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Callen EF, Lutgen CB, Robertson E, Loskutova NY. Assessment and management patterns for chronic musculoskeletal pain in the family practice setting. J Bodyw Mov Ther 2024; 39:50-56. [PMID: 38876675 DOI: 10.1016/j.jbmt.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 01/25/2024] [Accepted: 02/25/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Chronic pain affects 11% of the US population. Most patients who experience pain, particularly chronic musculoskeletal pain, seek care in primary care settings. Assessment of the patient pain experience is the cornerstone to optimal pain management; however, pain assessment remains a challenge for medical professionals. It is unknown to what extent the assessment of pain intensity is considered in context of function and quality of life. OBJECTIVE To understand common practices related to assessment of pain and function in patients with chronic musculoskeletal disorders. DESIGN Cross-sectional survey. METHODS A 42-item electronic survey was developed with self-reported numeric ratings and responses related to knowledge, beliefs, and current practices. All physicians and non-physician clinicians affiliated with the AAFP NRN and 2000 AAFP physician members were invited to participate. RESULTS/FINDINGS Primary care clinicians report that chronic joint pain assessment should be comprehensive, citing assessment elements that align with the comprehensive pain assessment models. Pain intensity remains the primary focus of pain assessment in chronic joint pain and the most important factor in guiding treatment decisions, despite well-known limitations. Clinicians also report that patients with osteoarthritis should be treated by Family Medicine. CONCLUSIONS Pain assessment is primarily limited to pain intensity scales which may contribute to worse patient outcomes. Given that most respondents believe primary care/family medicine should be primary responsible for the care of patients with osteoarthritis, awareness of and comfort with existing guidelines, validated assessment instruments and the comprehensive pain assessment models could contribute to delivery of more comprehensive care.
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Affiliation(s)
- Elisabeth F Callen
- American Academy of Family Physicians, Leawood, KS, 66211, USA; DARTNet Institute, Aurora, CO, 80045, USA.
| | - Cory B Lutgen
- American Academy of Family Physicians, Leawood, KS, 66211, USA; DARTNet Institute, Aurora, CO, 80045, USA
| | - Elise Robertson
- American Academy of Family Physicians, Leawood, KS, 66211, USA; DARTNet Institute, Aurora, CO, 80045, USA
| | - Natalia Y Loskutova
- American Academy of Family Physicians, Leawood, KS, 66211, USA; University of Kansas Medical Center, Kansas City, KS, 66160, USA
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2
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van den Broek B, Verrijt L, Rijnen S, van Heugten C, Bus B. Factors Related to the Quality and Stability of Partner Relationships After Stroke: A Systematic Literature Review. Arch Phys Med Rehabil 2024:S0003-9993(24)01005-0. [PMID: 38777292 DOI: 10.1016/j.apmr.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 05/02/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To provide an overview of the current state of knowledge on factors related to relationship quality and relationship stability after stroke. DATA SOURCES Cumulative Index to Nursing and Allied Health (CINAHL), Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on November 15, 2022, for literature on factors associated with (1) relation quality and (2) relation stability after stroke. STUDY SELECTION English quantitative and qualitative studies investigating factors associated with relation quality and/or stability after stroke were included. Three reviewers independently assessed eligibility. Consensus meetings were held in case of divergent opinions. A total of 44 studies were included. DATA EXTRACTION Information regarding study objectives and characteristics, participant demographics, independent and dependent variables, and main findings was extracted. Study quality was rated using the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies and/or the Critical Appraisal Skills Programme Checklist for Qualitative Research. Both were administered by the lead reviewer and checked by the second reviewer. Identified factors are described and presented according to the domains of the International Classification of Functioning, Disability, and Health model. DATA SYNTHESIS Thirty-seven factors related to relationship quality after stroke were identified, covering the domains of body functions and structures (eg, cognitive problems), activities (eg, decrease in physical intimacy), participation (eg, being socially active), environment (eg, medication side effects), and personal factors (eg, hypervigilance). Eight factors related to relationship stability were identified, covering the domains of participation (agreement on reciprocal roles) and personal factors (eg, quality of prestroke relation). CONCLUSIONS Relationship quality and stability after stroke are related to a multitude of factors. Future research should confirm the relevance of factors found in a few studies of suboptimal quality; explore possible associations between relationship stability and factors falling in the domains of body functions and structure, activity, and environmental factors; and explicitly explore potential positive effects of stroke on relationships.
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Affiliation(s)
- Brenda van den Broek
- Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel; School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht; Limburg Brain Injury Centre, Maastricht.
| | - Laura Verrijt
- Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel
| | - Sophie Rijnen
- Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel; Limburg Brain Injury Centre, Maastricht
| | - Caroline van Heugten
- Limburg Brain Injury Centre, Maastricht; Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, The Netherlands
| | - Boudewijn Bus
- Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel; Limburg Brain Injury Centre, Maastricht
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Roskvist R, Eggleton K, Arroll B, Stewart R. Non-acute heart failure management in primary care. BMJ 2024; 385:e077057. [PMID: 38580384 DOI: 10.1136/bmj-2023-077057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
- Rachel Roskvist
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand
| | - Kyle Eggleton
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand
| | - Ralph Stewart
- Department of Medicine, School of Medicine, University of Auckland, New Zealand
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Noordman J, Meurs M, Poortvliet R, Rusman T, Orrego-Villagran C, Ballester M, Ninov L, de Guzmán EN, Alonso-Coello P, Groene O, Suñol R, Heijmans M, Wagner C. Contextual factors for the successful implementation of self-management interventions for chronic diseases: A qualitative review of reviews. Chronic Illn 2024; 20:3-22. [PMID: 36744382 DOI: 10.1177/17423953231153337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To identify and describe the most relevant contextual factors (CFs) from the literature that influence the successful implementation of self-management interventions (SMIs) for patients living with type 2 diabetes mellitus, obesity, COPD and/or heart failure. METHODS We conducted a qualitative review of reviews. Four databases were searched, 929 reviews were identified, 460 screened and 61 reviews met the inclusion criteria. CFs in this paper are categorized according to the Tailored Implementation for Chronic Diseases framework. RESULTS A great variety of CFs was identified on several levels, across all four chronic diseases. Most CFs were on the level of the patient, the professional and the interaction level, while less CFs were obtained on the level of the intervention, organization, setting and national level. No differences in main themes of CFs across all four diseases were found. DISCUSSION For the successful implementation of SMIs, it is crucial to take CFs on several levels into account simultaneously. Person-centered care, by tailoring SMIs to patients' needs and circumstances, may increase the successful uptake, application and implementation of SMIs in real-life practice. The next step will be to identify the most important CFs according to various stakeholders through a group consensus process.
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Affiliation(s)
- Janneke Noordman
- Netherlands institute for health services research (Nivel), Utrecht, The Netherlands
| | - Maaike Meurs
- Netherlands institute for health services research (Nivel), Utrecht, The Netherlands
| | - Rune Poortvliet
- Netherlands institute for health services research (Nivel), Utrecht, The Netherlands
| | - Tamara Rusman
- Netherlands institute for health services research (Nivel), Utrecht, The Netherlands
| | - Carola Orrego-Villagran
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Avedis Donabedian Research Institute (FAD), Barcelona, Spain
- Health Services Research Network on Chronic Diseases (REDISSEC), Madrid, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barcelona, Spain
| | - Marta Ballester
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Avedis Donabedian Research Institute (FAD), Barcelona, Spain
- Health Services Research Network on Chronic Diseases (REDISSEC), Madrid, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barcelona, Spain
| | | | - Ena Niño de Guzmán
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | | | - Rosa Suñol
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Avedis Donabedian Research Institute (FAD), Barcelona, Spain
- Health Services Research Network on Chronic Diseases (REDISSEC), Madrid, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barcelona, Spain
| | - Monique Heijmans
- Netherlands institute for health services research (Nivel), Utrecht, The Netherlands
| | - Cordula Wagner
- Netherlands institute for health services research (Nivel), Utrecht, The Netherlands
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Raat W, Housiaux E, Smeets M, Janssens S, Schoenmakers B, Vaes B. How to Evaluate Online Education for General Practitioners: Development of a Tailored Questionnaire for Heart Failure Education. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2024; 11:23821205241232497. [PMID: 38464745 PMCID: PMC10924759 DOI: 10.1177/23821205241232497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/29/2024] [Indexed: 03/12/2024]
Abstract
Physician-oriented online education could be a pathway to improve care for patients with heart failure, however, it is difficult to measure the impact of such education. Self-efficacy is a potential outcome measure. In this article, we develop a methodology for analyzing an educational intervention for general practitioners (GPs) using self-efficacy as a concept. This study was partly conducted within the setting of an observational study, IMPACT-B, where we developed online education for GPs. We designed and refined a 24-item questionnaire using item analysis, and exploratory and confirmatory factor analysis. Ninety-one GPs completed the questionnaire before and after the online education. Follow-up data after 6 months was available for 13 GPs. Item analysis revealed a high degree of internal consistency (coefficient alpha 0.95) and validity. Each additional year of experience was associated with an average baseline self-efficacy score of 0.50 points (95% CI [0.21-0.80]), and each additional patient in HF follow-up with an average score of 2.0 points (95% CI [0.48-3.5]). Items that differentiated most between GPs with high and low self-efficacy were the treatment of congestion as well as titrating medication and MRA in heart failure with reduced ejection fraction. Factor analysis reduced the number of questions to 14, mapping to three factors (diagnosis, treatment, and follow-up), and improved the model fit as measured by the goodness-of-fit indicator comparative-fit-index (from 0.83 to 0.91). We demonstrated a method to assess the impact of online education on general practitioners. This led to a questionnaire that was reliable, valid, and convenient to use in an implementation context.
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Affiliation(s)
- Willem Raat
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Evelyne Housiaux
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Miek Smeets
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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6
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Mamataz T, Lee DS, Turk-Adawi K, Hajaj A, Code J, Grace SL. Factors Affecting Healthcare Provider Referral to Heart Function Clinics: A Mixed-Methods Study. J Cardiovasc Nurs 2024; 39:18-30. [PMID: 37669639 DOI: 10.1097/jcn.0000000000001029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
BACKGROUND Heart failure (HF) care providers are gatekeepers for patients to appropriately access lifesaving HF clinics. OBJECTIVE The aim of this study was to investigate referring providers' perceptions regarding referral to HF clinics, including the impact of provider specialty and the coronavirus disease pandemic. METHODS An exploratory, sequential design was used in this mixed-methods study. For the qualitative stage, semistructured interviews were performed with a purposive sample of HF providers eligible to refer (ie, nurse practitioners, cardiologists, internists, primary care and emergency medicine physicians) in Ontario. Interviews were conducted via Microsoft Teams. Transcripts were analyzed concurrently by 2 researchers independently using NVivo, using a deductive-thematic approach. Then, a cross-sectional survey of similar providers across Canada was undertaken via REDCap (Research Electronic Data Capture), using an adapted version of the Provider Attitudes toward Cardiac Rehabilitation and Referral scale. RESULTS Saturation was achieved upon interviewing 7 providers. Four themes arose: knowledge about clinics and their characteristics, providers' clinical expertise, communication and relationship with their patients, and clinic referral process and care continuity. Seventy-three providers completed the survey. The major negative factors affecting referral were skepticism regarding clinic benefit (4.1 ± 0.9/5), a bad patient experience and believing they are better equipped to manage the patient (both 3.9). Cardiologists more strongly endorsed clarity of referral criteria, referral as normative and within-practice referral supports as supporting appropriate referral versus other professionals ( P s < .02), among other differences. One-third (n = 13) reported the pandemic impacted their referral practices (eg, limits to in-person care, patient concerns). CONCLUSION Although there are some legitimate barriers to appropriate clinic referral, greater provider education and support could facilitate optimal patient access.
