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European Journal of Heart Failure 2002 4(6):771-777; doi:10.1016/S1388-9842(02)00119-8
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© 2002 European Society of Cardiology

Heart failure in primary care: qualitative study of current management and perceived obstacles to evidence-based diagnosis and management by general practitioners

Kamlesh Khuntia,*, Hilary Hearnshawb, Richard Bakerc and Gill Grimshawd

a Department of General Practice and Primary Health Care, University of Leicester, Leicester General Hospital Gwendolen Road, Leicester LE5 4PW, UK
b Centre for Primary Health Care Studies, University of Warwick Coventry, UK
c Clinical Governance Research and Development Unit, University of Leicester Leicester, UK
d Centre for Health Services Studies, Warwick Business School, University of Warwick Coventry, UK

* Corresponding author. Tel.: +44-116-258-4367; fax: +44-116-258-4982. E-mail address: kk22{at}le.ac.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Background: Chronic heart failure is a common clinical condition with high morbidity and mortality. Despite the evidence that appropriate treatment with angiotensin-converting enzyme inhibitors can improve morbidity, primary care studies show that patients with heart failure are incorrectly diagnosed and inadequately treated.

Aim: To explore general practitioners' accounts of their management of patients with heart failure and identify the perceived obstacles to diagnosis and management.

Methods: We conducted this qualitative study using semi-structured interviews in 18 general practices. The practices were stratified on the basis of size, location, and the level of practice development. The interviews were based on a schedule of open questions based on the literature on diagnosis and management of patients with heart failure. Transcriptions of the audiotaped interviews were independently analysed by two researchers and analysis was based on open coding using a constant comparative approach. Categories were reduced to major themes.

Results: General practitioners suspect heart failure when patients present with breathlessness or ankle oedema. Many general practitioners reported that they would diagnose heart failure after respiratory examination and a positive finding of basal crepitations. Many general practitioners arrange a chest X-ray to establish the diagnosis and some arrange an electrocardiogram. A few general practitioners mentioned that they diagnosed heart failure with a trial of diuretics. Obstacles to diagnosis were mentioned by most general practitioners and included lack of facilities for appropriate investigations (especially echocardiography) and lack of time and expertise. Obstacles to management included lack of time, high cost of drugs, difficulty with diagnosis, selection bias towards younger patients and not having the confidence to initiate angiotensin-converting enzyme inhibitors. Many general practitioners were unaware of the impact angiotensin-converting enzyme inhibitors can have on morbidity and mortality.

Conclusions: Although symptoms of heart failure are not sufficiently specific for diagnosing patients with heart failure, many general practitioners in European countries treat people with suspected heart failure on the basis of symptoms and signs alone. This study has identified many obstacles to the diagnosis and management of heart failure that may explain why patients are inadequately managed in primary care. Specific implementation strategies need to be tailored to overcome these obstacles.

Key Words: Heart failure • Obstacles • Primary care • Management

Received November 26, 2001; Revised March 10, 2002; Accepted May 21, 2002


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Chronic heart failure is a common clinical condition with high morbidity and mortality [1]. The public health burden of heart failure has been predicted to rise substantially over the next 10 years with an increase in both incidence and prevalence [2]. The quality of life of patients with heart failure is worse than with angina, diabetes, chronic obstructive airways disease and many other gastrointestinal diseases [3]. The 5-year survival of patients with chronic heart failure is worse than many malignant conditions [4]. However, there is substantial evidence that appropriate treatment with angiotensin-converting enzyme inhibitors can improve the symptoms and signs of all grades of heart failure and improve exercise tolerance, reduce hospitalisation rates and prolong survival [5]. Standards of care expected for people with heart failure have been published in the European Society of Cardiology Guidelines [6]. These include appropriate investigations to confirm diagnosis and then to offer appropriate treatment.

Most patients first present in primary care. Symptoms and signs can alert clinicians to the possibility of heart failure, but they are not sufficiently specific for confirming the diagnosis [7]. However, primary care studies from European countries show that patients with heart failure are incorrectly diagnosed [8,9] and inadequately treated [10,11]. These studies are based on audit data and identify current practice but do not explore the reasons behind the behaviour of clinicians. A recent study using a nominal group technique found many barriers to effective management of heart failure [12]. The study was, however, carried out in a select group of practices in the Medical Research Council General Practice Research Framework. Furthermore, the study failed to discuss strategies to overcome the barriers.

