"It's Somebody else's responsibility" - perceptions of general practitioners, heart failure nurses, care home staff, and residents towards heart failure diagnosis and management for older people in long-term care: a qualitative interview study

Informing understanding of coordination of care for patients with heart failure with preserved ejection fraction: a secondary qualitative analysis

BACKGROUND

Patients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple healthcare services. Regional variation in services and resourcing has been highlighted as a problem in heart failure care, with few teams bridging the interface between the community and secondary care. These reports conflict with policy goals to improve coordination of care and dissolve boundaries between specialist services and the community.

AIM

To explore how care is coordinated for patients with HFpEF, with a focus on the interface between primary care and specialist services in England.

METHODS

We applied systems thinking methodology to examine the relationship between work-as-imagined and work-as-done for coordination of care for patients with HFpEF. We analysed clinical guidelines in conjunction with a secondary applied thematic analysis of semistructured interviews with healthcare professionals caring for patients with HFpEF including general practitioners, specialist nurses and cardiologists and patients with HFpEF themselves (n=41). Systems Thinking for Everyday Work principles provided a sensitising theoretical framework to facilitate a deeper understanding of how these data illustrate a complex health system and where opportunities for improvement interventions may lie.

RESULTS

Three themes (working with complexity, information transfer and working relationships) were identified to explain variability between work-as-imagined and work-as-done. Participants raised educational needs, challenging work conditions, issues with information transfer systems and organisational structures poorly aligned with patient needs.

CONCLUSIONS

There are multiple challenges that affect coordination of care for patients with HFpEF. Findings from this study illuminate the complexity in coordination of care practices and have implications for future interventional work.

Identifying barriers and facilitators to the inclusion of older adults living in UK care homes in research: a scoping review

BACKGROUND

With an ageing population, older adults will have more complex health and social care needs and many of these older adults will be living in care homes. Despite the growth in care home populations, care home residents are often excluded from research that could potentially benefit their care. The purpose of this scoping review is to explore resident-related barriers and facilitators to including older people living in UK care homes in research and to identify potential approaches to modify such barriers.

METHOD

The 6-stage scoping review methodology framework proposed by Arksey and O'Malley guided this review. Five electronic databases (MedLine, PsychINFO, Scopus, Web of Science, CINAHL) and grey literature were searched. Identified articles went through two levels of screening, and those deemed relevant were collated, summarised and reported using a thematic analysis approach.

RESULTS

90 reports were eligible for inclusion and were synthesised into 7 themes and related subthemes: (1) research design; (2) understanding and beliefs about research (resident and care home staff); (3) communication; (4) relationships; (5) eligibility criteria (resident and care home); (6) preference-based decisions; and (7) care home staff and environment. Given the complex interplay of the factors identified, both direct and indirect factors were included.

CONCLUSIONS

A number of recurring barriers and facilitators to the inclusion of care home residents in research are reported. However, isolating resident-related barriers was complex as both direct and indirect factors must be considered as influential. Understanding the barriers and facilitators to inclusion will enable these factors to be addressed and increase the evidence-base for care provided to older people living in care homes.

Physician Perspectives on the Diagnosis and Management of Heart Failure With Preserved Ejection Fraction

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) carries high morbidity and mortality. Compared with HF with reduced ejection fraction (HFrEF), HFpEF is difficult to diagnose, and lacks evidence-based treatments. In this survey we assessed perceptions of cardiologists, internists, and primary care physicians (PCPs) regarding HFpEF diagnosis and management.

Methods

In total, 159 cardiologists, 89 internists, and 200 PCPs from across Canada completed an online survey, with response rates of 14%-17%.

Results

The perceived prevalence of HFpEF vs HFrEF was similar across physician types (58% HFrEF, 42% HFpEF). Thirty-seven percent of PCPs did not differentiate HF on the basis of ejection fraction. All physician types ranked symptom and mortality reduction as treatment priorities. Ninety-two percent of specialists believed that HFpEF is best comanaged by PCPs and specialists, whereas one-fifth of PCPs suggested PCP management alone. Compared with specialists, PCPs were more likely to underestimate HFpEF mortality and less aware of sex differences in the prevalence of HFpEF vs HFrEF (all P < 0.001). Fewer PCPs use natriuretic peptides for diagnosis (P < 0.001). All physician types listed cost and availability as barriers to natriuretic peptide use. Ninety-one percent of PCPs incorrectly identified various therapies as effective for improving HFpEF outcomes. Most of all physicians expressed a strong desire to increase knowledge of diagnostic and treatment algorithms for HFpEF.