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Mouquet F, Hugon G, Tindel M, Cohen S, Jourdain P. [Patients insuffisants cardiaques chroniques rarement adressés à un cardiologue libéral ou régulièrement suivis par un médecin généraliste et un cardiologue libéral : étude descriptive transversale (MIRROR-HF)]. Ann Cardiol Angeiol (Paris) 2023; 72:101598. [PMID: 37068350 DOI: 10.1016/j.ancard.2023.101598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/21/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND French health authorities recommend implementing a strong coordination between general practitioners and office-based cardiologists for the care and management of patients with chronic heart failure. The aim of this study was to describe the characteristics of patients with chronic heart failure who were infrequently referred to an office-based cardiologist (either first time referral or last visit more than 12 months before study inclusion) by a general practitioner or other healthcare professional versus those who were regularly followed by a general practitioner and an office-based cardiologist (at least one visit to an office-based cardiologist in the last 12 months). METHODS This was a non-interventional, cross-sectional study, conducted among office-based cardiologists in France during a single study visit. Descriptive statistics were performed. RESULTS 1460 patients were included in the study with 37.1% in the group infrequently referred to an office-based cardiologist and 62.9% in the regularly followed group. The patients who were infrequently referred to an office-based cardiologist had relatively less heart failure with reduced ejection fraction (29.2% versus 36.6%), less prior chronic heart failure hospitalization (15.9% versus 31.4%), and less atrial fibrillation and ischemic heart failure as comorbidities (40.2% versus 50.5% and 39.3% versus 50.1%, respectively) than patients who were regularly followed by an office-based cardiologist and a general practitioner. They also received less clinical exams (25.5% versus 97.4%) and pharmacological (89.3% versus 98.4%) and non-pharmacological (17.3% versus 27.1%) heart failure treatments before the study visit. CONCLUSIONS This study suggested that patients regularly followed by a general practitioner and an office-based cardiologist had globally a more severe chronic heart failure and a better medical monitoring and follow-up than other patients.
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Affiliation(s)
| | | | | | - Serge Cohen
- Hôpital Européen Marseille, Marseille, France
| | - Patrick Jourdain
- Cardiology Department, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Kremlin Bicêtre, France
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8
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Dai L, Dorje T, Gootjes J, Shah A, Dembo L, Rankin J, Hillis G, Robinson S, Atherton JJ, Jacques A, Reid CM, Maiorana A. Primary care Adherence To Heart Failure guidelines IN Diagnosis, Evaluation and Routine management (PATHFINDER): a randomised controlled trial protocol. BMJ Open 2023; 13:e063656. [PMID: 36972959 PMCID: PMC10069547 DOI: 10.1136/bmjopen-2022-063656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 02/06/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION General practitioners (GPs) routinely provide care for patients with heart failure (HF); however, adherence to management guidelines, including titrating medication to optimal dose, can be challenging in this setting. This study will evaluate the effectiveness of a multifaceted intervention to support adherence to HF management guidelines in primary care. METHODS AND ANALYSIS We will undertake a multicentre, parallel-group, randomised controlled trial of 200 participants with HF with reduced ejection fraction. Participants will be recruited during a hospital admission due to HF. Following hospital discharge, the intervention group will have follow-up with their GP scheduled at 1 week, 4 weeks and 3 months with the provision of a medication titration plan approved by a specialist HF cardiologist. The control group will receive usual care. The primary endpoint, assessed at 6 months, will be the difference between groups in the proportion of participants being prescribed five guideline-recommended treatments; (1) ACE inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor at least 50% of target dose, (2) beta-blocker at least 50% of target dose, (3) mineralocorticoid receptor antagonist at any dose, (4) anticoagulation for patients diagnosed with atrial fibrillation, (5) referral to cardiac rehabilitation. Secondary outcomes will include functional capacity (6-minute walk test); quality of life (Kansas City Cardiomyopathy Questionnaire); depressive symptoms (Patient Health Questionnaire-2); self-care behaviour (Self-Care of Heart Failure Index). Resource utilisation will also be assessed. ETHICS AND DISSEMINATION Ethical approval was granted by the South Metropolitan Health Service Ethics Committee (RGS3531), with reciprocal approval at Curtin University (HRE2020-0322). Results will be disseminated via peer-reviewed publications and conferences. TRIAL REGISTRATION NUMBER ACTRN12620001069943.
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Affiliation(s)
- Liying Dai
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Tashi Dorje
- Department of Cardiology, Mount Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Jan Gootjes
- WA Cardiology, Perth, Western Australia, Australia
| | - Amit Shah
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Lawrence Dembo
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Jamie Rankin
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Graham Hillis
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Suzanne Robinson
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- Deakin Health Economics, Deakin University, Melbourne, Western Australia, Australia
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Angela Jacques
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Institute for Health Research, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Christopher M Reid
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maiorana
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Department of Allied Health, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
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Rashid AM, Khan MS, Fudim M, DeWald TA, DeVore A, Butler J. Management of Heart Failure With Reduced Ejection Fraction. Curr Probl Cardiol 2023; 48:101596. [PMID: 36681212 DOI: 10.1016/j.cpcardiol.2023.101596] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is a complex and progressive clinical condition characterized by dyspnea and functional impairment. HFrEF has a high burden of mortality and readmission rate making it one of the most significant public health challenges. Basic treatment strategies include diuretics for symptom relief and use of quadruple therapy (Angiotensin receptor blocker/neprilysin inhibitors, evidence-based beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors) for reduction in hospitalizations, all-cause mortality, and cardiovascular mortality. Despite compelling evidence of clinical benefit, guideline directed medical therapy is vastly underutilized in the real-world clinical practice. Other medications such as intravenous iron, ivabradine, hydralazine/nitrates and vericiguat may also have a role in certain subgroup of HFrEF patients. Specific groups of patients with HFrEF may also be candidates for various device therapies such as implanted cardioverter defibrillators, cardiac resynchronization therapy and trans catheter mitral valve repair. This review provides a comprehensive overview of drug and device management approaches for patients with HFrEF, recommendations for initiation and titrations of therapies, and challenges associated with guideline directed medical therapy in the management of patients with HFrEF (Graphical abstract).
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Affiliation(s)
| | | | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Tracy A DeWald
- Division of Clinical Pharmacology, Duke University School of Medicine, Durham, NC
| | - Adam DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS; Baylor Scott and White Research Institute, Dallas, TX.
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Wang T, Tan JYB, Liu XL, Zhao I. Barriers and enablers to implementing clinical practice guidelines in primary care: an overview of systematic reviews. BMJ Open 2023; 13:e062158. [PMID: 36609329 PMCID: PMC9827241 DOI: 10.1136/bmjopen-2022-062158] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To identify the barriers and enablers to implementing clinical practice guidelines (CPGs) recommendations in primary care and to provide recommendations that could facilitate the uptake of CPGs recommendations. DESIGN An overview of systematic reviews. DATA SOURCES Nine electronic databases (PubMed, Cochrane Library, CINAHL, MEDLINE, PsycINFO, Web of Science, Journals @Ovid Full Text, EMBase, JBI) and three online data sources for guidelines (Turning Research Into Practice, the National Guideline Clearinghouse and the National Institute for Health and Care Excellence) were searched until May 2021. ELIGIBILITY CRITERIA Systematic reviews, meta-analyses or other types of systematic synthesis of quantitative, qualitative or mixed-methods studies on the topic of barriers and/or enablers for CPGs implementation in primary care were included. DATA EXTRACTION AND SYNTHESIS Two authors independently screened the studies and extracted the data using a predesigned data extraction form. The methodological quality of the included studies was appraised by using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Content analysis was used to synthesise the data. RESULTS Twelve systematic reviews were included. The methodological quality of the included reviews was generally robust. Six categories of barriers and enablers were identified, which include (1) political, social and culture factors, (2) institutional environment and resources factors, (3) guideline itself related factors, (4) healthcare provider-related factors, (5) patient-related factors and (6) behavioural regulation-related factors. The most commonly reported barriers within the above-mentioned categories were suboptimal healthcare networks and interprofessional communication pathways, time constraints, poor applicability of CPGs in real-world practice, lack of knowledge and skills, poor motivations and adherence, and inadequate reinforcement (eg, remuneration). Presence of technical support ('institutional environment and resources factors'), and timely education and training for both primary care providers (PCPs) ('healthcare provider-related factors') and patients ('patient-related factors') were the frequently reported enablers. CONCLUSION Policy-driven strategies should be developed to motivate different levels of implementation activities, which include optimising resources allocations, promoting integrated care models, establishing well-coordinated multidisciplinary networks, increasing technical support, encouraging PCPs and patients' engagement in guideline development, standardising the reporting of guidelines, increasing education and training, and stimulating PCPs and patients' motivations. All the activities should be conducted by fully considering the social, cultural and community contexts to ensure the success and sustainability of CPGs implementation.
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Affiliation(s)
- Tao Wang
- Faculty of Health, Charles Darwin University, Brisbane, Queensland, Australia
| | | | - Xian-Liang Liu
- Faculty of Health, Charles Darwin University, Brisbane, Queensland, Australia
| | - Isabella Zhao
- Faculty of Health, Charles Darwin University, Brisbane, Queensland, Australia
- Cancer and Palliative Care Outcomes Centre, Queensland University of Technology, Brisbane, Queensland, Australia
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Hadidi SE, Bazan NS, Byrne S, Darweesh E, Bermingham M. Factors influencing prescribing by critical care physicians to heart failure patients in Egypt: a cross-sectional survey. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2022. [DOI: 10.1186/s43094-022-00429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Heart failure (HF) guideline-led prescribing improves patient outcomes; however, little is known about the factors influencing guideline-led prescribing in critical care settings. This study used a cross-sectional survey to assess the factors that influence physicians when prescribing to heart failure patients in a critical care setting in Egypt.
Results
The response rate was 54.8%. The international HF guidelines were the primary source of prescribing information for 84.2% of respondents. Staff were more familiar with the latest guideline recommendations than associate staff (86.7% vs 36.8%, p = 0.012) and considered patient’s perspectives more often (86.7% vs 26.3%, p = 0.036). Renal function was the clinical factor that most frequently influenced the prescribing of loop diuretics or renin–angiotensin–aldosterone system inhibitors. Pulmonary function influenced beta-blockers prescription. The most frequently cited barrier to guideline-led prescribing was the absence of locally drafted guidelines. A majority of prescribers agreed that implementation of clinical pharmacy services, physician education and electronic reminders may improve the implementation of guideline-led prescribing.