This study reports a qualitative study to explore general practitioners views on management of patients with heart failure and the obstacles to their diagnosis and management. Our further aim was to discuss strategies that can be tailored to overcome the identified obstacles. Qualitative methods were chosen because our objectives were exploratory. Furthermore, qualitative methods can help bridge the gap between scientific evidence and practice [13]. The study was a part of a randomised control trial of academic detailing for implementing guidelines in primary care.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusion
 References
 
A power calculation for the main study showed that we required 36 practices for the randomised control trial. Seventeen practices received evidence-based heart failure guidelines implemented by academic detailing [14]. The sampling frame for the randomised controlled trial was constructed from all practices in Leicestershire Health Authority (n=154). Fifty practices agreed to participate in the study from which 36 were selected for participation. A stratified sample was selected on the basis of the size of practice, location of practice, and the level of development of the practice. Overall, there were 47 general practitioners in the participating practices. Table 1 shows the characteristics of practices and numbers of general practitioners that were interviewed. Two practices (one group and one single-handed practice) delivered care to mainly South Asian patients. The study was conducted in 1997 and was approved by the local research ethics committee.


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  		Table 1 Characteristics of general practices (n=18)

 
2.1. Interview procedure
Academic detailing comprises a personal visit by a trained person to a health provider and is modelled on methods by pharmaceutical sales representatives [14]. Initial aspect of academic detailing includes identification of motivations underlying present behaviour [14]. Academic detailing was conducted by KK at all 18 practices and lasted between 30 and 60 min. The practices were informed only that the study was investigating the implementation of heart failure guidelines. The first phase of the academic detailing consisted of an interview about general practitioners’ methods of diagnosing and managing patients with heart failure including their level of confidence and obstacles to diagnosis and appropriate management. KK mentioned the word ‘heart failure’ at the beginning of the interview and acknowledged there was research evidence of inadequate and inappropriate diagnosis. The interviews were semi-structured with additional questions being added as the interviews progressed. The interviews were based on a schedule of open questions based on the literature on diagnosis and management of patients with heart failure [1,15]. The interviews were piloted with four general practitioners. One of the pilot interviews was also videotaped and the interview schedule was further developed after discussions by the research team. The final version of the interview covered how general practitioners currently diagnosed and managed patients with suspected heart failure and determined their obstacles to diagnosis and management. Three of the interviews were conducted with one doctor alone while the other interviews were conducted with groups of doctors from the same practice. A total of 38 general practitioners were interviewed. All interviews were audiotaped with the consent of the interviewees.

2.2. Analysis
Transcriptions of the audiotaped interviews were analysed by KK and HH. Analysis was based on open coding using a constant comparative approach [16,17]. An initial categorisation of themes was agreed after independent analysis of two interviews. The two researchers generated similar categories, although they were initially described in slightly different terms. The revised scheme was then used with a further four interviews after which the researchers discussed their results and further revised the coding schemes. All interviews were then analysed independently by KK and HH using this scheme and any further discrepancies were resolved in discussions. Categories were reduced to major themes through on-going discussions between KK and HH and re-reading of transcripts. The analysis focused on two aspects: (a) the current methods of diagnosis and management of patients with heart failure and (b) the obstacles to the diagnosis and management of heart failure.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusion
 References
 
Responses to the questions fall into two broad categories: obstacles to diagnosis and management of patients with heart failure. Results are presented in these two categories and illustrated by examples of quotations from interview transcripts.

3.1. Obstacles to diagnosis
3.1.1. Clinical diagnosis
General practitioners frequently reported suspecting heart failure in patients who attended with breathlessness or ankle oedema. General practitioners relied on a variety of symptoms and clinical signs when diagnosing heart failure. In most practices, there was no systematic method of diagnosing such patients. There were also differing views between general practitioners from the same practice. One general practitioner did not consider a diagnosis of heart failure if the patients were only ‘a bit breathless’. Many mentioned that a past history of heart disease was more likely to alert them to a diagnosis of heart failure. Other symptoms mentioned included tiredness and fatigue, orthopnoea and paroxysmal nocturnal dyspnoea. Many general practitioners reported that they would diagnose heart failure after respiratory examination and a positive finding of basal crepitations. A few general practitioners mentioned a raised jugular venous pressure as a clue to the diagnosis. Some general practitioners excluded the diagnosis of heart failure if there were no positive clinical findings. Only a small number of general practitioners reported that they would conduct an examination for displaced apex beat or cardiomegaly.

‘We always ask the question, when do you get breathless? How much are you walking? That is done by the nurse.... They come to me, I assess their lungs, lung function, peak flow, ask them how many pillows they are using and if there was any family history of cardiac problems and take it from there. If there were any clinical signs of left ventricular failure obviously if there were any oedema, including JVP raised, then in that case diagnose congestive cardiac failure’ [Practice 17].