Conclusions

There are substantial knowledge gaps in the diagnosis and management of HFpEF, particularly among PCPs. Because of the prevalence of HFpEF in primary care, strategies are required to reduce these gaps.

Nurses' experiences of continuity of care for patients with heart failure: A thematic analysis

AIMS AND OBJECTIVES

This study aimed to describe nurses' experiences of continuity of care for patients with heart failure.

BACKGROUND

Heart failure is a life-influencing condition that causes varying care needs over time with risks of fragmentation. Nurses play an important role in caring for patients with heart failure. However, nurses' experiences of continuity of care seem to be less explored in this context.

DESIGN

A qualitative study with a descriptive design.

METHODS

Four focus groups were chosen to collect the data, and the analysis was made by using a method for thematic analysis. A purposeful sampling of nurses (n = 14) with experiences from hospital-connected heart failure clinics, primary healthcare centres and municipal home healthcare settings was recruited. The COREQ checklist was used in this study.

RESULTS

The nurses' experiences of continuity of care for patients with heart failure were described in four themes: access and flexibility, responsibility and transparency, trustful and caring relationships and communication and collaboration.

CONCLUSIONS

The results indicate that nurses have an excellent position to act as the "hub" in caring for patients with heart failure, but they need to have the possibility of networking and establishing trusting relationships with their colleagues. From the nurses' point of view, mutual trust between the nurse, the patient and the patient's next of kin is crucial for promoting and maintaining continuity of care in patients with heart failure.

RELEVANCE TO CLINICAL PRACTICE

To promote continuity of care for patients with heart failure, nurses expressed the necessity of establishing trusting relationships in a continuity-promoting organisation with seamless coordination. Nurses can be the "hub" supporting a person-centred care approach based on the patients' needs. There seems to be a need for better collaboration with common guidelines across and within primary healthcare centres, hospital-connected heart failure clinics and municipal home healthcare settings.

Changes over time in attitudes towards the management of older patients with heart failure by general practitioners: a qualitative study

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.

Setting Priorities to Inform Assessment of Care Homes' Readiness to Participate in Healthcare Innovation: A Systematic Mapping Review and Consensus Process

Organisational context is known to impact on the successful implementation of healthcare initiatives in care homes. We undertook a systematic mapping review to examine whether researchers have considered organisational context when planning, conducting, and reporting the implementation of healthcare innovations in care homes. Review data were mapped against the Alberta Context Tool, which was designed to assess organizational context in care homes. The review included 56 papers. No studies involved a systematic assessment of organisational context prior to implementation, but many provided post hoc explanations of how organisational context affected the success or otherwise of the innovation. Factors identified to explain a lack of success included poor senior staff engagement, non-alignment with care home culture, limited staff capacity to engage, and low levels of participation from health professionals such as general practitioners (GPs). Thirty-five stakeholders participated in workshops to discuss findings and develop questions for assessing care home readiness to participate in innovations. Ten questions were developed to initiate conversations between innovators and care home staff to support research and implementation. This framework can help researchers initiate discussions about health-related innovation. This will begin to address the gap between implementation theory and practice.

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

Background

In 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.

Objectives

To 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.

Methods

For 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).

Results

A 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.

Limitations

The research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.

Conclusions

Overall, 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 work

Research 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.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

"Being in good hands": next of kin's perceptions of continuity of care in patients with heart failure

BACKGROUND

Heart failure (HF) is a chronic condition with a variety of diverse symptoms. Patients with HF are usually elderly with multimorbidity, which are both multifaceted and challenging. Being a next of kin to patients with HF is described as a complex task consisting of managing care and treatment, monitoring illness and being an emotional support, while also being able to navigate the healthcare system especially in long-term contact. However, few studies have investigated next of kin's perceptions of continuity of care in connection with HF. The present study aimed to describe continuity of care as perceived by the next of kin who care for patients with HF.

METHODS

This study used a qualitative descriptive design. Semi-structured interviews were conducted with the next of kin (n = 15) of patients with HF to obtain their perceptions of continuity of care. A phenomenographic analysis method was used to capture the participants' perceptions of the phenomenon.