Conclusions
Although experienced physicians are familiar with and use international guidelines, physicians would welcome local guidance on HF prescribing and greater clinical pharmacist input.
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12
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Milinković I, Polovina M, Coats AJS, Rosano GMC, Seferović PM. Medical Treatment of Heart Failure with Reduced Ejection Fraction in the Elderly. Card Fail Rev 2022; 8:e17. [PMID: 35601008 PMCID: PMC9115638 DOI: 10.15420/cfr.2021.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/26/2021] [Indexed: 11/24/2022] Open
Abstract
The aging population, higher burden of predisposing conditions and comorbidities along with improvements in therapy all contribute to the growing prevalence of heart failure (HF). Although the majority of trials have not demonstrated age-dependent heterogeneity in the efficacy or safety of medical treatment for HF, the latest trials demonstrate that older participants are less likely to receive established drug therapies for HF with reduced ejection fraction. There remains reluctance in real-world clinical practice to prescribe and up-titrate these medications in older people, possibly because of (mis)understanding about lower tolerance and greater propensity for developing adverse drug reactions. This is compounded by difficulties in the management of multiple medications, patient preferences and other non-medical considerations. Future research should provide a more granular analysis on how to approach medical and device therapies in elderly patients, with consideration of biological differences, difficulties in care delivery and issues relevant to patients’ values and perspectives. A variety of approaches are needed, with the central principle being to ‘add years to life – and life to years’. These include broader representation of elderly HF patients in clinical trials, improved education of healthcare professionals, wider provision of specialised centres for multidisciplinary HF management and stronger implementation of HF medical treatment in vulnerable patient groups.
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Affiliation(s)
- Ivan Milinković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | | | | | - Petar M Seferović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Serbian Academy of Sciences and Arts, Belgrade, Serbia
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13
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van den Broek B, Rijnen S, Stiekema A, van Heugten C, Bus B. Factors related to the quality and stability of partner relationships after traumatic brain injury: A systematic literature review. Arch Phys Med Rehabil 2022; 103:2219-2231.e9. [PMID: 35395254 DOI: 10.1016/j.apmr.2022.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/22/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The latest literature review on partner relationships following traumatic brain injury (TBI), conducted a decade ago, discussed solely quantitative work and noted significant knowledge gaps. The current review updates and expands on this work by providing an overview of the current state of knowledge on factors related to relationship quality and stability following TBI. DATA SOURCES CINAHL, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on April 23, 2020, for literature on factors associated with 1)relationship quality and 2)relationship stability following TBI. STUDY SELECTION English quantitative and qualitative studies investigating factors associated with relationship quality and/or stability following TBI were included. Two reviewers independently assessed eligibility. If consensus was not reached, a third reviewer's conclusion was decisive. Forty-three studies were included. DATA EXTRACTION Information regarding study objectives and characteristics, participant demographics, (in)dependent variables, and main findings was extracted. Study quality was rated using the JBI Checklist for Analytical Cross Sectional Studies and/or the CASP Checklist for Qualitative Research. Both were performed by the lead reviewer and checked by the second reviewer. DATA SYNTHESIS Thirty-eight factors related to relationship quality and/or stability were identified, covering injury characteristics (e.g., severity), body functions (e.g., personality changes), activities (e.g., communication), participation (e.g., social dependence), environment (e.g., children), and personal factors (e.g., coping strategies). CONCLUSIONS Relationship quality and stability following TBI are found to be related to a multitude of factors, including newly identified factors such as personality changes and dependence. Future research may wish to quantitatively investigate factors thus far only identified in qualitative research, explore possible positive effects of TBI on relationships, study the experiences of same-sex couples, and include the perspectives of both partners with and without the injury.
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Affiliation(s)
- Brenda van den Broek
- Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel, the Netherlands; School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands; Limburg Brain Injury Centre, Maastricht, the Netherlands.
| | - Sophie Rijnen
- Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel, the Netherlands; Limburg Brain Injury Centre, Maastricht, the Netherlands
| | - Annemarie Stiekema
- School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands; Limburg Brain Injury Centre, Maastricht, the Netherlands
| | - Caroline van Heugten
- School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands; Limburg Brain Injury Centre, Maastricht, the Netherlands; Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, the Netherlands
| | - Boudewijn Bus
- Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel, the Netherlands; Limburg Brain Injury Centre, Maastricht, the Netherlands
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14
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Dias BM, Ramalho-de-Oliveira D, Santos BD, Neves CDM, Oliveira GCBD, Silva DÁM, Nascimento YDA, Cid AS, Buzelin GO, Ferreira SG, Detoni KB, Nascimento MMGD. Factors associated with the identification of drug therapy problems among older patients in Primary Health Care. EINSTEIN-SAO PAULO 2022; 20:eAO6544. [PMID: 35416833 PMCID: PMC9648945 DOI: 10.31744/einstein_journal/2022ao6544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To determine the frequency of drug therapy problems among older adults in Primary Health Care, and to analyze the factors associated with their identification in the initial patient assessment, carried out by pharmacists offering medication therapy management services. Methods A cross-sectional study conducted with data from 758 older adults followed up in medication therapy management services in Primary Health Care in the cities of Belo Horizonte, Betim, and Lagoa Santa (MG, Brazil). Univariate and multivariate analyses were performed to evaluate the factors associated with identification of four or more drug therapy problems in the initial clinical assessment. Results A total of 1,683 drug therapy problems were identified, 73.6% of older patients had at least one problem. The most frequent problems were nonadherence (23.0%) and the need for additional drug therapy (18.0%). Polypharmacy, chronic obstructive pulmonary disease, hypertension, diabetes mellitus, heart failure, and aged 75 years or older remained positively and statistically associated with identification of four or more drug therapy problems (p<0.05). Conclusion There is a high frequency of problems related to medication use among older users of Primary Health Care, and the medication therapy management services should be prioritized to the older patients, who present with polypharmacy, chronic obstructive pulmonary disease, hypertension, diabetes mellitus, heart failure, and age ≥ 75 years, since they are more likely to have more drug therapy problems.
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15
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Kwan T, Chua B, Pires D, Feng O, Edmiston N, Longman J. A qualitative analysis of the barriers and enablers faced by Australian rural general practitioners in the non-pharmacological management of congestive heart failure in community dwelling patients. BMC Health Serv Res 2022; 22:5. [PMID: 34974834 PMCID: PMC8722034 DOI: 10.1186/s12913-021-07383-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Congestive heart failure (CHF) is a significant health problem in Australia, and disproportionately affects rural Australians. Management of CHF in Australia is heavily centred around the general practitioner (GP). Australian and international literature indicates there is a gap between current and best practice in CHF management. There is little known about the non-pharmacological aspects of management, or CHF management in a rural Australian context. This study aimed to identify what Australian GPs practicing in the Northern Rivers Region of New South Wales, Australia, perceived were the barriers and enablers in the non-pharmacological management of CHF amongst community dwelling patients, to inform healthcare access, resourcing and delivery in Australian rural environments. METHODS Qualitative study involving a realist thematic analysis of data collected from semi-structured face-to-face interviews. RESULTS Fifteen GPs and GP trainees participated. Four interlinked key themes underpinning GPs' experiences with non-pharmacological management of CHF were interpreted from the interview data: (1) resources, (2) complexity of heart failure, (3) relationships, and (4) patient demographics, priorities and views affect how patients engage with non-pharmacological management of CHF. CONCLUSION Rural Australian GPs face considerable barriers to non-pharmacological management of CHF. The data suggests that increased rural Australian health services and community transportation, multidisciplinary management, and stronger professional networks have the potential to be invaluable enablers of CHF management. Further research exploring non-pharmacological management of CHF in other rural contexts may provide additional insights to better inform rural healthcare access and resourcing.
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Affiliation(s)
- Trevor Kwan
- Western Sydney University, Penrith, New South Wales, Australia.
| | - Benjamin Chua
- Western Sydney University, Penrith, New South Wales, Australia
| | - David Pires
- Western Sydney University, Penrith, New South Wales, Australia
| | - Olivia Feng
- Western Sydney University, Penrith, New South Wales, Australia
| | - Natalie Edmiston
- Western Sydney University, Penrith, New South Wales, Australia
- University Centre for Rural Health, Lismore, New South Wales, Australia
| | - Jo Longman
- University Centre for Rural Health, Lismore, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
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16
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Zhou Y, Zeng Y, Wang S, Li N, Wang M, Mordi IR, Ren Y, Zhou Y, Zhu Y, Tian H, Sun X, Chen X, An Z, Lang CC, Li S. Guideline Adherence of β-blocker Initiating Dose and its Consequence in Hospitalized Patients With Heart Failure With Reduced Ejection Fraction. Front Pharmacol 2021; 12:770239. [PMID: 34899323 PMCID: PMC8660072 DOI: 10.3389/fphar.2021.770239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/27/2021] [Indexed: 02/05/2023] Open
Abstract
Background: We aim to investigate the guideline adherence of β-blocker (BB) initiating dose in Chinese hospitalized patients with heart failure with reduced ejection fraction (HFrEF) and whether the adherence affected the in-hospital outcomes. Methods: This was a retrospective study of patients hospitalized with HFrEF who had initiated BBs during their hospitalization. We defined adherence to clinical practice guidelines as initiating BB with standard dose and non-adherence to guidelines if otherwise, and examined the association between adherence to guidelines and in-hospital BB-related adverse events. Subgroup analyses based on sex, age, coronary heart disease, and hypertension were performed. Results: Among 1,104 patients with HFrEF initiating BBs during hospitalization (median length of hospitalization, 12 days), 304 (27.5%) patients received BB with non-adherent initiating dose. This non-adherence was related to a higher risk (hazard ratio [95% confidence interval]) of BB dose reduction or withdrawal (1.78 [1.42 to 2.22], P < 0.001), but not significantly associated with risks of profound bradycardia, hypotension, cardiogenic shock requiring intravenous inotropes, and severe bronchospasm requiring intravenous steroid during hospitalization. Conclusion: This study identified that over a fourth of patients had received BBs with an initiating dose that was not adherent to guidelines in Chinese hospitalized patients with HFrEF, and this non-adherence was associated with BB dose reduction or withdrawal during hospitalization.
