A management programme for suspected heart failure in primary care in cooperation with specialists in cardiology

Referral and access to heart function clinics: A realist review

RATIONALE, AIM, AND OBJECTIVES

Heart failure (HF) clinics are highly effective, yet not optimally utilized. A realist review was performed to identify contexts (eg, health system characteristics, clinic capacity, and siting) and underlying mechanisms (eg, referring provider knowledge of clinics and referral criteria, barriers in disadvantaged patients) that influence utilization (provider referral [ie, of all appropriate and no inappropriate patients] and access [ie, patient attends ≥1 visit]) of HF clinics.

METHODS

Following an initial scoping search and field observation in a HF clinic, we developed an initial program theory in conjunction with our expert panel, which included patient partners. Then, a literature search of seven databases was searched from inception to December 2019, including Medline; Grey literature was also searched. Studies of any design or editorials were included; studies regarding access to cardiac rehabilitation, or a single specialist for example, were excluded. Two independent reviewers screened the abstracts, and then full-texts. Relevant data from included articles were used to refine the program theory.

RESULTS

A total of 29 papers from five countries (three regions) were included. There was limited information to support or refute many elements of our initial program theory (eg, referring provider knowledge/beliefs, clinic inclusion/exclusion criteria), but refinements were made (eg, specialized care provided in each clinic, lack of patient encouragement). Lack of capacity, geography, and funding arrangements were identified as contextual factors, explaining a range of mechanistic processes, including patient clinical characteristics and social determinants of health as well as clinic characteristics that help to explain inappropriate and low use of HF clinics (outcome).

CONCLUSION

Given the burden of HF and benefit of HF clinics, more research is needed to understand, and hence overcome sub-optimal use of HF clinics. In particular, an understanding from the perspective of referring providers is needed.

Adherence to guidelines in management of symptoms suggestive of heart failure in primary care

Objective

Clinical 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.

Methods

In 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).

Results

42 403 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).

Conclusions

Median 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.

Validation of heart failure diagnosis registered in primary care records in two primary care centres in Barcelona (Spain) and factors related. A cross-sectional study

BACKGROUND

Heart failure (HF) diagnosis as reported in primary care medical records is not always properly confirmed and could result in over-registration.

OBJECTIVES

To determine the proportion of registered HF that can be confirmed with information from primary care medical records and to analyse related factors.

METHODS

A cross-sectional study. The medical records of 595 HF patients attended in two primary healthcare centres in Barcelona (Spain) were revised and validated by a team of experts who classified diagnosis into confirmed, unconfirmed, and misdiagnosis. Variables potentially related to the confirmation of the diagnosis were analysed. The revision of medical records and data collection took place from 15 January to 31 March 2014.

RESULTS

Mean (standard deviation) age was 78 (10) years and 58% were women. The diagnosis could be confirmed in 53.6% of patients. Factors associated with a greater probability of having a confirmed diagnosis were age (yearly OR: 0.97, 95%CI: 0.95-0.99), cardiologist follow-up (OR: 3.66, 95%CI: 2.46-5.48), history of ischaemic heart disease (OR: 2.18, 95%CI: 1.36-2.48), atrial fibrillation (OR: 2.01, 95%CI: 1.34-3.03), and prescription of loop diuretics (OR: 3.24, 95%CI: 2.14-4.89).

CONCLUSION

Only in half of the patients labelled as HF in primary care medical records could this diagnosis be further confirmed. Variables regularly registered in clinical practice could help general practitioners identify those patients requiring a revision of their HF diagnosis.

Chronic heart failure management in primary healthcare in Poland: Results of a nationwide cross-sectional study

Background: Organizational and educational activities in primary care in Poland have been introduced to improve the chronic heart failure (CHF) management.

Objectives: To assess the use of diagnostic procedures, pharmacotherapy and referrals of CHF in primary care in Poland.

Methods: The cross-sectional survey was conducted in 2013, involving 390 primary care centres randomly selected from a national database. Trained nurses contacted primary care physicians who retrospectively filled out the study questionnaires on the previous year’s CHF management in the last five patients who had recently visited their office. The data on diagnostic and treatment procedures were collected.

Results: The mean age ± SD of the 2006 patients was 72 ± 11 years, 45% were female, and 56% had left ventricular ejection fraction <50%. The percentage of the CHF patients diagnosed based on echocardiography was 67% and significantly increased during the last decade. Echocardiography was still less frequently performed in older patients (≥80 years) than in the younger ones (respectively 50% versus 72%, Ρ <0.001) and in women than in men (62% versus 71%, P <0.001). The percentage of the patients treated with β-blocker alone was 88%, but those with a combination of angiotensin inhibition 71%. The decade before, these percentages were 68% and 57%, respectively. Moreover, an age-related gap observed in the use of the above-mentioned therapy has disappeared.

Conclusion: The use of echocardiography in CHF diagnostics has significantly improved in primary care in Poland but a noticeable inequality in the geriatric patients and women remains. Most CHF patients received drug classes in accordance with guidelines.