, there have been several challenges in keeping up with the practices in Cardiovascular Diseases (CVD) risk management. The aim of this study is to explore Primary Care Physicians’ (PCP) perceptions on barriers to CVD risk management and strategies to overcome these barriers in Suva, Fiji.

Methods

This is a qualitative study conducted in the Suva Medical area among 7 health centers from August 1st to September 30th, 2021. Purposive sampling was used to recruit participants who provided in-depth and detailed information. From those physicians who worked in the Suva medical area as Primary Health Care (PHC) physicians, those who had at least 6 months experience and those who had some Special Outpatients Department (SOPD) exposure, in-depth interview was conducted using semi-structured questionnaire over the telephone and recorded in a mobile app. The interview content was then transcribed and thematic analysis was done.

Results

This study included 25 PHC physicians. From the thematic analysis, 2 major themes were developed including perceived barriers to CVD risk management and some of the strategies to overcome these barriers. Some of the barriers identified include patient factors such as non-compliance, physician factors such as time-constraints and lack of training, and health system factors such as poor medical records system and lack of basic resource. The strategic support systems include patient expectations, physician’s encouragement, utilization of resources, laws and legislations and continuing evidence-based medicine.

Conclusions

Physicians’ perceptions on the barriers and the strategies to overcome those barriers in CVD risk management plays an important role. The barriers include those of physician factors, patient factors and the health system as a whole. It is suggested to encourage shared-decision making in CVD management, enhance physician support and reinforce policies and research to bring about positive change and improvements in the quality of care.

Effect of On-Site Cardiac Surgery Program on General Thoracic Surgery Outcomes

OBJECTIVE

Limited data exist exploring the relationship between multispecialty surgical collaboration and outcomes in general thoracic surgery. To address this, the Nationwide Inpatient Sample (NIS) was analyzed to determine whether the presence of an on-site cardiac surgery program is associated with improved general thoracic surgery outcomes.

METHODS

The NIS (1999-2008) was utilized to identify 389,959 patients who had a lobectomy, pneumonectomy, or esophagectomy. Short-term outcomes of patients undergoing these procedures were compared between hospitals with and without an on-site cardiac surgery program. Univariate and multivariate analyses were performed to determine patient and hospital predictors of mortality and morbidity.

RESULTS

During the study period, patients undergoing lobectomy (n = 314,130), pneumonectomy (n = 34,860), or esophagectomy (n = 40,969) were identified. Univariate analysis demonstrated lower mortality for lobectomy (P < 0.001) and esophagectomy (P < 0.001) but not pneumonectomy (P = 0.344) in hospitals with a cardiac surgery program. All-cause morbidity was significantly lower for all 3 procedures in hospitals with a cardiac surgery program. However, multivariate analysis demonstrated that a cardiac surgery program was not an independent predictor when adjusted for known confounders, particularly procedure volume and hospital academic teaching status.

CONCLUSIONS

The presence of an on-site cardiac surgery program is not in and of itself associated with improved general thoracic surgery outcomes. The presence of a cardiac surgery program is likely a surrogate for other known predictors of improved outcomes such as hospital teaching status and procedure volume.

A Nurse Practitioner Clinic: A Novel Approach to Supporting Patients Following Heart Valve Surgery

BACKGROUND

Valvular heart disease is an important healthcare issue and its impacts are increasing. Following valve surgery, traditional models of care involve medical personnel, however, significant gaps in guideline adherence and delays in follow-up have been reported. Internationally, there is increasing evidence that specialist nurses can function in a variety of clinical settings and improve patient management.

METHODS

In 2009, a nurse practitioner clinic to support patients following valve surgery was established. We used a retrospective clinical audit and clinical review with descriptive statistics to describe the development of the clinic and to provide guidance for other services for model of care development.

RESULTS

Over four years, 462 patients have been reviewed at least once, with over half having multiple assessments, 37% had rheumatic heart disease. These patients were 20 years younger and more likely to be women, non-European, current smokers and have atrial fibrillation. All patients received a focussed lifestyle, rheumatic, thromboembolic and endocarditis risk and symptom review with tailored support, advice and referral where appropriate. Four percent were referred back to a cardiologist for early evidence of valve dysfunction and a further 1.5% required urgent admission for unstable symptoms.

CONCLUSION

The nurse practitioner clinic offers a systematic approach to promoting guideline adherence post valvular surgery. Important clinical symptoms and differences in health needs were identified and were actioned appropriately.

Counseling patients for lifestyle change: making a 15-minute office visit work

Lifestyle counseling is an intervention that can improve chronic disease management as well as patient and provider satisfaction. Patients and providers are often frustrated with difficulties faced in the implementation and maintenance of lifestyle change. Can we change this paradigm? Are there new strategies that work and can be implemented in a typical office visit? The medical literature confirms the effectiveness of lifestyle interventions and recommends that lifestyle counseling be considered as a cornerstone of care. Here we present a case study of a midlife woman to show how motivational interviewing can be used to help her identify and meet her health goals.

Agents for change: nonphysician medical providers and health care quality

Quality medical care is a clinical and public health imperative, but defining quality and achieving improved, measureable outcomes are extremely complex challenges. Adherence to best practice invariably improves outcomes. Nonphysician medical providers (NPMPs), such as physician assistants and advanced practice nurses (eg, nurse practitioners, advanced practice registered nurses, certified registered nurse anesthetists, and certified nurse midwives), may be the first caregivers to encounter the patient and can act as agents for change for an organization's quality-improvement mandate. NPMPs are well positioned to both initiate and ensure optimal adherence to best practices and care processes from the moment of initial contact because they have robust clinical training and are integral to trainee/staff education and the timely delivery of care. The health care quality aspects that the practicing NPMP can affect are objective, appreciative, and perceptive. As bedside practitioners and participants in the administrative and team process, NPMPs can fine-tune care delivery, avoiding the problem areas defined by the Institute of Medicine: misuse, overuse, and underuse of care. This commentary explores how NPMPs can affect quality by 1) supporting best practices through the promotion of guidelines and protocols, and 2) playing active, if not leadership, roles in patient engagement and organizational quality-improvement efforts.