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Brooman-White R, Blakeman T, McNab D, Deaton C. Informing understanding of coordination of care for patients with heart failure with preserved ejection fraction: a secondary qualitative analysis. BMJ Qual Saf 2024; 33:232-245. [PMID: 37802647 DOI: 10.1136/bmjqs-2023-016583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/15/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Patients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple healthcare services. Regional variation in services and resourcing has been highlighted as a problem in heart failure care, with few teams bridging the interface between the community and secondary care. These reports conflict with policy goals to improve coordination of care and dissolve boundaries between specialist services and the community. AIM To explore how care is coordinated for patients with HFpEF, with a focus on the interface between primary care and specialist services in England. METHODS We applied systems thinking methodology to examine the relationship between work-as-imagined and work-as-done for coordination of care for patients with HFpEF. We analysed clinical guidelines in conjunction with a secondary applied thematic analysis of semistructured interviews with healthcare professionals caring for patients with HFpEF including general practitioners, specialist nurses and cardiologists and patients with HFpEF themselves (n=41). Systems Thinking for Everyday Work principles provided a sensitising theoretical framework to facilitate a deeper understanding of how these data illustrate a complex health system and where opportunities for improvement interventions may lie. RESULTS Three themes (working with complexity, information transfer and working relationships) were identified to explain variability between work-as-imagined and work-as-done. Participants raised educational needs, challenging work conditions, issues with information transfer systems and organisational structures poorly aligned with patient needs. CONCLUSIONS There are multiple challenges that affect coordination of care for patients with HFpEF. Findings from this study illuminate the complexity in coordination of care practices and have implications for future interventional work.
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Affiliation(s)
- Rosalie Brooman-White
- Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Thomas Blakeman
- Centre for Primary Care, University of Manchester Faculty of Medical and Human Sciences, Manchester, UK
| | - Duncan McNab
- Medical Directorate, NHS Education for Scotland, Glasgow, UK
| | - Christi Deaton
- Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
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Nauli SE, Prima Putri VK, Arifianto H, Prameswari HS, Lubis AC, Zulkarnain E, Hasanah DY, Dewi Yamin PP, Dewi TI. Heart Failure With Preserved Ejection Fraction: Current Status of Daily Clinical Practice in Indonesia. Cureus 2023; 15:e38086. [PMID: 37257168 PMCID: PMC10209474 DOI: 10.7759/cureus.38086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 06/02/2023] Open
Abstract
Introduction Heart failure (HF) is a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion. Among HF types, HF with preserved ejection fraction (HFpEF) is the commonest form. However, the diagnosis and management of HFpEF are challenging. In addition, the perception of healthcare professionals (HCPs) towards the diagnosis and management of HFpEF patients differs due to the existing gap between the guidelines and daily clinical practice. Therefore, an online survey was conducted to understand the HCPs' knowledge and practice gaps in the diagnosis, treatment, and management of patients with HFpEF. Methods A total of 160 respondents, i.e., cardiologists, internists, and cardiology residents from different community-based practices and hospitals across Indonesia participated in an online continuing medical education (CME) survey. A questionnaire was formulated to assess awareness, current practice patterns, challenges, and confidence of the HCPs related to the HFpEF. Results HCPs stated that diagnosis of HF is the prime responsibility of cardiologists and general physicians but not of general internists. According to the HCPs, reduction in mortality, reduction in hospitalization, and improved quality of life are the most important goals of HF treatment. The perceived prevalence of HFpEF is estimated to be 30-60% and mortality rates of HFpEF and HF with reduced ejection fraction (HFrEF) are similar. Further, mixed types of responses with different combinations of diagnosis, treatment, and prevention, were obtained when HCPs were asked about the challenges faced in HFpEF. Among the therapies, angiotensin-converting enzyme (ACE) inhibitors, mineralocorticoid receptor antagonists (MRA), beta-blockers, and diuretics are frequently used for the treatment of HF. Conclusion The perception of the HCPs toward the diagnosis and management of HFpEF may affect optimal care. Based on our findings, the cardiologists are well aware of the current situation of HF in Indonesia and treat patients with HFpEF effectively.