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Affiliation(s)
- Yiling Zhou
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Yuping Zeng
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Si Wang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Nan Li
- The Informatic Center, West China Hospital, Sichuan University, Chengdu, China
| | - Miye Wang
- The Informatic Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ify R. Mordi
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Scotland, United Kingdom
| | - Yan Ren
- Cochrane China Center, MAGIC China Center, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Youlian Zhou
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Ye Zhu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Haoming Tian
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Sun
- Cochrane China Center, MAGIC China Center, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoping Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenmei An
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Chim C. Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Scotland, United Kingdom
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Cochrane China Center, MAGIC China Center, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- Engineering Research Center of Medical Information Technology, Ministry of Education, West China Hospital, Sichuan University, Chengdu, China
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Scotland, United Kingdom
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17
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SeferoviĆ PM, Polovina M, Adlbrecht C, BĚlohlávek J, Chioncel O, Goncalvesová E, MilinkoviĆ I, Grupper A, Halmosi R, Kamzola G, Koskinas KC, Lopatin Y, Parkhomenko A, Põder P, RistiĆ AD, Šakalyt G, TrbušiĆ M, Tundybayeva M, Vrtovec B, Yotov YT, MiličiĆ D, Ponikowski P, Metra M, Rosano G, Coats AJ. Navigating between Scylla and Charybdis: challenges and strategies for implementing guideline-directed medical treatment in heart failure with reduced ejection fraction. Eur J Heart Fail 2021; 23:1999-2007. [PMID: 34755422 DOI: 10.1002/ejhf.2378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/18/2021] [Accepted: 11/05/2021] [Indexed: 11/07/2022] Open
Abstract
Guideline-directed medical therapy (GDMT) has the potential to reduce the risks of mortality and hospitalisation in patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, real-world data indicate that many patients with HFrEF do not receive optimised GDMT, which involves several different medications, many of which require up-titration to target doses. There are many challenges to implementing GDMT, the most important being patient-related factors (comorbidities, advanced age, frailty, cognitive impairment, poor adherence, low socioeconomic status), treatment-related factors (intolerance, side-effects) and healthcare-related factors that influence availability and accessibility of HF care. Accordingly, international disparities in resources for HF management and limited public reimbursement of GDMT, coupled with clinical inertia for treatment intensification combine to hinder efforts to provide GDMT. In this review paper, authors aim to provide solutions based on available evidence, practical experience, and expert consensus on how to utilise evolving strategies, novel medications, and patient profiling to allow the more comprehensive uptake of GDMT. Authors discuss professional education, motivation, and training, as well as patient empowerment for self-care as important tools to overcome clinical inertia and boost GDMT implementation. We provide evidence on how multidisciplinary care and institutional accreditation can be successfully used to increase prescription rates and adherence to GDMT. We consider the role of modern technologies in advancing professional and patient education and facilitating patient-provider communication. Finally, authors emphasise the role of novel drugs (especially sodium-glucose cotransporter-2 inhibitors), and a tailored approach to drug management as evolving strategies for the more successful implementation of GDMT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Petar M SeferoviĆ
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Department of Cardiology, University Clinical Centre, Belgrade, Serbia
| | | | - Jan BĚlohlávek
- Second Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest, Romania.,Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu'Bucharest, Romania
| | - Eva Goncalvesová
- Dept Cardiology, Faculty of Medicine, Comenius University and Nat Cardiovasc Inst, Bratislava, Slovakia
| | - Ivan MilinkoviĆ
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Department of Cardiology, University Clinical Centre, Belgrade, Serbia
| | - Avishay Grupper
- Cardiology division, Sheba Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Róbert Halmosi
- First Department of Medicine, University of Pecs, Medical School, Pecs, Hungary
| | - Ginta Kamzola
- Kamzola: Latvian Centre of Cardiology, Pauls Stradins Clinical University hospital, Riga, Latvia
| | | | - Yuri Lopatin
- Volgograd State Medical University, Regional Cardiology Centre Volgograd, Volgograd, Russian Federation
| | | | - Pentti Põder
- First Cardiology Department, North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Arsen D RistiĆ
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Department of Cardiology, University Clinical Centre, Belgrade, Serbia
| | - Gintar Šakalyt
- Department of Cardiology, Medical Academy, Faculty of Medicine Lithuanian University of Health Sciences
| | - Matias TrbušiĆ
- University of Zagreb School of Medicine, Zagreb, Croatia
| | | | | | - Yoto T Yotov
- First Department of Internal Medicine, Medical University of Varna, Varna, Bulgaria.,Second Cardiology Clinic, University Hospital St. Marina, Varna, Bulgaria
| | - Davor MiličiĆ
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Piotr Ponikowski
- Centre for Heart Diseases, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
| | - Marco Metra
- Cardiology, ASST Spedali Civili; Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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18
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Hobbs FR, Hussain RI, Vitale C, Pinto YM, Bueno H, Lequeux B, Pauschinger M, Obermeier M, Ferber PC, Gustafsson F. PRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic heart failure in primary care (PREFER): a real-world study. Open Heart 2021; 8:openhrt-2021-001630. [PMID: 34670830 PMCID: PMC8529980 DOI: 10.1136/openhrt-2021-001630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/23/2021] [Indexed: 11/21/2022] Open
Abstract
Objective To assess current management practice of heart failure with reduced ejection fraction (HFrEF) in multinational primary care (PC) and determine whether N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP)-guided referral of HFrEF patients from PC to a cardiologist could improve care, defined as adherence to European Society of Cardiology (ESC) guideline-recommended pharmacotherapy. Methods PRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic HF in PC (PREFER) study enrolled HFrEF patients from PC considered clinically stable and those with NT-pro-BNP ≥600 pg/mL were referred to a cardiologist for optimisation of HF treatment. The primary outcome of adherence to ESC HF guidelines after referral to specialist was assessed at the second visit within 4 weeks of cardiologist’s referral and no later than 6 months after the baseline visit. Based on futility interim analysis, the study was terminated early. Results In total, 1415 HFrEF patients from 223 PCs from 18 countries in Europe were enrolled. Of these, 1324 (96.9%) were considered clinically stable and 920 (65.0%) had NT-pro-BNP ≥600 pg/mL (mean: 2631 pg/mL). In total, 861 (60.8%) patients fulfilled both criteria and were referred to a cardiologist. Before cardiologist consultation, 10.1% of patients were on ESC guideline-recommended HFrEF medications and 2.7% were on recommended dosages of HFrEF medication (defined as ≥50% of ESC guideline-recommended dose). Postreferral, prescribed HFrEF drugs remained largely unchanged except for an increase in diuretics (+4.6%) and mineralocorticoid receptor antagonists (+7.9%). No significant increase in patients’ adherence to guideline-defined drug combinations (11.2% post-referral vs 10.1% baseline) or drug combinations and dosages (3.3% postreferral vs 2.7% baseline) was observed after cardiologist consultation. Conclusions PREFER demonstrates substantial suboptimal treatment of HFrEF patients in the real world. Referral of patients with elevated NT-pro-BNP levels from PC to cardiologist did not result in meaningful treatment optimisation for treatments with known mortality and morbidity benefit.
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Affiliation(s)
| | | | - Cristina Vitale
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy
| | - Yigal M Pinto
- Departments of Cardiology and Experimental Cardiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Hector Bueno
- Department of Cardiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | | | | | | | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet University of Copenhagen, Copenhagen, Denmark
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Kahn M, Grayson AD, Chaggar PS, Ng Kam Chuen MJ, Scott A, Hughes C, Campbell NG. Primary care heart failure service identifies a missed cohort of heart failure patients with reduced ejection fraction. Eur Heart J 2021; 43:405-412. [PMID: 34508630 PMCID: PMC8825238 DOI: 10.1093/eurheartj/ehab629] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 07/05/2021] [Accepted: 08/27/2021] [Indexed: 01/09/2023] Open
Abstract
AIMS We explored whether a missed cohort of patients in the community with heart failure (HF) and left ventricular systolic dysfunction (LVSD) could be identified and receive treatment optimization through a primary care heart failure (PCHF) service. METHODS AND RESULTS PCHF is a partnership between Inspira Health, National Health Service Cardiologists and Medtronic. The PCHF service uses retrospective clinical audit to identify patients requiring a prospective face-to-face consultation with a consultant cardiologist for clinical review of their HF management within primary care. The service is delivered via five phases: (i) system interrogation of general practitioner (GP) systems; (ii) clinical audit of medical records; (iii) patient invitation; (iv) consultant reviews; and (v) follow-up. A total of 78 GP practices (864 194 population) have participated. In total, 19 393 patients' records were audited. HF register was 9668 (prevalence 1.1%) with 6162 patients coded with LVSD (prevalence 0.7%). HF case finder identified 9725 additional patients to be audited of whom 2916 patients required LVSD codes adding to the patient medical record (47% increase in LVSD). Prevalence of HF with LVSD increased from 0.7% to 1.05%. A total of 662 patients were invited for consultant cardiologist review at their local GP practice. The service found that within primary care, 27% of HF patients identified for a cardiologist consultation were eligible for complex device therapy, 45% required medicines optimization, and 47% of patients audited required diagnosis codes adding to their GP record. CONCLUSION A PCHF service can identify a missed cohort of patients with HF and LVSD, enabling the optimization of prognostic medication and an increase in device prescription.
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Affiliation(s)
- Matthew Kahn
- Cardiology Department, Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | - Antony D Grayson
- Inspira Health Ltd, Oriel House, 2-8 Oriel Road, Bootle, Liverpool L20 7EP, UK
| | - Parminder S Chaggar
- Cardiology Department, Royal Cornwall Hospitals NHS Trust, Treliske, Truro, Cornwall TR1 3LJ, UK
| | - Marie J Ng Kam Chuen
- Cardiology Department, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham NG5 1PB, UK
| | - Alison Scott
- Medtronic Ltd, Building 9, Croxley Park, Hatters Lane, Watford WD18 8WW, UK
| | - Carol Hughes
- Inspira Health Ltd, Oriel House, 2-8 Oriel Road, Bootle, Liverpool L20 7EP, UK
| | - Niall G Campbell
- Cardiology Department, Institute of Cardiovascular Sciences, University of Manchester, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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20
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Raat W, Smeets M, Van Pottelbergh G, Van de Putte M, Janssens S, Vaes B. Implementing standards of care for heart failure patients in general practice - the IMPACT-B study protocol. Acta Cardiol 2021; 76:486-493. [PMID: 33161831 DOI: 10.1080/00015385.2020.1844504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Heart failure (HF) is an important health problem. Most chronic HF management occurs in primary care. Although guidelines exist, there is an important implementation gap in current HF care in Belgium. METHODS We will conduct a non-randomised, non-controlled prospective observational trial to implement guideline-recommended disease management interventions in primary care in Leuven, a region of ±100.000 inhabitants. These interventions include education of general practitioners, reimbursement of the analysis of circulating natriuretic peptides and audits in the electronic health record (EHR), training and implementation of HF educators in primary care, and a protocol to structure transition to primary care after discharge. The main objective is to study and implement interventions in an iterative implementation process. CONCLUSIONS We will evaluate the implementation of several guideline-recommended disease management interventions to optimise the diagnosis and treatment of heart failure in a real-world primary care setting. TRIAL REGISTRATION NCT04334447 (clinicaltrials.gov).
