J.J. Murphy

Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study

Abstract Objective: To ascertain the beliefs, current practices, and decision making of general practitioners in the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to good care. Design: A qualitative approach using focus groups with 30 general practitioners from four primary care groups. The sampling strategy was stratified and purposive. The contents of interviews were transcribed and analysed according to the principles of “pragmatic variant” grounded theory. Setting: North east England. Results: Three categories of difficulties contribute to variations in medical practice and to the reasons why general practitioners experience difficulties in diagnosing and managing heart failure. The first is uncertainty about clinical practice, including lack of confidence in establishing an accurate diagnosis and worries about using angiotensin converting enzyme inhibitors, β blockers, and spironolactone in patients who are often elderly and frail, with comorbidity and polypharmacy. The second is a lack of awareness of relevant research evidence in what was perceived to be a complex and rapidly changing therapeutic field. Doubts about the applicability of research findings in primary care, and fear of information overload also emerged. The third category consists of influences of individual preference and local organisational factors. Medical training, negative clinical experiences, and outside agencies influenced the behaviour of general practitioners and professional culture. Local factors included the availability of diagnostic services, resources (such as accessible cardiologists), and interactions between professionals in primary or secondary care, and they seemed to shape the practice and decision making processes in primary care. Conclusions: The national service framework for coronary heart disease stresses that the substandard care of patients with heart failure is unacceptable. This study identified barriers to be overcome across primary and secondary care in implementation strategies that are specific to the locality and multifaceted. Single strategies—for example, the provision of guidelines—are unlikely to have an impact on clinical outcomes, and new, conjoint models of care need to be explored. What is already known on this topic Heart failure is a common condition with a high morbidity and mortality and is largely managed in primary care Although modern management with accurate diagnosis and treatment improves prognosis considerably, unacceptable variations exist in the clinical application of current guidelines for heart failure What this study adds General practitioners expressed a lack of confidence in establishing an accurate diagnosis of left ventricular systolic dysfunction, even if open access echocardiography was available Uncertainty about diagnosis led to poor uptake of evidence based treatment strategies for heart failure patients, and, despite awareness, reluctance to initiate modern treatment Local organisational factors around NHS provision of diagnostic services, resources, and interaction between primary and secondary care influence how general practitioners manage heart failure Implementation strategies for heart failure management across primary and secondary care are needed that are specific to their locality and multifaceted

1494 Community Angina Rehabilitation: The Case for a New Paradigm

Introduction: Following acute myocardial infarction (AMI), rehabilitation reduces both mortality and morbidity, spanning the steps from in-patient to long-term rehabilitation. The National Service Framework recommends rehabilitation for all patients with ischaemic heart disease. We describe the establishment of a primary care angina rehabilitation programme which uses a flexible model that reflects the more complex patient pathway. Method: The service was initiated through a partnership between primary and secondary care, university, borough council, patient and voluntary groups. Referrals were made from the chest pain clinic, other secondary care clinics and primary care health professionals. The service consisted of initial assessment followed by: (i) Group rehabilitation: an 8 week exercise scheme; (ii) Home-based rehabilitation: the Angina Plan; (iii)dGet Fit For Your OpT for those awaiting cardiac surgery; (iv) Drop-in angina meetings. Patients could also access the services later if required. Outcome measures included the number of attenders, drop-out rates, risk factor management, uptake of secondary prevention and change in perceived fitness. Results: During 3 years, 528 patients were referred for assessment. 28 (5%) did not respond. 229 (43%) entered the group rehabilitation programme with a further 30 (6%) attending a modified group programme. 193 (37%) undertook the angina plan. 86 attended for assessment but chose not to be immediately enrolled. Of these 38 have since accessed the programme. 10 (2%) patients failed to complete the programme. During a median follow-up of 17 months, only 6 people from the rehabilitation programme were admitted to hospital due to ischaemic heart disease. We have observed: 70% reduction in blood pressure in hypertensives and 95% of the patients using the service were on statins. Self-reported fitness increased from week 1 to week 8 in 80% of patients. Conclusion: Patients with angina have rehabilitation needs similar to those with AMI but the more complex patient journey requires a more flexible model. By providing menu-based options, we have achieved 86% uptake of rehabilitation with only a 2% drop out rate. Home based rehabilitation was nearly as popular as the traditional group based model and the subsequent cardiac event rate was very low.