RESULTS

The analysis reveals that the next of kin perceive that support from healthcare professionals was strongly associated with experiences of continuity of care. Four categories reveal the next of kin's perceptions of continuity of care: Want to be involved without being in charge; A desire to be in control without acting as the driving force in the care situation; A need for sustainability without being overlooked; and Focusing on making life meaningful while being preoccupied with caregiving activities.

CONCLUSIONS

Next of kin perceive continuity of care, when they have access to care and treatment and when caregivers collaborate, regardless of healthcare is given by primary care, municipalities or specialist clinics. A sense of "being in good hands" sums up the need for continuous support, shared decision-making and seamless transitions between caregivers. It seems important that healthcare organisations safeguard effective and collaborative models. Moreover, professionals need to plan and perform healthcare in collaboration with patients and next of kin.

Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis

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.

General practitioners' perceptions about their role in current and future heart failure care: an exploratory qualitative study

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.

"It just happens". Care home residents' experiences and expectations of accessing GP care

BACKGROUND

Care homes provide personal care and support for older people who can no longer be supported in the community. As part of a larger study of integrated working between the NHS and care homes we asked older people how they accessed health care services. Our aim was to understand how older people resident in care homes access health services using the Andersen model of health care access.

METHODS

Case studies were conducted in six care homes with different socio-economic characteristics, size and ownership in three study sites. Residents in all care homes with capacity to participate were eligible for the study. Interviews explored how residents accessed NHS professionals. The Andersen model of health seeking behaviour was our analytic framework.

FINDINGS

Thirty-five participants were interviewed with an average of 4 different conditions. Expectations of their health and the effectiveness of services to mitigate their problems were low. Enabling factors were the use of intermediaries (usually staff, but also relatives) to seek access. Residents expected that care home staff would monitor changes in their health and seek appropriate help unprompted.

CONCLUSIONS

Care home residents may normalise their health care needs and frame services as unable to remediate these which may combine to disincline older care home residents to seek care. Care access was enabled using intermediaries -either staff or relatives-and the expectation that staff would proactively seek care when they observed new/changed needs. Residents may over-estimate the health-related knowledge of care home staff and their ability to initiate referrals to NHS professionals.

Evaluation of Access to Long-term Care Services for Old People Ageing in Place in Slovenia

Theory

The quality of long-term care services has an important effect on the quality of life of their users and their informal carers. By identifying gaps between provision of services and users' needs we can suggest adjustments of the long-term care services and advance their development.

Method

The data from the first Slovenian national survey of social homecare (SHC) users and their informal carers was utilised. Linear regression analysis was used to evaluate factors that affect assessments of five-dimensional concept of access.

Results

On average, affordability was rated the lowest (mean=2.9) and acceptability the highest (4.0), with availability, accessibility and accommodation (mean=3.6) in the middle. Regression analysis explains 15% of variability in affordability, while for other dimensions much less. Caregiver's needs are the most influential predictor of access, negatively influencing the rating of access (availability B=.127, accommodation B=-.113, acceptability B=-.120, affordability B=-.155). Care recipients' needs also affect the rating of affordability (B=-.132). Family income negatively influences the rating of availability (B=-.115), accessibility (B=-.076) and affordability (B=-.270). Residents of rural areas rate availability (B=-.070) and affordability (B=-.067) less favourable.

Discussion

This study showed that affordability is rated the least favourable among components of access. Adjustment in private out-of-pocket co-payment mechanism is suggested.

Community case management and unplanned hospital admissions in patients with heart failure: A systematic review and qualitative evidence synthesis

AIMS

The aim of this study was to describe case management as experienced by patients with heart failure and their health professionals with the aim of understanding why case management might contribute in reducing hospital admissions.

BACKGROUND

Heart failure is a common cause of unplanned hospital admission. The evidence for case management in patients with heart failure for reducing admissions is promising.

DESIGN

Systematic review and qualitative evidence synthesis.

DATA SOURCE

Searches were conducted in Medline, Psychinfo, Kings Fund database and Cinahl from inception of each database to 16 February 2017.

REVIEW METHODS

Robust systematic review methodology was used to identify qualitative studies describing the experiences of patients with heart failure and healthcare providers of case management. Data were synthesized thematically, and analytic themes were developed.

FINDINGS

Five studies (six papers) from which nine descriptive themes were used to determine three analytic themes. This synthesis showed that case management provides positive quality of care for patients, increases perceived access to services and creates more time to ask questions and develop trusted relationships. For health professionals, case management enhanced care by improved relationships with both patients and colleagues although concerns remained around resources, training and inter-professional conflict.