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Affiliation(s)
- Willem Raat
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Miek Smeets
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Gijs Van Pottelbergh
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Zorgzaam Leuven, Leuven, Belgium
| | | | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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21
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Beauvais F, Tartière L, Pezel T, Motet C, Aumont MC, Baudry G, Eicher JC, Galinier M, Gellen B, Guihaire J, Legallois D, Lequeux B, Mika D, Mouquet F, Salvat M, Taieb C, Zorès F, Berthelot E, Damy T. First symptoms and health care pathways in hospitalized patients with acute heart failure: ICPS2 survey. A report from the Heart Failure Working Group (GICC) of the French Society of Cardiology. Clin Cardiol 2021; 44:1144-1150. [PMID: 34173675 PMCID: PMC8364729 DOI: 10.1002/clc.23666] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/26/2021] [Accepted: 05/26/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Acute heart failure (AHF) is a common serious condition that contributes to about 5% of all emergency hospital admissions in Europe. HYPOTHESIS To assess the type and chronology of the first AHF symptoms before hospitalization and to examine the French healthcare system pathways before, during and after hospitalization. MATERIAL AND METHODS A retrospective observational study including patients hospitalized for AHF RESULTS: 793 patients were included, 59.0% were men, 45.6% identified heart failure (HF) as the main cause of hospitalization; 36.0% were unaware of their HF. Mean age was 72.9 ± 14.5 years. The symptoms occurring the most before hospitalization were dyspnea (64.7%) and lower limb edema (27.7%). Prior to hospitalization, 47% had already experienced symptoms for 15 days; 32% of them for 2 months. Referral to hospital was made by the emergency medical assistance service (SAMU, 41.6%), a general practitioner (GP, 22.3%), a cardiologist (19.5%), or the patient (16.6%). The modality of referral depended more on symptom acuteness than on type of symptoms. A sudden onset of AHF symptoms led to making an emergency call or to spontaneously attending an emergency room (ER), whereas cardiologists were consulted when symptoms had already been present for over 15 days. Cardiologists referred more patients to cardiology departments and fewer patients to the ER than general practitioners or the SAMU. CONCLUSION This study described the French healthcare system pathways before, during and after hospitalization AHF. AHF clinic network should be developed to provide adequate care for all HF patients and create awareness regarding AHF symptoms.
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Affiliation(s)
| | - Lamia Tartière
- Department of Cardiology, Hôpital Leon Berard, Hyères, France
| | - Théo Pezel
- Department of Cardiology, CHU Lariboisière, APHP, Paris, France
| | - Chloé Motet
- Faculty of Medicine, University of Nantes, Nantes, France
| | | | - Guillaume Baudry
- HCL, Service Insuffisance cardiaque, Hôpital Louis Pradel, Bron, France
| | | | | | - Barnabas Gellen
- Department of Cardiology, ELSAN - Polyclinique de Poitiers, Poitiers, France
| | - Julien Guihaire
- Department of Cardiology, Hôpital Marie Lanelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Le Plessis Robinson, France
| | | | - Benoit Lequeux
- Department of Cardiology, CHU Poitiers, Poitiers, France
| | - Delphine Mika
- Inserm, UMR-S 1180, Université Paris-Saclay, Chatenay-Malabry, France
| | | | - Muriel Salvat
- Department of Cardiology, CHU de Grenoble, Grenoble, France
| | | | | | | | - Thibaud Damy
- Department of Cardiology, Referral Center for Cardiac Amyloidosis and DHU ATVB, CHU Henri Mondor, APHP, Creteil, France
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Verhestraeten C, Weijers G, Debleu D, Ciarka A, Goethals M, Droogmans S, Maris M. Diagnosis, treatment, and follow-up of heart failure patients by general practitioners: A Delphi consensus statement. PLoS One 2021; 15:e0244485. [PMID: 33382755 PMCID: PMC7775077 DOI: 10.1371/journal.pone.0244485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/01/2020] [Indexed: 02/07/2023] Open
Abstract
Aims Creation of an algorithm that includes the most important parameters (history, clinical parameters, and anamnesis) that can be linked to heart failure, helping general practitioners in recognizing heart failure in an early stage and in a better follow-up of the patients. Methods and results The algorithm was created using a consensus-based Delphi panel technique with fifteen general practitioners and seven cardiologists from Belgium. The method comprises three iterations with general statements on diagnosis, referral and treatment, and follow-up. Consensus was obtained for the majority of statements related to diagnosis, referral, and follow-up, whereas a lack of consensus was seen for treatment statements. Based on the statements with good and perfect consensus, an algorithm for general practitioners was assembled, helping them in diagnoses and follow-up of heart failure patients. The diagnosis should be based on three essential pillars, i.e. medical history, anamnesis and clinical examination. In case of suspected heart failure, blood analysis, including the measurement of NT-proBNP levels, can already be performed by the general practitioner followed by referral to the cardiologist who is then responsible for proper diagnosis and initiation of treatment. Afterwards, a multidisciplinary health care process between the cardiologist and the general practitioner is crucial with an important role for the general practitioner who has a key role in the up-titration of heart failure medication, down-titration of the dose of diuretics and to assure drug compliance. Conclusions Based on the consensus levels of statements in a Delphi panel setting, an algorithm is created to help general practitioners in the diagnosis and follow-up of heart failure patients.
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Affiliation(s)
| | - Gijs Weijers
- Department of Cardiology, Centre Hospitalier Bois de l’Abbaye, Seraing, Belgium
| | | | - Agnieszka Ciarka
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Katholieke Universiteit Leuven, Leuven, Belgium
| | - Marc Goethals
- Department of Cardiology, OLV Hospital Aalst, Aalst, Belgium
| | - Steven Droogmans
- Department of Cardiology, Centrum Voor Hart-en Vaatziekten, Jette, Belgium
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Ament SMC, van den Beuken-Everdingen M, Maessen JMC, Boyne J, Schols JMGA, Stoffers HEJH, Bellersen L, Brunner-La Rocca HP, Engels Y, Janssen DJA. Professionals guidance about palliative medicine in chronic heart failure: a mixed-method study. BMJ Support Palliat Care 2020:bmjspcare-2020-002580. [PMID: 33243826 DOI: 10.1136/bmjspcare-2020-002580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/24/2020] [Accepted: 10/26/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Healthcare professionals (HCPs) experience difficulties in timely recognising and directing palliative care (PC) needs of their patients with chronic heart failure (CHF). The aim of this study was to develop a comprehensive tool to enable HCPs in timely recognising and directing PC needs in CHF. METHODS A four-stage mixed-method study was performed. Stage 1: identification of needs and questions of patients and families; stage 2: prioritisation and refinement of the needs and questions; stage 3a: testing and online feedback on V.1; stage 3b: selecting and refining care recommendations; stage 4: testing and review of V.2. Iterative reviews followed each step in the development process to ensure a wide range of stakeholder input. In total, 16 patients, 12 family members and 54 HCPs participated. RESULTS A comprehensive set of 13 PC needs was identified, redefined and tested. The resulting tool, called Identification of patients with HeARt failure with PC needs (I-HARP), contains an introduction prompt with open questions to start the conversation, 13 closed screening questions with additional in-depth questions, and recommendations on actions for identified needs. CONCLUSION I-HARP contains an evidence-based set of questions and palliative CHF care suggestions for HCPs in the Netherlands. The resulting tool, approved by HCPs, patients and family members, is a promising guidance for HCP to timely recognise and direct PC needs in CHF.
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Affiliation(s)
- Stephanie M C Ament
- Care and Public Health Research Institute (CAPHRI), Department of Health Services Research, Maastricht University Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
| | | | - José M C Maessen
- Department of Patient and Care, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Josiane Boyne
- Department of Patient and Care, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Jos M G A Schols
- Care and Public Health Research Institute (CAPHRI), Department of Health Services Research, Maastricht University Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Department of Family Medicine, Maastricht University Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
| | - Henri E J H Stoffers
- Care and Public Health Research Institute (CAPHRI), Department of Family Medicine, Maastricht University Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
| | | | | | - Yvonne Engels
- Anesthesiology, Pain and Palliative medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Daisy J A Janssen
- Care and Public Health Research Institute (CAPHRI), Department of Health Services Research, Maastricht University Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
- Research & Education, CIRO, Horn, The Netherlands
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Péptidos natriuréticos en la detección de disfunción ventricular izquierda en población de alto riesgo. Metaanálisis de pruebas diagnósticas. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Duflos C, Troude P, Strainchamps D, Ségouin C, Logeart D, Mercier G. Hospitalization for acute heart failure: the in-hospital care pathway predicts one-year readmission. Sci Rep 2020; 10:10644. [PMID: 32606326 PMCID: PMC7327074 DOI: 10.1038/s41598-020-66788-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 05/06/2020] [Indexed: 11/18/2022] Open
Abstract
In patients with heart failure, some organizational and modifiable factors could be prognostic factors. We aimed to assess the association between the in-hospital care pathways during hospitalization for acute heart failure and the risk of readmission. This retrospective study included all elderly patients who were hospitalized for acute heart failure at the Universitary Hospital Lariboisière (Paris) during 2013. We collected the wards attended, length of stay, admission and discharge types, diagnostic procedures, and heart failure discharge treatment. The clinical factors were the specific medical conditions, left ventricular ejection fraction, type of heart failure syndrome, sex, smoking status, and age. Consistent groups of in-hospital care pathways were built using an ascending hierarchical clustering method based on a primary components analysis. The association between the groups and the risk of readmission at 1 month and 1 year (for heart failure or for any cause) were measured via a count data model that was adjusted for clinical factors. This study included 223 patients. Associations between the in-hospital care pathway and the 1 year-readmission status were studied in 207 patients. Five consistent groups were defined: 3 described expected in-hospital care pathways in intensive care units, cardiology and gerontology wards, 1 described deceased patients, and 1 described chaotic pathways. The chaotic pathway strongly increased the risk (p = 0.0054) of 1 year readmission for acute heart failure. The chaotic in-hospital care pathway, occurring in specialized wards, was associated with the risk of readmission. This could promote specific quality improvement actions in these wards. Follow-up research projects should aim to describe the processes causing the generation of chaotic pathways and their consequences.
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Affiliation(s)
- Claire Duflos
- Department of Medical Information, CHU, University of Montpellier, Montpellier, France.