3.1.2. Investigations
Some general practitioners requested a full blood count and urea and electrolytes on all their patients with suspected heart failure. Many general practitioners mentioned that they would arrange for chest X-ray and some would arrange a 12 lead electrocardiogram. Some general practitioners excluded a diagnosis of heart failure on the basis of clinical examination and occasionally with the addition of a normal chest X-ray. Chest X-ray was preferred as an investigation of choice for two reasons: it was ‘easy to organise’ and it was ‘not expensive’. Very few general practitioners reported sending a patient for echocardiography to confirm a diagnosis of heart failure. The majority of these general practitioners were not aware of the usefulness of echocardiography. Some who were aware of the evidence did not use it because of ‘long waiting lists’ for echocardiography. A few general practitioners, who were mainly single-handed practitioners, reported that they would send all their patients to the rapid assessment cardiology clinic at the local hospital.

‘Well first of all you are going to be alerted to their symptoms, which would be breathlessness, particularly nocturnal dyspnoea, perhaps waking up with orthopnoea and sputum, increasing breathlessness on exercise, then listening to their chest you would expect to hear some basal creps. You would look for right sided heart failure and raised JVP, peripheral oedema, listen to their heart and make sure there is no heart murmur. The most useful tool really apart from examination is chest X-ray. If that's normal and there is no heart murmur then I would be fairly happy to not worry about failure’ [Practice 9].

‘I wouldn't rely solely on clinical findings although clinical findings are a concrete basis of the management plan but my routine investigations really would be chest X-ray, ECG and urea and electrolytes as a basic and then look for other areas as evidence for other reasons why the patient may be dyspnoeic’ [Practice 4].

Some practitioners who did not have direct access to echocardiography used other arrangement to gain rapid access:

‘the first thing you need is an echo [cardiogram], and echo is a major problem now. I have come over that by asking consultants straight away to organise an echo’ [Practice 17].

3.1.3. Trial of diuretics
Some general practitioners said that they would diagnose heart failure by organising a trial of diuretics, and would confirm the diagnosis if there was an improvement in symptoms.

‘Trial of therapy may be easier...lot of us do. ...and if they come back and they are feeling better and they have got less symptoms then you may feel reassured then. Without going on to echo's [cardiograms] and the like’ [Practice 16].

General practitioners acknowledged that this method of diagnosis was not ideal, but accepted the approach because of difficulty in obtaining echocardiography for their patients.

‘You often find that the symptoms have settled down completely on treatment but these are cases where it would be nice to have an echo but we haven't used it in the past quite simply because you may have to wait two or three months to get it done’ [Practice 6].

Most general practitioners mentioned the adequacy of facilities as an obstacle to diagnosing and managing patients with heart failure, specifically lack of access to an echocardiogram. Another obstacle was not having enough time to deal with patients suspected of having heart failure. Diagnostic confusion was perceived as an obstacle with difficulty in distinguishing the cause of breathlessness between a respiratory or cardiac origin. Even when practitioners were aware of the evidence about the validity of investigations or signs, the principal obstacle was the high demand by elderly patients including the time these patients take on getting dressed and undressed.

‘The problem with heart failure in this practice is because it's a geriatric practice and the problems really is time because basically ideally I would like with heart failure to examine everyone to find out if there is a cause for the heart failure and not just assume that the hospital has treated them with Digoxin and diuretics. It would be nice if I could put them on the couch, examine them to make sure that atrial fibrillation is controlled and treat them myself and not send them in but I don't have the time’ [Practice 11].

‘If I have the time. I am single handed now. The bottom line of it all is that I haven't the time. If I could investigate the patients it would be nice to have an ECG, nice to send off for urea and electrolytes at the end of the day, have a chest X-ray but it all takes time to gather the results and then make a decision’ [Practice 12].

Some obstacles were directly related to the organisational aspects of services. Many general practitioners mentioned poor access to echocardiography as a barrier to diagnosing patients with suspected heart failure. Doctors also perceived that they were more likely to refer younger patients to the hospital. Not being fund holders was also viewed as a major obstacle as these practices did not have open access to echocardiography. The general practitioners also reported interface problems with providers, who they perceived did not trust them to use the services appropriately.

‘I just feel that the echo should be open access to general practice. However, the argument will say there is no resources and people will be flooding everybody with echo because it's a new gimmick and a new thing. I think that is a misconception. If we have a scoring system and the GP's scored a system on a piece of paper for the referral, the patient should have an echo. If I have a heart failure or suspect myself as having a heart failure I will demand an echo’ [Practice 17].