CONCLUSIONS

This synthesis emphasizes the importance of the quality of being cared for as a patient and caring as a health professional. Case management enhances communication between patients and health professionals, supports patient self-care and self-management and can be an important contributing factor in reducing unplanned admissions for patients with heart failure.

Clinical practices and attitudes regarding the diagnosis and management of heart failure: findings from the CORE Needs Assessment Survey

AIMS

CORE is a continuing medical education initiative designed to support the evidence-based management of heart failure (HF) in the primary and secondary care settings. The goal of the CORE Needs Assessment Survey is to describe current clinical practice patterns and attitudes among global stakeholders in HF care.

METHODS AND RESULTS

The CORE Steering Committee guided the development of survey questions to assess clinical practice, confidence, and attitudes/perceptions among cardiologists, primary care physicians, and nurses involved in HF management. In total, 346 healthcare professionals from Australia (n = 59), Austria (n = 59), Canada (n = 60), Spain (n = 58), Sweden (n = 52), and the UK (n = 58) contributed survey data. Results revealed multiple gaps over the spectrum of HF care, including diagnosis (low recognition of the signs and symptoms of HF and limited use of diagnostic tests), treatment planning (underuse of recommended agents and subtherapeutic dosing), treatment monitoring and adjustment (lack of adherence to recommendations), and long-term management (low confidence in providing patient education). Although primary care and specialist physicians and nurses shared common unmet needs, healthcare professional-specific clinical gaps were also identified.

CONCLUSIONS

The CORE Needs Assessment Survey provides timely data describing current clinical practices and attitudes among physicians and nurses regarding key aspects of HF care. These findings will be useful for guiding the development of interventions tailored to the specific educational needs of different provider types and designed to support the evidence-based care of patients with HF.

Older people's perceptions of the quality of oral care in short-term care units: A cross-sectional study

BACKGROUND

There is a lack of knowledge about oral care among older people living in short-term care (STC) units and how the quality of oral care provided by nursing staff is perceived by the older people.

AIM

To (i) describe person-related conditions among older people in STC, (ii) describe and compare perceptions of the quality of oral care (including perceptions of care received and the subjective importance of such care), within and between older people who have the ability to perform oral self-care and those who are dependent on help with oral care and (iii) examine the relationship between person-related conditions and the quality of oral care.

METHODS

A cross-sectional study was conducted with 391 older people in STC units in Sweden based on self-reported questionnaire and clinical assessments.

RESULTS

The older people were assessed as having normal oral health (2%), moderate oral health problems (78%) or severe oral health problems (20%). When comparing older people's perceptions of quality of oral care in terms of perceived reality and subjective importance, significant differences appeared within and between groups. Psychological well-being had a significant relationship with perception of the quality of oral care (both perceived reality and subjective importance), and gender and oral health status had a significant relationship with subjective importance.

CONCLUSIONS

Older people's perceptions of areas for improvement regarding quality of oral care is a new and important knowledge for nursing staff in STC units. Older people want personalised information regarding oral health and oral care. Registered Nurses who take the responsibility in nursing care for older people's oral health may avoid unnecessary suffering by older people caused by oral health problems.

IMPLICATIONS FOR PRACTICE

Older people's perspective is an important component for quality work and might lead to improvements in the quality of oral care in STC.

Improving care for heart failure patients in primary care, GPs' perceptions: a qualitative evidence synthesis

OBJECTIVES

General practitioners (GPs) play a key role in heart failure (HF) management. Despite multiple guidelines, the management of patients with HF in primary care is suboptimal. Therefore, all the qualitative evidence concerning GPs' perceptions of managing HF in primary care was synthesised to identify barriers and facilitators for optimal care, and ideas for improvement.

DESIGN

Qualitative evidence synthesis.

METHODS

Searches of MEDLINE, EMBASE, Web of Science and CINAHL databases up to 20/12/2015 were conducted. The Critical Appraisal Skills Programme's checklist for qualitative research was used for quality assessment. Thematic analysis was used as method of analysis.

RESULTS

Of 5427 articles, 18 qualitative articles were included. Findings were organised in HF-specific factors, patient factors, physician factors and contextual factors. GPs' uncertainty in all areas of HF management was highlighted. HF management started with an uncertain diagnosis, leading to difficulties with communication, treatment and advance care planning. Lack of access to specialised care and lack of knowledge were identified as important contributors to this uncertainty. In an effort to overcome this, strategies bringing evidence into practice should be promoted. GPs expressed the need for a multidisciplinary chronic care approach for HF. However, mixed experiences were noted with regard to interprofessional collaboration.

