Unplanned admissions and the organisational management of heart failure: a multicentre ethnographic, qualitative study

Abstract

ObjectivesHeart failure is a common cause of unplanned hospital admissions but there is little evidence on why, despite evidence-based interventions, admissions occur. This study aimed to identify critical points on patient pathways where risk of admission is increased and identify barriers to the implementation of evidence-based interventions.DesignMulticentre, longitudinal, patient-led ethnography.SettingNational Health Service settings across primary, community and secondary care in three geographical locations in England, UK.Participants31 patients with severe or difficult to manage heart failure followed for up to 11 months; 9 carers; 55 healthcare professionals.ResultsFragmentation of healthcare, inequitable provision of services and poor continuity of care presented barriers to interventions for heart failure. Critical points where a reduction in the risk of current or future admission occurred throughout the pathway. At the beginning some patients did not receive a formal clinical diagnosis, in addition patients lacked information about heart failure, self-care and knowing when to seek help. Some clinicians lacked knowledge about diagnosis and management. Misdiagnoses of symptoms and discontinuity of care resulted in unplanned admissions. Approaching end of life, patients were admitted to hospital when other options including palliative care could have been appropriate.ConclusionsFindings illustrate the complexity involved in caring for people with heart failure. Fragmented healthcare and discontinuity of care added complexity and increased the likelihood of suboptimal management and unplanned admissions. Diagnosis and disclosure is a vital first step for the patient in a journey of acceptance and learning to self-care/monitor. The need for clinician education about heart failure and specialist services was acknowledged. Patient education should be seen as an ongoing ‘conversation’ with trusted clinicians and end-of-life planning should be broached within this context.

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

“…GPs regarded it as a ‘loaded’ term,31 having an effect on patients that was similar to being told they had cancer 2429 31 36 To avoid upsetting patients and extinguishing hope, some clinicians talked about HF in euphemistic terms, such as having an ‘ageing heart’, ‘stiff heart’ or ‘heart not pumping efficiently’ 2936…”

“…25 Additionally, GPs encountered difficulties associated with comorbidities and polypharmacy, especially in elderly patients 624 26 31 36 Moreover, several GPs saw ageism as a consideration for a less aggressive approach 24–2630 34…”

“…24–26 34 36 These barriers to service usage were attributed to the organisation of healthcare systems, varying from country to country (table 2). …”

Optimising Management of Patients with Heart Failure with Preserved Ejection Fraction in Primary Care (OPTIMISE-HFpEF): rationale and protocol for a multi-method study

“…Lastly, a persistent gap between best and current practice exists, which is compounded by a lack of integrated care. [14][15][16] The outcome of these challenges in HFpEF is high rates of hospitalisation, mortality, poor functioning, and low quality of life. 3,17 Some authorities have already called for dedicated HFpEF clinical programmes, and lessons will be garnered from pioneering initiatives.…”

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

“…Previous research shows that case management does not reduce unplanned admissions in study populations recruited on older age as opposed to a specific condition or for patients with COPD (Huntley et al., ; Purdy, ). It is likely that case management is particularly beneficial to patients with heart failure by allowing more quality time for focussed and difficult discussions between health professionals and patients around the diagnosis of heart failure and its implications (Simmonds et al., ). Case management also provides essential continuing education and support.…”