Referral and access to heart function clinics: A realist review

Abstract

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.

A 2020 Environmental Scan of Heart Failure Clinics in Ontario

“…They too underscored the need for specific, patient referral criteria in order to unify practice patterns and holistically inform future planning to ensure the optimal, distribution, number, and structure of HF clinics. However, these concerns are not uniquely Canadian, as discussed in the realist review by Fowokan et al 24 In their comprehensive review of 29 studies from five countries, the authors noted that regardless of the significant differences in healthcare infrastructures, the lack of clear, consensus guidelines on referral criteria were an underlying theme impacting appropriate HF clinic accessibility in various countries.…”

Therapeutic inertia in the pharmacological management of heart failure with reduced ejection fraction

“…34 Despite their usefulness, the use of HF clinics is suboptimal, possibly due to lack of capacity, geographical considerations, and funding issues. 35 Ambulatory disease management programmes DMP, usually providing care outside of hospitals, have been shown to reduce the risk of both all-cause mortality and HF-related hospital readmission by approximately 30% 36 and are now formally recommended in 2021 ESC guidelines on HF. The implementation of these DMPs now often relies on telemonitoring (and e-tools) and telemedicine solutions 37 (including remote monitoring of pulmonary artery pressure).…”

“…They may furthermore operate through ambulatory IV diuretics infusion 34 . Despite their usefulness, the use of HF clinics is suboptimal, possibly due to lack of capacity, geographical considerations, and funding issues 35 …”

“… 34 Despite their usefulness, the use of HF clinics is suboptimal, possibly due to lack of capacity, geographical considerations, and funding issues. 35 …”

Factors Affecting Healthcare Provider Referral to Heart Function Clinics

“…14 Although generalists and specialists play a key clinic referral gatekeeping role, there has been no quantitative study investigating factors affecting provider referral practices to our knowledge. 5,15,16 Interviews with policy-makers, clinics, and patients suggest limited capacity and hence long wait times, as well as variation and lack of clarity in clinic-specific inclusion criteria, are paramount. Moreover, some providers who should refer patients with HF have limited HF diagnostic and care knowledge impacting referral, and care-related barriers and preferences patients convey to their referring providers (including related to the coronavirus disease 2019 [COVID-19] pandemic) are influential as well.…”