- PhyMedExp, U1046, INSERM, Montpellier, France.
| | - Pénélope Troude
- Public Health Department, Universitary Hospital Saint-Louis - Lariboisière - Fernand-Widal, AP-HP, Paris, France
| | - David Strainchamps
- Department of Medical Information, CHU, University of Montpellier, Montpellier, France
| | - Christophe Ségouin
- Public Health Department, Universitary Hospital Saint-Louis - Lariboisière - Fernand-Widal, AP-HP, Paris, France
| | - Damien Logeart
- Cardiology Department, Universitary Hospital Saint-Louis - Lariboisière - Fernand-Widal, AP-HP, Paris, France
| | - Grégoire Mercier
- Department of Medical Information, CHU, University of Montpellier, Montpellier, France
- CEPEL, University of Montpellier, Montpellier, France
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Khattab M, Parwani P, Abbas M, Ali H, Lozano PM, Thadani U, Dasari TW. Utilization of guideline-directed medical therapy in patients with de novo heart failure with reduced ejection fraction: A Veterans Affairs study. J Family Med Prim Care 2020; 9:3065-3069. [PMID: 32984174 PMCID: PMC7491814 DOI: 10.4103/jfmpc.jfmpc_174_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/13/2020] [Accepted: 03/24/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The utilization of guideline-directed medical therapy (GDMT) significantly reduces morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). Previous studies have documented the underutilization of GDMT in HFrEF. The present study aimed to determine reasons for underutilization and achievement of target doses of GDMT in patients with de novo diagnosis of HFrEF. METHODS Patients presenting with de novo HFrEF at the Veterans Affairs Medical Center were included. Baseline demographic, clinical, and echocardiographic data were collected. The utilization of target doses of GDMT was assessed at the time of discharge and 1-, 3-, 6-, and 12-month follow-up. RESULTS Of the 95 patients who met the criteria for de novo HFrEF, 48 were included in the final analysis. Dose titration of either beta-blocker or angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) was attempted in 20 patients (42%) at 1 month, 21 patients (44%) at 3 months, 13 patients (27%) at 6 months, and 14 patients (29%) at 12 months. Nine (19%) patients were on a target dose of beta-blockers and three (6%) patients were on a target dose of an ACEi/ARB at 12 months. The most common reasons for underutilization were patient-level factors, such as hypotension, acute kidney injury/hyperkalemia, and patient noncompliance. CONCLUSIONS Utilization and achievement of target doses of GDMT were suboptimal among patients discharged with de novo HFrEF during a 1-year follow-up. Although patient factors may limit the up-titration of therapies, concerted efforts are needed to support primary care physicians in improving adherence to target doses of GDMT in patients with HFrEF.
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Affiliation(s)
- Mohamad Khattab
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Purvi Parwani
- Loma Linda University International Heart Institute, Loma Linda, CA, United States
| | - Mubasher Abbas
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Huzair Ali
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Pedro M. Lozano
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Veterans Affair Medical Center, Oklahoma City, OK, United States
| | - Udho Thadani
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Veterans Affair Medical Center, Oklahoma City, OK, United States
| | - Tarun W. Dasari
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Verhestraeten C, Heggermont WA, Maris M. Clinical inertia in the treatment of heart failure: a major issue to tackle. Heart Fail Rev 2020; 26:1359-1370. [PMID: 32474794 PMCID: PMC8510913 DOI: 10.1007/s10741-020-09979-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Despite an enormous improvement in heart failure management during the last decades, the hospitalization and mortality rate of heart failure patients still remain very high. Clinical inertia, defined as the lack of treatment intensification in a patient not at evidence-based goals for care, is an important underlying cause. Clinical inertia is extensively described in hypertension and type 2 diabetes mellitus, but increasingly recognized in heart failure as well. Given the well-established guidelines for the management of heart failure, these are still not being reflected in clinical practice. While the absolute majority of patients were treated by guideline-directed heart failure drugs, only a small percentage of these patients reached the correct guideline-recommended target dose of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors. This considerable under-treatment leads to a large number of avoidable hospitalizations and deaths. This review discusses clinical inertia in heart failure and explains its major contributing factors (i.e., physician, patient, and system) and touches upon some recommendations to prevent clinical inertia and ameliorate heart failure treatment.
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Affiliation(s)
| | - Ward A Heggermont
- Cardiovascular Center OLV Aalst, Moorselbaan 164, 9300, Aalst, Belgium.,Cardiovascular Research Center Maastricht, Universiteitssingel 50, 6202, Maastricht, The Netherlands
| | - Michael Maris
- Novartis Pharma nv-sa, Medialaan 40, 1800, Vilvoorde, Belgium.
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Piña IL. A "Silent" Passenger Speaks Loudly. JACC-HEART FAILURE 2020; 8:289-290. [PMID: 32241536 DOI: 10.1016/j.jchf.2019.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 10/24/2022]
Affiliation(s)
- Ileana L Piña
- Department of Medicine, Wayne State University, Detroit, Michigan.
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29
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How to develop a national heart failure clinics network: a consensus document of the Hellenic Heart Failure Association. ESC Heart Fail 2020; 7:15-25. [PMID: 32100972 PMCID: PMC7083479 DOI: 10.1002/ehf2.12558] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/01/2019] [Accepted: 10/31/2019] [Indexed: 12/26/2022] Open
Abstract
Heart failure (HF) is rapidly growing, conferring considerable mortality, morbidity, and costs. Dedicated HF clinics improve patient outcomes, and the development of a national HF clinics network aims at addressing this need at national level. Such a network should respect the existing health care infrastructures, and according to the capacities of hosting facilities, it can be organized into three levels. Establishing the continuous communication and interaction among the components of the network is crucial, while supportive actions that can enhance its efficiency include involvement of multidisciplinary health care professionals, use of structured HF‐specific documents, such as discharge notes, patient information leaflets, and patient booklets, and implementation of an HF‐specific electronic health care record and database platform.
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30
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Moscova L, Leblanc F, Cittee J, Le Breton J, Vallot S, Fabre J, Phan TT, Renard V, Ferrat E. Changes over time in attitudes towards the management of older patients with heart failure by general practitioners: a qualitative study. Fam Pract 2020; 37:110-117. [PMID: 31298275 DOI: 10.1093/fampra/cmz033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Underdiagnosis and undertreatment of chronic heart failure (CHF) are common in older patients, who are usually treated by general practitioners (GPs). In 2007, the French ICAGE study explored GPs' attitudes to the management of this condition in older patients. OBJECTIVES To explore changes over time in GPs' attitudes towards the management of CHF in patients aged ≥75 and to identify barriers to optimal management. METHODS In 2015, we performed a qualitative study of 20 French GPs via semi-structured interviews and a thematic content analysis. The results were compared with the findings of a 2007 study. RESULTS In 2015, the perceived barriers to diagnosis were the same as in 2007. Echocardiography was still the preferred diagnostic method but the GPs relied on the cardiologist to confirm the diagnosis. Many GPs were still unaware of the different types of CHF. In contrast, they reported greater knowledge of decompensation factors and the ultrasound criteria for CHF. They also prescribed a brain natriuretic peptide assay more frequently. Angiotensin-converting enzyme inhibitors and beta blockers were more strongly perceived to be core treatments. Few GPs initiated drug treatments and optimized dosages. Although patient education was never mentioned, the importance of multidisciplinary care was emphasized. CONCLUSION Our results evidenced a small recent improvement in the management of older patients with CHF. Appropriate guidelines and training for GPs, patient education and multidisciplinary collaboration might further improve the care given to this population.
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Affiliation(s)
- Laura Moscova
- Département de Médecine Générale; Faculté de Médecine; Université Paris-Est Créteil (UPEC), Créteil
| | - Fabien Leblanc
- Département de Médecine Générale; Faculté de Médecine; Université Paris-Est Créteil (UPEC), Créteil
| | - Jacques Cittee
- Département de Médecine Générale; Faculté de Médecine; Université Paris-Est Créteil (UPEC), Créteil
| | - Julien Le Breton
- Département de Médecine Générale; Faculté de Médecine; Université Paris-Est Créteil (UPEC), Créteil.,EA 7376 CEpiA (Clinical Epidemiology and Ageing), DHU A-TVB, IMRB, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Sophie Vallot
- Département de Médecine Générale; Faculté de Médecine; Université Paris-Est Créteil (UPEC), Créteil.,EA 7376 CEpiA (Clinical Epidemiology and Ageing), DHU A-TVB, IMRB, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Julie Fabre
- Département de Médecine Générale; Faculté de Médecine; Université Paris-Est Créteil (UPEC), Créteil.,EA 7376 CEpiA (Clinical Epidemiology and Ageing), DHU A-TVB, IMRB, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Tan-Trung Phan
- Département de Médecine Générale; Faculté de Médecine; Université Paris-Est Créteil (UPEC), Créteil
| | - Vincent Renard
- Département de Médecine Générale; Faculté de Médecine; Université Paris-Est Créteil (UPEC), Créteil.,EA 7376 CEpiA (Clinical Epidemiology and Ageing), DHU A-TVB, IMRB, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Emilie Ferrat
- Département de Médecine Générale; Faculté de Médecine; Université Paris-Est Créteil (UPEC), Créteil.,EA 7376 CEpiA (Clinical Epidemiology and Ageing), DHU A-TVB, IMRB, Université Paris-Est Créteil (UPEC), Créteil, France
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Ferreira JP, Kraus S, Mitchell S, Perel P, Piñeiro D, Chioncel O, Colque R, de Boer RA, Gomez-Mesa JE, Grancelli H, Lam CSP, Martinez-Rubio A, McMurray JJV, Mebazaa A, Panjrath G, Piña IL, Sani M, Sim D, Walsh M, Yancy C, Zannad F, Sliwa K. World Heart Federation Roadmap for Heart Failure. Glob Heart 2020; 14:197-214. [PMID: 31451235 DOI: 10.1016/j.gheart.2019.07.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 07/08/2019] [Indexed: 12/26/2022] Open
Affiliation(s)
- João Pedro Ferreira
- National Institute of Health and Medical Research, Center for Clinical Multidisciplinary Research, University of Lorraine, Regional University Hospital of Nancy, Nancy, France
| | - Sarah Kraus
- Groote Schuur Hospital and Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Pablo Perel
- London School of Tropical Hygiene and Medicine, London, United Kingdom
| | - Daniel Piñeiro
- Division of Medicine, Hospital de Clínicas Department of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases "C.C. Iliescu" Bucharest, University of Medicine and Pharmacy "Carol Davila" Bucharest, Bucharest, Romania
| | - Roberto Colque
- Coronary Care Unit, Sanatorio Allende Cerro, Cordoba, Argentina
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Hugo Grancelli
- Cardiology Department, Sanatorio Trinidad Palermo, Buenos Aires, Argentina
| | | | - Antoni Martinez-Rubio
- Department of Cardiology, University Hospital Sabadell Autonomous, University of Barcelona, Barcelona, Spain
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Alexandre Mebazaa
- Université de Paris, Paris, France; U942 MASCOT (cardiovascular MArkers in Stress COndiTions), National Institute of Health and Medical Research, France; Department of Anesthesia, Burn, Intensive Care, Saint Louis Lariboisière Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Gurusher Panjrath
- Department of Medicine /Cardiology, George Washington University School of Medicine, George Washington University, Washington, DC, USA
| | - Ileana L Piña
- Wayne State University, Michigan, USA; Wayne State University, Michigan, USA
| | - Mahmoud Sani
- Department of Medicine, Bayero University Kano, Kano, Nigeria; Aminu Kano Teaching Hospital, Kano State, Kano, Nigeria
| | - David Sim
- Department of Cardiology, Heart Failure Program at the National Heart Center Singapore, Singapore
| | - Mary Walsh
- Department of Heart Failure and Cardiac Transplantation, St. Vincent Heart Center, Indianapolis, IN, USA
| | - Clyde Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Faiez Zannad
- Department of Cardiology, Centre d'Investigation Clinique (CIC), Centre Hospitalier Universitaire, University Henri Poincaré, Nancy, France
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Cardiology and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Chambers D, Cantrell A, Booth A. Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BackgroundIn 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice.ObjectivesTo map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions.MethodsFor the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA).ResultsA total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights.LimitationsThe research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.ConclusionsOverall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services.Future workResearch should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Abstract
An effective discharge plan is associated with better outcomes in advanced heart failure (HF) patients. Furthermore, a patient-centred care planning can improve patients' satisfaction, quality of life, and enhance self-care. Telemedicine may allow optimized monitoring of advanced HF patients. Nevertheless, its implementation into clinical practice across European countries is still limited. This document reflects the key points discussed concerning effective management plans in advanced HF by a panel of experts during a Heart Failure Association meeting on physiological monitoring of the complex multimorbid HF patient.
