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

Abstract

ObjectivesGeneral 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.DesignQualitative evidence synthesis.MethodsSearches 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.ResultsOf 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.ConclusionsThe 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.

Routes to diagnosis of heart failure: observational study using linked data in England

“…From the GP’s perspective, the diagnosis is made harder by the lack of specificity of HF symptoms and the confusion with respiratory conditions12 (one in three of our cohorts had chronic obstructive pulmonary disease compared with just 2% for the general population29 and 11% for patients aged 75–79),30 limited time availability, limited access to investigations and low confidence in interpretation of investigation results 99 and not all will be aware of them.…”

“…There are significant challenges in the identification, diagnosis and management of HF in primary care 9. HF manifests itself in different ways, resulting in variation in patients’ health-seeking behaviour and GPs’ decision making.…”

“…Patients with HF often present first in primary care 9. Identification and diagnosis in primary care is supported by professional guidelines1 8 10 recommending minimum standards of investigation,11 as well as medications improving symptoms and prognosis (beta-blockers and ACE inhibitors).…”

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

“…New evidence takes time to translate into practice,24 and clinicians may experience guideline overload 25. Inaccessibility of investigations such as NP testing and echocardiography is a significant problem in primary care,5 26 and long waiting lists for specialist assessment provide disincentive to referral 25.…”

“…Inaccessibility of investigations such as NP testing and echocardiography is a significant problem in primary care,5 26 and long waiting lists for specialist assessment provide disincentive to referral 25. Furthermore, HF can be a difficult diagnosis to make,25 with variable presentation, diagnostic overlap and symptoms that are not specific to HF. Nevertheless, a significant proportion of patients with HF in our study did have recorded symptoms, raising the possibility of missed opportunities for their earlier investigation, diagnosis and management.…”