‘I think where a chest X-ray maybe useful is where you are in doubt clinically and echo isn't easily available. An echo is the ideal. The problem is that the waiting time for an echo is really rather too long’ [Practice 6].

3.2. Obstacles to treatment
The main obstacles identified in management of heart failure were lack of knowledge, classification of heart failure, the high cost of drugs, difficulty with diagnosis, selection bias towards younger patients and not having the confidence to initiate angiotensin-converting enzyme inhibitors. All general practitioners treated patients suspected of heart failure with loop diuretics, but only some reported using angiotensin-converting enzyme inhibitors. They used angiotensin-converting enzyme inhibitors mainly when high doses of diuretics were already required. These general practitioners perceived diuretics as being inadequate in treatment for heart failure. When angiotensin-converting enzyme inhibitors were initiated, they were used in small doses. Many general practitioners also referred to patients having "mild’ disease. These patients would be treated only with loop diuretics. Many general practitioners referred patients if they did not improve with loop diuretics. Some general practitioners had never initiated a patient with heart failure on an angiotensin-converting enzyme inhibitor. Very few general practitioners were aware of the benefits of treating patients with angiotensin-converting enzyme inhibitors.

‘Generally I would probably start with a diuretic just to see what sort of difference was made and if I got a good improvement with that then if they were comfortable with that management then I would probably leave it at that at least initially. If it only had a partial effect or if they were uncomfortable with that when I would probably switch to an angiotensin-converting enzyme inhibitor then’ [Practice 4].

Even when angiotensin-converting enzyme inhibitors were initiated, general practitioners were cautious in using high doses. The time required for initiating and monitoring patients on angiotensin-converting enzyme inhibitors was also mentioned as a barrier. Lack of confidence in initiating therapy was mainly derived from previous experience. Some general practitioners gave accounts of an adverse experience that their patients had when they had started on an angiotensin-converting enzyme inhibitor. Others expressed a view that litigation may be a possibility if patients had adverse outcomes.

‘Well I have had bad reports you know about starting angiotensin-converting enzyme with patients collapsing so I am not really ready to start patients on an angiotensin-converting enzyme but I know Dr C does’ [Practice 7].

‘But you have got to consider whether somebody is very old and got other illness as well.... The big thing is to check the renal function and make sure, because we have had one or two people who have. I know one person who went into hospital to have this, he really went off. They [hospitals] must have known he was at risk with a lot of other problems and he just couldn't tolerate it basically so they had to resuscitate him renally’ [Practice 9].

Some general practitioners accepted the treatment of heart failure if the patient had responded to treatment with diuretics.

‘Well we tend to stick to their present therapy if they are settled and happy. If they start getting worse, then re-assess their medication and decide if there are any other options available’ [Practice 9].

General practitioners were also reluctant to commence angiotensin-converting enzyme inhibitors because of the perceived increase in workload.

‘...you have to do U's and E's [urea and electrolytes] as well. That's the problem you see, starting an ACE [angiotensin-converting enzyme] inhibitor is that you have to carry on bringing patients in regularly for checks. You know if you are on Frusemide, just leave them on the dose—end of problem then’ [Practice 7].

Those few general practitioners and practices who admitted to routinely arranging echocardiograms for patients suspected of having heart failure were also more likely to report treating patients with angiotensin-converting enzyme inhibitors. These general practitioners were also more likely to be aware of the impact of heart failure on patients’ morbidity and mortality.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusion
 References
 
The recent European Society of Cardiology guidelines set out clear standards for diagnosis and management of patients suspected heart failure. This qualitative study has identified some of the reasons why general practitioners do not diagnose and manage patients with heart failure according to evidence-based recommendations [1]. One previous UK study has investigated the reasons for the gap between research and practice [18], but, this was a telephone marketing study which has limitations. Unlike the recently published study [12], we have described self-reported accounts of how general practitioners currently diagnose and manage patients with heart failure and identified various obstacles that explain the difficulties general practitioners face in diagnosis and management. Furthermore, both these studies did not report on the possible implementation strategies to overcome the identified obstacles. Most general practitioners in our study identified several barriers and there were only a few general practitioners who identified single barriers. Our study has also identified in detail a range of obstacles to adopting evidence-based diagnosis and management of heart failure in primary care. This study shows there are many obstacles to the diagnosis and management of heart failure in primary care. These may explain why only a small proportion of patients are diagnosed and managed in accordance with the research evidence [8,9].