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Affiliation(s)
- Loreena Hill
- Queen's University, Belfast, Northern Ireland, UK
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Smeets M, Aertgeerts B, Mullens W, Penders J, Vercammen J, Janssens S, Vaes B. Optimising standards of care of heart failure in general practice the OSCAR-HF pilot study protocol. Acta Cardiol 2019; 74:371-379. [PMID: 30507291 DOI: 10.1080/00015385.2018.1507426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Heart failure (HF) imposes a burden for patients and health economics. General practitioners (GPs) are confronted with the broadest range of HF management. Although guidelines exist, they are not fully implemented in the Belgian health care system. Methods: We will conduct a non-randomised, non-controlled prospective observational trial (six months follow-up) to implement a multifaceted intervention in Belgian general practice to support GPs in the implementation of evidence-based HF guidelines. The multifaceted intervention consists of an audit and feedback method to detect previously unrecognised patients with HF and to increase awareness for proactive HF management, an NT-proBNP point-of-care test to improve detection and adequate diagnosis of patients with HF and a specialist HF nurse to assist GPs in the education of patients, optimisation of treatment and follow-up after hospitalisation. All patients aged 40 years and older with a confirmed diagnosis of HF by their GP based on the clinical audit are eligible for participation. The main objective of this pilot study is to evaluate the feasibility of this multifaceted intervention and the evolution of predefined quality indicators. We will measure the impact on HF diagnosis, medication optimisation, multidisciplinary follow-up and patients' quality of life after six months. Additionally, the experiences of GPs and investigators will be studied. Conclusions: Heart failure is an important health problem in which GPs play a key role. Therefore, we will evaluate the feasibility of a multifaceted intervention to optimise diagnosis as well as implement the guideline recommended therapies in patients with HF in general practice.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Joris Penders
- Department of Clinical Biology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Jan Vercammen
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, KU Leuven (KUL), Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
- Institute of Health and Society, Université Catholique de Louvain (UCL), Brussels, Belgium
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Route to heart failure diagnosis in English primary care: a retrospective cohort study of variation. Br J Gen Pract 2019; 69:e697-e705. [PMID: 31455645 DOI: 10.3399/bjgp19x705485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/05/2019] [Indexed: 10/31/2022] Open
Abstract
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<0.001), not having chronic pulmonary disease (P<0.001), receiving further consultation for symptom(s) suggestive of HF (P<0.001), and presenting with breathlessness (P<0.001). Route to diagnosis also varied significantly between GP practices (P<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.
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Abstract
PURPOSE OF REVIEW Heart failure (HF) is the first cause of hospitalization in the elderly in Western countries, generating tremendous healthcare costs. Despite the spread of multidisciplinary post-discharge programs, readmission rates have remained unchanged over time. We review the recent developments in this setting. RECENT FINDINGS Recent data plead for global reorganization of HF care, specifically targeting patients at high risk for further readmission, as well as a stronger involvement of primary care providers (PCP) in patients' care plan. Besides, tools, devices, and new interdisciplinary expertise have emerged to support and be integrated into those programs; they have been greeted with great enthusiasm, but their routine applicability remains to be determined. HF programs in 2018 should focus on pragmatic assessments of patients that will benefit the most from the multidisciplinary care; delegating the management of low-risk patients to trained PCP and empowering the patient himself, using the newly available tools as needed.
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Affiliation(s)
- Nadia Bouabdallaoui
- Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000, Belanger East, Montreal, Quebec, H1T1C8, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000, Belanger East, Montreal, Quebec, H1T1C8, Canada.
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Schichtel M, Wee B, MacArtney JI, Collins S. Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis. BMJ Support Palliat Care 2019; 12:bmjspcare-2018-001747. [PMID: 31331916 DOI: 10.1136/bmjspcare-2018-001747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/23/2019] [Accepted: 05/01/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Clinicians hesitate to engage with advance care planning (ACP) in heart failure. We aimed to identify the disease-specific barriers and facilitators for clinicians to engage with ACP. METHODS We searched Medline, Embase, CINAHL, PubMed, Scopus, the British Nursing Index, the Cochrane Library, the EPOC register, ERIC, PsycINFO, the Science Citation Index and the Grey Literature from inception to July 2018. We conducted the review according to Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Two reviewers independently assessed original and empirical studies according to Critical Appraisal Skills Programme criteria. The SURE framework and thematic analysis were used to identify barriers and facilitators. RESULTS Of 2308 articles screened, we reviewed the full text of 42 studies. Seventeen studies were included. The main barriers were lack of disease-specific knowledge about palliative care in heart failure, high emotional impact on clinicians when undertaking ACP and lack of multidisciplinary collaboration between healthcare professionals to reach consensus on when ACP is indicated. The main facilitators were being competent to provide holistic care when using ACP in heart failure, a patient taking the initiative of having an ACP conversation, and having the resources to deliver ACP at a time and place appropriate for the patient. CONCLUSIONS Training healthcare professionals in the delivery of ACP in heart failure might be as important as enabling patients to start an ACP conversation. This twofold approach may mitigate against the high emotional impact of ACP. Complex interventions are needed to support clinicians as well as patients to engage with ACP.
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Affiliation(s)
- Markus Schichtel
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Bee Wee
- Oxford Centre for Education and Research in Palliative Care, Oxford University Hospital Trust, Oxford, UK
| | - John I MacArtney
- Academic Primary Care Unit, Medical Sciences Division, University of Warwick, Coventry, UK
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Smeets M, Zervas S, Leben H, Vermandere M, Janssens S, Mullens W, Aertgeerts B, Vaes B. General practitioners' perceptions about their role in current and future heart failure care: an exploratory qualitative study. BMC Health Serv Res 2019; 19:432. [PMID: 31253146 PMCID: PMC6599228 DOI: 10.1186/s12913-019-4271-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 06/17/2019] [Indexed: 12/28/2022] Open
Abstract
Background A comprehensive disease management programme (DMP) with a central role for general practitioners (GPs) is needed to improve heart failure (HF) care. However, previous research has shown that GPs have mixed experiences with multidisciplinary HF care. Therefore, in this study, we explore the perceptions that GPs have regarding their role in current and future HF care, prior to the design of an HF disease management programme. Methods This was a qualitative semi-structured interview study with Belgian GPs until data saturation was reached. The QUAGOL method was used for data analysis. Results In general, GPs wanted to assume a central role in HF care. Current interdisciplinary collaboration with cardiologists was perceived as smooth, partly because of the ease of access. In contrast, due to less well-established communication and the variable knowledge of nurses regarding HF care, collaboration with home care nurses was perceived as suboptimal. With regard to the future organization of HF care, all GPs confirmed the need for a structured chronic care approach and envisioned this as a multidisciplinary care pathway: flexible, patient-centred, without additional administration and with appropriate delegation of some critical tasks, including education and monitoring. GPs considered all-round general practice nurses as the preferred partner to delegate tasks to in HF care and reported limited experience in collaborating with specialist HF nurses. Conclusion GPs expressed the need for a protocol-driven care pathway in chronic HF care. However, in contrast to the existing care trajectories, this pathway should be flexible, without additional administrative burdens and with a central role for GPs. Electronic supplementary material The online version of this article (10.1186/s12913-019-4271-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok j bus 7001, 3000, Leuven, Belgium.
| | - Sofia Zervas
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok j bus 7001, 3000, Leuven, Belgium
| | - Hanne Leben
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok j bus 7001, 3000, Leuven, Belgium
| | - Mieke Vermandere
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok j bus 7001, 3000, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Wilfried Mullens
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, U Hasselt, Hasselt, Belgium.,Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok j bus 7001, 3000, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok j bus 7001, 3000, Leuven, Belgium.,Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
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Yates L, Valente M, Wadsworth C. Evaluation of Pharmacist Medication Review Service in an Outpatient Heart Failure Clinic. J Pharm Pract 2019; 33:820-826. [PMID: 31057060 DOI: 10.1177/0897190019842696] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Purpose: The purpose of this study was to evaluate the impact of pharmacist medication reviews on drug-related problems (DRPs) in a population with ambulatory heart failure (HF). Methods: The HF pharmacist medication review service incorporated a comprehensive medication review note provided to the cardiologist in a HF clinic. A retrospective chart review was performed on 64 control patients with no previous pharmacist review and 64 intervention patients who had a pharmacist medication review. The primary end point was the number of DRPs identified per patient in the intervention group 2 weeks after pharmacist medication review compared to the number of DRPs identified per patient in the control group. Results: The average DRPs per patient was reduced from 2.80 to 1.95 in intervention group after pharmacist intervention. There was a statistically significant difference between the average DRPs per patient in the control and intervention groups, 2.55 DRPs versus 1.95 DRPs per patient, respectively ( P = .016). Medication adherence (78%), renal dosing (67%), hypertension (58%), and HF DRPs (55%) had the highest acceptance rate. The majority of DRP recommendations in the intervention (87%) and control groups (87%) were high-impact recommendations. Conclusions: Pharmacist medication reviews in an ambulatory HF clinic lead to significantly fewer DRPs.
