Think-aloud study about the diagnosis of chronic heart failure in Belgian general practice

Smeets, Miek; Witte, Pieter De; Peters, Sanne; Aertgeerts, Bert; Janssens, Stefan; Vaes, Bert

doi:10.1136/bmjopen-2018-025922

Cited by 6 publications

(6 citation statements)

References 38 publications

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“…From the perspective of GPs, HF diagnoses often remained uncertain despite specialist referral. 35 Heart failure treatment Guideline-recommended therapies disseminated progressively into practice, showing a clear improvement in our study compared with older studies. 1,3,9,16,33 Even to this extent, there is currently little room for improvement in starting RAAS blockers and beta-blockers, especially in a population with a mean age of 75 years.…”

Section: Characteristics Of Heart Failure Patients In General Practicementioning

confidence: 53%

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Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR‐HF pilot study

et al. 2020

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Aims Identifying heart failure (HF) patients in general practice is challenging, and little is known about the current quality of care. We implemented an extended audit from the electronic health records (EHRs) of general practitioners (GPs) to identify HF patients and investigate patient characteristics and quality of care. Methods and results This study describes the baseline results of the OSCAR-HF pilot study in eight general practices (51 GPs) in Flanders, Belgium. This prospective trial ran for 6 months. Interventions included an extended audit, an N-terminal pro-Btype natriuretic peptide point-of-care test, and assistance of a specialist HF nurse. The extended audit searched on risk factors for HF, HF symptoms, signs, and medication in the GPs' EHR to generate a list of possible HF patients. GPs determined which patients had HF. Those HF patients constituted the OSCAR-HF study population. Each patient file was manually revised to extract biomarker measurements, echocardiography data, and quality indicators. An independent panel of experts assessed the validity of GPs' HF diagnoses. Feedback about the validity of the HF diagnosis was given to the GP. Out of 18 011 patients ≥ 40 years, we identified 310 patients with a registered HF diagnosis before the study start (HF prevalence: 1.7%). The extended audit led to a 74% increase in identified HF patients (n = 538, HF prevalence: 3.0%) with a mean age of 79 ± 11 years. The prevalence of HF with reduced ejection fraction (HFrEF) was 20% (n = 110). A high proportion of patients underwent echocardiography in the past 5 years (86%, n = 462). Natriuretic peptides were rarely available in patients' files (19%, n = 100). Medical specialists should improve communication about the HF diagnosis because a specialist diagnosis was present in only 225 patients (42%) while 67% (n = 359) of the HF diagnoses were judged objectified by a panel of experts. Assigning a diagnosis of HF was particularly difficult in HF patients with preserved EF (HFpEF). HFrEF treatment rates with renin-angiotensin-aldosterone system blockers (84%, n = 92) and beta-blockers (86%, n = 94) were very good; however, target doses were hardly reached (34% and 14%, respectively). Conclusions This study highlighted the need to improve case finding for HF in general practice and showed that an extended audit in the GPs' EHR was a successful strategy to do so. To improve the quality of HF care in general practice, specific strategies are needed to diagnose HFpEF and to reach target doses of disease-modifying drugs in HFrEF patients.

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Section: Characteristics Of Heart Failure Patients In General Practicementioning

confidence: 53%

“…Registration of the HF diagnosis by GPs correlated directly with the specialist HF diagnosis. From the perspective of GPs, HF diagnoses often remained uncertain despite specialist referral 35 …”

Section: Discussionmentioning

confidence: 99%

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR‐HF pilot study

et al. 2020

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“…Difficulties to attribute ambiguous symptoms for HF are a common problem in HF diagnosis in general practice 17 32. In this study, physicians were not asked to give a final correct diagnosis, but they were asked what diagnoses they were considering based on the information given in the video, as we were interested in whether HF was mentioned as a suspected diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Age and gender differences in diagnostic decision-making of early heart failure: results of a mixed-methods interview-study using video vignettes

et al. 2022

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ObjectivesMen and women at any age show similar symptoms and signs of heart failure (HF). Since early HF symptoms are ambiguous, doctors may overlook HF as possible cause and misinterpret the signs. The aim was to analyse differences in general practitioners’ (GPs) HF diagnosis and diagnostic certainty by patient age and gender and to identify reasons for possible differences.DesignFactorial design with video vignettes presenting patients (played by professional actors) with early HF symptoms was used. Video vignettes differed regarding patients’ gender (male/female), age (55 years/75 years) and migration background (no/yes: Turkish), while the dialogue was identical. GPs were asked about possible diagnoses and certainty of diagnoses (quantitative) and to narrate their thoughts on considered diagnoses (qualitative).SettingGeneral practices in northern Germany.Participants128 GPs stratified by gender and length of clinical experience (≤15 years or >15 years).ResultsGPs considered HF more often in women than men (predicted probabilities with 95% CI: 0.83 (0.68 to 0.92) vs 0.63 (0.44 to 0.79), p=0.02), especially in older women compared with younger men (predicted probabilities with 95% CI: 0.89 (0.68 to 0.96) vs 0.52 (0.31 to 0.72), p=0,03). Suspected HF was not reasoned by the patient’s gender and only seldom by the patient’s age, but by reported symptoms. Diagnostic certainty of HF was higher in women than in men (predicted proportions with 95% CI: 0.48 (0.39 to 0.58) vs 0.36 (0.27 to 0.45), p=0.01), with highest certainty in older women and lowest in younger men (0.57 (0.45 to 0.69) vs 0.27 (0.17 to 0.37), p<0.01). GPs explained their certainty referring to both typical HF symptoms and their gut feeling.ConclusionDespite an identical dialogue, the study showed differences by patients’ gender and age in frequency and certainty of HF diagnosis. In order to avoid that GPs overlook or misinterpret early signs of HF, it is important to critically reflect diagnostic decisions and possible social influences.

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“…If a GP can recognize these signs and symptoms in a timely manner and assure referral to a cardiologist in time, treatment can start early and the disease can be delayed which leads to an enormous reduction in HF hospitalization and mortality [15]. GPs find it difficult to correctly diagnose HF and the non-specific symptoms or the overlap of symptoms and signs with comorbidities make it even more challenging [16]. These barriers lead to under-and over-diagnosis of HF [15,17].…”

Section: Discussionmentioning

confidence: 99%

Diagnosis, treatment, and follow-up of heart failure patients by general practitioners: A Delphi consensus statement

Verhestraeten

Weijers²,

Debleu

et al. 2020

PLoS ONE

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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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Think-aloud study about the diagnosis of chronic heart failure in Belgian general practice

Cited by 6 publications

References 38 publications

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR‐HF pilot study

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR‐HF pilot study

Age and gender differences in diagnostic decision-making of early heart failure: results of a mixed-methods interview-study using video vignettes

Diagnosis, treatment, and follow-up of heart failure patients by general practitioners: A Delphi consensus statement

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