4.1. Strengths and limitations
The study addresses an important and previously poorly researched subject. Although we interviewed general practitioners from 18 different practices, some general practitioners were not available for interview. The general practitioners were aware that the study involved guidelines in management of heart failure and may therefore have stated socially desirable ideas about management of heart failure. We do not claim that we have identified a comprehensive set of obstacles experienced by all practitioners. Nevertheless, the obstacles identified are real and are likely to be experienced by general practitioners in many countries [10], therefore indicating a potential need for targeted interventions. This study also relies on the self-reported descriptions of how general practitioners currently manage patients with heart failure and their perceived obstacles to following evidence-based practice. We did not evaluate the accuracy of those self-reports of behaviour since the study was focusing on perceptions. The interviews were conducted by a local GP (KK) who was able to acknowledge some of the difficulties in diagnosis of heart failure in primary care. This may have allowed general practitioners to express their own experiences with few inhibitions.

4.2. Suggested implementation strategies
4.2.1. Current diagnosis and management of patients with heart failure
In line with previous studies [10,19], many general practitioners in this study were currently diagnosing patients with heart failure either clinically from history and examination or with the addition of a chest X-ray. Research evidence shows that symptoms and signs do not correlate well with impaired left ventricular systolic dysfunction and a normal chest X-ray does not exclude heart failure [20,21]. Some general practitioners are also relying on a trial of diuretics to confirm diagnosis. Since symptoms have low reliability [7], this may explain the finding that nearly half the patients being managed in primary care are incorrectly diagnosed. General practitioners who routinely referred patients to a cardiologist were also less likely to be aware of the benefits of angiotensin-converting enzyme inhibitors in patients with left ventricular systolic dysfunction. Conversely, a few general practitioners aware of both appropriate diagnosis and management of patients with heart failure were more likely to treat patients themselves.

Success in changing clinical behaviour of these general practitioners is more likely if the change strategy is chosen to fit the setting and circumstances [22]. A variety of combination of strategies will therefore be required for improving current methods of diagnosis and treatment of heart failure [23].

4.2.2. Obstacles to diagnosis and management of heart failure
Our results are in agreement with a recent study that showed that major obstacles to optimal management of patients with heart failure include difficulties in diagnosis and the perception that appropriate symptomatic treatment of heart failure is with diuretics [18]. General practitioners seem to actively investigate or refer younger patients presenting with breathlessness compared to older patients, a finding confirmed in recent studies [24,25]. In another community based study, advanced age was independently related to a decision to not request an echocardiogram [26]. The decision to investigate and aggressively manage patients with suspected heart failure will be influenced by co-morbidity. Therefore, age alone should not be a factor for investigation and managing these patients according to the evidence. However, heart failure is common in elderly patients in a primary care setting [27,28].

Some general practitioners in this study felt they did not have the expertise to diagnose heart failure and therefore referred patients to secondary care. However, there is evidence that appropriate patients can safely commence angiotensin-converting enzyme inhibitors within a primary care setting [29]. Lack of access to echocardiography is a major obstacle. General practitioners are keen to have access to echocardiography and there is research evidence that if this service is provided then general practitioners use it appropriately [22,30,31].

Some general practitioners have had previous bad experience of using angiotensin-converting enzyme inhibitors and fear of side effects and litigation from patients. Risk of using angiotensin-converting enzyme inhibitors was also identified in a European survey of primary care physicians [10]. Strategies tailored to enable general practitioners to overcome their fear of repeating the bad experience may be effective.

Practitioners who reported being confident in diagnosing and managing patients with heart failure in primary care identified lack of time as a major barrier. There is now evidence that a nurse-directed, multidisciplinary programme of home-based interventions of patients with heart failure can reduce the frequencies of unplanned re-admissions to hospitals [32] and out-of-hospital deaths [33]. Further research on nurse-led diagnosis and management of patients in primary care is required.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
References
 
The findings of this qualitative study have highlighted a number of obstacles general practitioners experience in the appropriate diagnosis and management of heart failure. Implementation strategies used specifically to tackle these obstacles may be effective in improving the current management of heart failure within primary care. This study has also indicated several approaches to implementation that should be investigated in future research.


   Acknowledgements
 
We thank all the practitioners who helped with the study. We would like to thank Professor Francine Cheater and Dr Tim Coleman for commenting on an earlier draft of the paper. The study was funded by the NHS Executive. Clinical Governance Research and Development Unit is funded by Leicestershire Health Authority and Trent Region.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 

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