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Affiliation(s)
- Siti E Nauli
- Department of Cardiology, Tangerang District Hospital, Tangerang, IDN
- Working Group on Heart Failure and Cardiometabolic Disease, Indonesian Heart Association, West Jakarta, IDN
| | - Vebiona K Prima Putri
- Department of Cardiology, Awal Bros Hospital, Pekanbaru, IDN
- Working Group on Heart Failure and Cardiometabolic Disease, Indonesian Heart Association, West Jakarta, IDN
| | - Habibie Arifianto
- Department of Cardiology, Universitas Sebelas Maret Hospital, Surakarta, IDN
- Working Group on Heart Failure and Cardiometabolic Disease, Indonesian Heart Association, West Jakarta, IDN
| | - Hawani S Prameswari
- Department of Cardiology, Hasan Sadikin General Hospital, Bandung, IDN
- Working Group on Heart Failure and Cardiometabolic Disease, Indonesian Heart Association, West Jakarta, IDN
| | - Anggia C Lubis
- Department of Cardiology, Haji Adam Malik General Hospital, Medan, IDN
- Working Group on Heart Failure and Cardiometabolic Disease, Indonesian Heart Association, West Jakarta, IDN
| | - Edrian Zulkarnain
- Department of Cardiology, Mohammad Hoesin General Hospital, Palembang, IDN
- Working Group on Heart Failure and Cardiometabolic Disease, Indonesian Heart Association, West Jakarta, IDN
| | - Dian Y Hasanah
- Department of Cardiology, National Cardiovascular Center Harapan Kita, West Jakarta, IDN
- Working Group on Heart Failure and Cardiometabolic Disease, Indonesian Heart Association, West Jakarta, IDN
| | - Paskariatne P Dewi Yamin
- Department of Cardiology, Gatot Soebroto Central Army Hospital, Central Jakarta, IDN
- Working Group on Heart Failure and Cardiometabolic Disease, Indonesian Heart Association, West Jakarta, IDN
| | - Triwedya I Dewi
- Department of Cardiology, Hasan Sadikin General Hospital, Bandung, IDN
- Working Group on Heart Failure and Cardiometabolic Disease, Indonesian Heart Association, West Jakarta, IDN
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Wan Ahmad WA, Mohd Ghazi A, Abdul Ghapar AK, Muthusamy TS, Liew HB, Zainal Abidin I, Ong ML, Ross NT, Cham YL, Ho WS, Fegade M, Chew DSP. From Primary to Tertiary Care: Expert Position Statements to Guide Heart Failure with Preserved Ejection Fraction Diagnosis. Malays J Med Sci 2023; 30:49-66. [PMID: 36875198 PMCID: PMC9984115 DOI: 10.21315/mjms2023.30.1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/31/2022] [Indexed: 03/05/2023] Open
Abstract
Globally, heart failure with preserved ejection fraction (HFpEF) is quickly becoming the dominant form of heart failure (HF) in ageing populations. However, there are still multiple gaps and challenges in making a firm diagnosis of HFpEF in many low-to-middle income Asian countries. In response to this unmet need, the Malaysian HFpEF Working Group (MY-HPWG) gathered and reviewed evidence surrounding the use of different diagnostic modalities indicated for patients with HFpEF to identify diagnostic tools that could be conveniently accessed across different healthcare settings. As a result, five recommendation statements were proposed and an accompanying algorithm was developed, with the aim of improving the diagnostic rate of HFpEF. The MY-HPWG recommends using more easily accessible and non-invasive tools, such as natriuretic peptide (NP) biomarkers and basic echocardiogram (ECHO), to ensure timely HFpEF diagnosis in the primary and secondary care settings, and prompt referral to a tertiary care centre for more comprehensive assessments in uncertain cases.
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Affiliation(s)
- Wan Azman Wan Ahmad
- Division of Cardiology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Azmee Mohd Ghazi
- Cardiology Department, The National Heart Institute of Malaysia, Kuala Lumpur, Malaysia
| | | | | | - Houng Bang Liew
- Cardiology Department, Queen Elizabeth Hospital II, Sabah, Malaysia
| | - Imran Zainal Abidin
- Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mei Lin Ong
- Cardiology Department, Gleneagles Hospital Penang, Pulau Pinang, Malaysia
| | - Noel Thomas Ross
- Medical Department, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Yee Ling Cham
- Cardiology Department, Sarawak Heart Centre, Sarawak, Malaysia
| | - Wing Sze Ho
- Novartis Corporation (Malaysia) Sdn. Bhd., Selangor, Malaysia
| | - Mayuresh Fegade
- Novartis Corporation (Malaysia) Sdn. Bhd., Selangor, Malaysia
| | - David Soon Ping Chew
- Cardiology Department, Cardiac Vascular Sentral Kuala Lumpur, Kuala Lumpur, Malaysia
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Almufleh A, Turgeon RD, Ducharme A, Billia F, Ezekowitz J. Proposal for an Ambulatory Heart Failure Management Curriculum for Cardiology Residency Training Programs. CJC Open 2022; 4:866-872. [PMID: 36254326 PMCID: PMC9568682 DOI: 10.1016/j.cjco.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background The suboptimal implementation of guideline-directed medical therapy (GDMT) for heart failure (HF) patients has been linked with poor clinical outcomes. Little is known about the potential role of cardiology residency training programs in improving trainees’ (ie, future cardiologists’) ability to utilize GDMT. Methods In this survey-based study, we examined the degree of exposure to ambulatory HF patient management among cardiology trainees in Canada. All cardiology residency program directors (n = 15; 100% response rate) completed our survey. Results Although 9 programs (60%) mandated ≥ 3 ambulatory cardiology rotations, only 3 (20%) required ≥ 2 ambulatory HF rotations. When HF rotations were provided, only 7 programs (47%) offered moderate or higher exposure to ambulatory nontransplant HF patients (defined as ≥ 5 clinics/rotations). This element was independent of program- and institution-specific characteristics. All institutions had a multidisciplinary HF clinic, and the majority (13 [87%]) had access to an inpatient HF service, a consultative HF service, and/or a specialist pharmacist. Furthermore, 13 program directors (87%) agreed on the importance of adopting HF training curriculum and their program’s readiness to implement such a module. Conclusions The current state of HF training among cardiology residencies is suboptimal and in need of improvement. Most programs have access to a HF clinic, a specialist pharmacist, or an inpatient consultative service, which would facilitate adoption of a HF management curriculum that focuses on practical and experiential aspects of GDMT optimization. This program, which is under development, will be offered to training programs nationwide, to enable trainees to manage this growing and increasingly complex patient population.
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