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Affiliation(s)
- Lauren Yates
- Department of Pharmacy, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH, USA
| | - Megan Valente
- Department of Pharmacy, MetroHealth Medical Center, Cleveland, OH, USA
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Smeets M, De Witte P, Peters S, Aertgeerts B, Janssens S, Vaes B. Think-aloud study about the diagnosis of chronic heart failure in Belgian general practice. BMJ Open 2019; 9:e025922. [PMID: 30898828 PMCID: PMC6475198 DOI: 10.1136/bmjopen-2018-025922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/17/2018] [Accepted: 02/06/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Diagnosing chronic heart failure (CHF) in general practice is challenging. Our aim was to investigate how general practitioners (GPs) diagnose CHF in real-world patients. DESIGN Think-aloud study. METHODS Fourteen GPs were asked to reason about four real-world CHF cases from their own practices. The cases were selected through a clinical audit. This was followed by an interview to get a deeper insight in their reasoning. The Qualitative Analysis Guide of Leuven was used as a guide in data analysis. RESULTS We developed a conceptual diagnostic model based on three important reasoning steps. First, GPs assessed the likelihood of CHF based on the presence or absence of HF signs and symptoms. However, this approach had serious limitations since GPs experienced many barriers in their clinical assessment, especially in comorbid elderly. Second, if CHF was considered based on step 1, the main influencing factor to take further diagnostic steps was the GPs' perception of the added value of a validated CHF diagnosis in that specific case. Third, the choice and implications of these further diagnostic steps (N-terminal pro B-type natriuretic peptide, ECG and/or cardiac ultrasound) were influenced by the GPs' knowledge about these tests and the quality of the cardiologists' reports. CONCLUSION This think-aloud study identified the factors that influenced the diagnostic reasoning about CHF in general practice. As a consequence, targets to improve this diagnostic reasoning were withheld: a paradigm shift towards an earlier and more comprehensive risk assessment with, among others, access to natriuretic peptide testing and convincing GPs of the added value of a validated HF diagnosis.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Pieter De Witte
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Sanne Peters
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Leuven Context, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
- Institute of Health and Society, Université Catholique de Louvain (UCL), Brussels, Belgium
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Smeets M, Vaes B, Mamouris P, Van Den Akker M, Van Pottelbergh G, Goderis G, Janssens S, Aertgeerts B, Henrard S. Burden of heart failure in Flemish general practices: a registry-based study in the Intego database. BMJ Open 2019; 9:e022972. [PMID: 30617099 PMCID: PMC6326340 DOI: 10.1136/bmjopen-2018-022972] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES To assess the prevalence and incidence of heart failure (HF) stages A to C/D and their evolution over a 16-year period. Additionally, trends in comorbidities and cardiovascular (CV) treatment in patients with HF were studied in the same period. DESIGN Registry-based study. SETTING Primary care, Flanders, Belgium. PARTICIPANTS Data were obtained from Intego, a morbidity registration network in which 111 general practitioners of 48 practices collaborate. In the study period between 2000 and 2015, data from 165 796 unique patients aged 45 years and older were available. OUTCOME MEASURES Prevalence and incidence were calculated for HF stage A, B and C/D by gender. Additionally, the trend in age-standardised prevalence and incidence rates between 2000 and 2015 was analysed with joint-point regression. The same model was used to study trends in comorbidity profiles in incident HF cases and trends in cardiovascular medication in prevalent HF cases. RESULTS We found a downward trend in the incidence and prevalence of HF stage C/D in Flemish general practice between 2000 and 2015, whereas the prevalence and incidence of stage A and B increased. The burden of comorbidities in incident HF cases increased during the study period, as shown by an increasing disease count (p<0.001). The prescription of cardiovascular medication such as renin-angiotensin-aldosterone system blockade, β-blockers and statins showed a sharp increase in the first part of the study period (2000-2008). CONCLUSION Age-standardised incidence and prevalence of HF stage C/D showed a slightly downward trend over the past 16 years, probably due to the sharp increase in cardiovascular treatment. However, the increasing age-standardised incidence and prevalence of stage A and B, as precursors of symptomatic HF, together with a rising comorbid burden, highlights the challenges we are still facing.
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Affiliation(s)
- Miek Smeets
- Departement of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bert Vaes
- Departement of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
- Louvain Drug Research Institute, Clinical Pharmacy Research Group and Institute of Health and Society (IRSS), Université catholique de Louvain (UCL), Brussels, Belgium
| | - Pavlos Mamouris
- Departement of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Marjan Van Den Akker
- Departement of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Gijs Van Pottelbergh
- Departement of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Geert Goderis
- Departement of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Stefan Janssens
- Departement of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Bert Aertgeerts
- Departement of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Séverine Henrard
- Departement of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
- Louvain Drug Research Institute, Clinical Pharmacy Research Group and Institute of Health and Society (IRSS), Université catholique de Louvain (UCL), Brussels, Belgium
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Hayhoe B, Kim D, Aylin PP, Majeed FA, Cowie MR, Bottle A. Adherence to guidelines in management of symptoms suggestive of heart failure in primary care. Heart 2018; 105:678-685. [DOI: 10.1136/heartjnl-2018-313971] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/17/2018] [Accepted: 11/06/2018] [Indexed: 11/04/2022] Open
Abstract
ObjectiveClinical guidelines on heart failure (HF) suggest timings for investigation and referral in primary care. We calculated the time for patients to achieve key elements in the recommended pathway to diagnosis of HF.MethodsIn this observational study, we used linked primary and secondary care data (Clinical Practice Research Datalink, a database of anonymised electronic records from UK general practices) between 2010 and 2013. Records were examined for presenting symptoms (breathlessness, fatigue, ankle swelling) and key elements of the National Institute for Health and Care Excellence-recommended pathway to diagnosis (serum natriuretic peptide (NP) test, echocardiography, specialist referral).Results42 403 patients were diagnosed with HF, of whom 16 597 presented in primary care with suggestive symptoms. 6464 (39%) had recorded NP or echocardiography, and 6043 (36%) specialist referral. Median time from recorded symptom(s) to investigation (NP or echocardiography) was 292 days (IQR 34–844) and to referral 236 days (IQR 42–721). Median time from symptom(s) to diagnosis was 972 days (IQR 337–1468) and to treatment with HF-relevant medication 803 days (IQR 230–1364). Factors significantly affecting timing of referral, treatment and diagnosis included patients’ sex (p=0.001), age (p<0.001), deprivation score (p=0.001), comorbidities (p<0.001) and presenting symptom type (p<0.001).ConclusionsMedian times to investigation or referral of patients presenting in primary care with symptoms suggestive of HF considerably exceeded recommendations. There is a need to support clinicians in the diagnosis of HF in primary care, with improved access to investigation and specialist assessment to support timely management.
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Bottle A, Kim D, Aylin PP, Majeed FA, Cowie MR, Hayhoe B. Real-world presentation with heart failure in primary care: do patients selected to follow diagnostic and management guidelines have better outcomes? Open Heart 2018; 5:e000935. [PMID: 30487985 PMCID: PMC6242017 DOI: 10.1136/openhrt-2018-000935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 11/26/2022] Open
Abstract
Objective To describe associations between initial management of people presenting with heart failure (HF) symptoms in primary care, including compliance with the recommendations of the National Institute for Health and Care Excellence (NICE), and subsequent unplanned hospitalisation for HF and death. Methods This is a retrospective cohort study using data from general practices submitting records to the Clinical Practice Research Datalink. The cohort comprised patients diagnosed with HF during 2010–2013 and presenting to their general practitioners with breathlessness, fatigue or ankle swelling. Results 13 897 patients were included in the study. Within the first 6 months, only 7% had completed the NICE-recommended pathway; another 18.6% had followed part of it (B-type natriuretic peptide testing and/or echocardiography, or specialist referral). Significant differences in hazards were seen in unadjusted analysis in favour of full or partial completion of the NICE-recommended pathway. Covariate adjustment attenuated the relations with death much more than those for HF admission. Compared with patients placed on the NICE pathway, treatment with HF medications had an HR of 1.16 (95% CI 1.05 to 1.28, p=0.003) for HF admission and 1.03 (95% CI 0.90 to 1.17, p= 0.674) for death. Patients who partially followed the NICE pathway had similar hazards to those who completed it. Patients on no pathway had the highest hazard for HF admission at 1.30 (95% 1.18 to 1.43, p<0.001) but similar hazard for death. Conclusions Patients not put on at least some elements of the NICE-recommended pathway had significantly higher risk of HF admission but non-significant higher risk of death than other patients had.
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Affiliation(s)
- Alex Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Dani Kim
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Paul P Aylin
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - F Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Martin R Cowie
- National Heart & Lung Institute, Royal Brompton Hospital, Imperial College London, Chelsea, UK
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Smith MW, Brown C, Virani SS, Weir CR, Petersen LA, Kelly N, Akeroyd J, Garvin JH. Incorporating Guideline Adherence and Practice Implementation Issues into the Design of Decision Support for Beta-Blocker Titration for Heart Failure. Appl Clin Inform 2018; 9:478-489. [PMID: 29949816 DOI: 10.1055/s-0038-1660849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The recognition of and response to undertreatment of heart failure (HF) patients can be complicated. A clinical reminder can facilitate use of guideline-concordant β-blocker titration for HF patients with depressed ejection fraction. However, the design must consider the cognitive demands on the providers and the context of the work. OBJECTIVE This study's purpose is to develop requirements for a clinical decision support tool (a clinical reminder) by analyzing the cognitive demands of the task along with the factors in the Cabana framework of physician adherence to guidelines, the health information technology (HIT) sociotechnical framework, and the Promoting Action on Research Implementation in Health Services (PARIHS) framework of health services implementation. It utilizes a tool that extracts information from medical records (including ejection fraction in free text reports) to identify qualifying patients at risk of undertreatment. METHODS We conducted interviews with 17 primary care providers, 5 PharmDs, and 5 Registered Nurses across three Veterans Health Administration outpatient clinics. The interviews were based on cognitive task analysis (CTA) methods and enhanced through the inclusion of the Cabana, HIT sociotechnical, and PARIHS frameworks. The analysis of the interview data led to the development of requirements and a prototype design for a clinical reminder. We conducted a small pilot usability assessment of the clinical reminder using realistic clinical scenarios. RESULTS We identified organizational challenges (such as time pressures and underuse of pharmacists), knowledge issues regarding the guideline, and information needs regarding patient history and treatment status. We based the design of the clinical reminder on how to best address these challenges. The usability assessment indicated the tool could help the decision and titration processes. CONCLUSION Through the use of CTA methods enhanced with adherence, sociotechnical, and implementation frameworks, we designed a decision support tool that considers important challenges in the decision and execution of β-blocker titration for qualifying HF patients at risk of undertreatment.
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Affiliation(s)
- Michael W Smith
- Department of Industrial & Mechanical Engineering, Universidad de las Americas Puebla, Cholula, PUE, Mexico
| | - Charnetta Brown
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States
| | - Salim S Virani
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
| | - Charlene R Weir
- Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
| | - Laura A Petersen
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
| | - Natalie Kelly
- Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States
| | - Julia Akeroyd
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States
| | - Jennifer H Garvin
- Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States.,Division of Health Information Management and Systems, The Ohio State University, Columbus, Ohio, United States.,Indianapolis VA Medical Center HSR&D Center for Health Information and Communication, Indianapolis, Indiana, United States
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Bottle A, Kim D, Aylin P, Cowie MR, Majeed A, Hayhoe B. Routes to diagnosis of heart failure: observational study using linked data in England. Heart 2017; 104:600-605. [PMID: 28982720 DOI: 10.1136/heartjnl-2017-312183] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/08/2017] [Accepted: 09/12/2017] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Timely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care. We describe the journey of people with HF in primary care from presentation through to diagnosis and initial management. METHODS We used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis. RESULTS 36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years prior to diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral. CONCLUSIONS Patients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. There are likely to be missed opportunities for earlier HF diagnosis in primary care.
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Affiliation(s)
- Alex Bottle
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Dani Kim
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Martin R Cowie
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, Imperial College London, London, UK
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