CONCLUSIONS

The main challenges identified in this synthesis were how to deal with GPs' uncertainty about clinical practice, how to bring evidence into practice and how to work together as a multiprofessional team. These barriers were situated predominantly on the physician and contextual level. Targets to improve GPs' HF care were identified.

A qualitative study of the current state of heart failure community care in Canada: what can we learn for the future?

Background

In North America and other industrialized countries, heart failure (HF) has become a national public health priority. Studies indicate there is significant heterogeneity in approaches to treat and manage HF and suggest targeted changes in health care delivery are needed to reduce unnecessary health care utilization and to optimize patient outcomes. Most recent published studies have reported on the care of HF patients in tertiary care hospitals and the perspective of non-specialist stakeholders on HF management, such as general practitioners and clinics or hospital administrators is rarely considered. This study explores the current state of community-based HF care in Canada as experienced by various healthcare stakeholders providing or coordinating care to HF patients.

Methods

This study employed a qualitative exploratory research design consisting of semi-structured telephone interviews conducted with health care providers and health care administrators working outside of tertiary care in the four most populous Canadian provinces. A modified thematic analysis process was used and the different data sources were triangulated. Findings were collectively interpreted by the authors.

Results

Twenty-eight participants were recruited in the study: eight cardiologists, five general practitioners/family physicians, eight nurse practitioners/registered nurses, four hospital pharmacists and three health care administrators/directors. Participants reported a lack of stakeholder engagement throughout the continuum of care, which hinders the implementation of a coordinated approach to quality HF care. Four substantive themes emerged that indicated challenges and gaps in the optimal treatment and management of HF in community settings: 1) challenges in the risk assessment and early diagnosis of HF, 2) challenges in ensuring efficient and consistent transition from acute care setting to the community, 3) challenges of primary care providers to optimally treat and manage HF patients, and 4) challenges in promoting a holistic approach in HF management.

Conclusions

As health systems evolve from tertiary-based care to community-based outpatient services for the management of chronic diseases, this study’s findings pinpoint challenges that have been observed in the Canadian context and can stimulate and orient dialogue toward solutions for a more coordinated approach to improve the care of HF patients and reduce pressure on the healthcare system.

Barriers to accurate diagnosis and effective management of heart failure have not changed in the past 10 years: a qualitative study and national survey

OBJECTIVES

To explore changes in healthcare professionals' views about the diagnosis and management of heart failure since a study in 2003.

DESIGN

Focus groups and a national online cross-sectional survey.

SETTING AND PARTICIPANTS

Focus groups (n=8 with a total of 56 participants) were conducted in the North East of England using a phenomenological framework and purposive sampling, informing a UK online survey (n=514).

RESULTS

4 categories were identified as contributing to variations in the diagnosis and management of heart failure. Three previously known categories included: uncertainty about clinical practice, the value of clinical guidelines and tensions between individual and organisational practice. A new category concerned uncertainty about end-of-life care. Survey responses found that confidence varied among professional groups in diagnosing left ventricular systolic dysfunction (LVSD): 95% of cardiologists, 93% of general physicians, 66% of general practitioners (GPs) and 32% of heart failure nurses. For heart failure with preserved ejection fraction (HFpEF), confidence levels were much lower: 58% of cardiologists, 43% of general physicians, 7% of GPs and 6% of heart failure nurses. Only 5-35% of respondents used natriuretic peptides for LVSD or HFpEF. Confidence in interpreting test findings was fundamental to the use of all diagnostic tests. Clinical guidelines were reported to be helpful when diagnosing LVSD by 33% of nurses and 50-56% of other groups, but fell to 5-28% for HFpEF. Some GPs did not routinely initiate diuretics (23%), ACE-inhibitors (22%) or β-blockers (38%) for LVSD for reasons including historical teaching, perceived side effects and burden of monitoring. For end-of-life care, there was no consensus about responsibility for heart failure management.

CONCLUSIONS

Reported differences in the way heart failure is diagnosed and managed have changed little in the past decade. Variable access to diagnostic tests, modes of care delivery and non-uniform management approaches persist. The current National Health Service (NHS) context may not be conducive to addressing these issues.